strategicpositionstatement for kwazulu-natal · strategicpositionstatement for kwazulu-natal ......

National Department of Health

National Service Planning Initiative

STRATEGIC POSITION STATEMENTfor

KWAZULU-NATAL

HLMSVArchitects

POBox36744MenloPark0102

Temwo Building,TheHillside,LynnwoodPretoria,SouthAfrica,0081

Telephone(012)3481329Fax(012) 3488664

[email protected]

NOVEMBER 2001

Revised in accordance withKwaZulu-Natal Department ofHealth GIS Map BookletMARCH 2002

fo r

KWAZULU-NATAL

HLMSV Architects

PO Box 36744 Menlo Park 0102

Temwo Building, The Hillside, LynnwoodPretoria, South Africa, 0081

Telephone (012) 3481329Fax (012) 3488664

E-Mail [email protected]

NOVEMBER 2001

Revised in accordance withKwaZulu-Natal Department ofHealth GIS Map BookletMARCH 2002

Acknowledgements page 1 of 173

National Planning Initiative

Strategic Position Statement for the KwaZulu-Natal Province i Acknowledgements

The successful completion of this report is due to the assistance and support of personnel in hospitals, clinics and the Department of Health in KwaZulu-Natal. The Department did a great deal of work before this project commenced, and this report builds on the following documents: • Health Information Bulletin KwaZulu-Natal 1999-2000 • Strategic Planning KwaZulu-Natal • HR Situational Analysis; HR Planning Project team 1999-2000 • A Strategic framework for the delivery of Hospital services in KwaZulu-Natal

ii Project team

Dr Anette vd Merwe Health Planner, Human Resource and Hospital Management Specialist Dr Anna-Marie Radloff Health Planner and Human Resource Specialist

Dr Shenaaz Mahomed Health Planner and Human Resource Specialist Malcolm Brown Financial Advisor

Brian Kenyon Equipment, Facilities and Information Technology Specialist Carlien Steyn Facilities and Costing Specialist (QS) Jon Mehl Facilities and Design Specialist (Architect) Philip Viljoen Facilities and Design Specialist (Architect) Willem Steyn Facilities and Design Specialist (Architect) iii KwaZulu-Natal Steering Committee Professor RW Green-Thompson Head of Department Mr G vd Merwe Head of Facilities Planning Dr P Ramdas Head of Hospital Services Dr M Mhlongo Head of PHC Services Mr HAW Conradie Chief Financial Officer Mrs S Skweyiya Head of Human Resources Mr GE Mkhize Head of Human Resource Practices Dr MLB Simelane Head of Emergency Medical Rescue Services Dr S Buthelezi Programme Manager for HIV/AIDS Mr V Magaqa Information Manager Mrs M Bouwer District Representation Dr M Mhlongo District Representation

Ms T Shezi Newcastle Director Mr R Mead KwaZulu-Natal IT Mr Z Ahmed Department of Informatics

Johan Britz Finance Department iv In addition, the project team referred to other research projects done, and with permission, used

intellectual input from these sources. : • Work done on staffing norms (Dr Rodion Krause) • Review of highly specialized services (Project Team Health Financing and Economics) • Assessment of Current Health care referral Systems in S.A. (Dr. Nic van Zyl - University of the

Free State) • A Comprehensive Primary Health Care Service Package for S.A. (Centre for Health Policy

Studies at Wits University)

List of abbreviations page 2 of 173

INDEX Page

i Acknowledgements 1 ii Project Team 1 iii KwaZulu-Natal Steering Committee 1

List of abbreviations 6

Definitions

7

Executive Summary

9

General comment 9 I Overall summary 9 II Health needs assessment 10 III Principles of the sustainability model 12 IV General issues impacting on services 19 V Primary Health Care 19 VI Hospital services review 20 VII The way forward 20 VIII Implementation 21 1 Aim of the Strategic Position Statement 22 1.1 The approach 22 1.2 The principles 22 2 Methodology and approach 23 2.1 Introduction 23 2.2 Core principles 23 2.3 General approach 24 2.4 Ensuring plans can be implemented 24 3 Health needs 26 3.1 Health priorities 26 3.2 Population characteristics 28 3.3 Socio economic status 33 3.4 The demand for health care 39 3.4.1 The Cholera Epidemic 39 3.4.2 The Malaria Epidemic 40 3.5 Health needs assessment 42 3.6 Impact of HIV/AIDS 42 4 Primary Healthcare Review 51 4.1 General comment 51 4.2 Configuration of services and type 52 4.3 Facilities 54 4.3.1 Existing facilities 54 4.3.2 Required facilities 54 4.3.3 Cost of provision of new clinics and upgrade 55 4.4 Referral patterns 55 4.5 Finance 60 4.5.1 Historic cost analysis 61 4.5.2 Estimated costs in 2010 based on 2001 Rc 61 4.6 Staffing – Current staffing levels 62 4.7 Plans for local authority devolution 64 4.8 Home-Based care 64


INDEX Page

4.9 General management & organisational development issues 65 4.9.1 Integrated planning 65 4.9.2 Monitoring & Evaluation 67 4.9.2.1 Key performance indicators 67 4.9.2.2 Outcome measurements 68 4.9.3 Treatment Protocols 69 4.9.4 Lack of skilled Human Resources 69 4.9.5 Inadequate physical facilities 69 4.9.6 Transport 69 5 Hospital services review 70 5.1 General comment 70 5.2 Configuration of services 71 5.2.1 National Central Hospital 71 5.2.2 Provincial Tertiary Services 72 5.2.3 Regional Hospital Services 73 5.2.4 District Hospital Services 75 5.2.5 Specialised Hospital Services 76 5.2.6 Mental Health Services 78 5.3 Demand for hospital services and utilisation 80 5.4 Referral patterns 81 5.5 Services offered 81 5.6 Private and non-government hospital service provision 83 5.7 Priority issues that impact on hospital service delivery 84 5.8 Finance – historical cost and utilisation 2001-2001 85 6 Human resource management review 86 6.1 Staff planning considerations 86 6.2 Recruitment and retention issues 87 6.3 Performance measurement 91 7 Financial management review 93 7.1 Funding and budget availability 93 7.2 Budget setting process 93 7.3 Budget priorities 94 7.4 Funding projections 95 7.5 Current capital building and maintenance costs 96 7.5.1 Current capital building cost 96 7.5.2 Current cost of equipment 97 7.5.3 Maintenance cost of buildings 98 7.5.4 Maintenance of equipment 98 7.6 Current running costs 99 7.7 Additional funding requirements – Transformation cost 101 7.7.1 Backlog in hospital equipment maintenance 101 7.7.2 Backlog in hospital facility maintenance 101 7.7.3 Estimated cost of hospital transformation 103 7.7.4 Backlog in Clinic Equipment and facilities maintenance 103 7.7.5 Backlog in Clinic Facilities 103 8 General management and organisational development issues 105 8.1 Integrated planning 105 8.2 Monitoring and evaluation 107 8.2.1 Key indicators 107


INDEX Page

8.2.2 Outcome measurements 109 8.2.3 Monitoring and evaluation building projects 109 8.3 Information management 110 8.4 HIV/AIDS planning 110 8.5 Legislation considerations 113 8.6 Cross boundary flow issues 115 8.7 Financial management process 115 9 Sustainable services 117 9.1 Principles of the sustainability model 117 9.2 Current resource envelope and the identified GAP 117 9.3 Key considerations for future configuration and sensitivity analysis 120 9.4 Identification of options based on model scenarios 123 9.4.1 Option 1 – Model designed for health care delivery based on national 123 9.4.2 Option 2 – Demand driven model 123 9.4.3 Option 3 – Appropriate level of care 124 9.4.4 Option 4 – Appropriate level of care plus improved access to primary 124 9.4.5 Option 5 – Selected practical proposal 124 9.5 Meeting provincial priorities 125 10 Options for closing the GAP 128 10.1 Option 1 – Model designed for health care delivery based on national 128 10.1.1 Option description 128 10.1.2 Principles underlying the option configuration 128 10.1.3 Number of hospitals (and level) 129 10.1.4 Number of beds 129 10.1.5 Estimated activity 130 10.1.6 PHC Structure required to support the option 130 10.1.7 Estimated running costs 131 10.1.8 Capital and equipment costs 132 10.1.9 What interventions are required to make the option viable 132 10.1.10 Benefits assessment 133 10.1.11 Funding issues 134 10.1.12 Priority development issues 134 10.2 Option 2 – Demand driven model 134 10.2.1 Option description 134 10.2.2 Principles underlying the option configuration 134 10.2.3 Number of hospitals (and level) 135 10.2.4 Number of beds 135 10.2.5 Estimated activity 136 10.2.6 PHC Structure required to support the option 136 10.2.7 Estimated running costs 137 10.2.8 Capital and equipment costs 138 10.2.9 What interventions are required to make the option viable 139 10.2.10 Benefits assessment 139 10.2.11 Funding issues 140 10.2.12 Priority development issues 140 10.3 Option 3 – Appropriate level of care 140 10.3.1 Option description 141 10.3.2 Principles underlying the option configuration 141 10.3.3 Number of hospitals (and level) 142


INDEX Page

10.3.4 Number of beds 142 10.3.5 Estimated activity 143 10.3.6 PHC Structure required to support the option 143 10.3.7 Estimated running costs 144 10.3.8 Capital and equipment costs 145 10.3.9 What interventions are required to make the option viable 146 10.3.10 Benefits assessment 146 10.3.11 Funding issues 147 10.3.12 Priority development issues 147 10.4 Option 4 – Appropriate level of care plus improved access to primary 148 10.4.1 Option description 148 10.4.2 Principles underlying the option configuration 148 10.4.3 Number of hospitals (and level) 149 10.4.4 Number of beds 150 10.4.5 Estimated activity 151 10.4.6 PHC Structure required to support the option 151 10.4.7 Estimated running costs 152 10.4.8 Capital and equipment costs 153 10.4.9 What interventions are required to make the option viable 154 10.4.10 Benefits assessment 155 10.4.11 Funding issues 156 10.4.12 Priority development issues 156 10.5 Option 5– Selected practical proposal 156 10.5.1 Option description 157 10.5.2 Principles underlying the option configuration 157 10.5.3 Number of hospitals (and level) 158 10.5.4 Number of beds 159 10.5.5 Estimated activity 160 10.5.6 PHC Structure required to support the option 160 10.5.7 Estimated running costs 161 10.5.8 Capital and equipment costs 162 10.5.9 What interventions are required to make the option viable 163 10.5.10 Benefits assessment 163 10.5.11 Funding issues 164 10.5.12 Priority development issues 165 11 SWOT analysis of options – Using option 5 as the preferred 166 11.1 Strengths 166 11.2 Weaknesses 166 11.3 Opportunities 166 11.4 Threats 167 12 High level resource assessment comparison of options 168 12.1 Tabular presentation of various options and cost implications 168 12.2 High-level activity assessment 169 13 Broad option assessment 172 Addendums 1 Criteria for stepdown facilities 2 Model assumptions for 2010 service levels expressed in 2001 rand 3 Summaries of Option 1- 4 4 Option 5


LIST OF ABBREVIATIONS CHC Community Health Centre COHSASA Council of Health Standards Accreditation CPN Control Professional Nurse DHS District Health System DOH Department Of Health DOTS Direct Observation Treatment System EDL Essential Drug List EMS Emergency Medical Services EN Enrolled Nurse ENA Enrolled Nurse Assistant ENT Ear Nose and Throat FMS Financial Management System HAC HIV /AIDS Communicator HBC Home Based Care HDI Human Development Index HIB Haemophilus influenza vaccine HIV / AIDS Acquired Immune Deficiency Syndrome HLMSV HLMSV Architects HR Human Resource IALCH Inkosi Albert Luthuli Central Hospital ICU Intensive Care Unit IPD In Patients Department KPA Key Performance Areas KPMG KPMG Management Consultants KZN KwaZulu-Natal LOS Length Of Stay MDR Multi Drug Resistance MEC Member of the Executive Committee MRC Medical Research Council MTCT Mother-To-Child Transmission MTEF Medium Term Economic Forecast MVA Motor vehicle accidents NdoH National Department Of Health NGO Non Governmental Organisation NHFA National Health Facilities Audit OP Out Patients OPD Out Patients Department PBM Per Bed per Month PDE Patient Day Equivalent PHC Primary Health Care PN Professional Nurse RSA Republic of South Africa SAH norms South African Hospital norms SANTA South African National Tuberculoses Association SPN Senior Professional Nurse SPS Strategic Position Statement STD Sexually Transmitted Diseases TB Tuberculoses TCBC Treasury Committee for Building Cost norms TTO Medicines taken by discharged hospital patients VTC Voluntary HIV Testing and Counselling WHO World Health Organisation

Definitions page 7 of 173

DEFINITIONS In order to clarify the use of terminology when referring to level of care ; broad definitions are included: i. Home-based care The provision of comprehensive services, which include health and social services, by formal and informal caregivers in the home. The objective is to restore, promote and maintain a person’s maximum level of comfort, function and health, including care towards a dignified death. Types of home-based care:

- Preventative - Promotive - Therapeutic - Rehabilitative - Maintenance - Palliative

Providers of care are professionals, non-professionals such as community care givers, volunteers and traditional healers as well and community based organisations. A team consists of 10 people. One team can serve a community of 17 000 persons. ii. Hospital-based care Hospital care is divided into level of care. The condition of the patient, technical expertise and infrastructural requirements of care, and the acuity of the patient determine the level of care required. Two approaches could be followed:

1 A structural approach

1.1 Hospitals are categorised according to level of care – viz:

Tertiary hospitals Regional hospitals District hospitals Step-down facilities Transit facilities Hospice facilities

1.2 Packages of care in each type of facility are defined, with concomitant essential

drug lists.

1.3 Building norms, maintenance norms and design norms are defined per level of care.

1.4 Staffing norms are defined

1.5 Patients requiring higher level of care are referred upwards

1.6 Advantages

1.6.1 Good budgetary control

Definitions page 8 of 173

1.6.2 Central policy making process

1.7 Disadvantages

1.7.1 Patients tend to gravitate towards higher level of care due to: - Budget incentives to ‘dump’ patients - Lack of skills on lower level of care especially in rural areas. 1.7.2 It is very expensive to treat patients in inappropriately high level of care . 1.7.3 Bottle necks occur in facilities where higher level of care are given.

1.7.4 Breakdown in referral system, with poor communication between

facilities lead to:

- Transfer delays - Duplication of tests and services - High cost

The second approach that could be followed is:

2 A functional approach

2.1 Hospitals could have beds from more than one level of care e.g.:

- L3 + step-down - L2 + step-down - L2 + L1+ step-down + hospice 2.2 Wards could be organised according to level of care 2.3 Equipment and staffing levels are determined by the level of care and patient

acuity. It requires a process of active management. Constant effort must be made to drive cost down and control staffing levels based on the appropriate level of care.

2.4 Case mangers are appointed to ensure patients receive care according to the

appropriate level of care.

2.5 The care follows the patient, and not the other way round.

2.6 Advantages 2.5.1 Could bring about massive cost savings. 2.5.2 More convenient for patients. 2.5.3 Fewer problems due to transfer delays etc.

2.6 Disadvantages

2.6.1 Requires a high level of management skill.

Executive summary page 9 of 173

EXECUTIVE SUMMARY General comment: The model is a theoretical model aimed at estimating the health care service requirements in 2010 based on assumptions made in today’s context. Four models have been prepared based on the development infrastructure by other departments and organisations, which will facilitate patient access, communications and water and electricity at all institutions. This is considered to be unattainable and a fifth model is presented as being more practical for KwaZulu-Natal. This model takes into account:

- Poverty levels - Poor infrastructure - An estimate of 2 million people who do not have access to health care facilities at present - Rural referral requirements.

The result of applying those estimates is a financial GAP of R 729 million. It is clear that the stated priority of meeting backlog and transformation costs is not feasible within the proposed funding envelope. It is not practical or feasible to reduce health care services as envisaged in the model including assumptions proposed by NdoH and additional funds will have to be allocated to KwaZulu-Natal to meet backlog and transportation costs, failing which patients will not receive adequate health care services. It is recommended a study be carried out to determine the relationship between patient needs at different level of care , considering the demographic distribution, infrastructure and disease profiles of the population. I Overall summary

a. Demographic profile

KwaZulu-Natal is the most highly populated province in South Africa; and houses 20.5% of the total South African population.

The total population (mid year estimate 2000) was 8 857 615. The predicted total population for 2010 is 9 560 153 according to the model.

53% of the population is urbanised.

The population growth rate is expected to decline to below 2% due to the effects of HIV/AIDS, some predict a growth rate as low as 1.4%. Currently approximately 2 million of the KwaZulu-Natal population does not have access to health care. We anticipate that this will be rectified by 2010 requiring additional health services.

b. Socio-economic profile

47% of females living in KwaZulu-Natal, are unemployed. The poverty rate in KwaZulu-Natal is very high, leading to an increase in health care demand. The topography and the lack of infrastructure in rural areas, make access to health facilities particularly difficult.


c. Epidemics

KwaZulu-Natal is the Province worst hit by epidemics: • Cholera epidemic in 2000 • Malaria Pandemic • TB incidence rate of 3/1000 • HIV/AIDS where the ante-natal survey showed a prevalence of 35% in 2000.

d. Violence

KwaZulu-Natal has the highest murder and rape rate in South Africa, and one of the highest motor vehicle accident rates. This puts extra strain on the provision of emergency services

II Health needs assessment

1. Provincial health priorities The Department of Health in KwaZulu-Natal has determined it’s main activities in priority order, through consultation and a participative process of strategic planning. These are:

• Clinics and Mobile Clinic Services • Clinic Building and Upgrading Programme • Community Health Centre Services • HIV/AIDS • Communicable Disease Control • Training and Education • Health Promotion • District Hospital Services • TB Hospitalisation • Environmental Health • Integrated Nutrition Services • Regional Hospital Services • Patient Transport Services • Emergency Medical Rescue Services • Maintenance of Buildings and Equipment • Malaria Control • Mental Health Hospitalisation • Central Hospital Services • Convalescent Hospitalisation • Oncology Services • Renal Services

2. Health Needs For the purposes of determining health needs, the following assumptions were used.

Current Option 1 Option 2 Option 3 Option 4 Option 5 Beds per 1000 population 3.08 2.09 2.10 2.05 2.31 2.69 Admissions per 1000 95.81 142.7 130 130 145 165 Length of stay 8.7 5.48 5.72 5.49 5.49 4.98 OPD visits per 1000 575.5 495.54 809.22 809.22 809.22 809.22 Primary Health Care Funding

R 1.181 mill R 1.780 mill R 2.029 mill R 2.029 mill R 2.500 mill R 2.500 mill


3. Assumptions in health care delivery options

3.1 Sustainable services

3.1.1 The proposed structure for health care delivery had to be done within the constraints of the funding envelope. This limited the range of health care services to be included.

3.1.2 The model presumes a shift of patients towards primary health care.

Notable success has been achieved. The number of Primary Health Care visits increased from 10 mill per annum (1996-1997) to 17 mill (2000/2001). The lack of infrastructure in rural areas has prevented the devolution of district health services to local authorities at a reasonable rate. As this proposal depends very heavily on the success of the primary health care system, this is a worrying factor.

3.1.3 The provision of Health Care is difficult due to the limited road network

as well as the inaccessible mountainous and hilly landscape of the Province. The success of the model also depends on improving the transport-and referral systems

3.1.4 A lack of skilled health care workers in rural areas has been a major

constraint. These shortages must be addressed if the District Health Care System is to be run efficiently.

3.1.5 It is recognized that hospitals must be used for treatment and diagnoses

of acute cases and chronic patients must be transferred to a more appropriate type of care. By reducing staffing levels and equipment in these ‘step-down’ facilities, savings can be achieved. (See Addendum 1).

3.1.6 Patients are often in hospitals for too long due to transport and social

reasons. To solve this problem; two types of step-down beds are proposed.

3.1.6.1 A step-down bed for admitting patients pre-operatively that

require special investigations and post operatively when patients require nursing care before discharge.

3.1.6.2 A transit bed where patients can be in a ‘holding area’ after discharge or before admission, whilst waiting for transport. No nursing is required.

3.1.7 Proper management in facilities will be important to achieve cost-

effective care. It is suggested that case managers should be appointed, with the sole function of ensuring that appropriate level of care are used. The savings could be substantial.

3.1.8 Psychiatric patients present a challenge. In KwaZulu-Natal a number of

beds are utilized for life-long custodian care of psychiatric patients. This makes interpretation of data (e.g. duration of stay & cost per admission) difficult to interpret. It is suggested that psychiatric beds are split into acute and custodial beds.


3.1.9 KwaZulu-Natal is the Province worst hit by the HIV/AIDS epidemic. In Chapter 3.6 it is discussed in greater detail. Whilst this model presumed that the underlying principle of HIV/AIDS care must be community based home-care, certain problems exist in KwaZulu-Natal.

• The lack of infrastructure in KwaZulu-Natal. • The severe poverty in rural areas. • Access problems in rural areas. • The high percentage of females (who must be the home care givers) that

are HIV positive themselves. As an interim measure, this model proposes the creation of a hospice type ‘home care’ bed, linked to rural clinics, for the care of HIV/AIDS patients.

3.1.10 The policy is that TB be treated along the DOTS principle, with hospital

admission for re-treatment and re-admission for Multi-Drug Resistant (MDR) cases. The low cure rate causes concern and in option 5 provision was made for a MDR rate of 4.5%.

III Principles of the sustainability model

The strategy followed in developing the sustainability model, was to determine in conjunction with Provincial management, the services required to meet the likely health care needs of the population in the year 2010, based on a funding envelope similar to that enjoyed in 2001. The NdoH has developed a ten-point plan for the provision of health services. The Province’s provision of health services should be in line with the ten-point plan and meet the health care needs of the provincial population.

In preparing the needs analysis cognizance is taken of the change in the disease profile of the population as a result of the HIV/AIDS pandemic and the impact it has on multi drug resistant TB cases in particular. Other disease profiles are assumed to remain similar to those experienced in 2001.

In view of various priorities the sustainability model as prepared by NdoH assumes the following service priorities:

• The transformation of health care facilities to provide the defined services. • The focus on primary health care including home based care services. • The provision only of optimal central hospital services. • The upgrading of emergency medical services. • The optimal treatment of HIV/AIDS and TB patients according to acute hospital care for

HIV/AIDS related incidents only and home based care services for chronic care. The allocation of remaining resources to the provision of level 1, level 2 and specialist hospital services as well as the introduction of step-down facilities, which indicates focusing on acute care in level 1 and 2 hospitals and chronic care in other institutions.

Options for closing the GAP

1 OPTION 1 - MODEL DESIGNED FOR HEALTH CARE DELIVERY BASED ON NATIONAL AVERAGES

This option is based on the provincial model prepared by the NdoH team according to their assessment of KwaZulu-Natal health service needs in 2010.


• It presumes a transfer of patients to step-down facilities. • Shift of patients towards primary health care. • Transformation of facilities to include building of new institution, redefining of

existing facilities to provide the required services. Number of Beds

The following is a schedule of the bed numbers according to service levels required, but before making any allowance for geographical and population distribution considerations.

Existing Usable beds Projected beds Step downs 0 3455 Level 1 hospitals 11191 3488 Level 2 hospitals 5556 3518 Tertiary 2355 1426 Psychiatric hospitals 3617 3798 TB hospitals 3117 683 Special unclassified 237 855 Total beds 26073 17223 Weaknesses

• Length of stay was reduced without mechanisms to achieve this. • The model was designed using National norms. It does not take cognizance of the

particular health care needs in KwaZulu-Natal.

2 OPTION 2 - DEMAND DRIVEN MODEL This model was designed in consultation with the provincial management. It focuses on volumes by service levels more appropriate to KwaZulu-Natal needs. Principles

• Step-down facilities are clearly defined. • Primary health care and Home-based care services at increased rates. • Increase step-down beds to bring about greater efficiency and reduce length of stay in

higher level of care .

Number of Beds


Existing Usable beds Projected beds

Step downs 0 5445 Level 1 hospitals 11191 3732 Level 2 hospitals 5556 4448 Tertiary 2355 804 Psychiatric hospitals 3617 2043 TB hospitals 3117 2153 Special unclassified 237 424 Total beds 26073 19050


Weaknesses

• Step-down facilities need nursing care. Some patients no longer need nursing care (e.g. patients waiting for transport) This model does not allow for accommodation without nursing care.

• Demands 200 new primary health care clinics. • Skills shortages on all level of care will render implementation difficult. • The indigent population was over estimated at 95% to allow for the poverty rate in

rural areas. In option 4 the poverty rate was accommodated by increasing the admission rate per 1000 population.

• Does not include 2 million patients without access to health care services. • Ration between district and regional beds are incorrect. • Three day length of stay is inadequate

3 OPTION 3 - APPROPRIATE LEVEL OF CARE This model provides for a more detailed definition of categories of services. It introduces new step-down beds to meet the needs of:

• Patients in transit • Terminally ill patients • Psychiatry and TB patients

Step-down facilities are divided into:

• Beds for pre-and post acute care. • Transfer beds for lodger mothers and patients waiting for transport • Hospice-type beds as an interim measure until communities develop the capacity to do

home-care for HIV/AIDS patients. Priorities for fund allocation is:

• Transformation of health care facilities to provide defined services. • Focus on primary health care including home-based care. • Provision only of optimal central hospital services. • Upgrading of EMS. • HIV/AIDS and TB admission only when acute care is required. • Home-based care services for chronic care.

Number of Beds



Existing Usable beds Projected beds Step downs 0 4629 Transit 0 689 Step-down acute beds 0 3750 Hospice beds for terminally ill 0 190 Level 1 hospitals 11191 3732 Level 2 hospitals 5556 4448 Tertiary 2355 804 Psychiatric hospitals 3617 1820 Custodial 0 864 Acute 0 956 TB hospitals 3117 2740 Special unclassified 237 424

Total beds 26073 18599

Benefits • Model 3 will promote improvement in efficiency levels. • Care will be given at the most appropriate level.

Weaknesses

• Demands 200 new primary health care clinics. • Non-availability of skills on all level of care will render implementation difficult. • The indigent population was overestimated at 95% as in option2. • Does not include 2 million patients without access to health care services. • Ration between district and regional beds are incorrect. • Three day length of stay is inadequate

4 OPTION 4 - APPROPRIATE LEVEL OF CARE PLUS IMPROVED ACCESS TO

PRIMARY HEALTH CARE • Reducing the indigent population to a more realistic 88%. • Increasing admission rate to 145 per 1000. • Reducing transformation costs of building. • Extending hours of work of primary health care clinics.

Number of Beds


Existing Usable beds Projected beds Step downs 0 4892 Transit 0 745 Step-down acute beds 0 3950 Hospice beds for terminally ill 0 197 Level 1 hospitals 11191 3872 Level 2 hospitals 5556 4622 Tertiary 2355 840 Psychiatric hospitals 3617 1985 Custodial 0 1041 Acute 0 944 TB hospitals 3117 2740 Special unclassified 237 459 Total beds 26073 19409


Benefits

• Reducing the transformation costs makes more money available for health care service delivery.

• This option attempts to bring service delivery in line with the health priorities stated by KwaZulu-Natal.

Weaknesses

• Demand 200 new primary health care clinics. • Non-availability of skills on all level of care will render implementation difficult.

5 OPTION 5 – SELECTED PRACTICAL PROPOSAL

• Reducing the indigent population to a more realistic 88%. • Increasing admission rate to 165 per 1000. • Adjusting split between district and regional beds. • Adjusting lengths of stay. • Adjusting bed occupancy for transit beds. • Reducing transformation costs of building • Extending hours of work of primary heath care clinics

Number of Beds


Existing Usable beds Projected beds Step downs 0 4456 Transit 0 1002 Step-down acute beds 0 2253 Hospice beds for terminally ill 0 1201 Level 1 hospitals 11191 7286 Level 2 hospitals 5556 3766 Tertiary 2355 956 Psychiatric hospitals 3617 2259 Custodial 0 1185 Acute 0 1074 TB hospitals 3117 2740 Special unclassified 237 1201 Total beds 26073 22 664

Benefits

• Accommodate the full population (including 2 million currently deprived) in providing access at the correct level of care by increasing admissions from 145 per 1000 to 165 per 1000 population.

• Adjustment of admission split and lengths of stay to attainable levels. Weaknesses

• Budget deficit of R 729 million. • Demand 200 new primary health care clinics. • Non-availability of skills on all level of care will render implementation difficult.


High-level activity assessment of options

The number of beds per level is calculated using four basic assumptions:

• Population (projected for 2010) - Population growth rate - Percentage indigent population

• Admissions per 1000 population projected for 2010 - Per level of care This gives an admission rate per 1000 population for each level of hospital

i. Admission per 1000 for tertiary hospitals ii. Admission per 1000 for L2 iii. Admission per 1000 for L1 iv. Admission per 1000 for step-down facilities v. Admission per 1000 for hospice beds vi. Admission per 1000 for transit beds

• Bed occupancy per level of hospital • Length of stay per level In table format

Current Projected Option 1 Option 2 Option 4 Option 5 Total Population (2001) 9 165 825 9 165 825 9 165 825 9 165 825 9 165 285 Growth rate 1.40 1.40 1.40 1.40 % Indigent 86% 86% 95% 88% 88% Public Population 7 776 528 8 221 732 9 082 145 8 412 934 8 412 934 Admissions per 1000 Tertiary 11.96 10.76 4.20 4.74 5.39 L2 31.66 36.88 33.52 37.60 30.64 L1 49.75 43.87 40.00 44.80 63.22 Step-down - 26.07 31.00 35.50

Transit - - - 10.50 11.95 Step-down - - - 24.28 27.70 Hospice - - - 0.73 0.83 HBC - 19.72 18.50 19.25 21.90

Specialised 2.44 - - - - TB - 0.50 1.30 1.45 1.65 Psychiatry - 2.67 1.30 1.45 1.65 Special - 2.23 0.18 0.21 0.17

Total 95.81 142.7 130.00 145.00 165.00 Bed occupancy Tertiary 71.30 85.00 65.00 65.00 65.00 L2 69.40 85.00 75.00 75.00 75.00 L1 64.80 85.00 80.00 80.00 80.00 Step-down - 85.00 85.00 85.00 -

Transit - - - 65.00 55.00 Step-down - - - 85.00 85.00 Hospice - - - 85.00 95.00

Specialised


Current Projected Option 1 Option 2 Option 4 Option 5

TB 68.60 95.00 95.00 95.00 95.00 Psychiatry 75.50 95.00 95.00 95.00 80.00 Special 67.60 95.00 95.00 95.00 95.00

Length of stay Tertiary 6.60 5.00 5.00 5.00 5.60 L2 5.70 3.60 4.00 4.00 4.00 L1 6.80 3.00 3.00 3.00 4.00 Step-down - 5.00 6.00 - -


Specialised - - - - - TB 66.20 41.50 70.00 77.30 77.30 Psychiatry 150.50 60 60.00 52.20 -

Custodial - - - 120.00 120.00 Acute - - - 30.00 30.00

Special 114.70 16.20 90.00 90.00 300.00

Number of beds Tertiary 2 355 1 426 804 840 956 L2 5 556 3 518 4 448 4 622 3 766 L1 11 191 3 488 3 732 3 872 7 286 Step-down - 3 455 5 445 4 892 -

Transit - - - 745 1 002 Step-down - - - 3 950 2 253 Hospice - - - 197 (500) 1 201 HBC - - - - -

Specialised - - - - TB 3 117 683 2 043 2 740 2 740 Psychiatry 3 617 3 798 2 153 1 985 -

Custodial - - - 1 049 1 185 Acute - - - 944 1 074

Special 237 855 424 459 1 201 Total 26 073 17 223 19 050 19 409 22 665 Patient days Tertiary 613 009 442 474 190 725 199 387 226 897 L2 1 407 907 1 091 556 1 217 734 1 265 305 1 031 056 L1 2 646 949 1 082 158 1 089 857 1 130 698 2 127 429 Step-down - 1 071 862 1 689 279 1 463 010 -

Transit - - - 176 672 201 069 Step-down - - - 1 225 344 699 090 Hospice - - - 60 994 416 440 HBC - - - - -

Specialised - - - - - TB 780 329 236 753 746 700 950 134 950 134 Psychiatry 997 089 1 317 121 708 407 636 649 -

Custodial - - - 360 915 410 888 Acute - - - 275 734 313 718

Special 58 474 296 352 147 131 159 004 416 440 Total 6.503mill 5.538mill 5.789mill 5.804mill 6.793mill


Current Projected Option 1 Option 2 Option 4 Option 5 Beds per 1000 head of population

Tertiary 0.30 0.17 0.09 0.10 0.11 L2 0.71 0.43 0.49 0.55 0.45 L1 1.44 0.42 0.41 0.46 0.87 Step-down (Include transit & hospice)

- 0.42 0.60 0.58 0.53

Specialised TB 0.40 0.08 0.24 0.33 0.33 Psychiatry 0.47 0.46 0.22 0.23 0.27 Special 0.03 0.10 0.05 0.05 0.14

Total 3.35 2.09 2.10 2.31 2.70

IV General issues impacting on services A number of issues were identified, that impact on service delivery. They are crucial issues and could prevent service delivery. Challenges

i. Exponential growth of the HIV/AIDS and TB epidemic, with additional demands on health

care resources. ii. Increased HIV/AIDS demand, beyond the capacity of the health care delivery system. This

will deny access to non-HIV/AIDS patients. V Primary health care KwaZulu-Natal has made great progress in shifting patients into primary health care facilities. Primary health care visits increase from 12 894 000 in 1999 to 17 056 140 in 2000. There are a number of issues that are delaying the progress:

Viz

• Delays in local government restructuring and in the demarcation process causing delays in the implementation of district health services.

• Lack of skills in rural areas and in lower level of care . • Critical shortages of health workers in key areas are creating bottlenecks and a ‘dumping’ of

patients to higher level of care .

• Lack of infrastructure in rural areas, causing access problems of health care facilities. Referral Problems

Bypass of the referral system by patients, is creating pooling of patients at inappropriate level of care.


Reasons for bypass

• Inconvenient clinic hours • Perceived lack of medicine • Wants to see a doctor

The report proposes a few possible solutions to this problem, including:

• Licensing of practitioners • Utilising private practitioners • Staff retention policies

The most important proposal is to extend working hours of peripheral clinics. This will ensure better access, greater penetration of primary health care services and greater patient satisfaction. VI Hospital services review KwaZulu-Natal has an extensive network of hospitals, with state aided hospitals and a vital private sector. Building on an exercise done by the KwaZulu-Natal Department of Health, this report proposes rationalisation of hospital beds to achieve:

• Quality of access. • Optimal utilisation of hospital beds. • Service delivery at appropriate level of care .

By introducing:

• Step-down facilities • Transit Beds • Hospice beds

Average duration of stay will be reduced to a more affordable five days in acute care facilities. Greater efficiency at hospital level must be achieved by:

• Hospital manager capacity building. • Delegation of authority and responsibility. • The introduction of case managers. • Implementation of and information system to enable monitoring and decision making on all

levels of management. VI The way forward The options described in this report will be used as inputs in the KwaZulu-Natal planning process for 2010. Implementation of the preferred option will present a challenge to the KwaZulu-Natal Department of Health. The Provincial Department of Health in KwaZulu-Natal has to consider the four proposed options.


VII Implementation

Ensuring plans can be implemented

This document will be used in a planning process, as suggested in phases two and three. We suggest that in the planning process, the KwaZulu-Natal Department take the following into consideration:

• Additional allocation of funds by treasury to meet backlog and transformation costs. • Further consultation with other levels of management. • The practicality and workability of the options outlined in the document.

• Capacity building through skills transfer training and education.

• Transforming facilities to accommodate the proposed configuration of services.

• Strengthening District Health Services to enable the development of an effective service that

can be transferred to the local authority when they have the capacity.

• Developing an alternative solution for controlling lengths of stay through utilisation of different types of care.

• Consultation with the community.

• Inter-Departmental liaison with regard to transport, water & electricity and social services.

• Strengthening managerial competency by appointing case managers and decentralising

management delegations.

• Setting managerial performance level benchmarks, monitoring performance and responding to trends.

Chapter 1 Page 22 of 173

CHAPTER 1 – AIM OF THE STRATEGIC POSITION STATEMENT This paper presents final results of a high-level health needs assessment in KwaZulu-Natal. It attempts to:

Assess primary health care services. Establish future levels of hospital activity. Define hospital performance measures. Determine & define different options for the provision of Health Care in the Province. Define the configuration and scale of hospital services and provide alternative options. Define the type of clinical services and support services to be provided in each option. Assess staffing requirements for the proposed configuration under each option. Assess the cost, as well as benefits and disadvantages, of each of the proposed options,

taking constraints into account. Consider the prevailing human resource constraints, financial resource constraints, and to

consider the current hospital and health services infrastructure. Consider appropriateness of care and efficiency of service delivery. Identify data gaps, and further planning requirements for implementation of the proposal.

1.1 The approach

The Terms of Reference recommended a consultative process involving a broad spectrum of workers and wide consultation on all levels. After consultation with the Director General of Health in KwaZulu-Natal, Professor R Green-Thompson, the HLMSV Team, opted to follow a different approach in designing the options. A lot of emphasis was placed on work already done in KwaZulu-Natal and contact between the project team and KwaZulu-Natal health workers, was restricted to members of the Steering Committee at KwaZulu-Natal.

When KwaZulu-Natal Health decides to implement the Plan they may opt to have workshops with middle management.

1.2 The principles

To understand the status of planning within each Province and to gauge future service configuration requirements, the first part of the planning framework is to establish: ‘a position paper that will set the outer framework with key strategic options that may best achieve the sustainable service delivery requirements of a province’ :(Three months review plus reporting period).

The options could include broad delivery alternatives, not necessarily hospital specific, that may most improve and achieve sustainability of the future service delivery within the constraints of the province’s resources.

The second part of the process is the implementation of pilot projects and ongoing reviews and analysis, for full strategic plans. (Twelve to eighteen months’ process) Part three will encompass a full evaluation of the pilot projects plus the setting of action plans for supporting management initiatives as well as the development of ten-year strategic plans and rolling implementation plans. (Six months’ process). The recommendations of this report are a guideline in the ongoing planning process.


CHAPTER 2 – METHODOLOGY AND APPROACH

2.1 Introduction

The terms of reference recommended a consultative process involving a broad spectrum of workers and wide consultation on all levels.

The required methodology for KwaZulu-Natal was different from the other Provinces. KwaZulu-Natal had already done a lot of the work that informed the SPS. The approach of the HLMSV Team was to:

2.1.1 Obtain pre-prepared reports and to use these reports as the basis for visits to the hospitals and clinics.

2.1.2 Set up meetings with senior management of finance, hospital

management as well as general management.

2.1.3 Develop options and interrogate these options with senior management to obtain their buy-in.

2.1.4 Leave behind a working model in order for the Province to do their own

scenarios and planning.

2.1.5 Hand a facilities model to the Province to establish capital cost and facility area norms.

2.2 Core principles

2.2.1 The proposed structure for health care delivery had to be done within the

constraints of the funding envelope. This limited the range of health care services to be included.

2.2.2 The model presumes a shift of patients towards primary health care.

Notable success has been achieved. The number of Primary Health Care visits increased from 10 mill per annum (1996-1997) to 17 mill (2001/2001). The lack of infrastructure in rural areas has prevented the devolution of district health services to local authorities at a reasonable rate. As this proposal depends very heavily on the success of the primary health care system, this is a worrying factor.

2.2.3 The provision of Health Care is difficult due to the limited road network

as well as the inaccessible mountainous and hilly landscape of the Province. The success of the model also depends on improving the transport-and referral systems.

2.2.4 A lack of skilled health care workers in rural areas has been a major

constraint. These shortages must be addressed if the District Health Care System is to be run efficiently.

2.2.5 It is recognized that hospitals must be used for treatment and diagnoses of

acute cases and chronic patients must be transferred to a more appropriate type of care. By reducing staffing levels and equipment in these ‘step-down’ facilities, savings can be achieved. (See attached criteria for different facilities).


2.2.6 Patients are often in hospitals for too long due to transport and social reasons. To solve this problem; two types of step-down beds are proposed.

2.2.6.1 A step-down bed for admitting patients pre-operatively that

require special investigations and post operatively when patients require nursing care before discharge.

2.2.6.2 A transit bed where patients can be in a ‘holding area’ after

discharge or before admission, whilst waiting for transport. No nursing is required.

2.2.7 Proper management in facilities will be important to achieve cost-

effective care. It is suggested that case managers should be appointed, with the sole function of ensuring that appropriate level of care are used. The savings could be substantial.

2.2.8 Psychiatric patients present a challenge. In KwaZulu-Natal a number of

beds are utilized for life-long custodian care of psychiatric patients. This makes interpretation of data (e.g. duration of stay & cost per admission) difficult to interpret. It is suggested that psychiatric beds are split into acute and custodial beds.

2.2.9 KwaZulu-Natal is the Province worst hit by the HIV/AIDS epidemic. In

Chapter 3.6 it is discussed in greater detail. Whilst this model presumed that the underlying principle of HIV/AIDS care must be community based home-care, certain problems exist in KwaZulu-Natal.

• The lack of infrastructure in KwaZulu-Natal. • The severe poverty in rural areas. • Access problems in rural areas. • The high percentage of females (who must be the home care

givers) that are HIV positive themselves. As an interim measure, this model proposes the creation of a hospice type ‘home care’ bed, linked to rural clinics, for the care of HIV/AIDS patients.

2.2.10 The policy is that TB be treated along the DOTS principle, with hospital

admission for re-treatment and re-admission for Multi-Drug Resistant (MDR) cases. The low cure rate causes concern and in option 4 and 5 provision was made for a MDR rate of 4.5%.

2.3 General approach

Already discussed

2.4 Ensuring plans can be implemented

This document will be used in a planning process, as suggested in phases two and three. We suggest that in the planning process, the KwaZulu-Natal Department take the following into consideration:

2.4.1 Further consultation with other levels of management. 2.4.2 The practicality and workability of the options outlined in the document.


2.4.3 Capacity building through skills transfer training and education.

2.4.4 Transforming facilities to accommodate the proposed configuration of services.

2.4.5 Strengthening District Health Services to enable the development of an

effective service that can be transferred to the local authority when they have the capacity.

2.4.6 Developing an alternative solution for controlling lengths of stay through

utilisation of different types of care.

2.4.7 Consultation with the community.

2.4.8 Inter-Departmental liaison with regard to transport, water & electricity and social services.

2.4.9 Strengthening managerial competency by appointing case managers and

decentralising management delegations.

2.4.10 Setting managerial performance level benchmarks, monitoring performance and responding to trends.

Chapter 3 page 26 of 173

CHAPTER 3 – HEALTH NEEDS

3.1 Health priorities

The Department, through strategic planning exercises and wide participation of the Health Managers, has determined its main activities in priority order and these are set out as follows: (The Department of Health is responsible for the delivery of, inter alia, the following services / activities that are listed in priority order with the previous rating in brackets)

Priority Level

3.1.1 Clinics and Mobile Clinic Services These facilities are the first level of Primary Health Care and provide services mainly to those patients who do not require admission to a more sophisticated facility.

(1)

3.1.2 Clinic Building and Upgrading Programme This programme is specifically geared to provide access to health services in the under served areas of the Province and to upgrade the present clinic infrastructure.

(6)

3.1.3 Community Health Centre Services These facilities provide a 24-hour health care service and have a doctor in attendance. They provide facilities for, inter alia, childbirth and those cases that cannot be treated at the clinic level, but do not necessarily require hospitalisation for more than 24 hours.

(3)

3.1.4 HIV/AIDS KwaZulu-Natal has the highest incidence of HIV/AIDS in South Africa. The service provides for the special programmes for education in and the prevention of HIV/AIDS.

(2)

3.1.5 Communicable Disease Control This service / activity is aimed at improving the awareness and control of communicable diseases and covers immunisation of children for, inter alia, polio, measles and HIB.

(7)

3.1.6 Training and Education This service / activity provides training for doctors, nursing and ambulance personnel, health workers and personnel in health management, administration and health promotion.

(8)

3.1.7 Health Promotion Through communication, this service / activity encourages the general population to live more healthy lifestyles, thereby playing a preventative rather than a curative role in health management.

(4)


Priority Level

3.1.8 District Hospital Services These facilities cater for patients who require admission to a hospital for treatment at a general practitioner level.

(5)

3.1.9 TB Hospitalisation This activity provides hospitalisation for patients especially suffering from resistant strains of tuberculosis as well as those who become TB infected as a result of HIV/AIDS.

(10)

3.1.10 Environmental Health This service ensures that, inter alia, the standards of food, domestic housing, water supplies, sanitation and refuse management are maintained in order to provide a safe environment for the general population. The inspection of ports and border posts, also fall under this activity.

(9)

3.1.11 Integrated Nutrition Services This service/activity supports a number of feeding schemes for the poor providing supplementary nutrition in order to prevent diseases that accompany inadequate nutrition.

3.1.12 Regional Hospital Services These services cater for those patients who need admission to hospital for treatment at specialist level.

(12)

3.1.13 Patient Transport Services This service/activity provides transport to indigent patients who have no other means of transport.

(15)

3.1.14 Emergency Medical Rescue Services This service provides emergency transport and paramedic personnel for victims of, inter alia, trauma, maternity, motor vehicle and other accidents.

(13)

3.1.15 Maintenance of Buildings and Equipment This activity ensures the maintenance of existing buildings and equipment in order to avoid the necessity for major works and replacements at a later stage.

(14)

3.1.16 Malaria Control Malaria is endemic in parts of the Province of KwaZulu-Natal and its incidence is monitored and controlled by means of this service.

(16)


Priority Level

3.1.17 Mental Health Hospitalisation This activity provides facilities for those patients requiring psychiatric care and psychological management. This also includes the management of substance abuse.

(18)

3.1.18 Central Hospital Services This service provides the facilities and expertise needed for sophisticated medical procedures as well as a platform for training health workers.

(17)

3.1.19 Convalescent Hospitalisation This service/activity provides facilities for those patients who require nursing care with minimal supervision by doctors. It is becoming increasingly important because of the increased HIV/AIDS incidence necessitating care for the terminally ill.

(20)

3.1.20 Oncology Services This service provides facilities for the treatment of cancer, including chemotherapy and radiotherapy.

(19)

3.1.21 Renal Services This service/activity provides both a hospital and home-based programme for those patients suffering from chronic renal disease.

(21)

3.2 Population characteristics

• The figures quoted were obtained from Statistics South Africa, based on the 1999 mid-year estimates and the KwaZulu-Natal GIS unit (March 2002).

• The model made use of Central Statistics Services’ predictions with the rate of change in 1996 being 2.2% reducing to 0.02% in 2008.

• The model predictions of the total population for 1999 is 9 042 474 and for 2000 it is 9 165 825 and for 2010 it will be 9 560 153.

• When the new census figures become available these projections should be revised. The indication from the 2000 mid year estimates are that the HIV/AIDS deaths might be higher in KwaZulu-Natal that the SPS model assumes.


POPULATION OF KWAZULU-NATAL BY DISTRICT AND GENDER

MID-YEAR ESTIMATE 1999 (STATISTICS SOUTH AFRICA)

Health District Female % Female Male % Male Total % per Inner / Outer West 339 405 51.20 323 519 48.80 662 924 7.43 Lower Tugela 145 611 51.76 135 718 48.24 281 329 3.15

Ndwedwe 108 176 52.98 96 001 47.02 204 177 2.29

North 68 284 51.40 64 572 48.60 132 856 1.49

North / South Central 889 136 51.27 845 255 48.73 1 734 391 19.44

South 57 064 48.39 60 859 51.61 117 922 1.32

Umbumbulu 108 045 53.54 93 745 46.46 201 790 2.26

Ilembe / Metro (Durban) 1 715 721 51.44 1 619 670 48.56 3 335 390 37.38

Eshowe / Nkandla 326 309 54.85 268 598 45.15 594 906 6.67 Jozini 174 420 54.48 145 749 45.52 320 169 3.59

Lower Umfolozi / Hlabisa 280 804 53.36 245 450 46.64 526 254 5.90

Uthungulu (Empangeni / Jozini) 781 533 54.22 659 797 45.78 1 441 330 16.15

Abaqulusi 120 190 52.77 107 554 47.23 227 744 2.55 Emakhosini 102 950 55.31 83 192 44.69 186 142 2.09

Usuthu 181 564 54.71 150 307 45.29 331 871 3.72

Zululand (Ulundi) 404 704 54.27 341 053 45.73 745 757 8.36

Msinga 95 707 57.89 69 609 42.11 165 316 1.85 Newcastle / Danhauser / Utrecht 45 670 49.37 46 830 50.63 92 500 1.04

Nqutu / Dundee / Glencoe 297 493 53.63 257 195 46.37 554 688 6.22

Umzinyathi (Newcastle) 438 870 54.01 373 634 45.99 812 504 9.10

Mnambithi 158 989 54.54 132 512 45.46 291 502 3.27 Mtshezi / Okhahlamba 159 502 53.93 136 251 46.07 295 753 3.31

Uthukela (Ladysmith) 318 492 54.23 268 763 45.77 587 255 6.58

Camperdown / Richmond / Ixopo 49 062 52.13 45 056 47.87 94 188 1.05 Impendle / Pholela / Underberg 82 716 54.58 68 835 45.42 151 552 1.70

Kranskop / Umvoti / New Hanover 158 718 54.86 130 595 45.14 289 313 3.24

PMB / Mooi River / Lions River / 361 593 52.58 326 044 47.42 687 638 7.71

Indlovo (Pietermaritzburg) 652 090 53.34 570 531 46.66 1 222 620 13.70

Mount Currie 24 584 51.73 22 937 48.27 47 521 0.53 Port Shepstone / Alfred County 199 557 54.79 164 684 45.21 364 241 4.08

Umzinto / Valamehlo 195 629 54.69 162 102 45.31 357 731 4.01

Ugu (Port Shepstone) 419 770 54.55 349 723 45.45 769 493 8.62

Outside KZN and within EA 4 343 45.00 5 308 55.00 9 651 0.11

KwaZulu-Natal 4 735 522 53.07 4 188 478 46.93 8 924 000 100.00

• The mid year estimates for 2000, already show the effect of HIV/AIDS.

Population KwaZulu-Natal 2000. 8 857 615 or 20 % of total population of S.A. It is estimated that the population would have been 8 986 857 without the increased deaths due to HIV/AIDS. (Stats S.A. Mid Year estimates for KwaZulu-Natal with and without additional HIV/AIDS deaths)


POPULATION OF KWAZULU-NATAL BY DISTRICT AND GENDER

KWAZULU-NATAL GIS UNIT MARCH 2002

Health District Female % Female Male % Male Total % per

Durban Metro eThekwini 1,519,624 51.26% 1,444,653 48.74% 2,964,277 32.68%

DC 21 Ugu 379,407 54.68% 314,520 45.32% 693,927 7.65%

DC22 uMgungundlovo 500,277 52.77% 447,792 47.23% 948,069 10.45%

DC 23 Uthukela 324,033 54.24% 273,411 45.76% 597,444 6.59%

DC 24 Umzinyathi 257,041 55.83% 203,360 44.17% 460,401 5.08%

DC 25 Amajuba 231,717 52.34% 210,959 47.66% 442,676 4.88%

DC 26 Zululand 417,616 54.32% 351,175 45.68% 768,791 8.48%

DC 27 Umkhanyakude 295,286 54.39% 247,668 45.61% 542,954 5.99%

DC28 Uthungulu 444,719 54.13% 376,832 45.87% 821,551 9.06%

DC 29 Ilembe 305,837 53.00% 271,237 47.00% 577,074 6.36%

DC 43 Sisonke 137,303 54.35% 115,304 45.65% 252,607 2.79%

TOTAL 4,812,860 53.06% 4,256,911 46.94% 9,069,771 100.00%

2010 PREDICTED POPULATION PER SPS DIVIDED INTO DISTRICTS AND GENDER

TOTAL EXPECTED POPULATION : 9 560 153 Factor 1.054

Health District Female % Female Male % Male Total % per

Durban Metro eThekwini 1,601,787 51.26% 1,522,762 48.74% 3,124,549 32.68%

DC 21 Ugu 399,921 54.68% 331,525 45.32% 731,446 7.65%

DC22 uMgungundlovo 527,326 52.77% 472,003 47.23% 999,329 10.45%

DC 23 Uthukela 341,553 54.24% 288,194 45.76% 629,746 6.59%

DC 24 Umzinyathi 270,939 55.83% 214,355 44.17% 485,294 5.08%

DC 25 Amajuba 244,245 52.34% 222,365 47.66% 466,610 4.88%

DC 26 Zululand 440,196 54.32% 370,162 45.68% 810,358 8.48%

DC 27 Umkhanyakude 311,251 54.39% 261,059 45.61% 572,310 5.99%

DC28 Uthungulu 468,764 54.13% 397,206 45.87% 865,970 9.06%

DC 29 Ilembe 322,373 53.00% 285,902 47.00% 608,275 6.36%

DC 43 Sisonke 144,727 54.35% 121,538 45.65% 266,265 2.79%

TOTAL 5,073,080 53.06% 4,487,073 46.94% 9,560,153 100.00%


Estimated Population Growth Rate 1996-2026

0

0.5

1

1.5

2

2.5

1996-2001 2011-2016 1026-31

%

Source : Institute for Futures Research

Estimated Crude Birth Rate : 1996-2031

0

5

10

15

20

25

30

1996-2001 2011-2016 2026-2031

Annual births per 1000 population


• The crude birth rate is estimated to come down from 28,8 in 2001 to 19,8 in 2016. (Annual

number of births per 1 000 population). The projections were done by the Institute for Futures Research and corresponds very closely with those used by the Consulting Team in Option 5.


Estimated Crude Death Rate : 1996-2031

10.511

11.512

12.513

13.514

1996-2001 2011-2016 2026-2031

Annual deaths per 1000 population


• The crude death rate (annual number of deaths per 1 000 population) is predicted to increase from 11,7 in 1996 to 13,9 in 2011. The projections were done by the Institute for Futures Research and corresponds very closely with those used by the Consulting Team in Option 5.

For planning purposes the population was taken to be 9 560 152.

• 53.7% of total population in KwaZulu-Natal live in rural areas


The population pyramid shows that: i. There is a slight dominance of females due to :

- Longer life expectancy of females - Tourist labour – males emigrate to Gauteng

The population pyramid for the total SA projected for 2010, by Professor Rob Dorrington of the Centre for Actuarial Research, UCT, clearly show the devastating effect HIV/AIDS is expected to have on the productive age groups.

There is no reason to believe that this pattern will not be present in KwaZulu-Natal. This has major implications for employers in terms of: - Lack of skills - Productivity - Payroll costs

3.3 Socio economic status KwaZulu-Natal has a migratory population with male workers leaving the rural areas in search of employment. The resultant disruption in family life has brought about a change in socio- economic circumstances for rural families KwaZulu-Natal has the highest incidence of HIV/AIDS in S.A. In addition, there are other pandemic and epidemics that impact on health demand, such as Malaria, TB, and recently cholera.

3.3.1 Poverty levels in KwaZulu-Natal are still amongst the highest in S.A.

According to the S.A. Indicator, 47 % of females and 36 % of males in KwaZulu-Natal were unemployed by Jan 2000.


LABOUR FORCE BY GENDER IN GAUTENG, KWAZULU-NATAL AND THE NORTHERN PROVINCE IN PERCENTAGES GAUTENG KWAZULU-NATAL NORTHERN

PROVINCE Female Male Female Male Female Male Unemployed 47 22 47 36 58 31 Odd jobs 19 25 19 17 15 15 Working 33 53 34 47 27 54 29 % of employed people in KwaZulu-Natal have income levels of less than R800 per month with 15% earning less than R200 per month.


The following was extracted from KwaZulu-Natal GIS Unit information which gives a better indication of poverty levels : POPULATION OF KWAZULU-NATAL BY DISTRICT, EMPLOYMENT AND INCOME KWAZULU-NATAL GIS UNIT MARCH 2002

Health District Employed % Unemployed % Not Working * % Unspecified % Total % per

Annual income per capita

Monthly income per capita

Durban Metro EThekwini 852,940 28.77% 409,906 13.83% 814,051 27.46% 887,377 29.94% 2,964,274 32.68% 8,725.59 727.13

DC 21 Ugu 92,116 13.27% 67,414 9.71% 252,844 36.44% 281,561 40.57% 693,935 7.65% 3,331.43 277.62

DC22 uMgungundlovo 216,110 22.80% 133,390 14.07% 274,791 28.99% 323,750 34.15% 948,041 10.45% 5,334.70 444.56

DC 23 Uthukela 75,348 12.61% 70,749 11.84% 207,092 34.66% 244,244 40.88% 597,433 6.59% 3,046.21 253.85

DC 24 Umzinyathi 38,953 8.46% 49,480 10.75% 173,194 37.62% 198,809 43.18% 460,436 5.08% 1,968.91 164.08

DC 25 Amajuba 83,074 18.77% 57,154 12.91% 133,590 30.18% 168,861 38.15% 442,679 4.88% 4,023.34 335.28

DC 26 Zululand 69,711 9.07% 86,410 11.24% 264,853 34.45% 347,807 45.24% 768,781 8.48% 2,156.32 179.69

DC 27 Umkhanyakude 40,116 7.39% 46,920 8.64% 205,744 37.89% 250,174 46.08% 542,954 5.99% 1,694.13 141.18

DC28 Uthungulu 106,910 13.01% 86,969 10.59% 282,691 34.41% 344,975 41.99% 821,545 9.06% 3,501.41 291.78

DC 29 Ilembe 97,277 16.86% 63,452 11.00% 200,390 34.72% 215,967 37.42% 577,086 6.36% 3,013.96 251.16

DC 43 Sisonke 34,990 13.85% 25,375 10.05% 82,049 32.48% 110,179 43.62% 252,593 2.79% 2,311.78 192.65

TOTAL 1,707,545 18.83% 1,097,219 12.10% 2,891,289 31.88% 3,373,704 37.20% 9,069,757 100.00% 5,018.80 418.23 * Not working includes housewives, home keepers, scholars, students, children below school going age, pensioners, retired people and those not wishing to work


3.3.2 Due to the lack of housing, water and sanitation in rural areas, the health care demand

increases. • In 2000 25 % of people living in KwaZulu-Natal did not have immediate or easy

access to water on tap. • 98 % of people in rural areas and 25 % in urban areas had no formal rubbish disposal

system.

MAIN SOURCE OF WATER FOR HOUSEHOLD USE

SOURCE GAUTENG KWAZULU-NATAL NORTHERN PROVINCE

Tap inside dwelling 59% 55% 38% Tap on premises 33% 19% 26% Tap in area 5% 9% 21% Borehole / well 1% 3% 5% River - 10% 9% Tank - 3% 1% Other 1% 1% 1% HOW IS RUBBISH REMOVED? IN PERCENTAGES PROVINCE By the

Munici-pality

Comm-refuse dump

There is no rubbish service

Private rubbish collec-tion

Own refuse dump

Urban/ Metro formal

94 3 1 1 1

Urban/ Metro informal

45 23 15 1 12

Gauteng

Rural 8 8 39 3 42 Urban/ Metro formal

89 0 8 1


64 14 9 11

KwaZulu-Natal

Rural 2 32 0 61 Urban/ Metro formal

85 2 3 1 7


56 17 28

Northern Province

Rural 2 2 39 0 56 3.3.3 In addition KwaZulu-Natal has the highest incidence of violence in S.A. • Rape - 99,6 per 100 000 of the population reported in 1999.

Murder - 70.2 per 100 000 of the population reported in 1999. (S.A. average 55.3)


The following statistics were extracted from coded data, over the period 1999 & 2000 by the King Edward VIII Hospital Medical records department:

YEAR MVA

(Motor vehicle accidents)

RAPE ASSAULTS (Violent crimes)

1999 546 8 1192 2000 489 11 1089

TOTAL 1035 19 2281

The Human Development Index

The Human development Index (HDI) is an international index that measures the ability of individuals to sustain themselves in a community. It offers a mean combining measurement of literacy, life expectancy at birth and per capita income.

South Africa increased their HDI from 0.645 in 1975, to 0.705 in 1990.

Unfortunately, due to the decrease in life expectancy, largely as a result of the HIV/AIDS epidemic, the HDI fell to 0.697 in 1998.

The HDI shows inequity between races, genders, provinces and urban vs. rural areas.

Black females in rural areas of KZN are one of the three most disadvantaged groups in South Africa.

3.3.4 Health indicators

Infant mortality rate in KwaZulu-Natal in 1998: 52.1 (number of deaths of infants under one year in 1 000 live births)

Under-five Mortality in 1998 was 74.5 (the number of deaths between birth and the 5th birthday per 1000 live births).

Infant and child mortality rates, by selected socio economic background

characteristics, for the ten-year period preceding the survey. South Africa - 1998

Background Characteristic

Neonatal Mortality

(NN)

Post- Neonatal Mortality

(PNN)

Infant Mortality

(1q0)

Child Mortality

(4q1)

Under -5 Mortality

(5q0)

Province Westen cape 4.0 4.4 8.4 4.8 13.2 Eastern Cape 24.7 36.5 61.2 20.5 80.5 Northern Cape 20.5 21.3 41.8 14.3 55.5 Free State 9.9 26.9 36.8 13.7 50.0 KwaZulu-Natal 23.2 28.9 52.1 23.6 74.5 North West 20.0 16.8 36.8 8.8 45.3 Gauteng 17.8 18.5 36.3 9.3 45.3 Mpumalanga 23.6 23.6 47.3 17.3 63.7 Northern 18.3 18.9 37.2 15.7 52.3


CHILD HEALTHCARE ATTENDANCE: APRIL 1999 – MARCH 2000

AUTHORITY FACILITY TYPE UNDER 5 YRS CHILD HEALTH CURATIVE

% CURATIVE RATE

Hospital 440 148 CHC 180 660 99 120 54.9 Clinic 1 902 792 1 247 808 65.6 Mobile 707 712 421 596 59.6

Provincial

Total 3 231 312 1 768 524 63.4 Clinic 773 940 554 604 71.7 Mobile 35 640 24 792 69.6

Local Authority

Total 809 850 579 396 71.6 State Aided Hospital 0

KwaZulu-Natal TOTAL 4 040 892 2 347 920 65.2 Note: Child Health curative care data not collected from hospital

KEY PROVINCIAL DEMOGRAPHIC AND SOCIO-ECONOMIC INDICATORS Eastern

Cape Free State

Gauteng KwaZulu-Natal

Mpuma- langa

Northern Cape

Northern Province

North West

Western Cape

Total

Area (km²) 169,580 129,480 17,010 92,100 79,490 361,830 123,910 116,320 129,370 1,219,090 Population density 37.2 20.3 432.0 91.4 35.2 2.3 39.8 28.8 30.6 33.3 Population 6,302,525 2,633,504 7,348,423 8,417,021 2,800,711 840,321 4,929,368 3,354,825 3,956,875 40,583,573

% Population 15.5 6.5 18.1 20.7 6.9 2.1 12.1 8.3 9.7 100.0 Rural as % population 63.4 31.4 3.0 56.9 60.9 29.9 89.0 65.1 11.1 46.3 % Population < 5 years

12.0 9.5 8.9 11.5 11.6 10.6 13.1 11.2 9.6 10.9

Poverty rates 78.0 66.0 19.0 53.0 52.0 57.0 77.0 57.0 23.0 53.0 % Population > 20 yrs with no schooling

20.9 16.1 9.5 22.9 29.4 21.7 36.9 22.7 6.7 19.3

% Population > 20 yrs with matric or high qualification

15.8 18.8 32.0 20.7 19.6 17.7 18.5 17.5 29.5 22.6

% Women > 20 years with no schooling

21.8 16.7 9.3 25.2 32.4 21.5 41.8 22.6 6.3 21.1

% economically active population unemployed

48.5 30.0 28.2 39.1 32.9 28.5 46.0 37.9 17.9 33.9

% households living in 2 or less rooms

39.1 37.3 36.3 29.6 28.1 35.1 29.4 33.1 23.1 32.6

% households living in 1 or less rooms

19.0 19.7 24.8 15.6 13.8 16.2 11.3 15.7 10.3 17.2

% Using electricity for cooking

23.4 42.2 73.5 46.1 35.9 52.7 19.6 34.0 77.0 47.4

% with tap in house 24.7 40.6 67.7 39.8 37.3 50.0 17.8 30.6 76.4 44.7 % with tap in house or yard

35.4 70.9 85.6 48.7 63.4 83.2 35.9 51.6 90.4 61.4

% with flush or chemical toilet

30.8 45.3 83.3 42.0 38.0 59.7 13.2 32.1 85.0 50.5

Disabled as % of population

7.3 9.8 6.2 6.0 7.6 5.6 6.0 8.3 3.7 6.5

Sources : All data (except poverty rates) from : Statistics South Africa (1998). The people of South Africa, Population census 1996: Census in brief. Pretoria: Statistics South Africa. Poverty Rate data from: Reconstruction and Development Programme (1995). Key indicators of poverty in South Africa. Pretoria


3.4 The Demand for Health Care

3.4.1 The Cholera Epidemic

An outbreak of Cholera, largely concentrated in KwaZulu-Natal, has occurred since October 2000. On the 13th August 2001 the national cumulative reported cases totalled 106 583. KwaZulu-Natal at that time still continued to report new cases daily (see graphs).

Figure 1: National Cumulative cases for South Africa 10 January to 13 August 2001

Figure 2: KwaZulu-Natal reported Cholera cases in 24 hrs, 15 October to 13 August 2001 Characteristic of the Epidemic

• Caused by Vibrio cholera 01 type El tor Ogana. • 75 % of cases are asymptomatic, but infectious. • Those infected shed millions of organisms for up to 2 weeks. • Cholera occurs with a seasonal pattern peaking in the (peaking in the summer months)

in high rainfall areas with poor water and sanitation. The fact that new cases are reported daily throughout winter means we may see another summer with high incidence.

Treatment • A very low case fatality rate (0,21 %) points to early detection and effective treatment.

KwaZulu-Natal should be congratulated on the way the epidemic has been handled thus far.


• According to a progress report, compiled on 6th July 2001 by the KwaZulu-Natal Provincial Project Management Task Team, interventions to prevent further spread were as follows: - Oral re-hydration centres were established. - 509 water tanks were placed in affected areas. - 8 000 plastic water containers were distributed. - 13 machines producing Sodium Hypochlorite (200l per 24h) were

distributed. - 168 new boreholes were drilled, 132 boreholes repaired, 174 hand pumps

repaired, 76 boreholes tested and 140 springs protected. - 261 ablution blocks were built and 15 248 VIP household toilets were built.

A further 208 246 were being planned. The Cost to the Department of Health KwaZulu-Natal

Expenditure in 2001: R46 million Total cost of the epidemic so far: R95 million Future expenses: R 50 million per annum to prevent spread

The way forward • Poverty alleviation through empowerment. • Education. • Collaboration with other Departments to improve infrastructure:

- Housing - Water Affairs - Education - Agriculture

• Early access to health facilities 3.4.2 The Malaria Epidemic

During the reporting period 1999 / 2000, a total of 28 816 cases were reported from the Malaria control programme. This was an increase of 62 % since the previous reporting period.

The malaria case fatality rate was 7.53 cases per 1 000 in this reporting period, showing a steady increase from 3,5 in 1996 / 1997.


At a workshop held on the 17th April 2001 in KwaZulu-Natal, a Task Team identified the following priorities to improve the management of Malaria:

3.4.2.1 Development of Treatment guidelines. 3.4.2.2 Active and passive surveillance with staff support and laboratory support. 3.4.2.3 Vector control programmes - an international collaborative effort including

Swaziland and Mozambique. 3.4.2.4 New drug treatment modalities (Artermisinin and Lumafantrene). Medical

Research Council studies in KwaZulu-Natal showed a 62 % resistance to previous treatment regime.

The increase in incidence, combined with the increase in case fatalities, is an area of concern. One wonders what effect the immuno-suppression due to HIV/AIDS is having. Based on the number of reported cases in the first three months of 2001, one could be guardedly optimistic that the spraying programme mentioned above, is having a positive effect. The next few months will tell us whether this is true. The next table shows the problems we experience in data collection through the official notification of infectious diseases programme. Both Malaria and Tuberculoses show a significant under reporting trend.

DISEASE YEAR NOTIFICATION SYSTEM

PROGRAMME % UNDER REPORTED

1998/99 11 094 25 835 57.1 Tuberculosis 1999/2000 9 965 26 313 62.1 1998/99 8 251 17 810 53.7 Malaria 1999/2000 127 28 816 99.6

Tuberculoses The trend of under reporting is making planning for Tuberculoses treatment very difficult. The cure rate of just over 45 % achieved by Kwa Zulu-Natal is very poor when compared to the national target of 85%. The implications are that one should expect a very high multi drug resistant rate with a high level of re-admissions. Option 5 allows for a MDR rate of 4.5%. The cost implications of this are discussed again in item 10.5 and in the sensitivity analysis 1 under 9.3

NUMBER OF CASES RATES (%) TREATMENT OUTCOME 1997 1998 1997 1998

Cured 3 502 3 940 45.67 45.56 Treatment completed 1 783 1 667 23.25 19.70 Treatment failure 97 116 1.26 1.37 Treatment interrupted 1 825 2 012 23.80 23.78 Died (TB) 395 658 5.15 7.78 Died (Other and unknown) 66 69 0.86 0.82 Total Known Cases 7 668 8 462 100.00 100.00 Transferred Out 2 707 3 612 25.90 29.28 Not TB 78 264 0.75 2.14

TOTAL 10 453 12 338 100.00 100.00


Comment: The total cases of 36881 in 2000 as reported in KwaZulu-Natal annual report corresponds with an incidence rate of 4.6

3.5 Health needs assessment

For the purposes of determining health needs, the following assumptions were used.

Current Option 1 Option 2 Option 3 Option 4 Option 5 Beds per 1000 population 3.08 2.09 2.10 2.05 2.31 2.69 Admissions per 1000 95.81 142.7 130 130 145 165 Length of stay 8.7 5.48 5.72 5.49 5.49 4.98 OPD visits per 1000 575.5 493.54 809.22 809.22 809.22 809.22 Primary Health Care Funding

R 1.181 mill R 1.780 mill R 2.029 mill R 2.029 mill R 2.500 mill R 2.500 mill

3.6 Impact of HIV/AIDS

According to the Department of Health antenatal clinic annual survey, the HIV/AIDS prevalence in S.A. was 22 % in 1999. KwaZulu-Natal has the highest prevalence at 32,5 %.

HIV Prevalence : Women at Ante Natal Clinics

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Work done by Professor Alan Smith, extrapolating these results on the total population, indicates that the prevalence is generally higher among women, with females aged 15 - 19 showing a prevalence of 43,3 % compared to males of the same age at 17,3 %.

Female prevalence peaks in the 25 - 29 year old age group, whereas male prevalence peaks in the 35 - 39 year old age group.

Prevalence by Age and Gender

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The Dorrington Report (Professor R Dorrington) predicts the following impact in KwaZulu-Natal: The number of HIV/AIDS positive people will continue to rise for the next five years, levelling off at over 35% by 2010.

HIV Prevalence by Province

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199819992000

• This year deaths resulting from HIV/AIDS will represent 50 % of all deaths in KwaZulu-Natal.


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It is predicted that by 2005 deaths from HIV/AIDS will exceed all other causes of death

combined.

The epidemic has a number of serious implications for health care delivery in KwaZulu-Natal. • Skills shortages:

The high prevalence amongst the productive age group implies a further loss of skilled health care workers. Already figures indicate an increase in deaths amongst KwaZulu-Natal health workers (detail discussed in chapter six). Females in the 25 - 29 year age group are most at risk of dying (the group most likely to contract the disease is the group of 20 – 24), implying a risk of increased nursing shortages. The cost of training to replace attrition losses due to HIV/AIDS, will be discussed in chapter six.

• Increased health care demand due to opportunistic infections in patients with HIV/AIDS.

The TB epidemic in KwaZulu-Natal is showing every sign of increasing beyond control. A higher incidence rate, lower cure rate, higher incidence of multi-drug resistance and higher case-fatality rate are all possible effects of the HIV/AIDS epidemic.

• Increased demand for health care for non-HIV/AIDS related diseases due to the increase in poverty levels.

• An increased number of maternal HIV/AIDS orphans, requiring health care due to malnutrition,

and poverty related diseases. • An increase in infant and child mortality and decrease in life expectancy.

• Sexually Transmitted Diseases (STD’s) play a major role in the transmission of HIV. 11 million

episodes of STD are treated annually in S.A. with ± Five million treated by Private Practitioners. Unfortunately Private Practitioners do not follow the recommended syndromal approach. In KwaZulu-Natal, a public/private initiative to treat STD’s in accordance with a treatment protocol is required.



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SEXUALLY TRANSMITTED DISEASE APRIL 1999 TO MARCH 2000

MALE URETHRAL DISCHARGE AUTHORITY FACILITY TYPE STD CASES Cases Rate

Hospital* 24 595 CHC 38 196 5 148 13.48 Clinic 313 584 66 420 21.18 Mobile 41 424 4 632 11.18

Provincial

Total 417 799 76 200 18.24 Clinic 167 748 31 176 18.59 Mobile 1 644 348 21.17

Local Authority

Total 169 392 31 524 18.61 Hospital 1 600 State Aided Total 1 600

GRAND TOTAL 588 791 107 724 18.30 *Note: Male Urethral Discharge data not collected at the hospital

For the purpose of determining future health care demand in KwaZulu-Natal, due to HIV/AIDS and TB, figures supplied by ABT Associates, were used. Due to the high incidence of HIV/AIDS and TB in KwaZulu-Natal the figures were adjusted. Total admission rate trends (per 1000 public population) Without AIDS

admissions AIDS admissions TB admissions Total admission

rate 96/97 104.41 7.59 112.00 97/98 102.13 10.47 112.60 98/99 89.57 14.11 103.67 99/00 Actual 76.04 17.59 0.36 93.63 00/01 94.29 22.31 0.39 116.61 2010 Adjusted 73.26 90.09 1.65 165.00 OPD headcounts / population predictions Without AIDS

visits / 1000 pop With AIDS visits / 1000 pop

Total visits / 1000 pop

96/97 526.18 118.21 644.39 97/98 533.05 163.18 696.23 98/99 570.72 219.84 790.56 99/00 Actual 324.28 287.02 611.30 00/01 332.62 193.86 526.48 2010 Adjusted 600.00 209.22 809.22 Ratio of 2010

total visits to 99/00 total visits

1.32

For the purpose of designing the options the following admission rates were used


With AIDS Without AIDS TOTAL Option 1 50 80 130.00 Option 2 50 80 130.00 Option 3 65 80 145.00 Option 4 89 50.9 139.90 Option 5 74 91 165.00


CHAPTER 4 – PRIMARY HEALTHCARE REVIEW

4.1 General comment

One of the ten key objectives of the National Department of Health in the current five- year plan (1999 - 2004) is “speeding up delivery of an essential package of services through the district health system.” Policy and Legal Background The basic approach taken since 1994 to address the health care needs of the country has been based on two major shifts. First there has been a shift in emphasis and in the basic premises, on which the health care system is built, towards a commitment to the principles of Primary Health Care. This goes far beyond merely strengthening the health systems ability to provide appropriate first contact health care facilities, and involves the integration of preventative, promotive and curative services at appropriate level of care with the aim of providing “Health for All”. KwaZulu-Natal has made good progress in this regard. There are a number of issues impacting on this process, which will be discussed in greater detail below. The second shift is a decision to base a National Health System on the district health mode. The developments in the DHS followed it’s own time frame. • The early phase consisted of setting up structures to govern until the local

government elections in 1995. • The interim phase since the local government elections which was expected to

last until November 2000. • The final stage, when the new system is implemented

The municipal demarcation process was a lengthy, confusing process. The Municipal Structures Act of 1998 created three categories of local government structures • Category A municipalities - Large metropolitan areas - now called unicities • Category B - Include all urban areas not included as metropolitan areas. • Category C - Referred to as District Councils.


In May 2000 the Department of Health in KwaZulu-Natal informed staff members of the new demarcation in KwaZulu-Natal. There are ten category C District Municipalities and one Metropolitan District Municipality. Further sub-division of districts was to await finalization by the Demarcation Board. A map of each district is appended. Delays in the local government restructuring and in the demarcation process have hampered progress in implementing a District Health Services. Until such time that the Local Authorities can take over the clinics it will remain the responsibility of the Province. The difference in remuneration of the Local Authorities and the Province is also

problematic. This must not detract from the excellent progress that has been made towards providing primary health care. 4.2 Configuration of services and type Provincial and State Aided Health Facilities: • 13 Community Centres • 362 Clinics excluding local authority clinics • 63 Hospitals • 142 Mobile Clinics excluding local authority clinics • 15 State Aided Clinics • 14 State Aided Hospitals Local authority clinics: • 37 mobile clinics • 53 local authority clinics


ACTIVITY STATISTICS CHC’S Monthly average

Maternal and Womens’ Health Attendance Ante-Natal Visit Delivery

HEALTH DISTRICT COMMUNITY HEALTH CENTRE

Months Submit

ted

Over 5 yrs

Under 5 yrs

Total

Child Health

Curative Care

First Total Live Births

Still Births

DC22 uMgungundlovo Embo 10 523 218 741 0 0 0 4 0 Durban eThekwini Kwadabeka CHC 12 7289 2645 9934 1708 118 748 102 2 DC29 Ilembe Ndwedwe 12 1668 532 2200 380 87 252 4 0

Tongaat CHC 12 7910 3230 11139 1465 141 1051 71 0 Inanda ‘C’ CHC 12 6705 2389 9094 1141 207 1219 88 0 Kwamashu Polyclinic

12 19813 612 20425 180 324 1253 151 4

Newtown ‘A’ CHC 12 3706 1404 5110 879 45 198 17 0

Durban eThekwini

Phoenix CHC 12 8685 643 9327 644 174 1820 101 0 Durban Ilembe / Metro 26299 11672 67971 6397 1075 6549 539 6 DC22 uMgungundlovo Imbalenhle CHC 12 9064 1769 10833 988 207 793 45 0 DC22 uMgungundlovo / Indlovo 9064 1769 10833 988 207 793 45 0 DC29 Ilembe Sundumbili CHC 12 4691 1614 6305 878 224 479 93 1

Uthungulu (Umkhanyakude) 4691 1614 6305 878 224 479 93 1 GRAND TOTAL 70 054 15055 85109 8260 1508 7821 677 7

MONTHLY AVERAGE

Reproductive Health Sexually Trans. Disease Family Planning

HEALTH DISTRICT COMMU= NITY

HEALTH CENTRE

Months Submit

ted

Under 18 yrs

Total Male

Urethral Discharge

Total

DC22 uMgungundlovo Embo 10 8 47 2 20 Durban eThekwini Kwadaboka

CHC 12 63 1237 184 595

DC29 Ilembe Ndwedwe 12 45 288 5 42 Durban eThekwini Tongaat

CHC 12 201 1981 35 309

Inanda ‘C’ CHC

12 177 979 38 529

Kwamashu Polyclinic

12 118 751 23 575

Newtown ‘A’ CHC

12 4 448 10 200

Phoenix CHC

12 48 1117 2 7

Durban Ilembe / Metro 661 8826 298 2277 DC22 UMgungundlovo Imbalenhle

CHC 12 473 2552 54 578

DC22 Umgungundlovo / Indlovo 473 2552 54 578 DC29 Ilembe Sundumbili

CHC 12 165 949 78 327

DC27 Uthungulu (Umkhanyakude) 165 949 78 327 GRAND TOTAL 1 300 10 327 429 3 182


4.3 Facilities

4.3.1 Existing facilities

Primary Health Care is currently provided at 362 Provincial clinics, 53 Local Authority clinics and 13 Community Health Centres. In addition about 200 mobile units deliver services to remote areas.

A telephonic survey has been done by the KwaZulu Department of Health, which indicates the condition and infrastructure of the Provincial clinics as follows:

Clinics in a good condition: 212 representing 59% Clinics in a medium condition: 103 representing 28% Clinics in a poor condition: 47 representing 13%

Clinics with Escom Electricity 328 representing 91% Clinics with Generator Electricity 24 representing 7% Clinics with Solar or other power 10 representing 3%

Clinics with piped water 111 representing 31% Clinics with borehole water 156 representing 43% Clinics with water tank 91 representing 25% Clinics with other water source 4 representing 1%

Access roads to 88% of the clinics are in a good or medium condition.

92% of clinics have telephones

Client transport is problematic as only 14% of clinics reported ‘good’, 58% reported ‘fair’ and 28% ‘poor’. Refer to a study done by the Health Systems Trust called “ No Transport, No Health Care!” which was done for the Eastern Cape but may serve to encourage District Health Management Teams to analyse and study how they are utilising their transport resources. The revised EMS will assist in the alleviation of this problem.

The KwaZulu-Natal Department of Health is currently auditing their clinics using the same methodology as the NHFA of the hospitals and will soon have more detailed information available

4.3.2 Required facilities

The WHO recommend one PHC clinic per 10 000 of the population. Assuming an indigent population of 8 412 935 (88% of 9 560 153) people and using the ratio of one clinic per 15 000 of the population, a total number of 560 clinics are required, which translates into an additional 145 clinics


4.3.3 Cost of provision of new clinics and upgrade

Building cost of 145 new clinics at average of R 1,5 m each R 217 500 000 Building cost of upgrading 212 “good” clinics – 10% of R1,5 m each R 31 800 000 Building cost of upgrading 103 “medium” clinics – 60% of R1,5 m each R 92 700 000 Building cost of replacement / upgrading 47 “poor” clinics – 100% of R1,5 m each R 70 500 000

Equipment for 145 new clinics at 15% of Building cost R 32 625 000 Equipment replacement for 212 “good” clinics R 4 770 000 Equipment replacement for 103 “medium” clinics R 13 905 000 Equipment replacement for 47 “poor” clinics R 10 575 000 Allowance for Hospice beds at clinics (500 beds) R 25 625 000

TOTAL TRANSFORMATION COST OF PHC FACILITIES R 500 000 000

A total of 192 clinics will have to be built – 145 new and 47 replacements. It is assumed that clinics will be substituted by CHC’c as required.

If the capital transformation takes place over a period of 20 years it will imply a yearly expenditure of R 25m.

Once the detailed audit of the clinics becomes available this figure may be calculated more accurately.

4.4 Referral patterns During the latter part of 2000, Dr. Nic Van Zyl from the Centre for Health Systems Research and Development, School of Management, University of Free State, did a study to assess current Health Care Referral Systems in RSA.

The study has not yet been released, but he kindly agreed to let us quote some of the findings. During visits to KwaZulu-Natal clinics, the key findings of the report were found to be true in KwaZulu-Natal too, although only a small number of KwaZulu-Natal clinics were included in the research project.

The referral system should work as follows: • Mobile Clinics. • Small rural clinics, single staff member. • Clinics operating a five day-week with access to twenty-four hour services at a

CHC. • Clinics, operating a seven day-week, able to offer some twenty-four hour

services. • Community Health Centres providing twenty-four hour service of PHC

outpatient services. • Small district hospital ± 60 beds. • Medium district hospital ± 60 - 120 beds. • Regional hospitals with L1 and L2 beds. • Tertiary hospitals


Patients are still inclined to bypass clinics and consequently end up in tertiary care hospitals. A recent review of highly specialised services in Public Sector Hospitals, (see again later) show unacceptably high levels of primary high care patients in tertiary hospitals.

Bypass of PHC clinics is due to a number of factors

i. Patient preference to see a doctor. ii. Consulting hours at PHC are inconvenient to patients who need to visit the clinic

after work hours. iii. Waiting times at clinics iv. Unavailability of drugs Reasons to refer i. Inappropriate facilities, equipment and maintenance cost ii. Lack of effective referral policies iii. Lack of communication between clinics and hospitals or between all the different

levels of service.

Discussion: Patient Preference to see a doctor

• A substantial number of cross- referrals occur between primary care providers in the private sector and higher level of care within the public sector. These private providers do not follow an accepted protocol when referring patients. In cases where hospitals demand a letter of referral, patients go to private providers to obtain letters.

In KwaZulu-Natal, 50 % of facilities visited mentioned the lack of skilled medical staff at clinics as the main reason for unnecessary referrals. (Doctors, who started their compulsory community service in 2000, may improve this situation.) Consumers in the referral study by Furter and Fourie in 1998, gave the following reasons for bypassing clinics: • A doctor instead of a nurse gives consultations at hospitals. • Clinics are not trusted • Emergency services at hospitals are free of charge. • The hospital is more capable of providing a good service than clinics.

Inconvenience of consulting hours . • Because workers often travel long distances they frequently arrive home late to

find a sick child with the caregiver. • Workers prefer not to take time off work • Child care givers need to be relieved from duty before visiting a clinic • Health care delivery is and will always be, a twenty-four hour business. A

paediatric emergency after hours is also an emergency. • Trauma departments at hospitals do not always function efficiently because of

the number of primary care emergencies that have to be seen after hours. To resolve the bypass problem, and to improve efficiency in hospital

departments, extended clinic hours must be considered.


Waiting times at clinics In the referral study, waiting times in clinics were found to be no problem.

Average waiting time in mobile clinics Less than 10 minutes • Waiting time in maternity an obstetric units: 77 % waited less than 10 minutes. • Waiting time at clinics: 50 % waited for 31 - 60 minutes. • Waiting time at pharmacies: 66,9 % waited 20 minutes or less.

However: In KwaZulu-Natal 60 % of patients at clinics visited, waited 50 -180 minutes at the pharmacy. Waiting times are not generally a problem, with two exceptions: • Patients at clinics waiting to see the doctor. • Patients waiting for medicine. Pharmacists, allocated to KZN for community

services since January 2001, may be improving this situation.

Availability of Drugs • Most of the clinics were found to be well stocked of the drugs that they should

have. However: • In the referral study, users still indicated that a lack of ‘proper medicines’ was a

major reason for bypassing facilities. This could indicate: • A need to review the EDL. • Patient perception, due to a historical lack of medicines at clinics, which must be

addressed through education. • The need to send follow-up medication through to clinics, when patients are

discharged from hospital. • Budget constraints. KwaZulu-Natal has adopted a policy to send TTO medicines to the referring clinic since 2000, and the positive effect will be experienced soon. This will improve utilization of clinics.

Inappropriate referral of patients by PHC workers; higher level of care . The referral study found an overall referral rate of 10 -15 %. This is excellent and indicates that PHC workers are performing well. 46 % of patients at District Hospital OPD were self-referred, and a further 20 % were referred on the patient’s request. However the reasons for referral by health workers were:

• Uncertain about diagnosis. • Uncertain about the treatment. • Lack of proper facilities, equipment and infrastructure.


This suggest that further training of PHC workers, and better support systems will improve the functioning of the PHC system even more.

The lack of effective referral policies was found to be problematic in KwaZulu-Natal, as in other provinces.

Referral policies • The most frequently mentioned problem amongst health workers in clinics

visited in KwaZulu-Natal corresponds exactly with the most frequently mentioned gap in the referral study, namely the need to standardize referral policies and protocols.

• These guidelines should clearly outline the: - Conditions - Requirements - Procedures for transfer and referral of patients between different

facilities and providers and different level of care . • Guidelines should address upward, downward and lateral referrals and the need

for rehabilitation related referrals. • These requirements will be crucial to the success of a future model of H/C

delivery. Proper utilization of step-down facilities, home care and transfer beds will depend on the existence of such protocols.

Other referral problems;

Lack of communication between PHC workers and higher level of care .

None of the clinics visited in KwaZulu-Natal had any back-referral books or links between the referring clinic and the facility of referral. All the clinics indicated that they receive no feedback from the higher level of care. Since most patients are referred for diagnosis and / or treatment, this indicates a serious problem. It is our opinion that resources will be wasted by unnecessary duplication. We suggested that the referral protocol would most certainly have to include this aspect. The appointment of case managers who must ensure • Proper utilization of level of care and the different types of beds. • Formalised communication system - will be a positive step to improve the lack

of communication.

Primary Care Outcomes

1999/2000 • Clinic Headcount 7 177 104 • CHC Headcount 1 021 308 • L/A Headcount 2 793 276 • Mobile visits 1 781 052 • L/A Mobile Visits 121 260 • Total 1999/2000 12 894 000


2000/2001

• Provincial headcount 13 040 680 • Local Authority headcount 4 015 460

Total Headcount for PHC Centres 17 056 140

Progress towards finding solutions

As far as the planning of the referral system goes, the KwaZulu-Natal Department of Health developed the following detailed action plan, which indeed constitutes a phased approach, for the establishment of a district referral system:

i. Formal classification of facilities within the region/district

• Define norms for classifications of facilities. • Table policy guidelines. • Provide baseline information on available private facilities.

ii. Align the capital development plan to the classification of facilities

• Review institutions five-year plans in relation to the classification of facilities.

• Upgrade or downgrade accordingly depending on the defined role of the facility.

• Utilise equipment audit information in forward planning. iii. Define packages of services or services within the Region/District

• Define services to be provided at community level. • Standardise packages of services and ensure programme integration at:

- Mobile clinics - Fixed clinics - Community health centres - District hospitals

• Secure political commitment to define packages of service. • Facilitate community participation and consultation with regards to the

package of services.

iv. Accommodate special facilities, e.g. state-aided and psychiatric institutions as well as other departments, e.g. welfare, police, medico-legal services, district medical officer services into the system. • Establish common groups for joint planning re:

- Criteria for referrals - Guidelines - Procedures

. v. Conduct research on patient choices and preferences for self-referrals

• Engage/involve tertiary facilities and NGOs in establishing baseline information.

• Define indicators for monitoring and evaluation. • Explore the impact of payment vs. non-payment for services.

vi. Communication systems and patient information systems

• Structure and clarify: - Telecommunication - Transport


- Pre-referral consultation mechanisms • Standardise patient information systems.

vii. Ensure availability of appropriate drugs as determined by the level of service

• Status-report on EDL drug availability. • Explore and action recommendations from the Drug Availability

Workshop

viii. Develop a regulatory framework for public-private partnerships • Develop guidelines on purchasing of services, e.g. EMS, laboratory

services, private doctor sessions at public facilities (specialists). • Explore public-private partnership referrals.

ix. Ensure availability of appropriate human resources for sustainability of the

referral system • Access current status report on available skills mix at district facilities

(or compile such a report) • Plan and provide required skills • Clarify the role of the flying doctor service

- Align with the human resource plan • Involve labour relations to facilitate deployment where necessary • Explore and address staff retention issues

xi. Address quality issues that impact on service utilisation within the system

• Access baseline information from the COHSASA document and ensure utilisation thereof

xi. Develop a framework to address cross-boundary referrals (provincial / national);

inter-regional referrals and inter-district referrals • Identify areas of occurrence • Establish joint planning groups to manage process • Establish mechanisms for monitoring the situation at international and

inter-provincial levels • Establish appropriate cost recovery mechanisms

. xii. Develop policies for inter-provincial transfers and zoning (with the aim of

arriving at a population-based system).

This is evidence of progress that has been made with the planning and development of a district-based regulated access referral system in the public health sector in South Africa. However, the obstacles and problems confronting the implementation of such a system remain real. To surmount them will require strong strategic leadership, clear policy direction, firm operational management and appropriate logistical support.

4.5 Finance The NDoH financial situation is clearly spelt out in section 7 of the report. The PHC financial situation is included in this section.


4.5.1 Historic cost analysis

Determining the cost of PHC per capita, per head count or per visit is not possible by PHC service level due to the lack of utilisation and financial data. This is a national situation and costs have to be determined based on ad-hoc studies. Such a study was completed by NdoH in March 2000 entitled “Estimating the costs of implementing the primary health care package.” The outcome of the study was to produce a cost of R173,50 per capita which is used in the health service model prepared by NdoH and discussed in paragraph 10.1 hereto.

Applying the same principles to the KZN PHC service we find the following:

Population of KZN for 2000/2001 9 165 825 Population 2010 9 560 153 Adjusted to 88% as being the PHC responsibility of the Province as opposed to 86% as determined by NdoH for the SPS model, to cater for poverty and migrants 8 412 935

Actual attendances during the 2000/2001 financial year totalled 17 056 140 which is equivalent to 2,12 visits per capita.

Cost of providing PHC for 2000/2001 R1 155 008 000 Management of DHS for 2000/2001 R 26 056 000 Total cost R1 181 064 000

Actual Cost per attendance based on actual attendances R 69,25 (2000/01) Actual Cost per capita p.a. R 146,77 (2000/01)

The intention in the PHC focus adopted by the DoH is to move OPD visits from the hospitals to PHC clinics and CHC’s. This would mean an increase in attendances per capita p.a from 2,12 to 3,5 attendances per capita p.a. The additional proportionate cost for PHC services would be R769 340 956.

The resultant costs per capita attendances would be:

Cost per capita p.a. R 242,38 (2000.01)

4.5.2 Estimate of costs in 2010 based on 2001 Rc (see option 4 in 10.4)

Population 9 560 153 88% of population is PHC responsibility of Province 8 412 935

Number of attendances per capita p.a. @ 3.5 per capita 29 445 271 Total cost at R 69,25 per attendance R 2 039 085 033

To this must be added the additional number of attendances by HIV/AIDS patients estimated to be 1 753 615 p.a. At an attendance rate of R 69,25 the annual cost amounts to R121 437 839.

Home based care for HIV/AIDS is important in the new PHC environment and the introduction of this care is estimated by NdoH to be 94 368 patient cases per


annum at a cost of R1 540 per patient case. The total cost is estimated at R 145 304 000 (Minmec).

The capital transformation cost of improving the PHC infrastructure to be spent over 20 years and in 2001 Rc amounts to R 500 000 000. Spreading this cost over 20 years means an annual charge of R 25 000 000 p.a.

In summary we can expect a PHC cost in 2010 in 2001 Rc of :

PHC R2 039 127 185 HIV/AIDS R 121 437 839 HBC R 145 304 000 Capital transformation R 25 000 000

Total R2 330 869 024 Additional costs required to meet KZN changing PHC demand

and patient access R 169 130 976 Total cost for purposes of the SPS model (option 5) R2 500 000 000

The additional cost is based on the demand for access outside normal hours in CHC’s and clinics. It is assumed that the cost is primarily for labour at 55% of the actual 2001 PHC cost in 30% of the facilities, rounded up to make the total PHC cost of R2 500 000 000.

4.6 Staffing – Current Staffing levels

By October 2000 the nursing shortage at district hospital level was critical. A total of 6 476 nurses were required, and only 4 899 posts were filled. Out of a total of 33 pharmacists posts only 18 were filled. The lack of skills on district level has been a major stumbling block in implementing the district health system. Clinics cannot function adequately, referring patients upwards. Many district hospitals, and even regional hospitals cannot function as such due to mainly a lack of medical professionals. KwaZulu-Natal built houses to attract nurses to the rural areas. Community Health Workers are also used and clinics were staffed and supervised out of district hospitals. The following areas should be addressed:

• Living conditions • Distance • Entertainment • Education

HLMSV suggests an inconvenience allowance for medical staff working in rural areas Ideally 560 teams are required


The norm 1: 15 000 population was used to calculate the number of primary health care teams per region.

Requirements for Primary Health Care teams

Region Population No of PHC Teams Durban 3 412 437 227 Pietermaritzburg 1 202 404 80 Port Shepstone 681 283 45 Newcastle 719 665 48 Ladysmith 560 694 37 Empangeni/Jozini 1 201 124 80 Ulundi 639 431 43

TOTAL 8,417,038 560

The above table adjusted for the new districts and in line with the expected 2010 population is as follows:

Region Population 2010 Public Population No of PHC teams Durban Metro eThekwini 3,124,549 2,749,603 183

DC 21 Ugu 731,446 643,673 43

DC22 uMgungundlovo 999,329 879,409 59

DC 23 Uthukela 629,746 554,177 37

DC 24 Umzinyathi 485,294 427,059 28

DC 25 Amajuba 466,610 410,617 27

DC 26 Zululand 810,358 713,115 48

DC 27 Umkhanyakude 572,310 503,633 34

DC28 Uthungulu 865,970 762,054 51

DC 29 Ilembe 608,275 535,282 36

DC 43 Sisonke 266,265 234,313 16

TOTAL 9,560,153 8,412,935 561

The following staff complement was recommended.

A clinic with 3 consulting rooms (5 day clinic) 15PN 3PN

1EN 1ENA

Clinic with 4 consulting rooms (5 day clinic) 15PN 4PN

1EN 1ENA

Clinic with 6 consulting rooms (5 day clinic) 15PN 6PN

2EN 2ENA

Clinic with 2 consulting rooms (24h clinic) 1CPN 3SPN

15SPN 6EN

6ENA


(Admin Clerk) Clinic with 6 consulting rooms (24h clinic) 1CPN

3SPN 18PN 6EN 6ENA (Admin Clerk)

Comment

i. The current structure, where specific hospitals are linked to referring clinics and

community health centres, is very effective in delivering the service. This system ensures: - Effective communication - Tracking of patients - Post-discharge medication and follow-up. - Transfer of skills. This seems to be a very effective interim solution, until local authorities develop the necessary skills and capacity to come on-line.

ii. There is a lack of proper waste management at clinic level. This will be

discussed in more detail later. 4.7 Plans for Local Authority Devolution

Devolution of PHC services to Local Authorities is dependant on the capacity and capabilities of the Local Authorities. The process was delayed by the demarcation of Districts, which took much longer than originally anticipated. Although KwaZulu-Natal has published their new Health Act, the National Health Act has not been published yet.

The greater Durban Metropole will be the first to take over provincial clinics in a phased process while 53 clinics are already run by Local Authorities

In the rural and deep rural areas of KwaZulu Natal some of the local authorities are so lacking in infrastructure that councillors have to meet under the trees! It will take time for these structures to develop. Devolution is therefore a phased process developing as and when Local Authorities are able to take over their responsibilities.

Refer to the “Annual Report of Provincial District Health Systems Committee, KwaZulu Natal” for more information. 4.8 Home-based care Home-based care is the provision of comprehensive services, which include health and social services by formal and informal care givers at home. The aim is to promote, restore and maintain a person’s level of comfort and autonomous function including care towards recovery or a dignified death. Home-based care is provided by doctors, nurses, social workers and non-professionals including volunteers, family members traditional healers, community organisations and religious organisations.


Teams consist of: • 1 x team manager / co-ordinator (full time) - SPN or senior social workers • 1 x Child and youth care worker • 1 x PN (part time) • 8 x Community care givers • Child care committee (10 x volunteers) It is estimated that the above team will handle 32 patients per month resulting in 384 patients / encounters per year with a cost of R 1 540.00 per admission equivalent. The model assumes 94 368 encounters per year which translates into 11.22 per 1000 population and 246 HBC teams. 4.9 General management & organisational development issues

4.9.1 Integrated planning

KwaZulu-Natal has already initiated a process of integrated planning. Throughout the exercise the need for better information for management decision-making was demonstrated. The planning model, which could be used by KwaZulu-Natal in future, allows for a flexible approach. Variables in the model allow for:

• Demographic changes - The results of the 2001 census could be incorporated - Changes in the percentage indigent population - Changes in across the border flow - Changes in the insured population making use of clinics and

community health centres.

The model is not sensitive enough to allow for changes in the age and gender profile of the population. As these aspects have a definite impact on health sector demand, this may be a future need for refining the model.

• Socio-Economic Changes The model allows for changes in socio-economic circumstances that have an impact on health care demand. - Poverty - Levels of violence - Epidemics Changes in socio-economic circumstances could be reflected in admissions per 1000 population, as well as clinic visits per 1000 population.

The impact of the HIV/AIDS and TB epidemics could be adjusted separately.

• Configuration of health provision Changes in policy regarding health care provision such as home based care and district health services can be incorporated.

The total number of consulting rooms is a calculated figure, depending on clinic visits per 1000 population. A change in any of these variables will result in a


change of consulting rooms required. Monitoring these figures will therefore be important to detect early trends, requiring adjustment. (see later) In addition, the hours that clinics stay open, could have an impact on the numbers of patients visiting outpatients departments at L2 and L3 hospitals.

• Changes in Resources The model is responsive to the incorporation of changes in policies regarding financial resources. It is important for middle management to understand the financial implication of inefficiencies and wastefulness in the health care delivery system.

E.g. TB Treatment

- An increase in Multi Drug Resistance due to a poor compliance with

the DOTS system and low cure rates: Increase of TB MDR from 1.6% to 4.5% results in an increase of R 100million per annum in TB expenditure. (See sensitivity analysis under 9.3) Every 1% improvement on TB cure rate can be demonstrated as a R 35.6 million saving in total TB expenditure.

A weakness in the model is the lack of responsiveness towards changes in human resources, availability and costs. This must certainly be a challenge for future improvement.

The following aspects must all be planned in more detail to evaluate the impact on service delivery: - Staffing levels and norms - Salary structures - Overtime and staff shortages - Attrition - Training Costs - Productivity Levels

-must all be planned in more detail to evaluate the impact on service delivery. Special attention must be given to develop strategies to attract health workers to rural areas.

• Changes in Technology The model incorporates detailed planning regarding facility and equipment capital costs, maintenance and replacement.

The impact of technology changes, changes in health care delivery trends and changes in demand can easily be determined in an integrated way.

• Case Management

This will enable KwaZulu-Natal to measure one health worker’s performance and treatment outcomes against the other to establish optimal treatment protocols for different diseases. These protocols could then be applied for case- and disease management.


4.9.2 Monitoring & Evaluation

The integrated planning process makes it possible to demonstrate the impact of variables on the total cost of health care delivery.

It is therefore of paramount importance to monitor key performance indicators in order to adjust efficiency, correct delivery trends and adjust planning. It is also necessary to identify trends in patient and disease profiles.

4.9.2.1 Key performance indicators

• Cost per clinic visit

- per district - per procedure - per category of health worker - per category of patient

• Cost per admission • Cost per health facility

- Step-down facilities - per home care visit or home care patient - per clinic

• Cost per support service

• Staff costs

- Cost per clinic - Cost per staff category - Staff cost per visit

• Other

- Staff turnover rate - Average staff life (from joining KwaZulu-Natal to leaving

KwaZulu-Natal). This measures the return on training investment. - Staff death rate - Absenteeism as percentage of paid hours. (This is usually an area

of massive waste unless it is managed well) • Pharmacy

- Turnover as percentage of stock level - Cost per item dispensed - Cost per script - Number of scripts and line items per pharmacist - Number of items out of stock - Number of orders per day / week / month] - Number of expired items per month


- Number of days stock in hand - Value of stock written off

• Activity

- Visits - Immunisations - TB visits - Maternal Health - Reproductive Health - STD’s - Mental Health - Child Wellness clinic visits - Percentage Malnutrition - Referrals - Chronic Diseases

4.9.2.2 Outcome measurements

It is important that outcome measurements be done regularly.

Aspects that could be measured:

i. Cure rates : e.g. TB, child clinics etc. ii. Complication rates and referral rates

The abovementioned four are all sensitive indicators of negligence, work overload or inefficiency. All have potentially massive cost implications and could even lead to legal actions.

v. Percentage controlled in

Hypertension Diabetes

vi. Percentage

Stunting Infant mortality Neonatal mortality

vii. Maternal deaths

iv. Waste disposal

No central policy regarding waste disposal exists. Most clinics don’t have a waste disposal policy There is an urgent need to develop a waste disposal protocol. • Safe disposal of sharps • Disposal of medical hazardous waste.

vi. Stock levels.


4.9.3 Treatment Protocols

The best way to improve efficiency on clinic level will be the implementation of treatment protocols. Some clinics have already implemented treatment protocols. These were the clinics that are linked to hospitals. The policies must be expanded to include the other clinics. 4.9.4 Lack of skilled Human Resources Peripheral clinics cannot perform with greater efficiency, unless attention is given to the following factors:

- Regular visiting doctors to support primary health care workers. - Appointment of health workers that have appropriate training in

primary health care

- Continuous training of primary health care workers to retain and develop skills

- Regular communication regarding new developments in the field of

primary health care.

4.9.5 Inadequate physical facilities Some clinics suffer from poor design. The need for privacy to perform HIV/AIDS counselling is an area that needs to be addressed. 4.9.6 Transport

Clinic staff is frustrated with the lack of transport infrastructure and the poor communication around referrals. This is discussed in more detail in 4.4.


CHAPTER 5 – HOSPITAL SERVICES REVIEW

5.1 General comment

The extreme shortage of experienced medical personnel remains an obstacle in the delivery of health care at hospital level. Some hospitals cannot function at their designated level of care due to these shortages. For instance there is a lack of medical officers or specialists who can perform surgery and anaesthetize patients. KwaZulu-Natal senior management has identified this problem and possible solutions are being proposed. A detailed discussion will follow in the Human Resources chapter. One such solution could be to license practitioners who are currently in the private sector, in order to ensure a more equitable distribution between the public sector and the private sector. This issue is highly controversial, amongst practitioners in the private sector. KwaZulu-Natal published a Health Act in 2000 enabling the Minister of Health in KwaZulu-Natal to license private h/c facilities. A draft discussion document outlining proposed regulations to implement this policy was circulated amongst stakeholders. Comments are awaited. The draft regulation describes a certificate of need process, whereby all private health care facilities will be licensed according to the national health plan in the Province. The definition of private health care facilities is sufficiently wide to include private practitioners (both general practitioners and specialists).

Medical Schemes Act: The Medical Schemes Act of 1997 is intended to prevent dumping of private patients on the public sector hospitals when funds run out. The concept of a compulsory minimum benefit package was introduced. Through the last 3 years, the market trend amongst the lower income, lower benefit type of scheme, has been to provide the minimum benefit only at public sector prices and standard. This has had the effect of channelling fully funded patients back into the public sector. Amendments to the Act are currently being drafted, with oral hearings by the Portfolio Committee on Health taking place at the end of October 2001. These amendments will not materially affect the Basic Minimum Package Policy. Proposed regulations that will further expand on the policy to channel paying patients back to public sector hospitals will follow soon. Two imperatives are required before KwaZulu-Natal could benefit from this policy: • Changes to the retention of revenue policy • Improved billing systems.

Although these patients might not be a financial burden to the Province, bed capacity must be retained to accommodate these patients. Currently 12% of the population in KwaZulu-Natal are covered by medical schemes. At least 50% of all schemes in KwaZulu-Natal are from the lower income and lower benefit category of scheme. A considerable number of these 0,5 million people will have to be absorbed by the public sector. Under present budgetary control systems these patients are a financial burden to the Provinces. Private patients are utilizing funds that should be used for indigent patients. In one of the proposed models for health care delivery, a figure of 95% indigent population is used, to allow for this factor. For KZN to benefit from this policy, attention must be given to the following policies. : • Retention of Funds on provincial level. • Billing systems and policies in hospitals


5.2 Configuration of services

• KwaZulu-Natal is divided into the following regions: Durban - eThekwini DC21 - Ugu DC22 - uMgungundlovu DC23 - Uthukela DC24 - Umzinyathi DC25 - Amajuba DC26 - Zululand DC27 - Umkhanyakude DC28 - Uthungulu DC29 - Ilembe DC43 - Sisonke

In providing health care to all people in KwaZulu-Natal, the following principles were followed. i. All hospitals are classified and provide care in accordance with the level of care

definition outlined in the National Policy. ii. Hospital bed distribution by level of care are based on norms per 1 000 population, on

activity levels and projected health care demand. Refer to summary of options – chapter 12.2.

iii. The geographical decentralization of beds to promote easier access.

a. One national central hospital in the Province b. One additional tertiary site in the Province (i.e. one additional to (a)) c. At least one regional hospital in each region. d. The most accessible level of care is the district hospital and this level must

be strengthened. e. Hospitals should ideally provide a single level of care, but in order to

maximize efficient use of existing resources, not more than two level of care would be provided. Hospitals must then be layered.

f. Each hospital has a defined catchment area. g. Referral patterns are defined to ensure an efficient network of care. h. There is to be a defined package of services related to each level of care i. Management at institutions will be decentralized to achieve maximum

efficiency.

5.2.1 National Central Hospital

The Inkosi Albert Luthuli Central Hospital (IALCH) has been designated as one of the central hospitals in S.A. IALCH is a Public / Private joint venture. Staff members, employed by the KwaZulu-Natal DoH provide all clinical services. All other services are provided on contract by a consortium of businesses. A fifteen-year contract has been signed with the consortium, and during the fifteen-year time the consortium is contractually obliged to maintain the buildings and equipment. At the end of the specified period, buildings and equipment will be handed back to the Province.


This Institution will provide highly specialised care for the entire KwaZulu-Natal population. IALCH has a bed capacity of 800 plus 46 burns beds. The total bed requirements for national central services will be 650 by 2010. This institution

will accept referrals from all provincial regional hospitals, as well as possibly, some referrals from the Eastern Cape.

5.2.2 Provincial Tertiary Services:

i. In a recent study done on highly specialized services in public sector

hospitals, the highly specialized services workload in KwaZulu-Natal was found to be:

52,312 admissions equates to 12 % of national admissions 17 749 day cases equates to 19 % of national day cases 417 697 OPD visits equates to 25 % of national visits

ii. A substantial level of tertiary care expenditure is incurred on specialized

services outside of the designated central hospital.

Expenditure Non-central Funding In Central Hosp. Hospitals From Central

hosp. grants R461 777,047 R497 725 224 R427 525 000

iii. KwaZulu-Natal spends 18 % of total expenditure on tertiary care, and has 22

% of the uncovered population resident in KwaZulu-Natal.

Total tertiary care expenditure is thus in line with the population. No substantial portion of the KwaZulu-Natal population benefits from tertiary care expenditure in other provinces, so total expenditure is in the line with expected demand in KwaZulu-Natal.

iv. The study still showed inequity in funding in tertiary care service amongst

the various provinces. • KwaZulu-Natal can be described as a Province with moderate

access to and Provision of tertiary health care services, with a relative under funding for these services.

1. Durban Metro / eThekwini District:

Currently a number of hospitals deliver tertiary care services: - Wentworth - Addington - King Edward VII - Over time, IALCH will provide all the tertiary care for this district, accepting referrals from Durban, Ugu, Uthungulu, Umkhanyakude and two thirds of the Zululand region. It will accept referrals from the following hospitals: - Port Shepstone - Addington - King Edward VII - RK Khan


- Prince Mshiyeni - Stanger - Ngwelezana / Epangeni Complex

2. uMgungundlovu District:

Greys Hospital will provide this level of service for one third of the Province viz, the uMgungundlovu (DC22), Uthukela(DC23), Amajuba (DC25) and one third of the Zululand (DC26) District. Referrals will be received from its own regional component, Edendale Hospital, Ladysmith Hospital and Newcastle/Madadeni Complex.

Comment for clarification:

There are two districts for tertiary services. Both regions refer patients to IALCH

IALCH CENTRAL HOSPITAL IALCH GREYS PROVINCIAL TERTIARY

Port Shepstone Greys REGIONAL Addington Edendale King Edward Ladysmith R.K. Khan Newcastle Prince Mshiyeni Stanger Empangeni Ngwelezana-Empangeni Complex Mahatma Gandhi 5.2.3 Regional Hospital Services

These services will be provided either by a single institution or by a group of institutions forming a complex. These institution/s would predominantly serve the needs of each of their respective health districts but in some instances may exceed the district boundaries. All these institutions are layered – providing partial regional and district level of care (except for Greys Hospital) to ensure that the needs of the population in the immediate vicinity are catered for.

1. Ugu (DC21) District:

Port Shepstone Hospital will provide the regional hospital services. It will receive referrals from all the district hospitals listed below except CJ Crookes, which will refer to Prince Mshiyeni Hospital in the eThekwini district.

2. Durban Metro / eThekwini District


Addington, King Edward, Prince Mshiyeni and R.K. Khan Hospitals would provide regional hospital services for this district. In the case of Prince Mshiyeni Hospital the catchment area and therefore the provision of services extends at least into a third of the Ugu District. The regional component of Addington Hospital will be relocated in the future to the Northern part of the Health District to improve access. 3. UMgungundlovu (DC22) District

Greys Hospital and Edendale Hospital are to provide the regional hospital services for this district. Greys Hospital is to receive its referrals from Northdale, Greytown (DC24), Utunjambili (DC29), Applesbosch and Montebello Hospitals. Edendale Hospital is to receive referrals from its own district component and from St. Appollinaris (DC43) and Christ the King Hospital(DC43).

4. Uthukela (DC23) District

Ladysmith Hospital is to provide the regional hospital services for this district. It will receive referrals from Emmaus and Estcourt Hospitals. 5. Umzinjati (DC24) District Greytown will refer to Greys Hospital

6. Amajuba (DC25)District

Both the Newcastle and Madadeni Hospitals would provide regional hospital services for the entire district. The Newcastle Hospital would provide all the gynaecological, maternity and child health services whilst Madadeni Hospital is to provide services related to the remaining disciplines of surgery, orthopaedics, medicine and other related sub disciplines (urology, ENT, ophthalmology) for this catchments population. It will receive referrals from the district hospitals listed under this region. 7. Zululand (DC26) District

For the immediate future no institution has been designated to provide regional hospital services for this district, due to the poor hospital service needs. Hospital services for this district will continue to be provided for by the Ngwelezana / Empangeni Hospitals (Utungulu DC28 District) for two thirds of this district. The remaining third will refer to Newcastle and Madadeni Hospitals (Amajuba DC25 District). This situation will be reviewed periodically to assess the feasibility of providing this level of service. 8. Umkhanyakude (DC27) District No institution in this region has been designated to provide regional hospital services. Empangeni and Ngwelezana will provide these services.

9. Utungulu (DC28) District

Both Ngwelezana and Empangeni Hospitals is to provide regional hospital services. Empangeni Hospital will continue to provide maternal and neonatal care and in the


future to provide child health, which would be relocated from Ngwelezana Hospital. The later hospital will provide surgery, orthopaedics and medicine and other related sub disciplines (urology, ENT, ophthalmology). These institutions are to serve the entire district as well as two thirds of the Zululand (DC26) District. All district hospitals listed below including Itshelejuba, Ceza, Nkonjeni, Benedictine and St. Mary’s Melmoth situated in the Zululand Region will refer to this complex.

10. Ilembe (DC29) District

Stanger Hospital would provide regional hospital services for this district. However Utunjambili refers to Greys Hospital. 11. Sisonke District

No institution in this ditrict has been designated to provide regional services. The district will refer to Greys and Edendale Hospital.

5.2.4 District Hospital Services

These services will continue to be provided for by the current hospitals (designated as district hospitals) in the various regions - including the hospitals listed above for regional hospital services, which all have a district component (except Greys Hospital). These hospitals will provide services for the immediate surrounding population. In addition, some of these hospitals will provide short-term convalescent care (step-down facility) and therefore have a specific number of beds allocated for this purpose. The district hospitals are listed below.

1. Durban Metro / eThekwini District

Mahatma Gandhi McCords Addington Osindisweni Prince Mshiyeni RK Kahn King Edward Umpumulo St. Mary’s (Marianhill) Clairwood (Step down) Hillcrest (Special) King George V 2. Ugu (DC21) District

Port Shepstone GJ Crookes Murchison St. Andrews

3. uMgungundlovu (DC22) District

Applesbosch Northdale

Greytown Montebello Edendale

4. Uthukela (DC23) District

Ladysmith Emmaus Estcourt


5. Umzinyathi (DC24) District

Untanjambili Church of Scotland Greytown Dundee Charles Jonson 6. Amajuba (DC25) District

Newcastle Madadeni Niemeyer Memorial 7. Zululand (DC26) District

Ceza Itshelejuba Nkonjeni Vryheid Benedictine Thulasizwe Mountain View Pongola 8. Umkhanyakude (DC27) District

Hlabisa Bethesda Mosvold Mseleni Manguzi 9. Uthungulu (DC28) District

Ngwelezana Empangeni Catherine Booth Ekombe Ekuphumuleni Eshowe Mbongolwane St Mary’s Nkandla 10. Ilembe (DC29) District

Stanger Umphumulo Amatikulu Chronic Sick Home Hospital

11. Sisonke (DC43) District

St Apollinaris Christ the King EG & Usher Memorial Taylor Bequet

5.2.5 Specialised Hospital Services

1. TB Services

The current bed status within the provincial and provincial subsidised hospitals (3117) will be maintained for the immediate future. The rising TB/HIV/AIDS epidemic particularly affecting this Province, together with the relatively underdeveloped DOTS


programme and treatment centres necessitates this scenario. This situation is to be reviewed periodically in relation to the epidemic and the roles of some of these hospitals may change to incorporate hospice type of care. However strict admission and discharge criteria for each level of care including the specialised hospitals together with a single standardised treatment protocol will have to be entrenched to ensure that these services are delivered efficiently.

King George V Hospital will be the Provincial referral centre of MDR cases managing and providing support on issues of MDR to all health care facilities in the Province. In addition the complicated and protracted surgical and medical management of TB cases will also be accommodated at this institution. Thulasizwe Hospital – Ulundi Region is the other Provincial Hospital providing exclusively TB care.

Many other acute care general hospitals have dedicated TB beds (not listed)

The Provincial Subsidised Hospitals providing TB care are as follows:

i. Durban Metro / eTekwini District

Charles James Centre Don McKenzi FOSA McCords ii. Ugu (DC21)District

Dunstan Farrall

iii. uMgungundlovu (DC22) District

Doris Goodwin Richmond Chest iv. Uthukela (DC23) District

None v. Umzinyathi (DC24) Distrct

None vi. Amajuba (DC25) District

None vii. Zululand (DC 26) District

Mountain View Siloah Lutheran viii. Umkhanyakude (DC27) District

None ix. Uthungulu (DC28) District


St Mary’s Hospital (Melmoth) x. Ilembe (DC29) District

None xi. Sisonke (DC43) District

Khotsong Santa Centre

5.2.6 Mental Health Services

Mental health services are to be delivered as follows: All district hospitals will treat acute mental health problems.

1. Durban Metro / eThekwini District King George hospital to be developed with a total of 130 psych beds will provide a centralised regional level of psychiatric unit receiving referrals from all the district hospital components within the district; a unit for certified patients and specialist units for child, adolescent and geriatric patients. These specialist units would receive referrals from eThekwini, Ugu, Uthungulu, Umkanyakude and the Zululand Districts. The medium to long term care for severe psych and severe-profoundly mentally disabled patients from the eThekwini and the Ugu districts would be provided at the Ekhulengeni Care Centre and other facilities to be identified.

2. Ugu (DC21) District

A psychiatric unit for acute regional level care will be based at Port Shepstone Hospital and will receive referrals from the district hospitals within the region. Medium to long-term beds needed for severe psychiatric and profoundly mentally disabled patients are to be accommodated within the Durban eThekwini District until such time physical capacity is developed within this region to accommodate these patients. 3. uMgungundlovu (DC22) District

Fort Napier Hospital would provide a centralised provincial forensic service and would include and observation unit and 200 forensic beds initially which would increse to 300 beds as the forensic unit at Madedeni Hospital is downsized. This Hospital would therefore down size over a period of time and the extra physical space would be used for purposes such as a village structure for discharged psychiatric patients. Town Hill Hospital would provide a centralised acute regional level psych unit receiving referrals from all the district hospitals in the region; some beds would be


used for accommodating certified patients, specialised units for child, adolescent and geriatric patients and for other highly specialised units e.g. Eating disorders. These specialised units would receive referrals from uMgungundlovu, Uthukela and the Amajuba Districts. The highly specialised units would be a provincial resource. In addition this hospital would also accommodate the medium to long-term care for severe psych from the uMgungundlovu District. This institution would need to downsize from its present bed status. Umgeni Care and Rehabilitation Centre Currently this facility has many patients from other provinces and approximately 73% from KwaZulu-Natal. This institution will not admit any more patients from outside the Province and ultimately provide accommodation for the severe-profoundly mentally retarded patients from the uMgungundlovu District. This institution would thus downsize over a medium to long-term period. It may then emerge that it would be more efficient to close this facility for inpatient care and make it available for other primary health care or community based programmes. These inpatients could then be accommodated at Townhill Hospital. This decision however would need to be reviewed much further into the future to assess its feasibility. 4. Uthukela (DC23) District

A psychiatric unit for acute regional level care is to be based at Ladysmith Hospital and is to receive referrals from the district hospitals within the district. Medium to long-term beds needed for severe psychiatric and profoundly mentally disabled patients are to be accommodated within the Amajuba (DC25) District as there is currently no physical capacity within the region to cater for these patients. 5. Umzinyathi (DC24) District

None

6. Amajuba (DC25) District

Madadeni Hospital will provide for acute services at the regional level and will receive referrals from all the district hospitals within the district; a medium to long term unit providing care for severe psychiatric and profoundly mentally disabled patients from the Amajuba, Uthukela and partially from the Zululand (DC 26) Districts and a forensic unit. This forensic unit will be phased out over a period of time and centralised at Fort Napier for the Province. The mental health component at Madadeni Hospital will thus downsize over a period of time. 7. Zululand (DC26) District

St. Francis Hospital will provide for acute regional level service for this District and the medium to long-term care for severe psychiatric and profoundly mentally disabled patients for the entire region. Should extra capacity be required to cater for these types of patients then they are to be accommodated within the Amajuba (DC25) District.


8. Umkhanyakude (DC27) District

None 9. Uthungulu (DC28) District

A psychiatric unit for acute regional level service will be based at the Ngwelezana Hospital receiving referrals from all the district hospitals within the region. Facilities for the medium to long term care for severe psychiatric and profoundly mentally disabled patients will be sought within this region. Currently there may be some capacity at either Catherine Booth or Mbongolwane Hospitals. 10. Ilembe (DC29) District

None 11. Sisonke (DC43) District

None

5.3 Demand for hospital services and utilisation

• Patient statistics according to diagnosis are not being collected. There is an urgent need for this to be implemented to monitor and evaluate trends and to adjust the health services delivery plan. The impact of HIV/AIDS, or any other epidemic, or violence, or lifestyle related disease could not be evaluated without data.

• There is a need to standardize terminology and to develop a data dictionary. • Although admissions increased during the period under review, in-patient days and

bed occupancy rates reduced. This suggests that duration of stay reduced, and better efficiency was achieved. Duration of stay is still however unacceptably high: - Seven days for district hospitals - Eight days for national hospitals - Six days for regional hospitals - Two to seven days for specialized, which includes psychiatric hospitals with

a component of long-term care.

Reason for long duration of stay:

i. Bottle Necks - Lack of support services such as radiology, can necessitate that a patient stay

longer to wait for an x-ray. - Theatre cancellation due to a shortage of beds, porters and anaesthetist can

cause delays. ii. Transport. Patients are often kept one to two days longer to await transport. iii. Shortage of doctors.


Patients are kept longer due to the excessive workload on doctors. Improved management, better workflow and better planning can solve most of these problems. The creation of transit beds will reduce the number of patients required to stay in hospital to wait for transport.

5.4 Referral patterns

• Referrals of patients from clinics to higher level of care have already been discussed. • The rationalization of services will improve referrals to hospitals. Across border referrals Evidence that across the border admissions is a major problem has been found. In none of KwaZulu-Natal hospitals were more than 5 % of patients from other Provinces, with the exception of • Lower Umfolozi War Memorial Hospital, where 25 % of patients were of unknown

origin. • Port Shepstone, where 15 % were from Eastern Cape and • St. Andrews, where 21% were from East Cape. • EG and Usher where more than 50% of patients were from across the border. • In response to a recent question in Parliament, the minister of Health in KwaZulu-Natal

described the situation as follows: “The conservative estimated annual cost of treating Eastern Cape patients in KwaZulu-Natal is R 50.04 million”

5.5 Services offered

Package of Services

• Proposed district hospital package of service

The district hospitals should generically provide diagnostic treatment, care, councelling and rehabilitation services. The range of services is as follows: Medicine Surgery Obstets and Gynae Paediatrics Mental Health Geriatrics Occupational Health Clinical Forensic Medical Services Rehabilitation OPD services Casualty Clinical support services Anaesthetics Theatres Radiology General support services Pharmacy Laboratory Access to Blood Bank • Proposed regional hospital package of service


The role of the regional hospital is to provide a specialist consultant service for patients referred from and to the district hospitals and the primary care sector. The range of services is as follows: General surgery General medicine Paediatrics Obstets and Gynae Orthopaedics ENT Ophthalmology Mental Health Oncology Occupational health Urology Dermatology Plastic surgery OPD Casualty Clinical support services Anaesthetics ICU Theatres Radiology General support services Pharmacy Laboratory Blood bank • Proposed tertiary hospital package of service The role of the tertiary hospital is to provide a sub-specialist consultant service for patients referred from and to the regional hospitals. The range of service is as follows: Surgical sub-disciplines Medical sub-disciplines Neurosurgery Neurology Plastic and reconstructive surgery Cardiology Cardio thoracic surgery Endocrinology Paediatric surgery Rheumatology Maxillo-Facial surgery Haematology Oesophageal surgery Respiratory medicine Ophthalmology Gastro-enterology ENT Nephrology Urology Obstets & Gynae Orthopaedics Paediatrics Oncology Mental health Occupational health Clinical support services:


Anaesthetics ICU Theatres Radiology Nuclear medicine Medical physics General support services Pharmacy Laboratory Blood bank

5.6 Private and non government hospital service provision

KwaZulu-Natal has a well developed “for profit private hospital sector”, concentrated in the urban areas. There are 26 private hospitals. The full range of tertiary care services are offered Surgical Medical Neurosurgery Neurology Plastic & reconstructive Cardiology Cardio-thoracic surgery Endicrimology Maxillo-Facial Rheumatology Opthalurology Haematology Ophthalmology Resp. Medicine ENT Gastro-enterology Urology Nephrology O&G Orthopaedics Paediatrics Oncology Mental Health Occupational Health

ICU Anaesthetics Theatres Radiology Nuclear medicine Medical physics

Pharmacy Laboratory Blood Bank


Hospital Beds

Bay Hospital, The 160

Chatsmed Garden Hospital 168

City Hospital 139

Crompton Hospital, The 147

Durdoc Clinic 42

Empangeni Garden Clinic 95

Entabeni Hospital 273

Hibiscus Hospital 40

Isipingo Hospital 80

Kingsway Hospital 125

La Verna Hospital 98

Margate Private Hospital 58

Maxwell Clinic 31

Midlands Medical Centre 105

Mount Edgecombe Hospital 122

Newcastle Private Hospital 76

Nu-Shifa Hospital 77

Parklands Hospital 188

Pietermaritzburg Medi-Clinic 113

Riverview Country Hospital 32

* St Aidan's Mission Hospital 157

St Anne's Hospital 146

St Augustine's Hospital 418

Umhlanga Hospital 177

Victoria Hospital 120

Westville Hospital 264

Total number of private beds 3451

The total population covered by Medical Schemes is 12% of 9 560 156 is 1 147 218 Thus: 3.01 private beds per 1000 population.

5.7 Priority issues that impact on hospital service delivery

The KwaZulu-Natal Institutional support Directorate has identified a number of priorities for service delivery improvements: • To implement effective / competent management structures and systems and to

decentralize control. • To ensure continued improvement of access to health services. • To continue to improve quality of care at institutions. • To improve communication and consultation within the health service and between the

h/c service and the community.


Comment KwaZulu-Natal has contracted with COHSASA to improve quality of care.

Hospitals that are involved in this process are generally more aware of quality and are working toward improved quality. COHSASA emphasizes the need for written policies and standardization

• Outcome measures must be instituted to achieve benchmarks and to measure success.

Greater efficiencies can be achieved in many areas.

5.8 Finance – historical cost and utilisation 2001-2001 The DoH financial situation is clearly spelt out in section 7 of the report. The hospital financial situation is set out in this section.

The following table sets out the historical cost and utilisation for the 2000/2001 financial year:

HISTORICAL COST AND UTILISATION FOR THE 2000/2001 FINANCIAL YEAR POPULATION : 7 776 528 (86% X 9 042 474) FOR 1999/2000 YEAR

Total District Regional Tertiary Psychiatric TB Special-

unclassified Hospitals 74 42 10 3 4 12 3

Usable beds 26,073 11,191 5,556 2,355 3,617 3,117 237

%beds 100.0% 42.9% 21.3% 9.0% 13.9% 12.0% 0.9%

Beds/1000 3.35 1.44 0.71 0.30 0.47 0.40 0.03

Beds/1000 2001 1.08 0.74 0.43 0.62

Admissions 745,060 386,913 246,178 93,044 6,623 11,792 510

Admissions/1000 95.81 49.75 31.66 11.96 0.85 1.52 0.07

%Admissions 100% 51.93% 33.04% 12.49% 0.89% 1.58% 0.07%

Inpatient days 6,503,757 2,646,949 1,407,907 613,009 997,089 780,329 58,474

LOS 8.7 6.8 5.7 6.6 150.5 66.2 114.7

OPD Headcounts 4,864,358 2,339,984 1,884,674 445,068 4,726 23,785 166,121

OP h/count : Admissions 6.53 6.05 7.66 4.78 0.71 2.02 325.73

OPD:IPD 0.748 0.884 1.339 0.726 0.005 0.030 2.841

OPD/1000 pop 625.5 300.9 242.4 57.2 0.6 3.10 21.4

%OPD 100% 48.1% 38.7% 9.1% 0.1% 0.5% 3.4%

Expenditure 00/01 3,948,073,092 1,622,860,708 1,403,361,151 639,021,408 146,400,000 116,729,825 19,700,000

Bed occupancy 68.3% 64.8% 69.4% 71.3% 75.5% 68.6% 67.6%

Note:The NdoH and the KZN DoH both use a relationship between Patient Day Equivalent costs and Outpatient Headcount Costs at a ratio of 3:1. This calculation is historic in nature and bears no resemblance to actual costs. No studies are available to us to determine the actual costs by level of care and as the policy of focusing on primary health care takes effect the costs of operating the hospitals will change. The differences between ratios of out patient days (OPD) to in patient days


(IPD) and OPD headcounts to 1000 head of population as per the above table will change. It is imperative that costs be determined for OPD and IPD per level of care as in the planning of hospital services into the future.


CHAPTER 6 – HUMAN RESOURCE MANAGEMENT REVIEW

6.1 Staff Planning Considerations

Comment • Information on the staff establishment in KwaZulu-Natal was generally of very poor

quality. • A skills audit was performed and the results released in June 2000, and again in

October. It is intended to be an ongoing exercise until accurate HR data collection and maintenance is achieved. Data from the skills audit could not be obtained from the PERSAL system, but had to be collected manually. This was time consuming and expensive.

• The data is perceived by management to be unreliable. According to the audit the shortages of staff per category are as follows:

Nursing staff:

District Hospitals 24 % shortage Regional Hospitals 25 % shortage Staff shortages at clinics is worse than the shortages at hospitals especially at the deep rural

clinics. Also refer to item 4.6

There is a ten fold oversupply of psychiatric nurses at this level of care.

Tertiary Hospitals An oversupply of staff nurses and nursing assistants with a 30 % shortage in areas such as ICU and a 100 % shortage in recovery nurses.

Medical Staff

District Hospitals 23 % Shortage

Regional Hospitals 26,8 % Shortage

Tertiary Hospitals 23 % Shortage

Age distribution: • A significant number of employees are of retirement age. By 1999, 104 employees in

the senior management post category were over 60 years of age. • It is thus critical that succession planning and transferring of skills be implemented.

Attrition The average annual attrition rate for doctors in 1998 was 28,2 % (434 resignations) and for nurses 12,5 % (1 444 resignations).

Reasons for the high turnover could be: • Perceived poor working conditions (work load) • Devaluation of the Rand makes salaries in £ and $ look attractive. • Stricter monitoring of overtime claims


• Abolishing limited private practice. • The loss of nurses is perceived to be due to more attractive salaries in the private

sector and offshore. • There is also a perception that a greater number of nurses are dying each year (a total

of 426 nurses died during 1996 - 1999). Research is urgently necessary to confirm or deny this perception.

6.2 Recruitment and Retention Issues

• Using the annual rate of attrition, the required number of posts, and the total number of posts it is calculated that KwaZulu-Natal had a nursing shortage of 36,37 % in 2000.

• It must be remembered that there is inequity of distribution, with greater shortages in rural areas. This implies that primary health care or health care in rural areas is in danger of collapse.

• A high number of employees have resigned or has transferred to other provinces because - Delays in payment of salaries and allowance - Administrative errors resulting in underpayment or over recovery - Problems with allowances These problems are of an administrative nature, but tend to cause high levels of frustration.

• Attention should be given to the payroll system • The following survey yielded a number of causes of resignation Causes of Resignation YES % NO 1 Salary not enough 22 61 14 2 Unacceptable / poor work conditions 11 33 22 3 Limited promotion opportunities 20 59 14 4 Management style not acceptable 8 25 24 5 New changes threatening 4 12 29 6 Career change 10 29 25 7 Better salary offered 28 65 15 8 Offered senior position 9 26 25 9 Relationship with supervisor / other team members 2 2 28 10 Stay if expectations met 42 61 14 11 Intend to come back / rejoin Department 16 50 16 STRATEGY FOR RETENTION OF PERSONNEL – (Retention policy devised by KwaZulu-Natal Province)

1. Recognition of good performance In order to retain the required personnel, the department is committed to promoting its serving personnel to senior positions based on good performance and proven managerial skills. In addition, at lower level of management, serving personnel who are in possession of the prescribed educational requirements must be afforded the first opportunity in the filling of entry grade posts. For example the General Assistants in possession of a senior certificate must be considered in the filling of these positions and for further training.


Employees must know what performance standards are. It must be made clear to all employees what is expected of them. The employees should receive regular feedback on their own performance and should perceive the performance appraisal as fair. Performance appraisal should be used to determine training needs and should be seen as a part of a development programme rather that a punitive measure. 2. Career Management

The DoH is committed to provide guidance and advice on career paths. It also commits itself to introducing systematic procedures for identifying potential. The manager should, in turn:

• Make the supervisee(s) aware of the career opportunities • Advise the supervisee(s) how the career aspirations can be met • Identify and make the supervisee(s) aware of training opportunities • Have a career discussion with the employee at least twice a year

3. Training and development

. Training and development are long-term investments in Human Resources. To this

end:

• All managers and supervisors are required to identify the training needs of their supervisees and ensure they are exposed to relevant training courses.

• The managers and supervisors are also expected to evaluate the performance of their supervisees after training, to determine if the identified training needs have been satisfied.

The Department undertakes to create its pool of talent by developing the serving personnel or prospective applicants. The deserving cases will be sent to tertiary institutions to acquire scarce and new skills. It is intended to create more opportunities for vertical mobility (promotion) and horizontal mobility (translation in rank from one to the other vocational class). It is believed that development will enable the Department to retain its personnel 4. Bursary Allocation The granting of bursary by the department plays an important part in the development and retention of personnel. It is the belief of the DoH that personnel development through granting of bursaries will ensure continuity, a reduction in costs for recruitment, loss of productivity and time lag before a new recruit can perform at the expected standard. The bursary will be granted in terms of scarcity of skills to ensure that the most scare skills are afforded first preference. The prospective applicants from the disadvantaged groups that are in the minority in the establishment will be given the first preference.


Personnel who are currently serving as assistants, (e.g. assistant radiographers, dental assistants, and pharmacy assistants) should be given first preference if they meet the entry criteria prescribed by the tertiary institutions. 10% of the bursary allocation must be set aside to subsidise part-time studies undertaken by the serving personnel and ‘plough-back’ must be according to appropriate contract entered into between employer and employee. The 10% must be allocated proportionally to the regions / districts based on needs. 5. Incentives / Rewards Incentives cover a wide spectrum. Included are both monetary and non-monetary incentives. They include salaries, allowances, merit awards, cash bonuses, special awards etc. The Provincial Department of Health has little or no influence in the determination of these incentives. However, the department plays a crucial part in the implementation thereof. The DoH is committed to rewarding certain identified target groups. Rewards will include time off for staff who have worked overtime; cash; length of service bonuses, bonuses related to individual or team outputs, assistance with transport costs, and provision of on-site facilities, such as crèches. Jobs must be rewarding in themselves. Jobs must be designed to maximise skills variety, task significance, autonomy and feedback. The content of the jobs / job description must be such that the incumbent is able to attain self-actualisation. Thus the tasks / activities must be challenging. In addition the jobs should also give an opportunity for learning and growth. The department will henceforth see to it that merit and special awards are paid to deserving cases. It is incumbent upon the supervisors to submit evidence of outstanding work performance of their supervisees to Head Office (Human Resource Practices) annually on 1 April for consideration. The granting or motivating cases of average workers for these awards defeat its objectives. Therefore, it is of crucial importance that only deserving cases are considered for these awards in order to motivate both exceptional and average workers to strive for excellence. It is important to announce to all staff the names of officers who were granted these awards. The announcement could be made in any form that will reach all the staff in that institution. The special award / advancement within the applicable salary range should be granted to officers in recognition of :

- Exceptional ability - Possession of special qualification - Rendering of meritorious service

The supervisors / managers should submit to Head Office (Human Resource Practices) such cases together with the relevant evidence as and when identified for consideration.


It is required of all heads of personnel offices to see to it that officers are paid correctly in time and that leg / rank promotions are effected within a month after they meet all the prescribed requirements. Allowance must be paid to personnel with scarce skills working at hospitals identified as underserved areas. Previously this allowance has been paid only to medical officers. Negotiations are under way to extend it to other health workers (with scarce skills). However, the recruitment allowance has made a little impact on attracting medical officers to these areas. Therefore, it is considered that the commencing salaries of these categories be put on a salary range / notch higher that the prescribed minimum salary range / notch. Non-monetary incentives are one of the most important motivating factors. They, inter alia, inculcate the sense of pride and identity. The heads of institutions / managers may choose any one from the available non-monetary incentives. The most common of these incentives are; certificates, medals and trophies etc. The heads of institutions should announce to their staff:

- The number and types of such incentives that are available - Which of them will be awarded to the teams and individuals - The requirements to quality for these incentives - How often per year will they be awarded?

In order to add value to these awards, it is necessary to hold a ceremony for presentation and where possible the head of the department ought to be invited to do the presentation 6. Work environment The managers are charged with the responsibility to:

- Provide their supervisees with the necessary material and authority to discharge their duties and responsibilities effectively.

- Look after the welfare of their supervisees, for example: provide crèche facilities.

- Monitor / Guide and manage work performance of their supervisees for career development and increased productivity.

- Ensure that their supervisees are working under good working conditions

- Create a learning culture where initiative, creativity and innovation are awarded within the shortest time possible.

- Give full attention to and address the supervisees problems

The establishment of EMPLOYEE ASSISTANCE PROGRAMME demonstrates the commitment of the department to creating of a conducive working environment. The intention is to help the workers as both employees and human beings.

• Strategy for retention of personnel KwaZulu-Natal has developed a staff retention policy, to address the problem of staff shortages and the high rate of attrition.


Comments In terms of the nursing shortage KwaZulu-Natal must develop a Human Resource plan, focused on supplementing shortages in key areas. Possible areas for further investigation: i. Who is doing what? We need to reconsider our current practices, particularly in areas where there is an extreme shortage of nurses, such as ICU, trauma, theatre, recovery. E.g.: • Can technicians become ‘scrub sisters’? • Do we need a person who has studied for 4-7 years to perform this function? • Can we have anaesthetic technicians like elsewhere in the world? • Can we introduce technical assistants in ICU to do the cleaning, checking, and setting

of equipment to free the nurses to do nursing • Nurses are multi-trained • Focused training in a very narrow band of task is quicker

ii. Training Most nursing colleges have reduced the numbers of nurses they train, whilst some medical schools seem to be training for the overseas market. Areas that need investigation: • Public/private partnerships in-training • Current training curricula and length of training • Selection criteria • Increased numbers of students in training to meet attrition rate.

Intake in KwaZulu-Natal Nelson Mandela Medical School has a capacity to accommodate 40 first-year students. Currently there are 200 first year students.

iii. Employment options • Flexible shift systems • Casual vs. permanent staff • A re-look at retirement age and a policy to utilize the scarce skill pool of retired

persons • Enhancing job satisfaction • Organizing work flow to reduce bottle necks and reduce work loads • Granting sabbatical leave for overseas work

iv. Remuneration strategies Many of the suspected reasons for the high attrition rate, are economic reasons. Scarcity allowances and allowance for inconvenient hours must be considered. • Incentives for staff in rural areas

6.3 Performance Measurement

A number of staff members mentioned their unhappiness about the staff appraisal system. During a survey of staff that had recently resigned, this factor was an important reason for resignation.


In a report published in June 2001 “An assessment of factors associated with Staff Resignations at Health Facilities in KwaZulu-Natal”, staff mentioned “an absence of an appropriate appraisal system” and “an unsatisfactory personnel profile method” as reasons for resignation.


CHAPTER 7 - FINANCIAL MANAGEMENT REVIEW

7.1 Funding and budget availability The following documents were made available to the project team in support of the funding, budget and financial considerations required for the SPS project:

• Department of Health Annual Financial Statements for the Financial Year

Ended 31st March 2001. • Appropriation Account Vote 7, Health for the year ended 31st March 2001 • Summary of expenditure Vote 7 setting out the following tables

1998/1999 actual 1999/2000 actual 2000/2001 budget 2000/2001 estimated actual 2001/2002 budget 2002/2003 Medium Term Expenditure Framework 2003/2004 Medium Term Expenditure Framework

• Financial Management System printout of 2000/2001 expenditure by service level and cost centre.

• Projection for 2001/2002 based on September 2001 actuals • Budget process used by Department of Health for the allocation of budgets.

Statistical and utilisation reports were extracted from the information system database for both public and state aided hospitals as follows:

• In-patient days by hospital • Admissions by hospital • Outpatient headcount by hospital • Casualty headcount by hospital • Usable beds by hospital

The “outputs” schedule in the model as provided by KPMG (NdoH) was compared with the above documents. The differences were of such significance that the information in the “output” schedule was replaced with information obtained from the above-mentioned documents. In addition it was considered that the official reports into the provincial and national treasury systems were the correct ones to be used for the comparative studies in the model. The reason for the difference between the figures provided to National Department of Health and those included in the official KwaZulu-Natal DoH official documents relate to the different methods used to record and report on data as well as timing differences.

7.2 Budget setting process

The following is extracted from the departmental document entitled “The budgeting process used by the department of health for the allocation of the budgets”.

The department follows a formal budgeting process based on four basic principles:

1. Prioritisation of identified activities 2. Pre-allocation for centrally controlled health services 3. District and regional hospital services equity formula


4. Balancing of the levels of service.

The Department “has included all stakeholders in the policies and priority determination of its funding options. In this regard the present MTEF cycle of the Finance Directorate of the Department included senior management, all institutional management, regional offices, district co-ordinators, emergency medical rescue services, nursing colleges, local government, head office responsibilities and selected primary health care nurses as well as the Health Portfolio Committee in the decision making process to determine the district and departmental priorities.”

In prioritising the identified activities the department considered the following criteria:

1. Service is to reach the majority of the population based on PHC principles

with focus on the most vulnerable groups especially woman and children, the rural, peri-urban and urban poor.

2. The service to have the maximum impact on the health status of the population with emphasis on woman and children, based on cost effective interventions, targeting areas with the highest infant mortality rate, under 5 mortality rate and maternal mortality rate.

3. Whether the activity contributes to comprehensiveness/integration of social services.

4. The feasibility of success taking into account acceptability, capacity to implement and existing resources.

5. Whether or not the services contribute to the empowerment of communities especially women in the community and involve all other partners including the private sector.

6. Whether or not the services promote capacity building at the targeted levels.

In balancing the levels of service the Department has defined the following broad targets, expressed in a percentage of the total allocation and compared with the actual budget allocation:

TARGET BUDGET

2001/2002 • Administration 2% 1,8% • District hospital care 22% 25,7% • Primary health care 26% 19,6% • Emergency medical rescue services 4% 2,6% • Regional hospital services 18% 25,7% • Specialised hospital services 6% 5,5% • Central hospital services 11% 8,5% • Health sciences (Training) 3% 2,5% • Capital and maintenance 8% 8,1%

7.3 Budget priorities

The following is extracted from the departmental document entitled “The budgeting process used by the department of health for the allocation of the budgets”.


The priorities set for the 2001/2002 financial year, in priority order, are as follows:

1. Clinics and mobile clinic services 2. Clinic building and upgrading programme 3. Community health centre services 4. HIV/AIDS 5. Communicable disease control 6. Training and education 7. Health promotion 8. District hospital services 9. TB hospitalization 10. Environmental health 11. Integrated nutrition services 12. Regional hospital services 13. Patient transport services 14. Emergency medical rescue services 15. Maintenance of buildings and equipment 16. Malaria control 17. Mental health hospitalization 18. Central hospital services 19. Convalescent hospitalization 20. Oncology services 21. Renal services

7.4 Funding Projections

Extracts from the above-mentioned documents reflect the following funding information:

Year Budget, Actual

or MTEF Expenditure

R ,000

Conditional Grant R ,000

Total Funding

R ,000 1998/1999 Actual 4 867 820 843 792 5 711 612 1999/2000 Actual 5 110 069 843 834 5 953 903 2000/2001 Actual 5 775 995 1 082 930 6 858 925 2001/2002 September ‘01

Budget Projection

6 019 930 933 546 6 953 476

2002/2003 MTEF 6 737 930 877 156 7 615 086 2003/2004 MTEF 7 007 399 933 935 7 941 334

The funding envelope included in the KPMG (NdoH) model reflects a core funding for the current year of R 6 348 109 000 projected to 2010 to be R 6 779 420 000 in 2001 Rand. This excludes a projected conditional grant of R 878 708 000 giving a total funding for 2010 of R 7 658 128 000 in 2001 Rand.

The projected funding for 2010 is less than the 2003/2004 MTEF projection by the Province of R 7 941 334 000 is of concern to the provincial authorities.


7.5 Current Capital building and maintenance costs

7.5.1 Current capital building cost is determined by the rate per m² multiplied by the m² allowance per bed in the model. This is a simplistic method of calculation, which has intrinsic inaccuracies, as it cannot accommodate the change in usage or length of stay. It is a known fact that the length of stay reduced in hospitals due to improved techniques etc. This has a major effect on hospitals of 20 years and older, for example X-Ray departments are too small, Theatres inadequate and Outpatients and Pharmacies too small. etc. The square meter allowances per bed were calculated when the SAH norms were developed in 1985 and this should have been revised subsequently. Unfortunately the Treasury Committee responsible for Building Cost norms (TCBC) no longer exists and no organization has done sufficient research to alter these allowances.

The HLMSV team has developed a model which can calculate the building area and cost according to the specific case load i.e. Inpatient days, length of stay, percentage occupancy, outpatient headcount, theatre and X-ray turnover, etc. The SAH norms were used for the individual components to arrive at the total area and cost. The team has made assumptions regarding the add-on cost which are excluded from the norms. The model is included for illustrative purposes acknowledging that assumptions had to be made where information was not available for example number of theatre cases, X- Rays, Dental surgery, etc. This model may be used to determine norms for briefing of consultants as it is it is a convenient tool to assess the viability of options and to establish the appropriate area and cost of a proposed project.

It develops established Province-wide utilisation and turnover statistics or projections to arrive at an acceptable norm of provision per population.

An opportunity is afforded in it for Health Care Professionals to evaluate the adequacy of existing facilities and utilisation patterns and to make adjustments deemed advisable to acquiesce to economic constraints and provide the best possible service.

From this adjusted norm it provides a tool to calculate what is required to transform an existing facility or establish a new one, taking into account demographics and other existing facilities.

It employs information from the national plan for health care facilities (SAH Norms) to arrive at predictions of areas and costs, modified to take into account the physical requirements generated by Day Patient and Primary Health Care turnover.

This accommodates the shift from horizontal to vertical patient care and concomitant reduction in length of stay per admission. Thereby it endeavours to remain applicable to changing health care approaches.

The following current Building cost rates per square metre were calculated:

Clinic R 3 400,00 CHC R 4 200,00 Transit facility R 4 000,00 Hospice R 4 200,00 Step Down R 4 400,00 Chronic R 4 620,00


District R 5 280,00 Regional R 6 050,00 Tertiary R 9 350,00

The above rates are current (October 2001) rates and do not allow for escalation pre- or during construction. In KwaZulu-Natal rates in Durban differ largely from rates in the rural and deep rural situations. It is recommended that a 10% increase be added to rural and 15% increase to deep rural.

The team are aware that, historically, rates per square metre have been inflated by excessive variation orders and resulting delays as well as by problems with emerging contractors. KwaZulu Natal has embarked on a program of drastically improving briefing to the project consultants by preparation of standards required and they are in the process of establishing norms, both area and cost, within which consultants will have to plan. They are setting up a project control office within Health, which will monitor progress and cashflows on a monthly basis which will enable them to identify problems at an early stage when rectification measures can still be taken. Most of the tender board problems have been resolved and it is expected that cost increases due to protracted tender periods will be something of the past.

A mentorship programme has been suggested to assist Emerging Contractors which will speed up the transfer of management skills to these contractors and will avoid major time delays and loss of profit.

The model projects the situation in 2010 by which time the current problems will have been resolved.

For the purposes of the model, the team have selected the target area per bed - as they do not have other areas based on recent research available

7.5.2 Current cost of Equipment

Equipment depends largely on the health services provided. Based on the equipment requirements for the new Inkosi Albert Luthuli Central Hospital the equipment as a % of the building cost was increased to 90% resulting from the dramatic increase in the R /$ exchange rate. The allowances made for equipment are as follows:

Clinics 15%

CHC’s 15% Transit 10%

Hospice 12% Step down 15% District 25% Regional 50% Tertiary 90% Psychiatric 20% TB 15% Specialized 12% Custodial 20%


7.5.3 Maintenance cost of buildings

Unfortunately, maintenance has been inadequate in the past and no records were kept of expenditure. When maintenance is neglected consequential damage occurs and often a maintenance item becomes a capital expenditure item if delayed long enough. Use is made of theoretical models, which are adjusted to allow for the different levels of maintenance required at different types of hospitals. The following percentages are considered realistic:

Clinics 2% CHC’s 2%

Transit 2% Hospice 2% Step down 2% District 2,5% Regional 4,5% Tertiary 4.5% Psychiatric 2% TB 2% Specialized 2%

The HLMSV Team changed the calculation in the model to calculate the above percentages from the existing type of beds as they believe that the maintenance will relate to the building and not to the revised usage of the beds.

It must be noted that the replacement cost is added to the above maintenance cost. If maintenance is executed properly the replacement cost is kept to a minimum. There is a thin line between maintenance and replacement, for example certain elements are replaced under maintenance for example floor finishes, roof sheeting, etc. When adjudicating the maintenance allowance the replacement allowance should be added. Life expectancy determines the percentage replacement cost as follows:

Clinics 40 years 2,5% CHC’s 40 years 2,5% Transit 40 years 2,5%

Hospice 40 years 2,5% Step down 40 years 2,5% District 40 years 2,5% Regional 40 years 2,5% Tertiary 30 years 3,33% Psychiatric 40 years 2,5% TB 40 years 2,5% Specialized 40 years 2,5% 7.5.4 Maintenance of Equipment

The level of sophistication of equipment depends on the different type of hospital and the ratio of imported equipment versus locally manufactured increases with increasing


sophistication of facility. The percentage allowed for maintenance should also differ but in the current model it is accepted as 10%

Again, the replacement cost should be viewed in conjunction with the maintenance. The model allows for an average lifespan of 10 years.

7.6 Current running costs

The following is a break down of the current running costs as per the 2000/2001 appropriation account and the 2001/2002 budget, excluding conditional grants:

Programme Expense item 2000/2001

Actual R ,000

2001/2002 Budget R ,000

Administration - Minister - Management

Personnel Administration Stores and Livestock Equipment Land & Building Professional Services Miscellaneous Total

69 581 13 128

2 002 2 810

15 13 656

1 529 __________

102 721 =========

____________ 111 950

=========== District Health Services - District management - Community Health services - Emergency Health services (EMS) - District Hospitals

Personnel Administration Stores and Livestock Equipment Land & Building Professional Services Transfer Payments Miscellaneous Total

1 775 049 96 802

519 818 69 713

1 058 178 887 238 445

12 700 ___________

2 892 472 ==========

___________ 3 061 809

========== Provincial Hospital services - Regional Hospitals - Specialised hospitals (Psychiatric , TB, and chronic)

Personnel Administration Stores and Livestock Equipment Professional Services Transfer Payments Miscellaneous Total

1 222 529 21 509

291 272 21 097

106 956 80 062

8 981 ___________

1 752 406 ==========

___________ 1 991 629

========== Central Health services - Central Hospitals - Central dental services

Personnel Administration Stores and Livestock Equipment Professional Services Miscellaneous

459 601 5 626

114 628 16 265 46 004

3 188


Programme Expense item 2000/2001 Actual R ,000

2001/2002 Budget R ,000

Total

___________ 645 312

==========

___________ 540 234

========== Health Sciences - Nurses Training Colleges - Ambulance Training College - Training other - Bursaries

Personnel Administration Stores and Livestock Equipment Professional Services Miscellaneous Total

117 697 12 093

3 039 362

3657 873

___________ 137 721

==========

___________ 159 962

========== Auxiliary and Associated Services - MEDVAS trading account - Physical facilities management - Provincial motor transport

Personnel Administration Stores and Livestock Equipment Land & Building Professional Services Total

14 344

13 578 15 857

112 009 99 478

___________ 241 280

==========

__________ 514 467

========= TOTALS (Includes conditional grants)

Personnel Administration Stores and Livestock Equipment Land & Building Professional Services Transfer Payments Miscellaneous Total

3 644 471 149 502 944 337 126 104 113 082 448 638 318 507

31 354 ___________

5 775 995 ==========

3 824 580 147 869

1 011 292 227 461 271 649 573 719 321 010

2 471 ___________

6 380 538 ==========

Specific costs incurred by the Province on items specifically included in the KPMG DOH model for the 2000/2001 financial year are as follows: (in R,000)

Emergency Medical Services (EMS) R 154 145 Management R 102 717 Training R 137 721 Laboratories R 114 711 Medicines Level 1 Hospitals R 108 824 Level 2 Hospitals R 115 244

Tertiary Hospitals R 38 192 Specialised Hospitals R 9 708 Community Health Services R 156 005 EMS R 196 R 428 169


Other non-personnel R 1 407 111 Total personnel costs R 3 644 471

7.7 Additional funding requirements

Refer to section 7.5 above for capital funding requirements.

In terms of the projected budget expenditure for 2001/2002 of R6 953 477 000 against the initial budget allocation of R6 380 538 000 there is an expected shortfall of R491 million.

HOSPITALS

7.7.1 Backlog in Hospital Equipment maintenance

KwaZulu Natal is in the process of compiling an equipment audit. Once available a more accurate estimation of the backlog in equipment maintenance can be prepared. For the model the HLMSV team used the same condition criteria for equipment as that for the hospitals and accepted that the average equipment value would be 35% of the Building cost value. The equipment transformation cost therefore amounts to R 1 196 620 770,00

7.7.2 Backlog in Hospital Facility Maintenance

KwaZulu Natal is the only Province which updates their National Health Facilities Audit on a regular basis and they should be commended for doing so. Each facility is re-audited on a 24 month cycle. From the audit the HLMSV team were able to ascertain the condition of each hospital in decimal figures. There is a 10% difference between condition 4 and 5 but a much higher difference between 3 and 4 and between 2 and 3. When estimating backlog maintenance, cognisance must be taken of the fact that it is more expensive to work on an existing hospital site, than on a new building. This is due to work having to be executed in patches and to match existing building look. There is a premium to be paid for renovation work. When executing renovation work inevitably additional work is required; for example where a consulting room is renovated in addition to replacing the finishes other building work is also required such as providing a new door, moving a hand basin, providing and additional cupboard etc. This work can be described as minor changes/additions.

The SAH norm stipulated that when renovation work exceeds 60% of the cost of constructing a new similar facility, it is counter productive to renovate and the facility should rather be rebuilt. The model the HLMSV team used to calculate the transformation building cost allows for the above. The transformation cost of buildings amount to R 3 418 916 483 without allowance for rural or deep rural.


Not all the facilities listed as requiring upgrading will ultimately need upgrading because the numbers of beds need to be reduced. However there will be a cost attached to closing beds, which the model estimates as 33% of replacement cost. Hospitals in the rural and deep rural areas will be more expensive to upgrade than in the Durban area. 7.7.3 The HLMSV team’s calculation of transformation costs includes the upgrading

of all facilities without an adjustment for closing beds. This is offset against the premium to be paid for rural hospitals.

Equipment backlog R 1 196 620 770 Buildings backlog R 3 418 916 483 Allowance to improve efficiency in planning (11.2%) R 384 462 747 ESTIMATED HOSPITAL TRANSFORMATION R 5 000 000 000 This represent a yearly expense of R 250 000 000 over 20 years.

CLINICS The KwaZulu-Natal Department of Health is conducting a facilities audit into the condition of all existing clinics. Unfortunately work is in process and the results are not yet available for this report. However a telephone survey was conducted where respondents categorised clinics into poor, medium or good condition. Although not very scientific, this gives an indication of condition and was used to calculate the backlog costs. Once the clinic audit becomes available the same methodology as for hospitals can be followed.

7.7.4 Backlog in Clinic and CHC Equipment and Facility Maintenance

The assumption that the condition of equipment would be the same as the condition of the buildings was applied to clinics. The average equipment value would be 15% of the Building Cost Value. Backlog in Clinic Facilities

Building cost of 145 new clinics at average of R 1,5 m each R 217 500 000 Building cost of upgrading 212 “good” clinics – 10% of R1,5 m each R 31 800 000 Building cost of upgrading 103 “medium” clinics – 60% of R1,5 m each R 92 700 000 Building cost of replacement / upgrading 47 “poor” clinics – 100% of R1,5 m each R 70 500 000

Equipment for 145 new clinics at 15% of Building cost R 32 625 000 Equipment replacement for 212 “good” clinics R 4 770 000 Equipment replacement for 103 “medium” clinics R 13 905 000 Equipment replacement for 47 “poor” clinics R 10 575 000 Allowance for Hospice beds at clinics (500 beds) R 25 625 000

TOTAL TRANSFORMATION COST OF PHC FACILITIES R 500 000 000


A total of 192 clinics will have to be built – 145 new and 47 replacements. It is assumed that clinics will be substituted by CHC’c as required.

If the capital transformation takes place over a period of 20 years it will imply a yearly expenditure of R 25m.


CHAPTER 8 – GENERAL MANAGEMENT & ORGANISATIONAL DEVELOPMENT ISSUES

8.1 Integrated planning

KwaZulu-Natal has already initiated a process of integrated planning. Throughout the exercise the need for better information for management decision-making was demonstrated. The planning model, which could be used by KwaZulu-Natal in future, allows for a flexible approach. Variables in the model allow for: • Demographic changes

- The results of the 2001 census could be incorporated - Changes in the percentage indigent population - Changes in across the border flow - Changes in the insured population making use of public sector hospitals

The model is not sensitive enough to allow for changes in the age and gender profile of the population. As these aspects have a definite impact on health sector demand, this may be a future need for refining the model. • Socio-Economic Changes The model allows for changes in socio-economic circumstances that have an impact on health care demand.

- Poverty - Levels of violence - Epidemics

Changes in socio-economic circumstances could be reflected in admissions per 1000 population. The impact of the HIV/AIDS and TB epidemics could be adjusted separately. • Configuration of health provision Changes in policy regarding health care provision such as home based care and district health services can be incorporated. The total number of hospital beds is a calculated figure, depending on bed occupation per length of stay and admission rates. A change in any of these variables will result in a change of bed numbers. Monitoring these figures will therefore be important to detect early trends, requiring adjustment. (see later) • Changes in Resources The model is responsive to the incorporation of changes in policies regarding financial resources. It is important for middle management to understand the financial implication of inefficiencies and wastefulness in the health care delivery system.

E.g. TB Treatment

- An increase in Multi Drug Resistance due to a poor compliance with the DOTS system and low cure rates: Increase of TB MDR from 1.6% to 4.5% results in an increase of more than


R 100million per annum in TB expenditure. (See sensitivity analysis 1 under 9.3) Every 1% improvement on TB cure rate can be demonstrated as R35.6 million saving in total TB expenditure.

A weakness in the model is the lack of responsiveness towards changes in

human resources, availability and costs. This must certainly be a challenge for future improvement.

The following aspects must all be planned in more detail to evaluate the impact on service delivery:

- Staffing levels and norms - Salary structures - Overtime and staff shortages - Attrition - Training Costs - Productivity Levels

-must all be planned in more detail to evaluate the impact on service delivery.

• Changes in Technology The model incorporates detailed planning regarding facility and equipment capital costs, maintenance and replacement. The impact of technology changes, changes in health care delivery trends and changes in demand can easily be determined in an integrated way. • Equally easy the model could be used to incorporate changes in health care demand

and public perceptions. Unfortunately no data was available regarding case-mix, as hospitals do not collect data regarding patient diagnosis and procedures.

• Case-Mix Management

The implementation of diagnosis and procedure coding systems must be seen as a high priority. This will provide health care planners with the ability to link clinical data with financial data. Once this is possible, sophisticated monitoring of cost per procedure as well as cost per diagnosis will be possible. The next step will be to monitor the impact of case-mix and to design a more sophisticated model, utilising case-mix management. • Case Management This will enable KwaZulu-Natal to measure one doctor’s performance and treatment outcomes against the other to establish optimal treatment protocols for different diseases. These protocols could then be applied for case- and disease management.


8.2 Monitoring & Evaluation

The integrated planning process makes it possible to demonstrate the impact of variables on the total cost of health care delivery. It is therefore of paramount importance to monitor key performance indicators in order to adjust efficiency, correct delivery trends and adjust planning. It is also necessary to identify trends in patient and disease profiles.

8.2.1 A few key performance indicators are mentioned, some of which are already used for integrated planning.

• Cost per patient day

- per discipline - per procedure - per category of doctor - per category of patient

• Cost per admission

Note :due to the variation in length of stay, cost per patient day is a better indicator to compare across disciplines and over time

• Cost per accommodation category PDE

- Step-down facilities - per level of care - per specialised services - per home care visit or home care patient

• Cost per theatre case

• Cost per support service

- Ambulance cost per admission - Laboratory cost per admission or per patient day - Radiology cost per admission or per patient day - Catering cost per day - Laundry cost per day and laundry cost per item - Electricity cost per day

Staff costs

- Housekeeping cost per patient day - Nursing cost per patient day - Nursing hours per patient day (an indicator of efficiency of staffing norms) - Doctors cost per patient day - Admin staff cost per patient day (This is often far too high in the Public

Sector) - Permanent staff cost per patient day - Overtime paid per patient day - Agency staff per patient day


• Other

- Staff turnover rate - Average staff life (from joining KwaZulu-Natal to leaving KwaZulu-Natal).

This measures the return on training investment. - Staff death rate - Absenteeism as percentage of paid hours. (This is usually an area of massive

waste unless it is managed well)

• Pharmacy - Turnover as percentage of stock level - Cost per item dispensed - Cost per script - Cost per Patient Day - Number of scripts and line items per patient - Number of scripts and line items per pharmacist - Number of items out of stock - Number of orders per day / week / month - Number of expired items per month - Number of days stock in hand - Value of stock written off - Value of stock in ward level (a security risk)

• Activity

- Admissions per day, week, month and year

per level of care, per type of bed - Bed occupancy

Approved beds Available beds per hospital per level of Care

- Length of Stay (An area where vast improvement of efficiency is required) - OPD visits

Headcount Visits or encounters Appropriateness of visit

- Admissions into transit beds Length of Stay

- Admission into step-down facilities must specifically be monitored, as these are new services and may be subject to abuse / wrong utilisation patterns.


8.2.2 Outcome measurements

It is important that outcome measurements be done regularly. Aspects that could be measured:

iii. Cure rates : e.g. TB, child clinics etc. iv. Complication rates and re-admission rates v. Nosocomial infection rates vi. Incidence rates e.g. falling off beds etc.

The abovementioned four are all sensitive indicators of negligence, work overload or inefficiency. All have potentially massive cost implications and could even lead to legal actions.

viii. Percentage controlled in

Hypertension Diabetes

ix. Percentage

Stunting Infant mortality Neonatal mortality

x. Maternal deaths

iv. It is a worthwhile exercise to compare cost per laundry item with best practices elsewhere. This service could be vastly improved.

vi. Waste disposal

No central policy regarding waste disposal exists. Hospitals generally contract with private companies to manage hazardous waste. Most clinics don’t have a waste disposal policy There is an urgent need to do central specifications for companies that do waste management to ensure. • Safe disposal of sharps • Disposal of medical hazardous waste. • Disposal of radio-active waste.

vii. Stock levels.

Hospitals are running at the barest minimum of stock levels. This appears to be an attempt to maintain budget limitations. However this could lead to later problems.

8.2.3 Monitoring and evaluation of Building Projects

The process of planning, documentation and the invitation of tenders is a cumbersome process and many delays have been experienced. The Tender Board was disbanded and it resulted in a six-month delay on projects, however, the new Tender System should improve the time required to appoint contractors.


A capital project support office is being set up in the department of Health. This unit will monitor the milestones, date planned against date achieved, as well as the project status and cashflow projections against actual cashflow achieved.

The briefing of Consultants is intended to be more precise with area and cost norms and consultants will be required to work within target dates. The progress against milestones will be monitored on a monthly basis and it can be expected that problems will be identified at an early stage when delays can still be limited.

Cost overruns are intended to be closely monitored and are expected to substantially less due to proper briefing. The monitoring and evaluation of the quality of building materials and workmanship will remain the responsibility of the Works Department

8.3 Information Management

KwaZulu-Natal needs a proper Information Management System that will provide information for:

i. Management decision making ii. Planning iii. Monitoring and evaluation of trends iv. Control

Or various levels of management E.g.

- KwaZulu-Natal Head Office - Hospital Level - Cost Centre Level

The system must integrate: Financial systems Staff payroll systems Pharmacy Hospital activity (Admissions) Clinical activity Billing systems

-in order to provide information that is accurate and available on time.

8.4 HIV/AIDS Planning

South Africa is experiencing an HIV/AIDS epidemic of shattering proportions. Since 1999 a process has been followed to develop a Rational HIV/AIDS Strategic Plan. It began with a meeting to review existing HIV/AIDS prevention, treatment and care practices, and the formulation of a committee, briefed to develop a Five Year Strategic HIV/AIDS and STD plan.


In September 1999 the National Minister of Health and the nine MEC’s for health met to identify HIV/AIDS strategy priority areas, and by November 1999, the Inter-Ministerial Committee on HIV/AIDS was presented with a draft document. The final HIV/AIDS Strategic Document was completed in January 2000. The HIV/AIDS strategy in KwaZulu-Natal was designed to follow the principles outlined in the National document. It was also designed to address all the major causes and determinants of the epidemic in KwaZulu-Natal. • Causes and Determinants The immediate determinants of the epidemic include behavioural factors such as:

- Unprotected sexual intercourse - Multiple sexual partners

and biological factors such as

- The high prevalence of sexually transmittable diseases which increase the risk of transfer of the organism during intercourse

- Lack of male circumcision The underlying causes of the epidemic include:

- Poverty - Migrant labour and disruption of families - Commercial sex workers - The low status of women - Illiteracy - Lack of formal education - Discrimination and stigmatisation

During 1997 a National HIV/AIDS Review was conducted. The review identified a number of weaknesses in the ability to respond to the HIV/AIDS epidemic. Most of these factors are still in existence in KwaZulu-Natal, and hamper the progress towards HIV/AIDS care. The factors are again listed here as follows:

- Delay in appointments of key personnel due to financial and human resource constraints

- District structures have not been established - Lack of structured referral systems and continuity of care - Lack of home based care and terminal care facilities - Lack of integration of STD and HIV/AIDS and TB Care - Lack of an effective interdepartmental collaboration process - Lack of provincial policies, guidelines and protocols for comprehensive care

and counselling - Lack of counselling facilities at hospital and clinic level

The National Policy was developed from on the following principles:

- People with HIV/AIDS ought to be involved in design of all strategies - People with HIV/AIDS and their families ought not to suffer from

discrimination - The vulnerable position of women must be addressed


- Confidentiality and informed consent when testing must be protected - A holistic approach to education and care needs to be followed. - STD prevention and control are central elements in the response to HIV /

AIDS.

The KwaZulu-Natal HIV/AIDS initiative To respond to the pandemic, the Province has set up a Provincial AIDS Action Unit. The role of the unit is to: • Facilitate planning, implementation and evaluation of HIV/AIDS activities in the

province. • Coordinate the HIV/AIDS activities directed at prevention of HIV infection and care

for those infected and affected. • Facilitate intersectoral collaboration • Mobilise for partnership against HIV / AIDS • Provide support for Non-Governmental Organisations / Community Based

Organisations and other Governmental Departments in relation to HIV/ AIDS. The unit comprises the following portfolios: • Home Based Care, Voluntary Counselling and Testing • Sexually Transmitted Diseases and Barrier Methods • Health, Public and Private including Indigenous Healers • Welfare and Social Services • Sports Arts and Culture • Life Skills Education • Traditional Affairs, Local Government, Safety and Security, Prisons and Army • Business and Organised Labour • Media Marketing and liaison with Faith Based Organisations • Grass Root Mobilisation, HIV /AIDS Communicators (HAC’s) and Community

Health Workers. The 2000/2001 strategic objectives as identified by the unit are: • Strengthen Partnerships between Departments • Strengthen Partnerships outside Government • Develop effective Awareness Campaigns • Implement Life Skills programmes • Implement the 1st Phase of the Voluntary Counselling and Testing Centres

Programme • Ensure 50% of Districts are implementing the Community / Home Care programme • Ensure all Districts have functional Drop-in-Centres (Resource Centres) • Review and update existing policies HIV/AIDS and STD Strategic Plan for South Africa 2000-2005 The Primary goals of the Strategic Plan are to • Reduce the number of new HIV/AIDS infections (especially among the youth)


• Reduce the impact of HIV/AIDS on individuals, families and communities. The Strategic Plan is structured according to the following four areas: • Prevention • Treatment, Care and Support • Human and legal rights • Monitoring, Research and Surveillance

- The youth will be broadly targeted as a priority population group, especially for prevention efforts.

Priority Areas and Goals Priority Area 1: Prevention

• Goal 1 Promote safe and healthy sexual behaviour • Goal 2 Improve the management and control of STDs • Goal 3 Reduce mother-to-child transmission (MTCT) • Goal 4 Address issues relating to blood transfusion and HIV/AIDS • Goal 5 Provide appropriate post-exposure services • Goal 6 Improve access to Voluntary HIV/AIDS Testing and Counselling (VTC) Priority Area 2: Treatment, Care and Support

• Goal 7 Provide treatment, care and support services in healthcare facilities • Goal 8 Provide adequate treatment, care and support services in communities • Goal 9 Develop and expand the provision of care to children and orphans Priority Area 3: Research, Monitoring and Evaluation

• Goal 10 Ensure HIV/AIDS vaccine development • Goal 11 Investigate treatment and care options • Goal 12 Conduct policy research • Goal 13 Conduct regular surveillance Priority Area 4: Human and Legal Rights

• Goal 14 Create a supportive and caring social environment • Goal 15 Develop an appropriate legal and policy environment

8.5 Legislation considerations

• The South African Constitution delegated the responsibility of Health Care delivery to the various Provinces.

• The National Health Act The delays in publication of the National Health Act, has caused delays in implementation of many health policies, including the District Health System. Enabling legislation to provide a legal framework for the delivery of health care is now urgently needed.


• Social Health Insurance A task team, (The Taylor Committee) considering the implications of an integrated approach in the welfare system that could incorporate a social health insurance, has completed their investigation. The report has not been released yet. A National Health task team was appointed to discuss implementation issues of a national health insurance system. The discussion document, following their investigation has not been released yet, but early discussions indicate that a number of future reforms will be necessary in order to implement a Social Health Insurance.

o Health Care delivery reforms - Delegation of managerial responsibility to hospital level must be

implemented - Improved efficiency of care must be achieved, with the improved

ability to monitor cost and outcomes.

o Health Care funding reforms

Further reforms will be required to achieve: - Equity of access - Community rating - Risk equalisation - Guaranteed minimum benefits - Increased access to lower income levels

• The KwaZulu-Natal Health Act The KwaZulu-Natal Health Act was published in 2000. Regulations to the Act are being drafted in phases. Currently the regulations regarding the licensing of Health Care facilities are being discussed. • Act 90 of 1997

This Act was passed in parliament in 1997, but implementation was delayed due to court

action against the NDoH regarding aspects of parallel importation. The court case was settled during 2001, and the regulations to the Act were published soon after. (June 2001)

It is expected that the Act will be implemented in phases. It has implications for public sector health care delivery, in that the cost of pharmaceuticals should be reduced. • Skills Development Act This Act, intended to create a system whereby employees must contribute 4% of payroll to a fund (SETA) to be utilised for education and training. Unfortunately, a decision was taken that Provincial Health Departments will neither contribute to this fund, nor will their employees participate in the training programme.


A wonderful opportunity to improve skills in the public sector, using contributions from the private sector has therefore not been utilised. • Medical Schemes Act

Amendments to the Act were tabled in Parliament in October 2001.

8.6 Cross Boundary Flow Issues

The KZN Province provides health care services to the northern part of Eastern Cape, Mozambique, Swaziland and Lesotho. The estimated cost of providing cross border health services to Eastern Cape citizens is R50,04 million which represents 46,7% of the health care expenditure of the institutions providing the service. The services provided to foreign countries is estimated at R2,09 million which represents 5% of the health care expenditure of the institutions providing the service.

The major cost relates to the Eastern Cape and this will continue until such time as the Eastern Cape Province DoH has the capacity to provide the services. Costs incurred resulting from international cross border patients will continue whilst the services are not available in their countries of origin.

The impact of these services has been excluded from this SPS model as the Eastern Cape is including full services for its population in their provincial SPS. Any variations will be negotiated at NdoH level. 8.7 Financial Management Process

Financial management is dependant on the timely and accurate preparation of reports and pro-active interpretation thereof. Financial reports should be brief and simple in their format and meaningful in their content. The reports are supported by detailed analyses of activities which enable in depth studies where required to determine the cause and influence of trends.

Financial decisions are taken on the basis of measurement of activities and costs against targeted volumes and costs per activity. In this way performance can be measured, trends identified, rectification steps taken, changes introduced and gaps filled. Accurate financial and activity information linked to good management forms the base for efficient budget management.

The basic principle in preparing budgets is to identify activities, estimate volumes and apply variable costs to each activity within an institution. The total estimated variable costs are then added to fixed overheads and expenditure under the control of the head office allocated to the institution. Measurement takes place by comparing activity volumes and determining why changes are taking place associated with the comparing of costs per activity and determining why there is a variance in costs per activity.

These methods are not possible with the traditional FMS used by the State for controlling State expenditure. Cost centres need to be determined and analysed according to these principles at ward, theatre, OPD, casualty, radiology, physiotherapy and other activity centres. These costs centres should include an allocation of overhead costs and actual costs in such a way that all the costs of operating an institution are allocated to cost centres. Each cost centre will set its targets for activity volumes and cost per activity and then the measurement of actual volumes and costs per activity against these targets can provide


management at all levels with the required support for cost containment management processes.

The PERSAL salary and wage system also fails to provide the necessary data to enable the allocation of personnel costs to the cost centres. Each institution will require a system to control the personnel expenditure items and allocate the costs to cost centres for purposes of measuring performance.

Stores and pharmacy control systems are equally important in financial management in that each cost centre should be charged with its utilisation of stores items. An effective stores and pharmacy control system will record stock holdings, receipts, issues and losses. The stores control system will provide management with the information they require regarding out of stock situations and shrinkage through damage, out of date losses, handling losses and theft. This type of control is essential in performance and cost measurement at institution level.

For these reasons the Province should be investigating and implementing financial and stock control systems, which will permit effective financial management at all management and institution levels. PRIMARY HEALTH CARE – GENERAL MANAGEMENT AND ORGANISATIONAL DEVELOPMENT ISSUES While a substantial part of the above apply equally to Primary Health Care also refer to Chapter 4 from item 4.9 for specific comments on Primary Health Care.


CHAPTER 9 – SUSTAINABLE SERVICES (THE ACTUAL MODEL WILL BE AN APPENDIX)

9.1 Principles of the Sustainability Model

The strategy followed in developing the sustainability model is to determine in conjunction with Provincial management the services required to meet the likely health care needs of the population in the year 2010 based on a funding envelope similar to that enjoyed in 2001.

The NdoH has developed a 10 point plan for the provision of health services and the provinces provision of health services should be in line with the 10 point plan and meet the health care needs of the provincial population.

In preparing the needs analysis cognisance is taken of the change in the disease profile of the population as a result of the HIV/AIDS pandemic and the impact it has on multi drug resistant TB cases in particular. Other disease profiles are assumed to remain similar to those experienced in 2001.

In view of various priorities the sustainability model as prepared by NdoH assumes the following service priorities:

• The transformation of health care facilities to provide the defined services. • The focus on primary health care including home based care services. • The provision only of optimal central hospital services. • The upgrading of emergency medical services. • The optimal treatment of HIV/AIDS and TB patients according to acute

hospital care for HIV/AIDS related incidents only and home based care services for chronic care.The allocation of remaining resources to the provision of level 1, level 2 and specialist hospital services as well as the introduction of step-down facilities, which indicates focusing on acute care in level 1 and 2 hospitals and chronic care in other institutions.

9.2 Current resource envelope and the identified GAP

In terms of the policies mentioned above an initial model has been prepared. In the following table we compare the appropriation account for 2000/2001 with the outcomes of the SPS option number five reflecting the gap between the different service levels.

Appropriation

account 2000/2001 R,000

SPS Option number

Five R,000

GAP R,000

Tertiary Care R 639 021 R 960 724 R 321 703 Level 2 Hospital R 1 403 361 R 1 662 052 R 258 691 Level 1 Hospital R 1 622 860 R 1 609 755 R (13 105) Step-down facilities R - R 226 227 R 226 227 Psychiatric R 146 400 R 182 608 R 36 208 TB R 116 730 R 312 642 R 195 912 Specialised other R 19 700 R 124 697 R 104 997 Total Hospital services

______________ R 3 948 072

______________ R 5 078 705

______________ R 1 130 633


Appropriation account 2000/2001

R,000

SPS Option number

Five R,000

GAP R,000

Primary health Care including Home Based Care and capital transformation.

R 1 192 055 R 2 500 000 R 1 307 945

Emergency Medical Services

R 154 145 R 312 951 R 158 806

Management R 102 721 R 292 526 R 189 805 Training R 137 721 R 146 496 R 8 775 Auxilliary and associated services (included in other headings see note)

R 241 280 R - R (241 280)

Capital Transformation other than PHC (after allowing for replacement costs included in other headings. See note)

R - R 56 993 R 56 993

Total operational costs

_______________ R 5 775 994

______________ R 8 387 671

_____________ R 2 611 677 ============

Funding envelope inclusive of tertiary conditional grant of R 878 708 .

R 5 832 108 R 7 658 128

Surplus/deficit

_______________ R 56 114 =============

_______________ (R 729 542) =============

Note: that in the SPS option 5 the following costs have been absorbed into hospital costs.

• Maintenance per annum R 436 534 153 • Replacements per annum R 449 345 130

In view of the break-even situation arising in option 1 there is no large gap, which requires attention. This conclusion is subject to changes in utilisation and disease profiles as well as the introduction of transition and transformation procedures as envisaged in option one. Other options have been prepared as indicated in section 10 below and a summary of these options is reflected in the following table:


Option1 Option 2 Option 3 Option 4 Option 5 Hospital costs R 4 430 967 000 R 4 521 719 000 R 4 586 070 000 R 4 583 546 000 R 5 078 705 000 PHC costs R 1 780 939 000 R 2 028 674 000 R 2 028 674 000 R 2 500 000 000 R 2 500 000 000 Capital transformation R 196 132 000 R 182 882 000 R 45 120 000 R 43 739 000 R 56 993 000 Surplus (deficit) R 475 589 000 R 147 986 000 R 221 397 000 (R 21 131 000) (R 729 542 000) Number of beds 17 223 19 050 18 599 19 409 22 664

The transformation cost is obtained by deducting replacement costs from transformation costs where transformation costs per level of care exceed the replacement costs.

The Following reflects the differences in utilisation levels between 2000/2001 utilisation levels and those used in the SPS option four:

Service level

utilisation item Utilisation 2000/2001

Expected utilisation 2010 (option 5)

Gap

Usable Beds - Step Down - Level 1 - Level 2 - Tertiary - Psychiatric - TB - Special other

Total beds

- 11 191 5 556 2 355 3 617 3 117 237

________ 26 073

=======

4 456 7 286 3 766 956 2 259 2 740 1 201

________ 22 664

=======

4 456

( 3 905) ( 1 790) ( 1 399) ( 1 358) ( 377) 964

_________ ( 3 409)

======== Admissions

- Step Down - Level 1 - Level 2 - Tertiary - Psychiatric - TB - Special other

Total admissions

- 386 913 246 178 93 044 6 623 11 792 510

_________ 745 060

========

340 506 531 867 257 764 45 379 13 881 11 775 1 388

_________ 1 202 560

========

340 506 144 954

11 586 ( 47 665) 7 258

( 17) 878

__________ 457 500

========= Patient day equivalents and LOS


Total PDE’s & LOS

Patient days LOS

- - 2 646 949 6,8 1 407 907 5,7 613 009 6,6 997 089 150,5 780 329 66,2 58 474 114,7

_________ 6 503 757 ========

Patient days LOS

1 316 599 3 2 127 429 4 1 031 056 4 226 897 5

724 606 60 950 133 60

416 440 300 _________ 6 793 161 ========

Patient days

1 316 599 ( 519 520)

( 376 851) ( 386 112) ( 272 483) 169 804 357 966

___________ 289 403

==========


Service level utilisation item

Utilisation 2000/2001

Expected utilisation 2010 (option 5)

Gap

Out patient and casualty head count


Total OPD’s & Casualties OPD’s for patients in step downs, psychiatric , TB and special are treated in the level 1, 2 and tertiary hospitals.

- 2 339 984 1 884 674 445 068 4 726 23 785 166 121 ___________ 4 864 358 ==========

- 1 667 939 2 450 849 1 021 187 - - - ___________ 5 139 975 ==========

- ( 672 045) 566 175 576 119 ( 4 726) ( 23 785) ( 166 121) ___________ 275 617 ==========

Primary health care head counts

17 056 140 29 445 271 12 389 131

9.3 Key considerations for future configuration

In order to understand the impact of different trends on the future planning of health care services a sensitivity analysis was completed and the following tables demonstrate the impact of the sensitivity of variables on the finances of the department. Kindly note that all variables remain the same while only the “sensitivity variable” is adjusted. In practice however, changing of one variable might lead to a change in another variable. Sensitivity 1

MDR OPTION 5 4.5%

worst case

3%

worst case

2%

worst case

OPTION 1 1.6%

mid case Surplus / Deficit (729 452 000) (675 706 000) (640 120 000) (603 571 000) TB Beds 2 740 2 387 2 153 1 914 MDR Cases 2 030 1 350 900 438 TB recurrent cost 312 641 000 259 461 000 224 279 000 188 159 000 TB admission rate 1.4 1.32 1.27 1.21 Admissions 11 775 11 094 10 645 10 183 Inpatient days 950 133 827 697 746 697 663 537 If the success of the DOTS programme can be increased the MDR rate will decrease. A 1% decrease will save R35.586 million.


Sensitivity 2 Admission rate split between district and regional

ADMISSION

RATE

BEDS ADMISSION INPATIENT DAYS

SURPLUS / DEFICIT

District 68.22 7 862 573 930 2 295 722

Regional 25.64 3 152 215 708 862 831 (673 662 000)

District (Option 5) 63.22 7 286 531 857 2 127 429

Regional (Option 5) 30.64 3 766 257 764 1 031 056 (729 542 000)

District 58.22 6 710 489 801 1 959 204

Regional 35.64 4 381 299 837 1 199 348 (785 639 000)

District 53.22 6 133 447 736 1 790 946

Regional 40.64 4 996 341 902 1 367 607

(841 804 000)

Movement of admissions of 5/100 from regional to district represents a saving of R 56 million per annum. Sensitivity 3 Admissions per 1000

Admissions per 1000 TOTAL BEDS SURPLUS /

DEFICIT

145/1000 20 360 (315 601 000)

150/1000 20 936 (418 934 000)

155/1000 21 512 (522 368 000)

160/1000 22 089 (625 908 000)

165/1000 (Option 5) 22 665 (729 542 000)

Current 95.81 / 1000 HBC 21.90 / 1000 (HIV/AIDS) Step-Down 27.70 / 1000 (Length of stay) 145.41 / 1000 Actual increase between current and option 5 : 165 – 145.40 / 1000 – 19.6 / 1000 An additional admission rate of 5/1000 results in an additional 576 beds and an additional cost of R 104 million per annum.


Sensitivity 4 Length of stay of district beds

Length of Stay

BEDS INPATIENT

DAYS SURPLUS /

DEFICIT

3 Days 5 464 1 595 572 (402 276 000)

3.5 Days 6 375 1 861 501 (565 771 000)

4 Days(Option 5) 7 286 2 127 429 (729 542 000)

4.5 Days 8 196 2 393 358 (893 619 000)

5 Days 9 107 2 659 287 (1 058 041 000)

A reduction in length of stay by 0.5 days results in a saving of R 163 million per annum and a reduction of 911 beds. Sensitivity 5 Bed occupancy – district beds

BED OCCUPANCY

BEDS INPATIENT

DAYS SURPLUS /

DEFICIT

80% (Option 5) 7 286 2 127 429 (729 542 000)

78% 7 413 2 127 429 (736 684 000)

76% 7 669 2 127 429 (744 217 000)

74% 7 876 2 127 429 (752 173 000)

70% 8 327 2 127 429 (769 508 000)

Reduction in the number of usable beds by 1041 beds increases the required bed occupancy level form 70% to 80% with a saving of R 40 million per annum. Sensitivity 6 Admission rate split between district and step-down

RATE BEDS ADMISSION INPATIENT

DAYS SURPLUS /

DEFICIT

Step-down (Option 5) 27.70 2 253 233 030 699 090 District (Option 5) 63.22 7 286 531 857 2 127 429 (729 542 000)

Step-down 32.70 2 660 275 103 825 309 District 58.22 6 710 489 801 1 959 204 (651 373 000)

Step-down 37.70 3 067 317 168 951 503 District 53.22 6 133 447 736 1 790 946 (573 176 000)

Movement of admissions of 5/1000 from district to step down represents a saving of R 78 million per annum.


Sensitivity 7 Population

POPULATION INDIGENT INDIGENT

POPULATION SURPLUS /

DEFICIT

Option 5 9 560 153 88 % 8 412 935 (729 542 000)

9 560 153 90 % 8 604 138 (846 808 000)

9 560 153 92 % 8 795 341 (964 130 000)

9 560 153 94 % 8 986 544 (1 081 508 000)

11 000 000 88 % 9 680 000 (1 507 721 000)

A change per head of population represents R 613.00 per annum Sensitivity 8 Total transformation cost

TRANSFORMATION COST

SURPLUS / DEFICIT

(Option 5) R 5 billion (729 542 000)

R 6 billion (751 843 000)

R 7 billion (774 144 000)

(Option 1) R 8 billion (796 444 000)

9.4 Identification of options based on model scenarios

9.4.1 Option 1 – Model designed for health care delivery based on national averages

i. Provincial model prepared by NDoH team. ii. Using national norms and the national assessment of future KZN health care

delivery needs iii. Presumes a shift of patients towards primary health care iv. Focuses on transformation of health care facilities

v. Increases EMS allowance

9.4.2 Option 2 – Demand driven model

i. Achieved after workshopping with KwaZulu-Natal ii. Service configuration was designed based on demand identified by

KwaZulu-Natal Provincial Management team.


iii. Involves a rationalisation of services based on traditional level of care .

iv. Primary health care delivery cost increased to meet demand created by

poverty, lack of access and migration.

9.4.3 Option 3 – Appropriate level of care i. This option considered the three level of care within step-down facilities to

cater for: - Transit patients - Hospice patients - Pre- and post acute hospital patients

ii. Psychiatric services were redesigned to cater for:

- Custodial care - Acute care

iii. The capital cost for maintenance and replacement was brought in line with

the facilities audit in KwaZulu-Natal 9.4.4 Option 4 – Appropriate level of care plus improved access to primary

health care i. The percentage indigent population was reduced to 88% to be more realistic. ii. Admission rates were increased to take cognisance of epidemics and higher

demand due to socio-economic circumstances.

iii. MDR rate was adjusted to be more realistic.

iv. Primary health care allocation was increased to allow for extended hours of care and greater penetration in rural areas.

v. Transformation costs were brought in line with KZN facilities audit.

vi. Attention was given to increase access to appropriate level of care , to

improve efficiency.

9.4.5 Option 5 – Selected practical proposal i. The percentage indigent population was reduced to 88% to be more realistic. ii. The admission rate was increased to 165 per 1000.

iii. The split between district and regional beds was adjusted.

iv. Lengths of stay was adjusted.


v. Bed occupancy for transit beds was adjusted.

vi. Transformation costs of building were adjusted.

vii. Hours of work of primary health care clinics should be extended.

9.5 Meeting provincial priorities (What are the ten-year objectives; What can be done; What options are available)

Presenting the Provincial Parliament Health Vote, the Minister of Health Dr ZL Mkhize, identified the following strategic objectives:

• Mission

To develop a sustainable, coordinated, integrated and comprehensive health system at all level of care , based on the primary health care approach through the district health system.

The following priorities were identified:

1. To continue to develop and upgrade basic services in under-served areas through the primary care approach. The aim is to provide quality service at a rate of 2.8 visits per non-medical aid member of the population per annum.

The current visits are 2.12 visits per annum. The additional visits per annum are projected visits by the year 2010 and allows for changes in healthcare demand largely due to the impact of HIV/AIDS. Comment: • Options 4 and 5, allow for 3.5 visits per annum, of the non

medical-aid population. Access to primary care will be improved through extended clinic hours and provision of clinics in under-served areas.

2. To ensure that quality services are provided at clinics.

Comment: • The extended clinic hours will assist in this • Better provision of drugs at clinic level will be achieved by the

greater allocation of funds to primary health care services • Taking into consideration the lack of infrastructure at local

authority level, interim provision of care by the Province is envisaged.

• The inability of communities to provide home-based care is accommodated in an interim arrangement of providing hospice-type of step-down beds at clinics or in communities.

3. A shift towards equity within districts

Comment: • The extension of services into the rural areas and the capital

transformation programme will achieve this. • Rationalisation of services in areas of over supply will take place


• The transformation of facilities must be complemented by a process of skills development, and a retention policy for KwaZulu-Natal staff members.

3. Extend services to provide access to all

• Due to poor infrastructure and deep rural demographics access by ± 2 million is extremely limited. If they have access, utilisation will increase substantially.

Additional aspects towards achieving the health objectives in KwaZulu-Natal

1. Equity of access to various level of care will be achieved through provision of care based on KwaZulu-Natal health care needs.

2. Appropriate utilisation of health care services is promoted

3. Efficiency of care is promoted

4. An integrated, coordinated service will be provided throughout the entire

spectrum of care pathways.

5. Development of managerial capacity at central and institutional level, will be required if these objectives are to be met. - Only through proper case and disease management can this model

be sustained. 6. The development of a strong district model of delivery is a pre-requisite for

the successful implementation of the health care delivery model. Education and consultation of communities will be an integral part of the implementation process.

Targets for expenditure

TARGET BUDGET 2001/2002

• Administration 2% 1,8% • District hospital care 22% 25,7% • Primary health care 26% 19,6% • Emergency medical rescue services 4% 2,6% • Regional hospital services 18% 25,7% • Specialised hospital services 6% 5,5% • Central hospital services 11% 8,5% • Health sciences (Training) 3% 2,5% • Capital and maintenance 8% 8,1%

100% 100%


Option 5 will achieve the following:

TARGET Option 5 • Step-down - 2,70% • District hospital care 22% 19,19% • Primary health care 26% 29,81% • Emergency medical rescue services 4% 3,73% • Regional hospital services 18% 19,81% • Specialised hospital services 6% 7,39% • Central hospital services 11% 11,45% • Capital & Maintenance 8% (10,56%

included in other costs)

• Other Admin & health services 2% 3.49% • Health sciences (Training) 3% 1,75% • Transformation costs - 0,68%

100% 100%


CHAPTER 10 – OPTIONS FOR CLOSING THE GAP

10.1 Option 1 – Model designed for health care delivery based on national averages

This option is based on the provincial model prepared by the NDoH KPMG team according to their assessment of the KZN health services in 2010

10.1.1 Option description

Transfer of patients to step-down facilities. Step-down facilities have not been defined by the NDoH, but the service is assumed to be for patient care in a facility which provides nursing at a rate lower than laid down for a level 1 hospital.

The PHC and HBC services are rendered at increased rates using per capita utilisation rates and per capita costs per annum.

HIV/AIDS and TB disease profiles will show an increase in infected persons per 1000 head of population and the option reflects the increases as projected by NDoH based on the ABT Associates study on HIV/AIDS and TB projections to 2010.

10.1.2 Principles underlying the option configuration

Hospitals are to provide an acute hospital service, transferring chronic patients to their homes under home-based care services. Step-down facilities to be used for pre- and post-hospital care.

Facilities are to be transformed and upgraded to the level of service, which they provide. This will include building new institutions, closing down present institutions and reclassifying existing buildings so that the facilities are appropriate to the level of care provided in the facility. The cost has been estimated and the option reflects that the process will take some 20 years to complete, with an annual capital allocation equal to 1/20th of the total cost.

The priority of funds allocation is:

• The transformation of health care facilities to provide the defined services. • The focus on primary health care including home based care services. • The provision only of optimal central hospital services. • The upgrading of emergency medical services. • The optimal treatment of HIV/AIDS and TB patients according to acute hospital

care for HIV/AIDS related incidents only and home based care services for chronic care.

• The allocation of remaining resources to the provision of level 1, level 2 and specialist hospital services as well as the introduction of step-down facilities, which indicates focusing on acute care in level 1 and 2 hospitals and chronic care in other institutions.

The population served by the public sector health care services for the Province is as suggested by NDoH at 86% of the projected population in 2010 after allowing for HIV/AIDS pandemic. (8 221 732)


10.1.3 Number of Hospitals (and level)

The existing hospital numbers and level at the date of this report is as follows: HOSPITALS BEDS

District 42 11 191 Regional 10 5 556 Tertiary 3 2 355 Psychiatric 4 3 617 TB 12 3 117 Specialised other 3 237 Total 74 26 073

Current practice is to admit PHC patients into regional hospitals as well as into tertiary hospitals. The total number of beds on these two levels is an over estimate of real utilized admission practices and can therefore not be compared to projected beds. The hospital strategic plan (The KwaZulu-Natal Hospital Strategic plan) anticipates the restructuring and reclassification of hospital services to be as follows:

2008 2013 District Hospitals 14 098 15 428 Beds Regional Hospitals 5 300 5 800 Beds Tertiary Hospitals 1 060 1 160 Beds Central Hospitals 720 785 Beds Specialised Hospitals 4 240 4 640 Beds Total Beds 25 418 27 813 Beds

The option does not determine how many hospitals will be included in the 2010 structure. The Department’s task is to determine and plan the hospital levels during the planning phase taking into account the transformation of existing premises, building new premises and closing down existing premises. Critical to these calculations will be the placement of facilities close to the population so as to manage health care services to the public and manage the cost of providing these services.

10.1.4 Number of Beds


Existing usable beds Option 1 Beds / 1000

Projected beds Step downs 0 3455 0.42 Level 1 hospitals 11191 3488 0.42 Level 2 hospitals 5556 3518 0.43 Tertiary 2355 1426 0.17 Psychiatric hospitals 3617 3798 0.46 TB hospitals 3117 683 0.08 Special unclassified 237 855 0.10 Total beds 26073 17223 2.09


Note : Projected beds are calculated by using the following assumptions:

1 Population 2 Admission rate 3 Length of stay 4 Bed occupancy rates

10.1.5 Estimated activity

The following table is the estimate of service utilisation by service level: Service level Admission rate

per 1000 Admissions Patient days Out patient

head counts Home based care 19.72 visits 162 156 - -

Step downs 26.07 214 372 1 071 862 631 301

Level 1 hospital 43.87 360 719 1 082 158 1 616 939 Level 2 hospital 36.88 303 210 1 091 556 1 260 981 Tertiary 10.76 88 495 442 474 456 323 Psychiatric 2.67 21 952 1 317 121 4 726 TB 0.50 5 699 236 753 23 785 Special 2.23 18 293 296 352 166 121 Totals 142.70 1 174 896 5 538 276 3 528 875

Note: Out patient head counts for step-downs, TB, psychiatric and special hospitals are not in respect of OPD services conducted in those institutions. They have been included under these levels to indicate source of OPD visits in the other hospitals.

10.1.6 PHC Structure required to support the option

The primary health care services are to be improved to allow for services in community health centres, clinics and through home based care.

Costs have been included at rates arising from national studies and have not been compared with actual costs incurred in the Province. The rates applied are as follows:

Community health centre and clinic visits: • Estimated cost per capita per annum R 173,50 • Estimated visits per capita per annum 2,45 • Estimated cost per visit R 71,00 • Estimated cost per additional HIV/AIDS visit R 30,26 • Estimated additional HIV/AIDS visits per annum 1 753 615

Home based care • Total team cost per annum R591 360 • Patient visits per annum per team 384 (32 per month) • Cost per patient under HBC R 1 540 • Estimated patient visits pa 162 156 (141 553

HIV/AIDS)


The total cost for PHC in the option is made up as follows: • Core package per capita R 1 426 470 000 • Additional HIV/AIDS clinic visits R 58 176 000 • Additional HIV/AIDS HBC admissions R 217 956 000 • Capital transformation per annum over 20 years R 78 336 000 • Total cost for PHC per annum R 1 780 938 000

10.1.7 Estimated running costs

The estimated running costs for this option are set out in the following table:

Category Expenditure R0,000 Comments

Tertiary care 851 373

Includes maintenance and replacement costs with a total rate per admission of R 7 159,43

Step-down care 469 331 Includes maintenance and replacement costs with a total rate per admission of R 1 587,37

Level 1 hospital care 994 114 Includes maintenance and replacement costs with a total rate per admission of R 1 839,66

Level 2 hospital care 1 306 659 Includes maintenance and replacement costs with a total rate per admission of R 3 111,33

Psychiatric hospital care 538 229 Includes maintenance and replacement costs with a total rate per admission of R 24 489,15

TB hospital care 108 575 Includes maintenance and replacement costs with a rate per admission of R 8 100 for re-treatment patients and R73 214 for MDR patients.

Special unclassified care 162 686 Includes maintenance and replacement costs with a total rate per admission of R 7 493,07

Total hospital care

____________ 4 430 967

Primary health care 1 780 939 See calculations above Emergency Medical Services 394 015 National project cost input Management 323 200 At national input rates Training 57 286 At national input rates including

information systems Capital Transformation 196 132 See 10.1.8 for details Total running costs per annum

____________ 7 182 539

Capital transformation costs are treated as running costs.

Funding 7 658 128 Funding envelope plus conditional grant of R878 708

Surplus

___________ 475 589

==========

This surplus is available for increasing services and contingencies.


10.1.8 Capital and Equipment costs

The National Department of Health has carried out a study of the expected maintenance, replacement and transformation costs for each Province. The option includes the rates recommended by the National Department of Health without any testing for validity in the province.

The calculations are based on rates per square meter for constructing and equipping a new institution at the particular level of care. These rates are then used to determine maintenance costs, replacement costs and transformation costs. These annualised costs are then included in running costs based on life spans of 40 years for buildings and 10 years for equipment. Transformation costs are assumed to be expended over 20 years in equal proportions per annum measured in 2001 Rc. It is assumed in the option that replacement expenditure is deducted from the transformation cost as a first charge and where replacement costs exceed the estimated transformation cost then there is no charge for transformation.

The following table demonstrates how these costs have been included in the running costs as set out above (costs are reflected at cost per admission):

Category Maintenance @ 4,5% for buildings and 10% for equipment

Replacement @ 2,5% for buildings and 10% for equipment

Transformation cost @ proportionate rate of total estimates by NDoH

Nett transformation cost included in running cost

Step downs 116.04 77.36 339.07 261.71 Level 1 226.27 156.65 349.67 193.02 Level 2 556.97 408.44 3.83 0.00 Tertiary 1531.02 1208.70 1567.92 359.21 Psychiatric 3374.19 2335.98 381.05 0.00 TB 622.93 415.28 6500.14 6084.86 Special 911.03 630.71 1378.43 747.72

10.1.9 What interventions are required to make the option viable

The geographical and terrain conditions which apply to the Province are of such a nature that access to institutions by the public and the professional will be difficult to implement.

Cooperation by the departments of roads and water affairs are essential for the success of the option and as these departmental expenditures are also subject to availability of funds the problem is exacerbated. The situation can be described as “deep rural” conditions of providing services. Staff is reticent to take up residence in these deep rural areas because of the demands that are then made on their own lifestyle.

The rural staffing situation needs to be approached in a pro-active manner with a view to encouraging professional staff to take up posts in the rural institutions. This will require compensation outside the present criteria adopted by the State for its employees. Therefore special representations need to be made by the health authorities to central government for special dispensation for rural health workers.


This option is therefore considered to be the base model from which the other options are developed.

10.1.10 Benefits assessment

Advantages

i. Primary health care and hospital services are developed together.

ii. A comprehensive framework of hospital and primary health care services are developed.

iii. Planning of service delivery and health care provision is integrated.

iv. There is a move towards equity of access to health care.

v. There is the opportunity for better management of referrals

vi. Patients will make greater use of primary health care facilities, with reduction of workload on higher level of care , and bringing savings about.

vii. Rationalisation of services according to national priorities

Disadvantages

i. Underestimates the impact of various epidemics and violence in KwaZulu-Natal.

ii. Does not take cognisance of poverty in deep rural areas on health care demand and lack of infrastructure on health care service delivery.

iii. Will take time to implement.

iv. There will be a need for a well functioning primary health care and district health care service. Not enough attention to improve efficiency on this level of care.

v. No attention to improving efficiency in hospital services

vi. The cost of restructuring is higher than in other alternatives, which impacts on available resources for service delivery.

vii. No cognisance of patient preference and home environment constraints

viii. Will need a considerable public relations exercise and education of communities.

ix. Clinical skills shortages in rural areas could make implementation impossible.


10.1.11 Funding issues

The option reflects an excess of income over expenditure and the provincial management will in planning for the introduction of services utilise this surplus in additional service delivery.

10.1.12 Priority development issues

Priorities have been set by NDoH as described in paragraph 10.1.2 above and as this is a base option the Province has not set any further priorities for consideration in this option. Further options will have a greater emphasis on provincial priorities.

10.2 Option 2 – Demand driven model

Using option 1 as a base the Provincial management in consultation with the SPS team prepared a second option, which focuses on volumes by service levels, considered being more appropriate to the provincial needs.


Transfer of patients to step-down facilities. Step-down facilities have been defined for this purpose of this option as those institutions, which provide cost-effective non-acute and sub-acute care to patients. The service involves pre- and post- acute hospitalisation and nursing care where the patient needs supervision other than home care.

The PHC and HBC services are rendered at increased rates. HBC is a problem in the deep rural areas due to lack of infrastructure and this leads to greater use of step-down facilities. Nevertheless the option uses per capita utilisation rates and per capita costs per annum along the same principles applied by NDoH.

HIV/AIDS and TB disease profiles show an increase in infected persons per 1000 head of population and the option reflects the increases as projected by NDoH based on the ABT Associates study on HIV/AIDS and TB projections to 2010.


Hospitals are to provide an acute hospital service, transferring chronic patients to their homes under home-based care services. Step-down facilities to be used for pre- and post-hospital care.



• The transformation of health care facilities to provide the defined services. • The focus on primary health care including home based care services. • The provision only of optimal central hospital services. • The upgrading of emergency medical services.


• The optimal treatment of HIV/AIDS and TB patients according to acute hospital care for HIV/AIDS related incidents only and home based care services for chronic care.

• The allocation of remaining resources to the provision of level 1, level 2 and specialist hospital services as well as the introduction of step-down facilities, which indicates focusing on acute care in level 1 and 2 hospitals and chronic care in other institutions.

The population served by the public sector health care services for the Province is as suggested by KZN DoH at 95% of the projected population in 2010 after allowing for HIV/AIDS pandemic. (9 082 145)

10.2.3 Number of hospitals and level

HOSPITALS BEDS


The hospital strategic plan anticipates the restructuring and reclassification of hospital services to be as follows:


The option does not determine how many hospitals will be included in the 2010 structure. The department’s task is to determine and plan the hospital levels during the planning phase taking into account the transformation of existing premises, building new premises and closing down existing premises. Critical to these calculations will be the placement of facilities close to the population so as to manage health care services to the public and manage the cost of providing these services.

10.2.4 Number of beds



Existing usable beds Option 2 Beds / 1000 Projected beds

Step downs 0 5445 0.42 Level 1 hospitals 11191 3732 0.42 Level 2 hospitals 5556 4448 0.43 Tertiary 2355 804 0.17 Psychiatric hospitals 3617 2043 0.46 TB hospitals 3117 2153 0.08 Special unclassified 237 424 0.10 Total beds 26073 19050 2.09 Note : Projected beds are calculated by using :


10.2.5 Estimated activity The following table is the estimate of service utilisation by service level:

Service level Admission rate



Step downs 31.00 281 547 1 689 278 -

Level 1 hospital 40.00 363 286 1 089 857 1 800 616 Level 2 hospital 33.52 304 434 1 217 734 2 645 803 Tertiary 4.20 38 145 190 725 1 102 418 Psychiatric 1.30 11 807 708 407 - TB 1.30 10 645 746 700 - Special .18 1 635 147 131 - Totals 130.00 1 179 516 5 789 832 5 548 837

10.2.6 PHC structure required to support the option



Community health centre and clinic visits:

• Estimated cost per capita per annum R 173,50 • Estimated visits per capita per annum 2,45 • Estimated cost per visit R 71,00 • Estimated cost per additional HIV/AIDS visit R 30,26 • Estimated additional HIV/AIDS visits per annum 1 753 615


Home based care

• Total team cost per annum R591 360 • Patient encounters per annum per team 384 (32 per month) • Cost per patient encounters R 1 540 • Estimated patient encounters pa 168 017 (HIV/AIDS

94 368)

The total cost for PHC in the option is made up as follows: • Core package per capita R 1 575 752 000 • Additional HIV/AIDS clinic visits R 58 176 000 • Additional HIV/AIDS HBC encounters R 145 304 000 • Capital transformation per annum over 20 years R 78 336 000 • Total cost for PHC per annum R 1 857 568 000 • Additional cost to cater for poverty and migrants R 171 106 000 • Total cost for option R 2 028 674 000

In view of the deep rural and poverty situation in the Province it was felt that the national proposed costs were too low and that in transferring patients from hospital OPD’ to PHC that the running costs should be increased to cater for contingencies to be met.

10.2.7 Estimated running costs The estimated running costs for this option are set out in the following table:

Category Expenditure

R0,000 Comments


Includes maintenance and replacement costs with a total rate per admission of R 10 245 Exceeds conditional grant of R878 708.

Step-down care 319 258 Includes maintenance and replacement costs with a total rate per admission of R 1 134

Level 1 hospital care 1 007 618 Includes maintenance and replacement costs with a total rate per admission of R 1 789


Psychiatric hospital care 204 066 Includes maintenance and replacement costs with a total rate per admission of R 17 284


Special unclassified care 41 350 Includes maintenance and replacement costs with a total rate per admission of R 25 294

Total hospital care

____________ 4 521 719

Primary health care 2 028 674 See calculations above Emergency Medical Services 337 845 Estimated at the provincial rate in their

priority for the current year.


Category Expenditure R0,000

Comments

Management 292 526 Estimated to increase management capacity and information systems to manage change and measure performance.

Training 146 496 Based on 2001 expenditure. Capital Transformation 182 882 See 10.2.8 for details Total running costs per annum

____________ 7 510 142



Surplus

___________ 147 986

==========


10.2.8 Capital and equipment costs

The National Department of Health has carried out a study of the expected maintenance, replacement and transformation costs for each Province. The option includes the rates recommended by the National Department of Health without any testing for validity in the Province, but subject to a change in life expectancy levels.

The calculations are based on rates per square meter for constructing and equipping a new institution at the particular level of care . These rates are then used to determine maintenance costs, replacement costs and transformation costs. These annualised costs are then included in running costs based on life spans of 30 years for buildings and 8 years for equipment. Transformation costs are assumed to be expended over 20 years in equal proportions per annum measured in 2001 Rc. It is assumed in the option that replacement expenditure is deducted from the transformation cost as a first charge and where replacement costs exceed the estimated transformation cost then there is no charge for transformation.


Category Maintenance @ 4,5% for buildings and 10% for equipment

Replacement @ 2,5% for buildings and 10% for equipment

Transformation cost @ proportionate rate of total estimates by NDoH


Step downs 104.43 90.65 375.18 284.52 Level 1 172.60 159.25 378.81 219.56 Level 2 555.25 560.12 330.05 0.00 Tertiary 2 276.68 2 458.73 38.33 0.00 Psychiatric 1 912.04 1 715.93 2527.66 811.72 TB 934.39 811.10 1948.41 1137.31 Special 2 219.18 1 881.76 560.40 0.00


10.2 9 What interventions are required to make the option viable (staff, equipment, transport etc.)

The geographical and terrain conditions, which apply to the Province, are of such a nature that access to institutions by the public and professionals mean that this option will be difficult to implement.

Cooperation by the departments of roads and water affairs are essential for the success of the option and as these departmental expenditures are also subject to availability of funds the problem is exacerbated. The situation can be described as “deep rural” conditions of providing services. Staff are reticent to take up residence in these deep rural areas because of the demands that are then made on their own lifestyle.

The province will need to build 200 new and replacement clinics and step-down facilities near hospitals to accommodate patients who do not need to be in hospital but have no support infrastructure or are distant from their homes and require follow up consultations before being sent home.



Advantages




iv. There is a move toward equity of access to health care.

v. There is opportunity for better management of referrals



viii. Focuses on volumes by service levels, more appropriate to KwaZulu-Natal needs.

ix. More consideration of local KwaZulu-Natal conditions and KwaZulu-Natal demand patterns

x. Hospital service delivery is rationalised in accordance with health needs.


xi. Management delegations will be decentralised, allowing for integrated management autonomy.

Disadvantages

i. The different costs for different types of service in step-down and psychiatry were not taken into consideration,

ii. High indigent population makes for unwieldy future planning.

iii. The assumed 95% indigent population figure to compensate for poverty levels, migration and poor access makes future planning unwieldy

iv. This model still uses national norms for transformation costs. It is not tailored to KwaZulu-Natal needs.

10.2.11 Funding issues The option reflects an excess of R 147 986 income over expenditure and the provincial management will in planning for the introduction of services utilise this surplus in additional service delivery.

10.2.12 Priority development issues The priorities are based on the NDoH priorities amended to include the KZN DoH perceived service requirements. The development of services for, and implementation of this option, will be dependent on various critical issues as described in paragraphs 11 and 13 hereto.

10.3 Option 3 – Appropriate level of care

Option number 2 was discussed with provincial management and it was felt that the option did not cater for three specific problem areas. The option components for step-downs and psychiatric needed to be further broken down and the capital costs were not appropriate to the provincial situation.

Step-downs as defined are for the hospital patients both pre- and post- hospital treatment. The accommodation of patients who experience transport problems needed to be addressed as well as the accommodation of terminally ill patients. It was decided to test the situation by introducing 3 level of care in step-downs, namely Transit , step-down and hospice.

The cost of hospitalisation of custodial psychiatric patients is substantially different from that of acute psychiatric patients. It was decided to identify costs for each type of patient in the option.

Capital costs to be used in the transformation were tested by institution as described in paragraph 7 hereto. With this detailed knowledge it was decided to prepare the option with these adjusted variables.



Transfer of patients to step-down facilities. Step-down facilities have been defined for this purpose of this option as those institutions, which provide cost-effective non-acute and sub-acute patient care. The service involves pre- and post- acute hospitalisation and nursing care where the patient needs supervision other than home care.

Patients who travel distances and require accommodation before and after hospitalisation should not be accommodated in hospitals or step-down facilities. The transformation process to include the provision of Transit facilities of a domestic nature to accommodate these patients.

Patients who are terminally ill and cannot be nursed in their own homes should not be accommodated in hospitals or step-down facilities as these institutions should focus on acute care. In order to accommodate the terminally ill the Province needs to develop hospice type accommodation with nursing staff qualified to nurse terminally ill patients and to counsel their families. The health care workers in these institutions could be trained community members who do not necessarily have to have a nursing qualification, but who are employed under supervision from qualified professional nurses.




Hospitals are to provide an acute hospital service, transferring chronic patients to their homes under home-based care services. Step-down facilities to be used for pre- and post-operation care. Transit facilities are to be developed to accommodate patients between their homes and admission or discharge from hospital and step-down facilities. Hospices are to be developed to accommodate terminally ill patients who cannot be nursed in their homes.



• The transformation of health care facilities to provide the defined services. • The focus on primary health care including home based care services. • The provision only of optimal central hospital services.


• The upgrading of emergency medical services. • The optimal treatment of HIV/AIDS and TB patients according to acute hospital

care for HIV/AIDS related incidents only and home based care services for chronic care.

• The allocation of remaining resources to the provision of level 1, level 2 and specialist hospital services as well as the introduction of step-down facilities, Transit facilities and hospices. This approach involves focusing on acute care in level 1 hospitals, level 2 hospitals and step-down facilities and chronic care at home or in other institutions.

The population served by the public sector health care services for the Province is as suggested by KwaZulu-Natal DoH at 95% of the projected population in 2010 after allowing for HIV/AIDS pandemic. ( 9 082 145)


The existing hospital numbers and level at the date of this report is as follows:

HOSPITALS BEDS




The option does not determine how many hospitals will be included in the 2010 structure. The department’s task is to determine and plan the hospital levels during the planning phase taking into account the transformation of existing premises, building new premises and closing down existing premises. Critical to these calculations will be the placement of facilities close to the population so as to manage health care services to the public and manage the cost of providing these services.

10.3.4 Number of beds




Step downs 0 4629 0.42 Transit 689 Step-down acute beds 3750 Hospice beds for terminally ill 190 Level 1 hospitals 11191 3732 0.42 Level 2 hospitals 5556 4448 0.43 Tertiary 2355 804 0.17 Psychiatric hospitals 3617 1820 0.46 Custodial 864 Acute 956 TB hospitals 3117 2740 0.08 Special unclassified 237 424 0.10 Total beds 26073 18599 2.09 Note : Projected beds are calculated by using :

1 Population 2 Admission rate 3 Length of stay 4 Bed occupancy rates 10.3.5 Estimated activity

The following table is the estimate of service utilisation by service level:




Step downs

Transit Step down Hospice

9.00 21.35

0.65

81 739 193 904 5 903

163 479 1 163 423

59 034

-

Level 1 hospital 40.00 363 286 1 089 857 1 800 616 Level 2 hospital 33.52 304 434 1 217 734 2 645 803 Tertiary 4.20 38 145 190 725 1 102 418 Psychiatric Custodial Acute

0.275

1.025

2 498 9 309

299 711 279 276

-

TB 1.30 11 775 950 134 - Special .18 1 635 147 131 - Totals 130.00 1 180 645 5 560 504 5 548 837





Community health centre and clinic visits:

• Estimated cost per capita per annum R 173,50 • Estimated visits per capita per annum 2,45 • Estimated cost per visit R 71,00 • Estimated cost per additional HIV/AIDS visit R 30,26 • Estimated additional HIV/AIDS visits per annum 1 753 615

Home based care

• Total team cost per annum R591 360 • Patient encounters per annum per team 384 (32 per month) • Cost per patient encounter R 1 540 • Estimated patient encounter pa 168 017 (HIV/AIDS

94 368)








Step-down care Transit Step down Hospice

17 566

232 402 10 649

Includes maintenance and replacement costs with a total rate per admission of Transit R 215 Step-down R 1 057 Hospice R 1 804




Category Expenditure R0,000 Comments Psychiatric hospital care Custodial Acute

64 823 83 446

Includes maintenance and replacement costs with a total rate per admission of Custodial R25 954 Acute R 8 963


Special unclassified care 44 056 Includes maintenance and replacement costs with a total rate per admission of R 26 949

Total hospital care

____________ 4 586 070

Primary health care 2 028 674 See calculations above Emergency Medical Services

337 845 Estimated at the provincial rate in their priority for the current year.

Management 292 526 Estimated to increase management and information system capacity to manage change and measure performance.


____________ 7 436 731



Surplus

___________ 221 397

==========



The National Department of Health has carried out a study of the expected maintenance, replacement and transformation costs for each Province. The option has been amended from the NDoH figures in accordance with studies done by the consulting team in conjunction with the provincial management.

The calculations are based on rates per square meter for constructing and equipping a new institution at the particular level of care . These rates are then used to determine maintenance costs, replacement costs and transformation costs. These annualised costs are then included in running costs based on life spans for buildings and equipment. Transformation costs are assumed to be expended over 20 years in equal proportions per annum measured in 2001 Rc. It is assumed in the option that replacement expenditure is deducted from the transformation cost as a first charge and where replacement costs exceed the estimated transformation cost then there is no charge for transformation.



Category Maintenance of buildings and equipment

Replacement of buildings and equipment

Transformation cost @ proportionate rate of total estimates


Step downs Transit Step down Hospice

25.29 89.35

129.96

31.61

111.68 162.45

68.74

217.62 337.18

37.13

105.93 174.73

Level 1 162.74 183.08 198.88 15.80 Level 2 671.85 618.81 64.62 0.00 Tertiary 2 660.17 2 873.64 1767.11 0.00 Psychiatric Custodial Acute

3 197.69

949.32

3 997.12 1 186.64

7 111.17 1 938.00

3 114.05

751.35 TB 839.39 1 049.24 124.46 0.00 Special 1 918.62 2 398.27 2 197.46 0.00

10.3 9 What interventions are required to make the option viable (staff, equipment, transport, etc.)

The geographical and terrain conditions, which apply to the Province, are of such a nature that access to institutions by the public and professionals mean that this option will be difficult to implement.


The Province will need to build 200 new clinics, step down facilities, Transit and hospice facilities near hospitals to accommodate patients who do not need to be in hospital but have no support infrastructure or are distant from their homes and require follow up consultations before being sent home.



Advantages









viii. Service delivery is in line with provincial objectives and priorities.

ix. There is opportunity for better management of referrals.

x. Lengths of stay in hospitals are reduced, by utilising more appropriate, more cost effective types of accommodation.

xi. Better utilisation of scarce resources.

xii. This model has the potential for improving delays due to inter-hospital transfers.

xiii. Gives more attention to improving efficiency.

xiv. Redesigned services to provide care where it is best needed.

xv. Takes into consideration patient preference, and constraints regarding socio-economic circumstances.

Disadvantages

i. The assumed 95% indigent population figure to compensate for poverty levels, migration and poor access makes future planning unwieldy

ii. This model still uses national norms for transformation costs. It is not tailored to KwaZulu-Natal needs.

10.3.11 Funding issues

The option reflects an excess of income of R 221 397 over expenditure and the

Provincial management will in planning for the introduction of services utilise this surplus in additional service delivery.

10.3.12 Priority development issues The priorities are based on the NDoH priorities amended to include the KwaZulu-Natal DoH perceived service requirements. The development of services for, and implementation of this option, will be dependent on various critical issues as described in paragraphs 11 and 13 hereto.


10.4 Option 4 – Appropriate level of care plus improved access to primary health care

Option three was evaluated and the SPS team felt that some of the variables should be reconsidered. These included

• Amending the utilisation formula for hospital admissions by changing the indigent

population to 88% (from 95%) of the total population. (8 412 934) • Increasing the hospital admission rate to 145 (from 130) per 1000 head of population.

Increasing the total cost of PHC from R2 billion to R2,5 billion. • Increasing the MDR hospital admission rate to 4.5% from the initial 1,6%. • Reducing the transformation costs for hospital services to R5 billion from R7,979

billion, and • Reducing the transformation cost for clinics and community health centres to R0,5

billion from R1,567 billion.



Patients who travel distances and require accommodation before and after hospitalisation should not be accommodated in hospitals or step-down facilities. The transformation process to include the provision of Transit facilities of a domestic nature to accommodate these patients.

Patients who are terminally ill and cannot be nursed in their own homes should not be accommodated in hospitals or step-down facilities as these institutions must focus on acute care. In order to accommodate the terminally ill the Province needs to develop hospice type accommodation with nursing staff qualified to nurse terminally ill patients and to counsel their families. The health care workers in these institutions could be trained community members who do not necessarily have to have a nursing qualification, but who are employed under supervision from qualified professional nurses.




Hospitals are to provide an acute hospital service, transferring chronic patients to their homes under home-based care services. Step-down facilities to be used for pre- and post-operation care. Transit facilities are to be developed to accommodate patients


between their homes and admission or discharge from hospital and step-down facilities. Hospices are to be developed to accommodate terminally patients who cannot be nursed in their homes. TB hospitals are to be upgraded to cater for an increase in MDR patients to 4%. The PHC facilities and services to be increased to cater for a greater utilisation by the public.




hospital care for HIV/AIDS related incidents only and home based care services for chronic care.


The population served by the public sector health care services for the Province is as suggested by the equity study at 88% of the projected population in 2010 after allowing for HIV/AIDS pandemic.


HOSPITALS BEDS District 42 11 191

Regional 10 5 556 Tertiary 3 2 355 Psychiatric 4 3 617 TB 12 3 117 Specialised other 3 237 Total 74 26 073




The option does not determine how many hospitals will be included in the 2010 structure. The Department’s task is to determine and plan the hospital levels during the planning phase taking into account the transformation of existing premises, building new premises and closing down existing premises. Critical to these calculations will be the placement of facilities close to the population so as to manage health care services to the public and manage the cost of providing these services. For the care model as outlined in option 4, a combination of the structural and functional approach was used, i.e.:

• Hospitals were still classified according to level of care .

• Patients were devolved to the lowest appropriate level of care.

• Low cost facilities such as step-down facilities, transit facilities and hospice

facilities are proposed.

• These facilities could be linked to existing district and regional hospitals.

• Case managers should be appointed.

• Careful attention should be given to:

- Reduce duration of stay. - Reduce staff levels where low cost beds are created. - Ensure patients receive care according to their medical condition and

acuity level and not according to the type of hospital. 10.4.4 Number of beds



Step downs 0 4892 0.42 Transit 745 Step-down acute beds 3950 Hospice beds for terminally ill 197 Level 1 hospitals 11191 3872 0.42 Level 2 hospitals 5556 4622 0.43 Tertiary 2355 840 0.17 Psychiatric hospitals 3617 1985 0.46 Custodial 1 041 Acute 944 TB hospitals 3117 2740 0.08 Special unclassified 237 459 0.10 Total beds 26073 19410 2.09


Note : Projected beds are calculated by using :







Step downs


10.50 24.275

0.725

88 336 204 224 6 099

176 672 1 225 344 60 994

-


0.36 1.09

3 008 9 191

360 915 275 734

-

TB 1.45 11 775 950 133 - Special 0.21 1 767 159 004 - Totals 145.00 1 219 452 5 804 186 5 139 975



Costs have been included at costs incurred by the Province in the 2000/2001 financial year adjusted upwards to account for the additional utilisation by the public due to increase in number of clinics and transfer of patients from hospital out patient departments. The rates applied are as follows:

Community health centre and clinic visits: • Estimated cost per capita per annum R 242,36 • Estimated visits per capita per annum 3,50 • Estimated cost per visit R 69,25 • Estimated cost per additional HIV/AIDS visit R 69,25 • Estimated additional HIV/AIDS visits per annum 1 753 615


Home based care • Total team cost per annum R591 360 • Patient encounters per annum per team 384 (32 per month) • Cost per patient encounter R 1 540 • Estimated patient encounter pa 161 950 (HIV/AIDS

94368) • Teams required 245

Transformation costs are estimated at a lower value and the cost per annum has been adjusted accordingly at R25 000 000.









18 984

244 771 11 003

Includes maintenance and replacement costs with a total rate per admission of Transit R 215 Step-down R 1 199 Hospice R 1 804



Psychiatric hospital care Custodial Acute

78 061 82 388


TB hospital care 312 642 Includes maintenance and replacement costs with a rate per admission of R 15 794for re-treatment patients and R78 182 for MDR


Category Expenditure R0,000 Comments patients.

Special unclassified care

47 612 Includes maintenance and replacement costs with a total rate per admission of R 26 949

Total hospital care

____________ 4 583 546



Management 292 526 Estimated to increase management capacity to manage change and measure performance.


____________ 7 879 258



Deficit

___________ (221 130)

==========

This shortfall is to be covered by planning for reduced services.










Buildings and equipment


25.29 89.35

129.96

31.61

111.68 162.45

68.44

216.66 335.70

36.82

104.98 173.25


3 197.69

949.31

3 997.11 1 186.64

7 079.91 1 963.18

3 082.80

776.54 TB 839.39 1 049.24 119.93 0.00 Special 1 918.62 2 398.27 2 394.51 0.00

10.4.9 What interventions are required to make the option viable (staff, equipment, transport etc.)

The geographical and terrain conditions which apply to the Province are of such a nature that access to institutions by the public and the professional are of such a nature that this option will be difficult to implement.






Advantages








viii. Improved access to primary health care facilities.

ix. Demand for primary health care is met by supply across the Province

x. Better utilisation of resources in primary health care facilities.

xi. Greater patient satisfaction with improved service delivery and access.

xii. Greater efficiency in higher level of care due to reduced bottlenecks.

xiii. Patients will access health care delivery system at most appropriate level of care. This will save costs.

xiv. Investment in underdeveloped areas.

xv. A more realistic figure was used for capital and transformation costs, allowing more finances available for service delivery.

xvi. Service delivery is in line with provincial priorities.

xvii. Improved equity of access

xviii. More realistic indigent population figures at 88%, with more realistic utilisation figures, tailored to meet demand due to poverty levels, and migratory problems.

Disadvantages

i. Requires intersectoral cooperation with other departments for provision of housing, water and sanitation.


ii. Requires a skills development and capacity building programme to ensure rural areas have enough.

iii. Does not meet access requirements to 2 million people currently deprived.

iv. The ration between district and regional beds is not practical.

v. Recommended length of stay are not achievable.

10.4.11 Funding issues The option indicates a deficit of R 221 130 000 or 2,81% of the total expenditure.

Whilst this sum is within a reasonable range, the shortfall will need to be funded by a request for additional allocation from the Treasury departments. The expected demand by the public of KZN in 2010 cannot be accurately determined, as the impact of HIV/AIDS and TB epidemics can only be estimated and not accurately predicted. The fear is that the demand by these patients will be of such a nature that non-aids cold case hospital services may have to be rationed.

The questions of equity and access to the health system for all remains critical and this, and the other options, assume that HIV/AIDS treatment will proceed according to present national health policies for the treatment of HIV/AIDS patients. 10.4.12 Priority development issues

The introduction and implementation of the option is dependant on a number of development factors, such as:

Roads, water and electricity infrastructure in the rural districts

Staff numbers and distribution to enable equity in health care services throughout the Province.

The capacity of local authorities to accept their responsibility for District Health Services.

Management methods used to measure health care trends, performance, health outcomes, financial performance, cost containment, case and disease management and management information systems.

The political will to implement the principles of facility transformation and focus on primary health care, alternative step-down facilities and home based care.

10.5 Option 5 – Selected practical proposal

Option four was evaluated together with the KwaZulu-Natal department management and the team felt that some of the variables should be reconsidered. These included

• Increasing the hospital admission rate to 165 (from 145 in option 4) per 1000 head of

population. • Amending the admission splits by level of care. • Amending lengths of stay • Amending bed occupancy levels




Patients who travel distances and require accommodation before and after hospitalisation should not be accommodated in hospitals or step-down facilities. The transformation process is to include the provision of Transit facilities of a domestic nature to accommodate these patients.

Patients who are terminally ill and cannot be nursed in their own homes should not be accommodated in hospitals or step-down facilities as these institutions must focus on acute care. In order to accommodate the terminally ill the Province needs to develop hospice type accommodation with nursing staff qualified to nurse terminally ill patients and to counsel their families. The health care workers in these institutions could be trained community members who do not necessarily have to have a nursing qualification, but who are employed under supervision from qualified professional nurses.


HIV/AIDS and TB disease profiles show an increase in infected persons per 1000 head of population and the option reflects the increases as projected by NDoH based on the ABT Associates study on HIV/AIDS and TB projections to 2010. Considering referral processes more appropriate to the geographics, infrastructure and demographics of KwaZulu-Natal province.


Hospitals are to provide an acute hospital service, transferring chronic patients to their homes under home-based care services. Step-down facilities to be used for pre- and post-operation care. Transit facilities are to be developed to accommodate patients between their homes and admission or discharge from hospital and step-down facilities. Hospices are to be developed to accommodate terminally patients who cannot be nursed in their homes. TB hospitals are to be upgraded to cater for an increase in MDR patients to 4.5%. The PHC facilities and services to be increased to cater for a greater utilisation by the public.

Facilities are to be transformed and upgraded to the level of service, which they provide. This will include building new institutions, closing down present institutions and reclassifying existing buildings so that the facilities are appropriate to the level of care provided in the facility. The cost has been estimated and the option reflects that


the process will take some 20 years to complete, with an annual capital allocation equal to 1/20th of the total cost.



hospital care for HIV/AIDS related incidents only and home based care services for chronic care.


The population served by the public sector health care services for the Province is as suggested by the equity study at 88% of the projected population in 2010 after allowing for HIV/AIDS pandemic.


HOSPITALS BEDS District 42 11 191

Regional 10 5 556 Tertiary 3 2 355 Psychiatric 4 3 617 TB 12 3 117 Specialised other 3 237 Total 74 26 073



The option does not determine how many hospitals will be included in the 2010 structure. The Department’s task is to determine and plan the hospital levels during the planning phase taking into account the transformation of existing premises, building new premises and closing down existing premises. Critical to these calculations will be the placement of facilities close to the population so as to manage health care services to the public and manage the cost of providing these services. For the care model as outlined in option 5, a combination of the structural and functional approach was used, i.e.:


• Hospital beds were classified according to level of care albeit in the same

building.

• Patients were devolved to the lowest appropriate level of care.

• Low cost facilities such as step-down facilities, transit facilities and hospice facilities are proposed whether in the same building or separate structures.

• These facilities could be linked to existing district and regional hospitals.

• Case managers should be appointed.

• Careful attention should be given to:

- Optimal duration of stay. - Reduce staff levels where low cost beds are created. - Ensure patients receive care according to their medical condition and

acuity level and not according to the type of hospital. 10.5.4 Number of beds



Step downs 0 4456 0.53 Transit 1002 Step-down acute beds 2253 Hospice beds for terminally ill 1201 Level 1 hospitals 11191 7286 0.87 Level 2 hospitals 5556 3766 0.45 Tertiary 2355 856 0.11 Psychiatric hospitals 3617 2259 0.27 Custodial 1185 Acute 1074 TB hospitals 3117 2740 0.33 Special unclassified 237 1201 0.14 Total beds 26073 22664 2.70 Note : Projected beds are calculated by using :








Step downs


11.95 27.70 0.820

100 535 233 030 6 941

201 069 699 090

416 440

-


0.41 1.24

3 424

10 457

410 888 313 718

-

TB 1.65 11 775 950 098 - Special 0.17 1 388 416 440 - Totals 165.00 1 388 900 6 793 125 5 139 975



Costs have been included at costs incurred by the Province in the 2000/2001 financial year adjusted upwards to account for the additional utilisation by the public due to increase in number of clinics and transfer of patients from hospital out patient departments. The rates applied are as follows:

Community health centre and clinic visits: • Estimated cost per capita per annum R 242.36 • Estimated visits per capita per annum 3,50 • Estimated cost per visit R 69,25 • Estimated cost per additional HIV/AIDS visit R 69,25 • Estimated additional HIV/AIDS visits per annum 1 753 615

Home based care • Total team cost per annum R591 360 • Patient encounters per annum per team 384 (32 per month) • Cost per patient encounter R 1 540 • Estimated patient encounter pa 184 243 (HIV/AIDS

94368)

Transformation costs are estimated at a lower value and the cost per annum has been adjusted accordingly at R25 000 000.










21 605

139 648 64 974

Includes maintenance and replacement costs with a total rate per admission of Transit R 215 Step-down R 599 Hospice R 9 361




88 870 93 738


TB hospital care 312 642 Includes maintenance and replacement costs with a rate per admission of R 15 794for re-treatment patients and R78 182 for MDR patients.

Special unclassified care

124 697 Includes maintenance and replacement costs with a total rate per admission of R 89 830

Total hospital care

____________ 5 078 705



Management 292 526 Estimated to increase management capacity to manage change and measure performance.

Training 146 496 Based on 2001 expenditure.


Category Expenditure R0,000 Comments Capital Transformation 56 993 See 10.4.8 for details Total running costs per annum

____________ 8 387 671



Deficit

___________ (729 542)

==========

This shortfall is to be covered by planning for reduced services.









Buildings and equipment


25.29 89.35

129.96

31.61

111.68 162.45

68.44

216.66 335.70

36.82

104.98 173.25


3 197.69

949.31

3 997.11 1 186.64

7 079.91 1 963.18

3 082.80

776.54 TB 839.39 1 049.24 119.93 0.00 Special 1 918.62 2 398.27 2 394.51 0.00


10.5.9 What interventions are required to make the option viable (staff, equipment, transport etc.)

The geographical and terrain conditions which apply to the Province are of such a nature that access to institutions by the public and the professional are of such a nature that this option will be difficult to implement.





Advantages




iv. Access to health care for the total population.

v. There is opportunity for better management of referrals according to geographics, infrastructure and demographics.


vii. Appropriate distribution of admissions between district and regional

viii. Rationalisation of services according to national priorities

ix. Achievable lengths of stay

x. Improved access to primary health care facilities.


xi. Demand for primary health care is met by supply across the Province

xii. Better utilisation of resources in primary health care facilities.

xiii. Greater patient satisfaction with improved service delivery and access.

xiv. Greater efficiency in higher level of care due to reduced bottlenecks.

xv. Patients will access health care delivery system at most appropriate level of care. This will save costs.

xvi. Investment in underdeveloped areas.

xvii. A more realistic figure was used for capital and transformation costs, allowing more finances available for service delivery.

xviii. Service delivery is in line with provincial priorities.

xix. Improved equity of access

xx. More realistic indigent population figures at 88%, with more realistic utilisation figures, tailored to meet demand due to poverty levels, and migratory problems.

xxi. Practical application of providing health care services.

Disadvantages

i. Budget deficit indicates desired priority to meet backlog and transformation is not achievable.

ii. Requires intersectoral cooperation with other departments for provision of housing, water and sanitation.

iii. Requires a skills development and capacity building programme to ensure rural areas have enough.

10.5.11 Funding issues The option indicates a deficit of R 729 542 000 or 8,70% of the total expenditure.

Whilst this sum is within a reasonable range, the shortfall will need to be funded by a request for additional allocation from the Treasury departments. The expected demand by the public of KZN in 2010 cannot be accurately determined, as the impact of HIV/AIDS and TB epidemics can only be estimated and not accurately predicted. The fear is that the demand by these patients will be of such a nature that non-aids cold case hospital services may have to be rationed.

The questions of equity and access to the health system for all remains critical and this, and the other options, assume that HIV/AIDS treatment will proceed according to present national health policies for the treatment of HIV/AIDS patients.


10.5.12 Priority development issues

The priority set out in 10.5.2 is not achievable and treasury will have to decide on whether the backlog and transformation is more important than patient care. Additional funds required to meet backlog and transformation will need to be allocated to provide future service.

The introduction and implementation of the option is dependant on a number of development factors, such as:

Roads, water and electricity infrastructure in the rural districts

Staff numbers and distribution to enable equity in health care services throughout the Province.

The capacity of local authorities to accept their responsibility for District Health Services.

Management methods used to measure health care trends, performance, health outcomes, financial performance, cost containment, case and disease management and management information systems.

The political will to implement the principles of facility transformation and focus on primary health care, alternative step-down facilities and home based care.


CHAPTER 11 - SWOT analysis of options – Using Option 5 as the preferred recommended option

11.1 Strengths

i. Uses KwaZulu-Natal health needs as the basis for planning of health care delivery. ii. Increases equity of access to primary health care facilities

iii. Increases equity of access to higher level of care

iv. Provides health care at the appropriate level of acuity

v. Allocates funds to the transformation of facilities

vi. Introduces transit, step-down and hospice facilities to improve cost efficiency of acute

hospital care

vii. Achievable length of stay

11.2 Weaknesses

i. Budget deficit indicates desired priority to meet backlog and transformation is not achievable.

ii. Depends on provision of roads, water and housing infrastructure, which is provided by

other departments.

iii. Follows a phased implementation process according to availability of funds

iv. Rate of demographic changes due to HIV/AIDS and TB may be underestimated.

11.3 Opportunities

i. Developing managerial skills to ensure proper case and disease management ii. Development of treatment protocols and disease management protocols

iii. Skills development programme and a staff retention policy to ensure capacity at all

level of care and in all geographic regions.

iv. Development of a strong local authority network to embrace the district health delivery system

v. Development of good communication and collaborative efforts with local

communities to enable home-based care and strengthen the district health care delivery system

vi. Introduction of an integrated information system that will enable management control,

cost control, early identification of trends, store and pharmacy control, performance and outcome measurement and integrated planning.


11.4 Threats

i. Exponential growth of the HIV/AIDS and TB epidemic, with additional demands on health care resources.

ii. Increased HIV/AIDS demand, beyond the capacity of the health care delivery system.

This will deny access to non HIV/AIDS patients

iii. Health status of population may not be improved if funds are not made available to meet the financial GAP.


CHAPTER 12 – HIGH LEVEL RESOURCE ASSESSMENT COMPARISON OF OPTION

12.1 Tabular presentation of various options and cost implications

Description of service

OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5


886 900

917 378

899 957

960 724


469 331 319 258 17 566

232 402 10 649

18 984

244 771 11 003

21 605

139 648 64 974

Level 1 hospital care

994 114 1 007 618 1 012 687 1 010 860 1 609 755

Level 2 hospital care

1 306 659 1 837 064 1 890 420 1 877 270 1 662 052


538 229 204 066

64 824 83 446

78 061 82 388

88 870 93 738

TB hospital care 108 575 225 463 312 642 312 642 312 642 Special unclassified care

162 686 41 350 44 056 47 612 124 697

Total hospital care

___________ 4 430 967

___________ 4 521 719

___________ 4 586 070

___________ 4 583 548

___________ 5 078 705

Primary health care

1 780 939 2 028 674 2 028 674 2 500 000 2 500 000

Emergency Medical Services

394 015 337 845 337 845 312 951 312 951

Management 323 200 292 526 292 526 292 526 292 526 Training 57 286 146 496 146 496 146 496 146 496 Capital Transformation

196 132 182 882 45 120 43 739 56 993

Total running costs per annum

___________ 7 182 539

___________ 7 510 142

___________ 7 436 731

___________ 7 879 260

___________ 8 387 670

Funding 7 658 128 7 658 128 7 658 128 7 658 128 7 658 128 Surplus (Deficit)

___________ 475 589

==========

___________ 147 986

==========

___________ 221 397

==========

___________ (221 132)

==========

___________ (729 542

==========


12.2 High-level activity assessment of options

The number of beds per level is calculated using four basic assumptions:

• Population (projected for 2010) - Population growth rate - Percentage indigent population

• Admissions per 1000 population projected for 2010

- Per level of care

This gives an admission rate per 1000 population for each level of hospital

vii. Admission per 1000 for tertiary hospitals viii. Admission per 1000 for L2 ix. Admission per 1000 for L1 x. Admission per 1000 for step-down facilities xi. Admission per 1000 for hospice beds xii. Admission per 1000 for transit beds

• Bed occupancy per level of hospital • Length of stay per level

In table format

Current Projected

Option 1 Option 2 Option 4 Option 5 Total Population (2001) 9 165 825 9 165 825 9 165 825 9 165 825 9 165 285 Growth rate 1.40 1.40 1.40 1.40 % Indigent 86% 86% 95% 88% 88% Public Population 7 776 528 8 221 732 9 082 145 8 412 934 8 412 934 Admissions per 1000 Tertiary 11.96 10.76 4.20 4.74 5.39 L2 31.66 36.88 33.52 37.60 30.64 L1 49.75 43.87 40.00 44.80 63.22 Step-down - 26.07 31.00 35.50

Transit - - - 10.50 11.95 Step-down - - - 24.28 27.70 Hospice - - - 0.73 0.83 HBC - 19.72 18.50 19.25 21.90

Specialised 2.44 - - - - TB - 0.50 1.30 1.45 1.65 Psychiatry - 2.67 1.30 1.45 1.65 Special - 2.23 0.18 0.21 0.17

Total 95.81 142.7 130.00 145.00 165.00


Current Projected

Option 1 Option 2 Option 4 Option 5 Bed occupancy Tertiary 71.30 85.00 65.00 65.00 65.00 L2 69.40 85.00 75.00 75.00 75.00 L1 64.80 85.00 80.00 80.00 80.00 Step-down - 85.00 85.00 85.00 -



Length of stay Tertiary 6.60 5.00 5.00 5.00 5.60 L2 5.70 3.60 4.00 4.00 4.00 L1 6.80 3.00 3.00 3.00 4.00 Step-down - 5.00 6.00 - -


Specialised - - - - - TB 66.20 41.50 70.00 77.30 77.30 Psychiatry 150.50 60 60.00 52.20 -

Custodial - - - 120.00 120.00 Acute - - - 30.00 30.00

Special 114.70 16.20 90.00 90.00 300.00

Number of beds Tertiary 2 355 1 426 804 840 956 L2 5 556 3 518 4 448 4 622 3 766 L1 11 191 3 488 3 732 3 872 7 286 Step-down - 3 455 5 445 4 892 -

Transit - - - 745 1 002 Step-down - - - 3 950 2 253 Hospice - - - 197 (500) 1 201 HBC - - - - -

Specialised - - - - TB 3 117 683 2 043 2 740 2 740 Psychiatry 3 617 3 798 2 153 1 985 -

Custodial - - - 1 049 1 185 Acute - - - 944 1 074

Special 237 855 424 459 1 201 Total 26 073 17 223 19 050 19 409 22 665


Current Projected Option 1 Option 2 Option 4 Option 5 Patient days Tertiary 613 009 442 474 190 725 199 387 226 897 L2 1 407 907 1 091 556 1 217 734 1 265 305 1 031 056 L1 2 646 949 1 082 158 1 089 857 1 130 698 2 127 429 Step-down - 1 071 862 1 689 279 1 463 010 -

Transit - - - 176 672 201 069 Step-down - - - 1 225 344 699 090 Hospice - - - 60 994 416 440 HBC - - - - -

Specialised - - - - - TB 780 329 236 753 746 700 950 134 950 134 Psychiatry 997 089 1 317 121 708 407 636 649 -

Custodial - - - 360 915 410 888 Acute - - - 275 734 313 718

Special 58 474 296 352 147 131 159 004 416 440 Total 6.503mill 5.538mill 5 789 834 5 804 187 6 793 161 Beds per 1000 head of population

Tertiary 0.30 0.17 0.09 0.10 0.11 L2 0.71 0.43 0.49 0.55 0.45 L1 1.44 0.42 0.41 0.46 0.87 Step-down (Include transit & hospice)

- 0.42 0.60 0.58 0.53


Total 3.35 2.09 2.10 2.31 2.70


CHAPTER 13 Broad option assessment

In conclusion This report has been based on high-level interaction with senior management of KwaZulu-

natal Department of Health.

Previous reports, and studies of the KwaZulu-Natal Department of Health were incorporated into this report. In addition, on site observations were included in the findings. The various options of delivery of health care models were developed on a progressive basis, using national norms as a point of departure. The norms were adapted to meet the perceived needs of the Province, taking into consideration the specific geographic, demographic, economic, social and financial constraints of KwaZulu-Natal. The options described in this report will be used as inputs in the KwaZulu-Natal planning process for 2010. Implementation of the preferred option will present a challenge to the KwaZulu-Natal Department of Health for reasons discussed under opportunities above.

ADDENDUM 1

CRITERIA FOR STEPDOWN FACILITIES Definition Step-down facilities are cost effective means of providing non-acute or sub-acute care to patients. It is used to provide pre and post-acute hospitalisation for diagnostic tests and nursing care when the patient is not yet well enough to go home. Description A step-down facility has wards for accommodation Theatre Outpatients department No high care of ICU beds No pharmaceutical service No emergency unit

A step-down facility should not be used for Acute care Specialised acute care (TB and psychiatry) Chronic acute care (TB and psychiatry) Convalescent acute care Rehabilitation

Building Requirements Administration Accommodation area Kitchen Laundry Clean Utility Dirty Utility Staff rest rooms Engineering service requirements

Accommodation Area

Must essentially meet all requirements of R158 except: There should be at least 6 m² square of floor space

KWAZULU-NATAL PROVINCESTRATEGIC POSITIONING STATEMENT OCTOBER 2001MODEL ASSUMPTIONS FOR 2010 SERVICE LEVELS EXPRESSED IN 2001 RAND

OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5NDOH/KPMG KPMG DEMAND APPROPRIATE APPROPRIATE SELECTED

DESCRIPTION LEVEL OF CARE ASSUMPTIONS Adjusted DRIVEN LEVELS LEVELS PRACTICALKZN actual MODEL OF CARE OF CARE PROPOSAL

+ PHC adj----------------- ----------------- ----------------- ----------------- ----------------- -----------------

Public Sector responsibility Percentage of population 86 86% 95% 95% 88% 88%

Population 8,221,731 8,221,732 9,082,145 9,082,145 8,412,935 8,412,935

Funding Envelope 7,658,128 7,658,128 7,658,128 7,658,128 7,658,128 7,658,128

Personnel Costs (PDE's) Stepdown 217.55 217.55 138.78 138.78 138.78 138.78District 403.70 403.70 403.70 403.70 403.70 403.70Regional 518.87 518.87 518.87 518.87 518.87 518.87Tertiary 792.27 792.27 1,065.00 1,065.00 1065.00 1065.00Psychiatry 293.17 293.17 198.30 198.30 198.30 198.30TB 201.27 201.27 201.27 201.27 201.27 201.27Specialised unclassified 293.17 293.17 214.20 214.20 214.20 214.20Transit 60.00 60.00 60.00Hospice 120.00 120.00 120.00Custodial 120.00 120.00 120.00

Increase in staff costs over CPI 0.01 0.01 0.01 0.01 0.01 0.01Percent establishment employed Stepdown 100.00% 100.00% 100.00% 90.00% 90.00% 90.00%

District 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Regional 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%Tertiary 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%Psychiatry 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%TB 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%Specialised unclassified 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Transit 90.00% 90.00% 90.00%Hospice 90.00% 90.00% 90.00%Custodial 90.00% 90.00% 90.00%

PHC costs 1,780,938 1,780,938 2,028,674 2,028,674 2,500,000 2,500,000

HBC Team Capacity (patients per month) 32 32 32 32 32 32PHC-DHC overlap (removed est. PHC visits from DH OP count 3 3 3 3 3 3

Expenditure projection for EMS Expenditure per capita 28 28 28 28 28 28Incidence rate 75 75 60 60 60 60Cost per incident 583.00 583.00 583.00 583.00 583 583

Recurrent cost per admission Stepdown 1,587.37 1,587.37 1,133.95 1,198.54 1,198.54 599.27 District 1,839.66 1,839.66 1,788.60 1,802.58 1,802.58 2,403.44 Regional 3,111.33 3,111.33 3,499.72 3,675.02 3,675.02 3,675.02 Tertiary 7,159.43 7,159.43 10,245.44 11,044.44 11,044.44 11,044.44 Psychiatry 24,489.15 24,489.15 17,283.76 8,963.85 8,963.85 8,963.85 TB 7,911.78 7,911.78 15,492.84 15,635.98 15,635.98 15,635.98 Specialised unclassified 7,493.07 7,493.07 25,293.80 26,949.19 26,949.19 89,830.62 Transit 214.90 214.90 214.90 Hospice 1,803.91 1,803.91 9,361.41 Custodial 25,954.41 25,954.41 25,954.41

Cost per OPD headcount Stepdown 204.41 204.41 - - 0 0District 204.41 204.41 198.73 198.73 198.73 198.73Regional 288.09 288.09 291.64 291.64 291.64 291.64Tertiary 477.30 477.30 450.00 450.00 450.00 450.00Psychiatry 136.05 136.05 96.02 96.02 96.02 96.02TB 87.91 87.91 86.07 86.07 86.07 86.07Specialised unclassified 154.18 154.18 - - 0 0

Admissions Without AIDS 89.00 89.00 50.00 50.00 65.00 74AIDS 50.90 50.90 80.00 80.00 80.00 91

Admission split % by level of care Home Based Care 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Stepdown 15.00% 15.00% 30.00% 19.50% 19.50% 19.60%District 35.00% 35.00% 32.00% 32.00% 32.00% 40.30%Regional 30.00% 30.00% 27.20% 27.20% 27.20% 18.90%Tertiary 12.00% 12.10% 3.60% 3.60% 3.60% 3.60%Psychiatry 3.00% 3.00% 1.00% 0.45% 0.45% 0.45%TB 1.00% 0.60% 1.00% 1.00% 1.00% 1.00%Specialised unclassified 3.00% 2.50% 0.20% 0.20% 0.20% 0.10%Transit 10.00% 10.00% 1.00%Hospice 0.50% 0.50% 0.50%Custodial 0.55% 0.55% 0.55%

Admission rate non HIV Home Based Care 4.45 4.45 2.50 2.50 3.25 3.70Stepdown 13.35 13.35 15.00 9.75 12.68 14.50District 31.15 31.15 16.00 16.00 20.80 29.82Regional 26.70 26.70 13.60 13.60 17.68 13.99Tertiary 10.76 10.76 1.80 1.80 2.34 2.66Psychiatry 2.67 2.67 0.50 0.23 0.29 0.33TB 0.50 0.50 0.50 0.50 0.65 0.74Specialised unclassified 2.23 2.23 0.10 0.10 0.13 0.07Transit 5.00 6.50 7.40Hospice 0.25 0.33 0.37Custodial 0.28 0.36 0.41Total 91.81 91.81 50.00 50.00 65.00 74.00




+ PHC adj----------------- ----------------- ----------------- ----------------- ----------------- -----------------

Options for AIDS care 2010 % Home Based Care 30.00% 30.00% 20.00% 20.00% 20.00% 20.00%by level of care Stepdown 25.00% 25.00% 20.00% 15.00% 15.00% 15.00%

District 25.00% 25.00% 30.00% 30.00% 30.00% 37.00%Regional 20.00% 20.00% 24.90% 25.00% 25.00% 18.30%Tertiary 0.00% 0.00% 3.00% 3.00% 3.00% 3.00%Psychiatry 0.00% 0.00% 1.00% 1.00% 1.00% 1.00%TB 0.00% 0.00% 1.00% 1.00% 1.00% 1.00%Specialised unclassified 0.00% 0.00% 0.10% 0.00% 0.00%Transit 5.00% 5.00% 5.00%Hospice 0.00% 1.00% 1.00%Custodial 0.00% 0.00%

Admission rate HIV Home Based Care 15.27 15.27 16.00 16.00 16.00 18.20Stepdown 12.72 12.72 16.00 11.60 11.60 13.20District 12.72 12.72 24.00 24.00 24.00 33.40Regional 10.18 10.18 19.92 19.92 19.92 16.65Tertiary 0.00 0.00 2.40 2.40 2.40 2.73Psychiatry 0.00 0.00 0.80 0.80 0.80 0.91TB 0.00 0.00 0.80 0.80 0.80 0.91Specialised unclassified 0.00 0.00 0.08 0.08 0.08Transit 4.00 4.00 4.55Hospice 0.40 0.40 0.46Custodial 0.00 0.00Total 50.89 50.90 80.00 80.00 80.00 91.00

Total utilisation by level of care Home Based Care 19.72 19.72 18.50 18.50 19.25 21.90Stepdown 26.07 26.07 31.00 21.35 24.28 27.70District 43.87 43.90 40.00 40.00 44.80 63.22Regional 36.88 36.88 33.52 33.52 37.60 30.64Tertiary 10.76 10.76 4.20 4.20 4.74 5.39Psychiatry 2.67 2.67 1.30 1.03 1.09 1.24TB 0.50 0.50 1.30 1.30 1.45 1.65Specialised unclassified 2.23 2.23 0.18 0.18 0.21 0.07Transit 142.70 142.70 130.00 9.00 10.50 11.95Hospice 0.65 0.73 0.83Custodial 0.28 0.36 0.41Total 130.00 145.00 165.00

Outpatients Non AIDS 359.32 280.25 600 600 600.00 600.00AIDS 213.29 213.29 209.22 209.22 209.22 209.22Total 572.61 493.54 809.22 809.22 809.22 809.22

Outpatient Distribution Home Based Care 0.00 0.00 0 0 0 0Stepdown 0.36 0.36 0 0 0 0District 0.29 0.29 0.49 0.49 0.49 0.49Regional 0.21 0.21 0.36 0.36 0.36 0.36Tertiary 0.14 0.14 0.15 0.15 0.15 0.15Psychiatry 0.00 0.00 0 0 0 0TB 0.00 0.00 0 0 0 0Specialised unclassified 0.00 0.00 0 0 0 0

Length of stay Stepdown 5.00 5.00 6.00 6.00 6.00 3.00District 3.00 3.00 3.00 3.00 3.00 4.00Regional 3.60 3.36 4.00 4.00 4.00 4.00Tertiary 5.00 5.00 5.00 5.00 5.00 5.00Psychiatry 60.00 60.00 60.00 30.00 30.00 30.00TB 30.00 30.00 60.00 60.00 60.00 60.00Specialised unclassified 16.20 16.20 90.00 90.00 90.00 300.00Transit 2.00 2.00 2.00Hospice 10.00 10.00 60.00Custodial 120.00 120.00 120.00

Bed Occupancy Rate Stepdown 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%District 85.00% 85.00% 80.00% 80.00% 80.00% 80.00%Regional 85.00% 85.00% 75.00% 75.00% 75.00% 75.00%Tertiary 85.00% 85.00% 65.00% 65.00% 65.00% 65.00%Psychiatry 95.00% 95.00% 95.00% 80.00% 80.00% 80.00%TB 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Specialised unclassified 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Transit 65.00% 65.00% 55.00%Hospice 85.00% 85.00% 95.00%Custodial 95.00% 95.00% 95.00%

Tuberculosis (all hospitalisation) Retreat LOS 30.00 30.00 60.00 60.00 60.00 60.00Admissions retreatments 5,261.18 5,261.18 9,745.00 9,745.00 9745.00 9745.00MDR 438.43 438.43 900.00 2,030.00 2030.00 2030.00Total admissions 5,699.62 5,699.62 10,645.00 11,775.16 11775.16 11775.16Admission rate 0.69 0.69 1.26 1.3 1.40 1.40Bed days 236,753.28 236,753.28 746,700.00 950,133.00 950133.60 950133.60Retreat costs per admission 8,100.30 8,100.30 15,889.36 15,794.39 15794.39 15794.39MDR cost per admission 73,214.37 73,214.37 78,467.60 78,182.18 78182.18 78182.18Retreat costs per admission 74,384.10 74,384.10 154,841.78 153,195.70 153915.70 153915.70MDR cost 32,099.52 32,099.52 70,620.84 158,725.46 158725.46 158725.46Total 106,483.62 106,483.62 225,463.00 312,641.16 312641.16 312641.16




+ PHC adj----------------- ----------------- ----------------- ----------------- ----------------- -----------------

Capital and maintenance costsCosts per sq metre Stepdown 4000 4000 3000 4400 4400 4400

District 6000 6000 4000 5280 5280 5280Regional 8000 8000 5000 6050 6050 6050Tertiary 10000 10000 8000 9350 9350 9350Psychiatry 6000 6000 3400 4620 4620 4620TB 4000 4000 3000 4620 4620 4620Specialised unclassified 6000 6000 3000 4620 4620 4620Transit 4000 4000 4000Hospice 4200 4200 4200Custodial 4620 4620 4620

Area per bed Stepdown 30 30 30 30 30 30District 60 60 60 60 60 60Regional 80 80 80 80 80 80Tertiary 100 100 100 100 100 100Psychiatry 50 50 50 50 50 50TB 30 30 30 30 30 30Specialised unclassified 50 50 50 50 50 50Transit 25 25 25Hospice 30 30 30Custodial 50 50 50

Equipment as % of building cost Stepdown 15.0% 15.0% 15.0% 15.0% 15.0% 15.0%District 20.0% 20.0% 25.0% 25.0% 25.0% 25.0%Regional 30.0% 30.0% 50.0% 50.0% 50.0% 50.0%Tertiary 50.0% 50.0% 90.0% 90.0% 90.0% 90.0%Psychiatry 20.0% 20.0% 20.0% 20.0% 20.0% 20.0%TB 15.0% 15.0% 15.0% 15.0% 15.0% 15.0%Specialised unclassified 20.0% 20.0% 12.0% 12.0% 12.0% 12.0%Transit 10.0% 10.0% 10.0%Hospice 12.0% 12.0% 12.0%Custodial 20.0% 20.0% 20.0%

Other capital factors Buildings Maintenance proportion 0.045 0.045 0.045Step down 0.020 0.020 0.020District 0.025 0.025 0.025Regional 0.045 0.045 0.045Tertiary 0.045 0.045 0.045Psychiatry 0.020 0.020 0.020TB 0.020 0.020 0.020Special 0.020 0.020 0.020Custodial 0.020 0.020 0.020Transit 0.020 0.020 0.020Hospice 0.020 0.020 0.020

Buildings Life expectancy (yrs) 40.000 40.000 30.000 40.000 40.000 40.000Buildings Life Expectancy Tertiary (Yrs) 30.000 30.000 30.000Equipment Maintenance proportion 0.100 0.100 0.100 0.100 0.100 0.100Equipment Life expectancy (yrs) 10.000 10.000 8.000 8.000 8.000 8.000Cost value ratio 0.760 0.760 0.760 0.760 0.760 0.760Income to asset value ratio 1.000 1.000 1.000 1.000 1.000 1.000Cost of trasnsformation - Hospitals 7.979 7.979 7.979 5.000 5.000 5.000Cost of trasnsformation - Clinics (20 1.567 1.567 1.567 0.500 0.500 0.500Rate of transformation (yrs) 20.000 20.000 20.000 20.000 20.000 20.000Proportion of replacement cost for d 0.250 0.250 0.330 0.330 0.330 0.330

Beds Stepdown 3,455 3455 5445 3750 3,950 2253District 3,488 3488 3732 3732 3,872 7287Regional 3,518 3518 4448 4448 4,622 3766Tertiary 1,426 1426 804 804 840 956Psychiatry 3,798 3798 2043 956 944 1074TB 683 683 2153 2740 2,740 2740Specialised unclassified 855 855 424 424 459 1201Transit 689 745 1002Hospice 190 197 1201Custodial 864 1,041 1185Total 17,223 17,223 19,050 18,599 19,409 22665

Summary Tertiary care 878708 878708 878708 878708 878708General acute hospital care 3552258 3643011 3707362 3704838 4199995

------------------------------------------------------------------------- -----------------Hospital total 4430967 4521719 4586070 4583546 5078704PHC 1780939 2028674 2028674 2500000 2500000EMS 394015 337845 337845 312951 312951Management 323200 292526 292526 292526 292526Training 57286 146496 146496 146496 146496Capital Transformation 196132 182882 45120 43739 56993

------------------------------------------------------------------------- ------------------Total cost 7182539 7510142 7436731 7879259 8387670Funding envelope 7658128 7658128 7658128 7658128 7658128

------------------------------------------------------------------------- ------------------Surplus(deficit) 475589 147986 221397 -221131 -729542

=======================================================================

Scenario Input selections

PopulationSelected

2010 Expected Population 98 Population 99 2010 Expected 2010 ABT 2010 BMR 8,221,731.55 7,648,698 7,776,528 8,221,732 8,153,044 8,072,320

Funding EnvelopeSelected

Treasury 2010 Funds 98/99 Funds 99 Treasury 2010 Merchant Bank 2010 Funds 2003/04 6,779,420.00 29,646,016 29,991,185 6,779,420 6,441,450

Personnel Costs (PDE's)

Selected Stepdown District Regional Tertiary Psychiatry TB Specialised unclassifiedExpected 217.55 403.70 518.87 792.27 293.17 201.27 293.17

Expected 217.55 403.70 518.87 792.27 293.17 201.27 293.17 High 229.19 451.39 529.34 1,064.50 393.23 217.55 393.23 Low 201.27 376.94 494.44 520.03 229.19 201.27 229.19

Increase in staff costs over cpi Selected Expected Expected Historical Baseline

Increase in staff costs over cpi 0.01 0.01 0.025 0Increase 2001 to 2010 0.09 0.09 0.25 0

Percent establishment employed

Selected Stepdown District Regional Tertiary Psychiatry TB Specialised unclassifiedExpected 1.00 0.95 0.90 0.80 0.90 0.90 0.95

Expected 100% 95% 90% 80% 90% 90% 95%Full 100% 100% 100% 100% 100% 100% 100%Low 80% 80% 80% 80% 80% 80% 80%

PHC costsSelected

Expected 98/99 actual Expected 2010 without HBC2010 AIDS OP No

HBC 1,780,938.76 4,480,251 1,780,939 1,562,983 4,538,427

HBC Team Capacity (Patients per month)Selected

HBC model HBC model High Low32 32 45 20

PHC-DH overlap Removed estimated PHC visits from DH OP count by including selected DH OP vbisits per admission Selected

High Low High Baseline 3.00 2 3.0 4.10

Other costs

Expenditure projection for EMSSelected

expected low medium high expected 98/99expenditure per capita (99/00 prices) 28 24 28 32 28 21 incidence rate per 1000 75 50 75 100 75 49 cost per incident (99/00 prices) 583 350 466 583 583 352

Selected Expected Expected 98/99

Management 0.10 10% 0Education & training - 0% 0

Selected

Incorporated 98/99 99/00 Incorporated Balanced option 1

Provincial Works - 837,601 - 837,601 Laboratories - 217,054 - 217,054 Medical aid for health employees - 558,490 - 558,490 Provincially aided and contract hospitals - 357,470 - 357,470

Unknown - 66,630 - 66,630 Other - 1,449,396 - 1,449,396

Recurrent cost per admission

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified

Model 2010 1,587.37 1,839.66 3,111.33 7,159.43 24,489.15 7,911.78 7,493.07 Acual 99/00 0.0 3552 4321 6062 24196 10744 21751Model 2010 1,587 1840 3111 7159 24489 7912 7493Option stepdown 1,587

Cost per OPD headcount

Selected Step Down District RegionalAcademic /

central Psychiatry TBSpecialised unclassified

Model (cost sheet) 204.41 204.41 288.09 477.30 136.05 87.91 154.18 Actual 99/00 173.1 251.9 306.7 53.6 54.1 63.2Model (cost sheet) 204.4 204.4 288.1 477.3 136.1 87.9 154.2Model (sum sheet) #REF! #REF! #REF! #REF! #REF! #REF!

Admissions Selected

Without AIDS

2010 High decrease Baseline 99

2010 Minimum decrease

2010 Moderate decrease

2010 High

decrease 89.00 77.81 95 92 89

Notes a) minimum decrease assumes additional demand realised as services improve to offset lowering admission trendb) high decrease set at 25% of AIDS admission rate increase, regarded as likely ceilingc) moderate decrease is median of minimum and high

SelectedAIDS Lower Baseline 99 Abt 2010 Higher Lower

50.90 18.00 54.90 58.91 50.90

Level of hospital care options (excluding AIDS)

Beds distribution by level of care

Selected District Regional Tertiary Psychiatry TBSpecialised unclassified

High change 11,149 3,555 819 4,408 5,747 395 Existing 11,191 5,556 2,355 3,617 3,117 237 High change 11,149 3,555 819 4,408 5,747 395 Medium change 11,201 3,989 1,148 4,210 5,209 316 Low change 11,253 4,422 1,477 4,013 4,671 237

Admissions split % by level of care

SelectedHome based

care Stepdown District Regional Tertiary Psychiatry TBSpecialised unclassified

Hospital admission Total

Level of care 0.050 0.150 0.350 0.300 0.121 0.030 0.006 0.025 1.000 Existing 0.00% 0.00% 51.93% 33.04% 12.5% 0.89% 1.58% 0.07% 100.00%Rationalised 5.00% 10.00% 38.00% 30.00% 11.0% 3.00% 0.50% 2.50% 100.00%Level of care 5.00% 15.00% 35.00% 30.00% 12.09% 3.00% 0.56% 2.50% 103.15%

Admission rateSelectedLevel of care 4.450 13.350 31.150 26.700 10.764 2.670 0.498 2.225 91.807

Options for AIDS care 2010 % by level of care

Selected HBC Stepdown District Regional Tertiary Psychiatry TBSpecialised unclassified Total

non tert 0.300 0.250 0.250 0.200 - - - - 1.000 Actual '99/00 0.0% 0.0% 51.9% 33.0% 12.5% 0.9% 1.6% 0.1% 100.0%non tert 30.0% 25.0% 25.0% 20.0% 0.0% 0.0% 0.0% 100.0%Model 30% 25% 20% 15% 10% 100%

Admission Rate HIV

SelectedHome based


non tert 15.269 12.724 12.724 10.179 - - - - 50.896

Total utilisation by level of careAdmission rate

Home based care Stepdown District Regional Tertiary Psychiatry TB

Specialised unclassified


Total selected 19.719 26.074 43.874 36.879 10.764 2.670 0.498 2.225 142.702

Outpatients SelectedABT 2010 Actual 99 ABT 2010

Non AIDS 280.25 331.82 280.25 AIDS 213.29 293.70 213.29 Total 493.54 625.52 493.54

Outpatient distribution Admissions % by level

Selected HBC Stepdown District Regional Tertiary Psych TBSpecialised unclassified

Model 0 0.360 0.290 0.210 0.140 - - - 1.000 Actual 99/00 48.1% 38.7% 9.1% 0.10% 0.49% 3.42% 100%Model 0% 36% 29% 21% 14% 100%

Length of stay

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total

Model - Challenging 5.00 3.00 3.60 5.00 60.00 30.00 16.20 actual 99 0.00 6.84 5.72 6.59 150.55 60.00 114.65 Model - Basic 5.00 4.70 4.70 5.50 60.00 60.00 16.20 (n.b. Based on current median performance less outliers)Model - Challenging 5.00 3.00 3.60 5.00 60.00 30.00 16.20 (n.b. Based on current performance of the top tenth centile

Bed Occupancy Rate

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total

Model - Challenging 0.85 0.85 0.85 0.85 0.95 0.95 0.95 actual 99 0.00 0.65 0.69 0.71 0.76 0.69 0.68 0.68Model - Basic 0.80 0.80 0.80 0.80 0.90 0.90 0.90 (n.b. Based on current median performance less outliers)Model - Challenging 0.85 0.85 0.85 0.85 0.95 0.95 0.95 (n.b. Based on current performance of the top tenth centile

Tuberculosis (n.b. this represents all hopitalisation of TB cases, not necessarily in specialised TB hospitals only)Admissions: Total Admission Retreat Cost MDR Cost

Selected Retreat LOS Retreatments MDR Admissions Rate Bed Days per Admiss per Admission Retreat Cost MDR Cost Total CostLOS 30 30.00 5,261.18 438.43 5,699.62 0.69 236,753.28 8,100.30 73,214.37 74,384.10 32,099.52 106,483.62

Actual 99 60 11,792 11,792 1.52 780,329 8,624 126,688LOS 30 30 5,261 438 5,700 0.69 236,753 8,100 73,214 42,617 32,100 74,717LOS 60 60 5,261 438 5,700 0.69 394,589 14,138 73,214 74,384 32,100 106,484

Capital and maintenance costs

Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified

Costs per sq metreSelectedLatest hospitals 4000 6000 8000 10000 6000 4000 6000Latest hospitals 4,000.00 6,000.00 8,000.00 10,000.00 6,000.00 4,000.00 6,000.00 Low estimate 3,000.00 4,000.00 5,000.00 8,000.00 3,400.00 3,000.00 3,000.00

Area per bedSelectedTarget 30 60 80 100 50 30 50Target 30.00 60.00 80.00 100.00 50.00 30.00 50.00 Maximum (NHFA) 47.00 96.00 140.00 228.00 59.00 47.00 65.00 Minimum (NHFA) 15.00 52.00 74.00 96.00 11.00 15.00 47.00 Average (NHFA) 27.00 76.00 79.00 154.00 47.00 27.00 65.00

Equipment as % of building costSelectedLatest hospitals 0.15 0.2 0.3 0.5 0.2 0.15 0.2Latest hospitals 15% 20% 30% 50% 20% 15% 20%Conservative 10% 15% 20% 35% 15% 10% 15%Highly equiped 15% 25% 40% 60% 25% 20% 25%

Other capital factors SelectedMixed Expected High Medium Low Mixed Expected

Buildings Maintenance proportion of cost 0.045 0.045 0.035 0.025 0.045 Life expectancy (yrs) 40.000 40 50 60 40

Equipment Maintenance proportion of cost 0.100 0.10 0.09 0.08 0.10 Life expectancy (yrs) 10.000 8 9 10 10

Cost value ratio 0.760 1.00 0.88 0.76 0.76 Income to asset value ratio 1.000 0.70 1.00 1.20 1.00 Cost of trasnsformation - Hospitals (2001 Rand billions) 7.979 7.98 7.50 7.00 7.98 Cost of trasnsformation - Clinics (2001 Rand billions) 1.567 1.80 1.57 1.30 2 Rate of transformation (yrs) 20.000 12 15 20 20 Proportion of replacement cost for downsizing 0.250 0.3 0.25 0.15 0.25

Summary of model

Scenario:5. Population & AIDS Demand, Challenging Performance Improvements, Optimal Cost Structure

Full impact of population and AIDS-related demand growthOptimal cost structure - staffing, maintenance, drugs, labs, PHCChallenging performance and practice improvementsFunding growth at MTEF projected levelsMore appropriate AIDS care

PHC Package fully funded? YesAlternative AIDS care models? YesSustainable Maintenance exp? YesImproved Drug exp.? YesChanged Level of Care Split Yes

Expenditure all programs expressed 2001 prices (R 000)Check

Category ExpenditureNHA core 2001

pricesModel

99 prices

NHA core 98/99 99

pricesTertiary care 878,708

General Acute care 3,552,258.95 18,630,411 3,240,119 16,993,344 Provincial works - - -

Medical aid for health employees - 558,490 - 509,415 Hospitals missing PAH and contract - 357,470 - 326,059

Hospitals unallocated - - Hospitals sub-total 4,430,967 19,546,371 3,240,119 17,828,818

PHC (incl. Home Based Care) 1,780,939 4,480,250 1,624,446 4,086,567 EMS 394,015 490,903 359,393 447,767

Management 323,200 2,946,467 294,800 2,687,559 Training 57,286 515,575 52,252 470,271

Laboratories - 217,054 197,981 Other - 1,449,396 - 1,322,037

Non hospital unallocated - - - Capital Transformation 196,132

Total 7,182,539 29,646,016 5,571,011 27,041,000 Funding Envelope 7,658,128 29,646,016 6,985,203 27,041,000

Surplus / Deficit 475,589.2 0 433,798.9 0.0

hlmsv option 1.xls

Hospital component

Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total

WorkloadAdmission rate selected 26.07 43.87 36.88 10.76 2.67 0.50 2.23 142.7Admission rate 99/00 49.75 31.66 11.96 0.85 1.52 0.07 95.8Admissions selected 214,372 360,719 303,210 88,495 21,952 4,098 18,293 1,173,261Admissions actual 99/00 386,913 246,178 93,044 6,623 11,792 510 745,060Selected LOS - acute 5.00 3.00 3.60 5.00 3.81 Selected LOS - chronic 60.00 30.00 16.20 41.73

Inpatient days selected 1,071,862 1,082,158 1,091,556 442,474 1,317,121 236,753 296,352 5,538,278

Inpatient days actual 2,646,949 1,407,907 613,009 997,089 780,329 58,474 6,503,757

OPD:IPD ratio model 0.85 0.85 0.85 0.02 0.1

OPD:IPD ratio actual 99/00 0.88 1.34 0.73 0.00 0.03 2.84OPD visits actual 99/00 2,339,984 1,884,674 445,068 4,726 23,785 166,121 4,864,358Outpatient visits model - Non-AIDS 1,108,391 892,722 210,817 2,239 11,266 78,687 2,304,123Outpatient visits AIDS check 631,301 508,548 368,259 245,506 2,487 12,519 87,434OPD visits 631,301 1,616,939 1,260,981 456,323 4,726 23,785 166,121Outpatient conversion to PDEs 0.33 0.33 0.33 0.33 0.33 0.33 0.33

CostRecurrent cost per admission (R) 1,587 1,840 3,111 7,159 24,489 8,100 7,493 Transformation cost per admission (R) 262 193 - 359 - 6,085 748 Inpatient costs (R 000's) 340,289 663,601 943,388 633,572 537,586 106,484 137,073 3,361,993Outpatient cost (R 000's) 129,042 330,513 363,272 217,801 643 2,091 25,612 1,068,974Total recurrent cost (R 000's) 469,331 994,114 1,306,659 851,373 538,229 108,575 162,686 4,430,967Total transformation cost (R 000's) 56,104 69,628 - 31,789 - 24,934 13,678 196,132

BedsBed occupancy model 85% 85% 85% 85% 95% 95% 95%Bed occupancy actual 64.8% 69.4% 71.3% 75.5% 68.6% 67.6% 68.3%Beds Required (model occupancy) 3,455 3,488 3,518 1,426 3,798 683 855 17,223Occupancy rate (beds /1000 pop) 0.42 0.42 0.43 0.17 0.46 0.08 0.10 2.09 Beds Required (model demand, 99/00 occupancy) 4,575 4,308 1,700 4,778 946 1,201 22,2021999/00 Actual Beds (by hospital) 0 11,191 5,556 2,355 3,617 3,117 237 26,0731999/00 Actual Beds (by level) 0 11,149 3,555 819 4,408 5,747 395 26,073

Excess 99/00 Actual Beds over Model Predicted Beds -3,455 7,661 37 -607 610 5,064 -459 8,850

Model maintenance cost p.a. (R bill) 0.025 0.08 0.17 0.14 0.07 0.00 0.02 0.51 Current maintenance cost p.a. (R bill) 0.00 0.26 0.17 0.08 0.09 0.04 0.01 0.64

Model replacement cost p.a. (R bill) 0.02 0.06 0.12 0.11 0.05 0.00 0.01 0.37 Current replacement cost p.a. (R bill) 0.00 0.18 0.13 0.06 0.06 0.03 0.01 0.46

Net annual saving on maintenance through transformation 0.14 Net annual saving on replacement through transformation 0.09

Net total annual saving through transformation 0.23

hlmsv option 1.xls

Summary of model






pricesModel

99 prices

NHA core 98/99 99


General Acute care 3,643,011 18,630,411 3,322,897 16,993,344 Provincial works - - -

Medical aid for health employees - - - - Hospitals missing PAH and contract - - - -




Laboratories - 217,054 197,981 Other - - - -



Surplus / Deficit 147,986 2,687,266 134,982.2 2,451,134.0

hlmsv option 2.xls

Hospital component

Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total

WorkloadAdmission rate selected 31.00 40.00 33.52 4.20 1.30 1.30 0.18 130.0Admission rate 99/00 45.04 28.66 10.83 0.77 1.37 0.06 86.7Admissions selected 281,547 363,286 304,434 38,145 11,807 11,807 1,635 1,180,679Admissions actual 99/00 386,913 246,178 93,044 6,623 11,792 510 745,060Selected LOS - acute 6.00 3.00 4.00 5.00 4.24 Selected LOS - chronic 60.00 60.00 90.00 63.46

Inpatient days selected 1,689,279 1,089,857 1,217,734 190,725 708,407 746,700 147,131 5,789,834



OPD:IPD ratio actual 99/00 0.88 1.34 0.73 0.00 0.03 2.84OPD visits actual 99/00 2,339,984 1,884,674 445,068 4,726 23,785 166,121 4,864,358Outpatient visits model - Non-AIDS 1,335,075 1,961,743 817,393 0 0 0 4,114,212Outpatient visits AIDS check 0 465,541 684,060 285,025 0 0 0 1,434,626OPD visits 0 1,800,616 2,645,803 1,102,418 0 0 0 5,548,838Outpatient conversion to PDEs 0.33 0.33 0.33 0.33 0.33 0.33 0.33

CostRecurrent cost per admission (R) 1,134 1,789 3,500 10,245 17,284 15,889 25,294 Transformation cost per admission (R) 285 220 - - 812 1,137 - Inpatient costs (R 000's) 319,258 649,775 1,065,433 390,812 204,066 225,463 41,350 2,896,156Outpatient cost (R 000's) - 357,843 771,631 496,088 - - - 1,625,563Total recurrent cost (R 000's) 319,258 1,007,618 1,837,064 886,900 204,066 225,463 41,350 4,521,719Total transformation cost (R 000's) 80,106 79,764 - - 9,584 13,428 - 182,882

BedsBed occupancy model 85% 80% 75% 65% 95% 95% 95%Bed occupancy actual 64.8% 69.4% 71.3% 75.5% 68.6% 67.6% 68.3%Beds Required (model occupancy) 5,445 3,732 4,448 804 2,043 2,153 424 19,050Occupancy rate (beds /1000 pop) 0.60 0.41 0.49 0.09 0.22 0.24 0.05 2.10 Beds Required (model demand, 99/00 occupancy) 4,608 4,806 733 2,570 2,983 596 23,211

1999/00 Actual Beds (by hospital) 0 11,191 5,556 2,355 3,617 3,117 237 26,0731999/00 Actual Beds (by level) 0 11,149 3,555 819 4,408 5,747 395 26,073

Excess 99/00 Actual Beds over Model Predicted Beds -5,445 7,416 -893 16 2,365 3,593 -29 7,023

Model maintenance cost p.a. (R bill) 0.029 0.06 0.17 0.09 0.02 0.01 0.00 0.39 Current maintenance cost p.a. (R bill) 0.00 0.19 0.14 0.09 0.05 0.03 0.00 0.49

Model replacement cost p.a. (R bill) 0.03 0.06 0.17 0.09 0.02 0.01 0.00 0.38 Current replacement cost p.a. (R bill) 0.00 0.17 0.14 0.10 0.04 0.03 0.00 0.48



hlmsv option 2.xls

Summary of model






pricesModel

99 prices

NHA core 98/99 99


General Acute care 3,707,362 18,630,411 3,381,593 16,993,344 Provincial works - - -








Surplus / Deficit 221,397 2,687,266 201,942.8 2,451,134.0

hlmsv option 3.xls

Hospital component

Transit Hospice Step Down District Regional Tertiary Custodial Psychiatry TBSpecialised unclassified Total

WorkloadAdmission rate selected 9.00 0.65 21.35 40.00 33.52 4.20 0.28 1.03 1.30 0.18 130.0Admission rate 99/00 45.04 28.66 10.83 0.77 1.37 0.06 86.7Admissions selected 81,739 5,903 193,904 363,286 304,434 38,145 2,498 9,309 11,807 1,635 1,180,679Admissions actual 99/00 386,913 246,178 93,044 6,623 11,792 510 745,060Selected LOS - acute 2.00 10.00 6.00 3.00 4.00 5.00 120.00 4.07 Selected LOS - chronic 30.00 60.00 90.00 60.51

Inpatient days selected 163,479 59,034 1,163,423 1,089,857 1,217,734 190,725 299,711 279,276 950,134 147,131 5,560,503




CostRecurrent cost per admission (R) 215 1,804 1,199 1,803 3,675.016 11,044 25,954 8,964 15,794 26,949 Transformation cost per admission (R) 37 175 106 16 - - 3,114 751 - - Inpatient costs (R 000's) 17,566 10,649 232,402 654,851 1,118,798 421,290 64,823 83,446 312,641 44,056 2,960,523Outpatient cost (R 000's) - 357,836 771,622 496,088 - - - 1,625,547Total recurrent cost (R 000's) 17,566 10,649 232,402 1,012,687 1,890,420 917,378 64,823 83,446 312,641 44,056 4,586,070Total transformation cost (R 000's) 3,035 1,031 20,541 5,741 - - 7,778 6,995 - - 45,120

BedsBed occupancy model 65% 85% 85% 80% 75% 65% 95% 80% 95% 95%Bed occupancy actual 64.8% 69.4% 71.3% 75.5% 68.6% 67.6% 68.3%Beds Required (model occupancy) 689 190 3,750 3,732 4,448 804 864 956 2,740 424 18,599Occupancy rate (beds /1000 pop) 0.08 0.02 0.41 0.41 0.49 0.09 0.11 0.30 0.05 2.05 Beds Required (model demand, 99/00 occupancy) 4,608 4,806 733 1,013 3,795 596 22,2921999/00 Actual Beds (by hospital) 0 0 0 11,191 5,556 2,355 0 3,617 3,117 237 26,0731999/00 Actual Beds (by level) 0 0 0 11,149 3,555 819 0 4,408 5,747 395 26,073

Excess 99/00 Actual Beds over Model Predicted Beds -689 -190 -3,750 7,459 1,108 1,551 -864 2,661 377 -187 7,474

Model maintenance cost p.a. (R bill) 0.017 0.06 0.20 0.10 0.01 0.01 0.00 0Current maintenance cost p.a. (R bill) 0.00 0.18 0.16 0.10 0.04 0.03 0.00 1

Model replacement cost p.a. (R bill) 0.02 0.07 0.19 0.11 0.01 0.02 0.00 0Current replacement cost p.a. (R bill) 0.00 0.20 0.15 0.11 0.05 0.03 0.00 1



hlmsv option 3.xls

Summary of model






pricesModel

99 prices

NHA core 98/99 99










Surplus / Deficit -221,131 2,687,266 -201,699.8 2,451,134.0

hlmsv option 4.xls

Hospital component



Inpatient days selected 176,672 60,994 1,225,344 1,130,698 1,265,305 199,387 360,915 275,734 950,134 159,004 5,804,187




CostRecurrent cost per admission (R) 215 1,804 1,199 1,803 3,675 11,044 25,954 8,964 15,794 26,949 Transformation cost per admission (R) 37 173 105 4 - - 3,083 777 - - Inpatient costs (R 000's) 18,984 11,003 244,771 679,390 1,162,504 440,422 78,061 82,388 312,641 47,612 3,077,776Outpatient cost (R 000's) - 331,470 714,766 459,534 - - - 1,505,770Total recurrent cost (R 000's) 18,984 11,003 244,771 1,010,860 1,877,270 899,957 78,061 82,388 312,641 47,612 4,583,546Total transformation cost (R 000's) 3,253 1,057 21,439 1,582 - - 9,272 7,137 - - 43,739

BedsBed occupancy model 65% 85% 85% 80% 75% 65% 95% 80% 95% 95%Bed occupancy actual 64.8% 69.4% 71.3% 75.5% 68.6% 67.6% 68.3%Beds Required (model occupancy) 745 197 3,950 3,872 4,622 840 1,041 944 2,740 459 19,409Occupancy rate (beds /1000 pop) 0.09 0.02 0.47 0.46 0.55 0.10 0.11 0.33 0.05 2.31 Beds Required (model demand, 99/00 occupancy) 4,780 4,993 766 1,000 3,795 644 23,2681999/00 Actual Beds (by hospital) 0 0 0 11,191 5,556 2,355 0 3,617 3,117 237 26,0731999/00 Actual Beds (by level) 0 0 0 11,149 3,555 819 0 4,408 5,747 395 26,073

Excess 99/00 Actual Beds over Model Predicted Beds -745 -197 -3,950 7,319 934 1,515 -1,041 2,673 377 -222 6,664





hlmsv option 4.xls

Scenario Input selections

PopulationSelected

2010 Expected Population 98 Population 99 2010 Expected 2010 ABT 2010 BMR 8,412,934.61 7,826,575 7,957,377 8,412,935 8,342,649 8,260,049

Funding EnvelopeSelected

Treasury 2010 Funds 98/99 Funds 99 Treasury 2010 Merchant Bank 2010 Funds 2003/04 6,779,420.00 29,646,016 29,991,185 6,779,420 6,441,450

Personnel Costs (PDE's)

Selected Stepdown District Regional Tertiary Psychiatry TB Specialised unclassified Transit Hospice CustodialExpected 138.78 403.70 518.87 1,065.00 198.30 201.27 214.20 60 120 120

Expected 217.55 403.70 518.87 792.27 293.17 201.27 293.17 High 229.19 451.39 529.34 1,064.50 393.23 217.55 393.23 Low 201.27 376.94 494.44 520.03 229.19 201.27 229.19 KZN 138.78 403.70 518.87 1,065.00 198.30 201.27 214.20 60 120 120

Increase in staff costs over cpi Selected Expected Expected Historical Baseline

Increase in staff costs over cpi 0.01 0.01 0.025 0Increase 2001 to 2010 0.09 0.09 0.25 0

Percent establishment employed

Selected Stepdown District Regional Tertiary Psychiatry TB Specialised unclassified transit hospice custodialExpected 0.9 0.95 0.9 0.8 0.9 0.9 0.95 0.9 0.9 0.9

Expected 100% 95% 90% 80% 90% 90% 95%Full 100% 100% 100% 100% 100% 100% 100%Low 80% 80% 80% 80% 80% 80% 80%KZN 0.9 0.95 0.9 0.8 0.9 0.9 0.95 0.9 0.9 0.9

PHC costsSelected

Expected 98/99 actual Expected 2010 without HBC2010 AIDS OP

No HBC 2,500,000.00 4,480,251 2,330,869 2,185,565 4,601,689 2,500,000.00

HBC Team Capacity (Patients per month)Selected

HBC model HBC model High Low32 32 45 20

PHC-DH overlap Removed estimated PHC visits from DH OP count by including selected DH OP vbisits per admission Selected

High Low High Baseline 3.00 2 3.0 4.10

Other costs

Expenditure projection for EMSSelected

expected low medium high expected 98/99expenditure per capita (99/00 prices) 28 24 28 32 28 21 incidence rate per 1000 60 50 75 100 60 49 cost per incident (99/00 prices) 583 350 466 583 583 352

Selected Expected Expected 98/99

Management 0.10 10% 0Education & training - 0% 0

Selected

Incorporated 98/99 99/00 Incorporated Balanced option 1

Provincial Works - - - - Laboratories - - - - Medical aid for health employees - - - - Provincially aided and contract hospitals - - - -

Unknown - 66,630 - 66,630 Other - - - -

Recurrent cost per admission

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Transit Hospice custodial

Model 2010 599.27 2,403.44 3,675.02 11,044.44 8,963.85 15,635.98 89,830.62 214.90 9,361.41 25,954.41 Acual 99/00 0.0 3552 4321 6062 24196 10744 21751Model 2010 599 2403 3675 11044 8964 15636 89831Option stepdown 599 KZN 599 2403 3675 11044 8964 15636 89831 215 9361 25954

Cost per OPD headcount

Selected Step Down District RegionalAcademic /

central Psychiatry TBSpecialised unclassified

Model (cost sheet) - 198.73 291.64 450.00 96.02 86.07 - Actual 99/00 173.1 251.9 306.7 53.6 54.1 63.2Model (cost sheet) 200.3 200.3 306.3 736.3 99.6 86.9 99.8Model (sum sheet) #REF! #REF! #REF! #REF! #REF! #REF!KZN 198.7 291.6 450.0 96.0 86.1

Admissions Selected

Without AIDS

2010 High decrease Baseline 99

2010 Minimum decrease

2010 Moderate decrease

2010 High

decrease KZN 74.00 76.04 95 92 89 74

Notes a) minimum decrease assumes additional demand realised as services improve to offset lowering admission trendb) high decrease set at 25% of AIDS admission rate increase, regarded as likely ceilingc) moderate decrease is median of minimum and high

SelectedAIDS Lower Baseline 99 Abt 2010 Higher Lower kzn

91.00 17.59 53.66 57.57 49.74 91

Level of hospital care options (excluding AIDS)

Beds distribution by level of care

Selected District Regional Tertiary Psychiatry TBSpecialised unclassified

High change 11,149 3,555 819 4,408 5,747 395 Existing 11,191 5,556 2,355 3,617 3,117 237 High change 11,149 3,555 819 4,408 5,747 395 Medium change 11,201 3,989 1,148 4,210 5,209 316 Low change 11,253 4,422 1,477 4,013 4,671 237

Admissions split % by level of care

SelectedHome based


Hospital admission Total transit hospice custodial

Level of care 5.00% 19.60% 40.30% 18.90% 3.60% 0.45% 1.00% 0.10% 0.00% 10.00% 0.50% 0.55% 100.00%Existing 0.00% 0.00% 51.93% 33.04% 12.5% 0.89% 1.58% 0.07% 100.00%Rationalised 5.00% 10.00% 38.00% 30.00% 11.0% 3.00% 0.50% 2.50% 100.00%Level of care 5.00% 15.00% 35.00% 30.00% 12.09% 3.00% 0.56% 2.50% 103.15%KZN 5.00% 19.60% 40.30% 18.90% 3.60% 0.45% 1.00% 0.10% 0.1 0.005 0.0055 100.00%

Admission rateSelectedLevel of care 3.70 14.50 29.82 13.99 2.66 0.33 0.74 0.07 65.82 7.40 0.37 0.41 74.00

Options for AIDS care 2010 % by level of care

Selected HBC Stepdown District Regional Tertiary Psychiatry TBSpecialised unclassified Total transit hospice custodial

non tert 20% 15% 37% 18% 3% 1% 1% 0% 0% 5% 1% 0% 100.10%Actual '99/00 0.0% 0.0% 51.9% 33.0% 12.5% 0.9% 1.6% 0.1% 100.0%non tert 30.0% 25.0% 25.0% 20.0% 0.0% 0.0% 0.0% 100.0%Model 30% 25% 20% 15% 10% 100%KZN 20% 15% 37% 18% 3% 0.01 0.01 0.001 0.05 0.005 0 100.10%

Admission Rate HIV

SelectedHome based


non tert 18.20 13.20 33.40 16.65 2.73 0.91 0.91 0.09 4.55 0.46 - 91.09

Total utilisation by level of careAdmission rate

Home based care Stepdown District Regional Tertiary Psychiatry TB



Total selected 21.90 27.699 63.22 30.64 5.39 1.2430 1.65 0.17 165.09 11.95 0.825 0.407 165.0910

Outpatients SelectedABT 2010 Actual 99 ABT 2010 KZN

Non AIDS 600.00 324.28 267.40 600AIDS 209.22 287.02 208.44 209.22Total 809.22 611.30 475.84 809.22

Outpatient distribution Admissions % by level

Selected HBC Stepdown District Regional Tertiary Psych TBSpecialised unclassified

Model 0% 0% 49% 36% 15% 0% 0% 0% 100%Actual 99/00 48.1% 38.7% 9.1% 0.10% 0.49% 3.42% 100%Model 0% 36% 29% 21% 14% 100%KZN 0% 0% 49% 36% 15%

Length of stay

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total transit hospice custodial

Model - Challenging 3.00 4.00 4.00 5.00 30.00 60.00 300.00 2.00 60.00 120.00 actual 99 0.00 6.84 5.72 6.59 150.55 60.00 114.65 Model - Basic 5.00 4.70 4.70 5.50 60.00 60.00 16.20 (n.b. Based on current median performance less outliers)Model - Challenging 5.00 3.00 3.60 5.00 60.00 30.00 16.20 (n.b. Based on current performance of the top tenth centile hospital - less outliers)KZN 3.00 4.00 4.00 5.00 30.00 60.00 300.00 2 60 120

Bed Occupancy Rate

Selected Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Total Transit Hospice Custodial

Model - Challenging 0.85 0.80 0.75 0.65 0.80 0.95 0.95 0.55 0.95 0.95 actual 99 0.00 0.65 0.69 0.71 0.76 0.69 0.68 0.68Model - Basic 0.80 0.80 0.80 0.80 0.90 0.90 0.90 (n.b. Based on current median performance less outliers)Model - Challenging 0.85 0.85 0.85 0.85 0.95 0.95 0.95 (n.b. Based on current performance of the top tenth centile hospital - less outliers)KZN 0.85 0.80 0.75 0.65 0.80 0.95 0.95 0.55 0.95 0.95

Tuberculosis (n.b. this represents all hopitalisation of TB cases, not necessarily in specialised TB hospitals only)Admissions: Total Admission Retreat Cost MDR Cost

Selected Retreat LOS Retreatments MDR Admissions Rate Bed Days per Admiss per Admission Retreat Cost MDR Cost Total CostLOS 30 60.00 9,744.96 2,030.20 11,775.16 1.40 950,133.60 15,794.39 78,182.18 153,915.70 158,725.46 312,641.16

Actual 99 60 11,792 11,792 1.48 780,329 8,624 126,688LOS 30 30 5,261 438 5,700 0.68 236,753 9,756 78,183 51,329 34,278 85,607LOS 60 60 5,261 438 5,700 0.68 394,589 15,794 78,183 83,097 34,278 117,375KZN 60 9,745 2,030 11,775 1.40 950,134 15,794 78,182 153,916 158,725 312,641


Step Down District Regional Tertiary Psychiatry TBSpecialised unclassified Transit Hospice Custodial

Costs per sq metreSelectedLatest hospitals 4,400.00 5,280.00 6,050.00 9,350.00 4,620.00 4,620.00 4,620.00 4,000.00 4,200.00 4,620.00 Latest hospitals 4,000.00 6,000.00 8,000.00 10,000.00 6,000.00 4,000.00 6,000.00 Low estimate 3,000.00 4,000.00 5,000.00 8,000.00 3,400.00 3,000.00 3,000.00 KZN 4,400.00 5,280.00 6,050.00 9,350.00 4,620.00 4,620.00 4,620.00 4000 4200 4620

Area per bedSelectedTarget 30.00 60.00 80.00 100.00 50.00 30.00 50.00 25.00 30.00 50.00 Target 30.00 60.00 80.00 100.00 50.00 30.00 50.00 Maximum (NHFA) 47.00 96.00 140.00 228.00 59.00 47.00 65.00 Minimum (NHFA) 15.00 52.00 74.00 96.00 11.00 15.00 47.00 Average (NHFA) 27.00 76.00 79.00 154.00 47.00 27.00 65.00 KZN 30.00 60.00 80.00 100.00 50.00 30.00 50.00 25 30 50

Equipment as % of building costSelectedLatest hospitals 15% 25% 50% 90% 20% 15% 12% 10% 12% 20%Latest hospitals 15% 20% 30% 50% 20% 15% 20%Conservative 10% 15% 20% 35% 15% 10% 15%Highly equiped 15% 25% 40% 60% 25% 20% 25%KZN 15% 25% 50% 90% 20% 15% 12% 0.1 0.12 0.2

Other capital factors SelectedMixed Expected High Medium Low Mixed Expected

Buildings Maintenance proportion of cost 0.045 0.045 0.035 0.025 0.045 step down 0.020 district 0.025 regional 0.045 tertiary 0.045 psychiatry 0.020 tb 0.020 specialised 0.020 custodial 0.020 transit 0.020 hospice 0.020 hbc - Life expectancy (yrs) 40.000 40 50 60 40 tertiary 30.000

Equipment Maintenance proportion of cost 0.100 0.10 0.09 0.08 0.10 Life expectancy (yrs) 8.000 8 9 10 10

Cost value ratio 0.760 1.00 0.88 0.76 0.76 Income to asset value ratio 1.000 0.70 1.00 1.20 1.00 Cost of trasnsformation - Hospitals (2001 Rand billions) 5.000 7.98 7.50 7.00 7.98 Cost of trasnsformation - Clinics (2001 Rand billions) 0.500 1.80 1.57 1.30 2 Rate of transformation (yrs) 20.000 12 15 20 20 Proportion of replacement cost for downsizing 0.330 0.3 0.25 0.15 0.25

Variables for Transit Variables for Hospice Variables for Custodial

Admission rate selected 10.5 0.73 0.3575Selected LOS 2 10 120Recurrent cost per Admission 214.9 1803.91 25954.41Transformation cost per admission 39.66 187.14 3375.71bed occupancy 0.65 0.85 0.95

Summary of model






pricesModel

99 prices

NHA core 98/99 99










Surplus / Deficit -729,542 2,687,266 -665,436.6 2,451,134.0

hlmsv option 5.xls

Hospital component



Inpatient days selected 201,069 416,440 699,090 2,127,429 1,031,056 226,897 410,888 313,718 950,134 416,440 6,793,161




CostRecurrent cost per admission (R) 215 9,361 599 2,403 3,675 11,044 25,954 8,964 15,794 89,831 Transformation cost per admission (R) 54 1,739 58 - - - 3,472 545 - 5,994 Inpatient costs (R 000's) 21,605 64,974 139,648 1,278,285 947,286 501,190 88,870 93,738 312,641 124,697 3,572,934Outpatient cost (R 000's) - 331,470 714,766 459,534 - - - 1,505,770Total recurrent cost (R 000's) 21,605 64,974 139,648 1,609,755 1,662,052 960,724 88,870 93,738 312,641 124,697 5,078,704Total transformation cost (R 000's) 5,400 12,068 13,618 - - - 11,887 5,700 - 8,320 56,993

BedsBed occupancy model 55% 95% 85% 80% 75% 65% 95% 80% 95% 95%Bed occupancy actual 64.8% 69.4% 71.3% 75.5% 68.6% 67.6% 68.3%Beds Required (model occupancy) 1,002 1,201 2,253 7,286 3,766 956 1,185 1,074 2,740 1,201 22,665Occupancy rate (beds /1000 pop) 0.12 0.14 0.27 0.87 0.45 0.11 0.14 0.13 0.33 0.14 2.69 Beds Required (model demand, 99/00 occupancy) 8,995 4,069 872 1,138 3,795 1,688 27,2331999/00 Actual Beds (by hospital) 0 0 0 11,191 5,556 2,355 0 3,617 3,117 237 26,0731999/00 Actual Beds (by level) 0 0 0 11,149 3,555 819 0 4,408 5,747 395 26,073

Excess 99/00 Actual Beds over Model Predicted Beds -1,002 -1,201 -2,253 3,905 1,790 1,399 -1,185 2,543 377 -964 3,408





hlmsv option 5.xls

Total cost of service delivery / admission for different bed types

Comparative PDE costs in 2001 prices

Home based Stepdown District Regional Tertiary Psychiatry TBSpecialised unclassified transit hospice custodial

Actual 96/97 (NHA) 406 474 1,379Actual 97/98 (NHA) 372 464 1,558Actual 98/99 (from NHA) 495 476 1,691Actual 96/97 (NHA) alt ratio 544 977Actual 97/98 (NHA) 533 1,123Actual 98/99 (from NHA) 543 1,219Actual 99/00 519 756 920 161 162 190Actual (npf3101) 433 608 975 224 133 248

Calculation of total cost per admissionPers per PDE 138.78 403.70 518.87 1,065.00 198.30 201.27 214.20 60 120 120

target alos 3 4 4 5 30 60 300 2 60 120 percent establishment 90% 95% 90% 80% 90% 90% 95% 90% 90% 90%

pers per admission 374.71 1,534.06 1,867.93 4,260.00 5,354.10 10,868.58 61,047.00 108.00 6,480.00 12,960.00 nonpers per admission 124.05 408.28 516.42 1,250.63 1,473.80 2,878.77 14,394.00 50.00 2,589.00 5,799.60

maintenance per admission 44.67 216.99 671.85 2,660.17 949.32 839.39 6,395.39 25.29 129.96 3,197.69 replacement per admission 55.84 244.11 618.81 2,873.64 1,186.64 1,049.24 7,994.23 31.61 162.45 3,997.12

transformation capital per admission 58.44 - - - 545.03 - 5,993.98 53.71 1,738.71 3,471.72 Total (excluding transformation) 599.27 2,403.44 3,675.02 11,044.44 8,963.85 15,635.98 89,830.62 214.90 9,361.41 25,954.41

Cost/PDE 199.76 600.86 918.75 2,208.89 298.80 260.60 299.44 107.45 156.02 216.29 Cost /PDE (npf3101) 475.88 668.34 1,093.75 217.18 423.33 246.78

Cost/OP visit 66.59 200.29 306.25 736.30 99.60 86.87 99.81 35.82 52.01 72.10 pers as % of total 0.63 0.64 0.51 0.39 0.60 0.70 0.68 0.50 0.69 0.50

capital as % of total 0.27 0.19 0.35 0.50 0.30 0.12 0.23 0.51 0.22 0.41

CommentLinks to other tables not finalisedLink to capital sheet (?per PDE or per bed) needs finalisationStepdown is an estimate based on specialised unclassified staff cost plus district hospital non-personnel cost

NHA costs 99 prices

Home based Stepdown District RegionalAcademic / central Psychiatry TB


Actual 96/97 (NHA) 370.56 432.48 1,257.73 Actual 97/98 (NHA) 339.55 423.34 1,420.84 Actual 98/99 (from NHA) 451.35 434.55 1,542.55 Actual 96/97 (NHA) alt ratio 496.30 891.58 Actual 97/98 (NHA) 486.02 1,024.50 Actual 98/99 (from NHA) 495.18 1,112.17 Actual 99/00 473.56 689.23 839.31 146.60 148.09 173.04

Tuberculosis HospitalisationCost Retreatment MDRPersonnel cost per PDE 201.27 201.27 Non-pers cost per admission 2,878.77 42,314.59

Primary health care

Core package funding 2001 pricesFunding / capita (R) 242.38Cost per Clinic Visit 30.26

Utilisation rate Cost per visit (R)CHP 2.45 99Eastern CapeOther

Predicted funding 2010Utilisation rate Cost per visit (R) Cost / capita Total (R '000)

Core package 265.73 2,039,127Capital transformation 25,000AIDS-related PHC Visits 1,753,615 69.25 121,438 Additional HIV/AIDS visits (from Out-pr)AIDS-related HBC stays 145,304 From MINMEC policy on HBCTotal 2,330,869Adjustment 169,131Assumed costs 2,500,000

Other optionsActual 99/00 excl DH component 4,480,251 Check

Core package +10% 292 2,459,125Modified 2.9 84 244 2,051,612Modified 3.3 84 278 2,334,592

Tertiary care

Summary of levels and costs of tertiary care funded within the conditional grant envelope

National Tertiary Services Grant 4,687,170

Provincial Allocation

Option 1 Option 2 Option 3 Option 4

ProposedModerate increase High increase Decrease

E Cape 429,418 447,537 480,729 385,567Free State 452,909 416,792 500,535 401,452Gauteng 1,551,955 1,636,590 1,857,842 1,490,076KwaZulu Natal 878,708 907,458 1,004,698 805,815Mpumalanga 69,004 81,336 93,784 75,219North West 63,281 78,679 92,580 74,253Northern Cape 69,277 51,317 84,795 68,010Northern Province 91,040 118,379 126,916 101,793Western cape 1,081,578 1,168,884 1,251,492 1,003,755

4,687,170 4,906,972 5,493,371 4,405,940

Level of care adjustments

byfrom

Districtfrom

Regionalfrom

Tertiaryfrom

Psychiatryfrom TB

from Specialised unclassified

ExistingBeds Nos hospital 11,191 5,556 2,355 3,617 3,117 237

% reduction 0% 0% 0% 0% 0% 0%Beds Nos level 11,191 5,556 2,355 3,617 3,117 237 26,073

Model Max adjustment% reduction to district - 25% 20% 0% 0% 0%

to regional 2% - 40% 0% 0% 0%to tertiary 0% 5% - 0% 0% 0%

to psychiatry 0% 10% 10% - 0% 0%to TB 15% 15% 5% 0% - 0%

to spec-un 0% 2% 2% 0% 0% -

Beds Nos level 11,149 3,555 819 4,408 5,747 395 26,073

Model Medium adjustment% reduction to district - 20% 15% 0% 0% 0%



to spec-un 0% 1% 1% 0% 0% -

Beds Nos level 11,201 3,989 1,148 4,210 5,209 316 26,073

Model Minimum adjustment% reduction to district - 15% 10% 0% 0% 0%



to spec-un 0% 0% 0% 0% 0% -

Beds Nos level 11,253 4,422 1,477 4,013 4,671 237 26,073

Other programmes

Expenditure on other programs (2001 prices)Exp 96/97 Exp 97/98 Expenditure 98/99 Predicted 2010

Management including national DOH 3,140,090 2,852,214 250,000 292,526EMS 570,211 640,687 154,144 312,951Education and training 632,399 524,589 137,719 146,496 Other 1,718,070 1,764,557 0 0Laboratories 203,234 180,270 0 0Medical aid for health employees 0 0 0 0Provincially aided and contract hospitals 0Works 0

Program 6 = Laundries, forensics, orthotics and prosthetics, engineering presumed included elsewhere

Comment? How to handle Health Professional Training and Research Grant? How to handle program 6

Expenditure on other programs (1999 prices)Exp 96/97 Exp 97/98 Expenditure 98/99 Predicted 2010

Management including national DOH 2,864,168 2,601,588 250,000 275,000 EMS 520,107 584,389 154,144 294,201 Education, training and research 576,830 478,493 137,719 137,719 Other (NHA other - PAH-contract) 1,567,102 1,609,504 Laboratories 185,376 164,430 Medical aid for health employeesProvincially aided and contract hospitalsWorksNotes a) EMS 98/99 data from EMS returns

Expenditure projection for EMSexpected

expenditure per capita (99/00 prices) 28 incidence rate per 1000 60 cost per incident (99/00 prices) 583 incidence nos (2010) 504,776 budget 2010 294,201

Total envelope for health funding

Health budget actual and predicted

Budget Review 2001 NHA in 2001 prices

Year Nominal pricesReal 2001

prices % change

historic change per

annum Narrow Core Full Core as % Narrow1996/97 20,640,000 28,525,855 25,695,918 28,163,770 33,921,726 110%1997/98 23,001,000 29,394,437 3.04% 27,138,696 30,079,069 36,138,516 111%1998/99 23,528,000 27,963,699 -4.87% 27,024,677 29,646,016 35,844,698 110%1999/2000 24,937,000 27,339,325 -2.23% 29,991,185 2,621,3392000/01 27,195,000 28,928,200 5.81% 0.35% 6,301,8132001/02 29,624,000 29,624,000 2.41% 6,348,0192002/03 31,378,000 29,432,564 -0.65% 6,394,564 CPI 6.2% (Budget Review 2001)2003/04 33,465,000 29,757,881 1.11% 6,441,450 CPI 5.2% (Budget Review 2001)2004/05 29,825,124 0.23% 6,488,680 Real Annual Growth (MTEF Budget Review)2005/06 29,892,519 0.23% 6,536,256 0.23%2006/07 29,960,067 0.23% 6,584,181 0.73%2007/08 30,027,767 0.23% 6,632,4572008/09 30,095,620 0.23% 6,681,0872009/10 30,163,626 0.23% 30,163,626 6,730,074 6,779,4202010/11 30,231,786 0.23% 0.43% 6,779,420

Note: Specify what is included or excluded e.g.LG, National DOH, Works Departments, Narrow=NDOH+PDOHsMRC, Public financing of medical schemes for employees Core= Narrow+Las+worksAnnexure to provide details Full= Core+other national depts and funds+other prov.

Envelope for hospital services in 2010Funds available 27,440,686 NHA in 99 pricesExpenditure predicted by model #REF! Narrow Core FullDifference #REF! 1996/97 23,438,000 25,689,000 30,941,000

1997/98 24,754,000 27,436,000 32,963,0001998/99 24,650,000 27,041,000 32,695,000

Macroeconomic asssupmtions:Average Annual Growth in Health Expenditure

Scenario:0.005 0.006 0.012 0.012 0.012 0.012 0.012 0.012 0.012

Health SpendingRand Billions 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10

Treasury (MTEF 2000/01 projections extrapolated) 27.20 27.34 27.50 27.83 28.16 28.50 28.84 29.19 29.54 29.89 ABSA Optimistic 27.20 27.74 28.30 28.86 30.02 31.22 32.47 33.77 35.12 36.52 FNB 27.20 27.09 27.50 27.77 28.05 28.33 28.61 28.90 29.19 29.48 ABT Associates (full AIDS needs, maximum substitution) 27.20 29.88 32.55 35.23 37.90 39.26 40.50 41.58 42.48 43.21 Merchant 27.20 27.34

Assumptions underlying scenarios:

Treasury ABSA FNB MerchantLon run average annual GDP growth 3.3% 4.6% 2.0% -2%Long run average government expend growth 2.6% 4.0% 1.0% 0%Long run average health expend growth 1.2% 4.0% 1.0% 0%

Description of scenarios:

Status: Features:Treasury Current spending plans High economic growth, very tight expenditure control, health share of GDP shrinks from 3% to 2.5% by 2010ABSA Optimistic Best case High economic growth, more generous government expenditure growth, health share of GDP shrinks from 3% to 2.8% by 2010FNB Worst case Low economic growth, extremely tight government expenditure growth, health share of GDP shrinks to 2.6% by 2010Merchant bank Negative growthAbt Associates Illustrative All AIDS care needs met without ARVs, maximum use made of hospital substitutes (HBC and step-down)

All options data

Provincial health expenditure 2000/01 27,200,000,000 Hosp budget = 63.8% Prov. health budget 17,353,600,000 Estimated provincial health exp 2009/10 43,200,000,000 Scenario: ABT Assoc.Estmated Hospital budget 2009/10 13,168,320,000 Hosp budget = 63.8% Prov. health budgetReductions for HSS (4,917,176,471) Reductions for PHC package (1,588,235,294) Residual Hospital budget 2009/10 6,662,908,235

Academic District && tertiary Regional Community Total 1000000

Hospitals budget (R mill)1998/1999 4,867 5,307 7,203 17,377 Data from National Health Accounts, 2000 Rand value2000/2001 4,860 5,300 7,193 17,354

all hospitals - 2008/2009 1,866 2,035 2,762 6,663 Same spending mix as 2000/01, at 2009/10 projected hospitals budgetadjusted for HSS & PHC -

2008/2009 hss grant 2,827 3,836 6,663 Residual spending on acute hospitals


Buildings Step Down District RegionalAcademic / central Psychiatry TB

Specialised unclassifie transit hospice custodian

cost per bed 132,000.00 316,800.00 484,000.00 935,000.00 231,000.00 138,600.00 231,000.00 100,000.00 126,000.00 231,000.00 annual maintenance (%) 2,640.00 7,920.00 21,780.00 42,075.00 4,620.00 2,772.00 4,620.00 2,000.00 2,520.00 4,620.00

annual replacement cost (life yrs) 3,300.00 7,920.00 12,100.00 31,166.67 5,775.00 3,465.00 5,775.00 2,500.00 3,150.00 5,775.00

Equipment Step Down District RegionalAcademic / central Psychiatry TB

unclassified

cost per bed 19,800.00 79,200.00 242,000.00 841,500.00 46,200.00 20,790.00 27,720.00 10,000.00 15,120.00 46,200.00 annual maintenance (%) 1,980.00 7,920.00 24,200.00 84,150.00 4,620.00 2,079.00 2,772.00 1,000.00 1,512.00 4,620.00

annual replacement cost (life yrs) 2,475.00 9,900.00 30,250.00 105,187.50 5,775.00 2,598.75 3,465.00 1,250.00 1,890.00 5,775.00

Buildings + Equipment Step Down District RegionalAcademic / central Psychiatry TB

unclassified

Expected total bed cost 151,800.00 396,000.00 726,000.00 1,776,500.00 277,200.00 159,390.00 258,720.00 110,000.00 141,120.00 277,200.00 Value per bed 115,368.00 300,960.00 551,760.00 1,350,140.00 210,672.00 121,136.40 196,627.20 83,600.00 107,251.20 210,672.00

Total maintenance cost per bed 4,620.00 15,840.00 45,980.00 126,225.00 9,240.00 4,851.00 7,392.00 3,000.00 4,032.00 9,240.00 Total replacement cost per bed 5,775.00 17,820.00 42,350.00 136,354.17 11,550.00 6,063.75 9,240.00 3,750.00 5,040.00 11,550.00

Ongoing recurrent costs per admission Step Down District RegionalAcademic / central Psychiatry TB

punclassifie

dTotal annual recurrent cost of capital 10,395.00 33,660.00 88,330.00 262,579.17 20,790.00 10,914.75 16,632.00 6,750.00 9,072.00 20,790.00

Target ALOS 3.00 4.00 4.00 5.00 30.00 60.00 300.00 2.00 10.00 120.00 Target BOR 0.85 0.80 0.75 0.65 0.80 0.95 0.95 0.65 0.85 0.95

Target admissions per annum per bed 103.42 73.00 68.44 47.45 9.73 5.78 1.16 118.63 31.03 2.89 maintenance cost per admission 44.67 216.99 671.85 2,660.17 949.32 839.39 6,395.39 25.29 129.96 3,197.69 replacement cost per admission 55.84 244.11 618.81 2,873.64 1,186.64 1,049.24 7,994.23 31.61 162.45 3,997.12

Capital transformation cost per admission Step Down District RegionalAcademic / central Psychiatry TB

punclassifie

d transit hospice custodian TotalExcess/shortfall of beds -2,253 3,905 1,790 1,399 2,543 377 -964 -1,002 -1,201 -1,185

Allocation proportions 0.260 0.388 0.326 0.623 0.177 0.015 0.190 0.084 0.129 0.250 2.44 Division of capital transformation cost 0.53 0.79 0.67 1.28 0.36 0.03 0.39 0.17 0.26 0.51 5.00

Annual capital transformation cost 0.03 0.04 0.03 0.06 0.02 0.00 0.02 0.01 0.01 0.03 0.25 Cost per admission 114.28 74.71 129.50 1,406.76 1,731.67 111.19 13,988.22 85.32 1,901.16 7,468.84

Net capital transformation per admission 58.44 - - - 545.03 - 5,993.98 53.71 1,738.71 3,471.72

Input data from scenario sheet

maintenance costreplacement costtransformation costnet transformation cost

Recurrent non-personnel costs per PDE and admission in 1999 and 2001 prices

Cost per PDE

Adjusted Estimates (99/0 prices):District Regional Tertiary Psychiatric TB Specialised

Medicines 34.11 53.57 134.20 9.25 5.60Laboratories 6.89 8.38 18.72 4.82 3.33

Other non-pers (excl capital and maintenance) 51.79 55.41 74.47 30.59 34.68Total non pers 92.79 117.37 227.39 44.66 43.62

Adjusted to 01/02 prices:District Regional Tertiary Psychiatric TB Specialised transit hospice custodial step down TB

Medicines 37.52 58.93 147.62 10.18 6.16 0 5.00 10.18 1.00 6.16 Laboratories 7.58 9.22 20.59 5.30 3.67 0 0 0 2.20 3.67

Other non-pers (excl capital and maintenance) 56.97 60.96 81.91 33.65 38.15 25.00 38.15 38.15 38.15 38.15 Total non pers 102.07 129.10 250.13 49.13 47.98 25.00 43.15 48.33 41.35 47.98

Cost per Admission

Adjusted Estimates (99/0 prices):District Regional Tertiary Psychiatric TB Specialised

Medicines 136.45 214.28 671.00 277.60 335.91 Laboratories 27.55 33.53 93.60 144.58 200.10

Other non-pers (excl capital and maintenance) 207.16 221.66 372.33 917.63 2,081.05 Total non pers 371.16 469.47 1,136.94 1,339.81 2,617.06

Adjusted Estimates (01/02 prices):District Regional Tertiary Psychiatric TB Specialised transit hospice custodial step down TB

Medicines 150.09 235.71 738.10 305.36 369.50 0 300.00 1,221.60 3.00 1,848.00 Laboratories 30.31 36.88 102.96 159.04 220.11 0 0 0 6.60 1,101.00

Other non-pers (excluding capital and maintenance) 227.88 243.82 409.57 1,009.40 2,289.16 50.00 2,289.00 4,578.00 114.45 11,445.00 Total non pers 408.28 516.42 1,250.63 1,473.80 2,878.77 50.00 2,589.00 5,799.60 124.05 14,394.00

Outputs

Outputs Actual 99/00 (and other data from hospitals dataset)Total District Regional Tertiary All acute Psych TB Spec-unclass All chronic

Hospitals 74 42 10 3 4 12 3Usable beds 26,073 11,191 5,556 2,355 3,617 3,117 237%beds 100.0% 42.9% 21.3% 9.0% 13.9% 12.0% 0.9%Beds/1000 3.28 1.41 0.70 0.30 0.45 0.39 0.03Beds/1000 2000 1.08 0.74 0.43 0.62Admissions 745,060 386,913 246,178 93,044 726,135 6,623 11,792 510 18,925Admissions/1000 93.63 48.62 30.94 11.69 91.25 0.83 1.48 0.06 2.38%Admissions 100% 51.93% 33.04% 12.49% 0.89% 1.58% 0.07%Inpatient days 6,503,757 2,646,949 1,407,907 613,009 4,667,865 997,089 780,329 58,474 1,835,892LOS 8.7 6.8 5.7 6.6 6.43 150.5 66.2 114.7 97.01 OPD Headcounts 4,864,358 2,339,984 1,884,674 445,068 4,726 23,785 166,121OP h/count : Admissions 6.53 6.05 7.66 4.78 0.71 2.02 325.73 OPD:IPD 0.748 0.884 1.339 0.726 0.005 0.030 2.841OPD/1000 pop 611.3 294.1 236.8 55.9 0.6 3.0 20.9%OPD 100% 48.1% 38.7% 9.1% 0.1% 0.5% 3.4%Expenditure 99/00 3,948,073,093 1,622,860,708 1,403,361,151 639,021,408 146,400,000 116,729,826 19,700,000 462,851,411Expenditure 99/00 in 01/02 prices 4,328,413,812 1,779,200,267 1,538,555,048 700,582,037 160,503,559 127,975,085 21,597,815Bed occupancy 68.3% 64.8% 69.4% 71.3% 75.5% 68.6% 67.6%Expend per PDE 486 474 689 839 147 148 173Expend per PDE in 2001 prices 533 519 756 920 161 162 190Expenditure per admission 4650 3552 4321 6062 24196 10744 21751Inpatient exp 3,300,195,741 1,374,242,715 1,063,851,841 564,069,919 160,250,374 126,687,905 11,092,987Outpat exp 1,028,218,071 404,957,552 474,703,207 136,512,118 0 253,185 1,287,180 10,504,828

4,328,413,812 1,779,200,267 1,538,555,048 700,582,037 160,503,559 127,975,085 21,597,815Cost on sum sheet 5,078,704 1,609,755 1,662,052 960,724 93,738 312,641 124,697OPD exp/OPD 173 252 307 54 54 63

CommentDH / PHC overlap dealt with in model as follows:

a) Removed estimated PHC visits from DH OP count by including only DH OP visits per admission Actual 6,907,964b) All hospitals below 30 beds assumed as CHC's and costs assumed covered in PHC package Actual/1000 198 National

per admiss 4.1

Outputs - prediction summary

Total admission rate trends (per 1000 public population)

Without AIDS admissions AIDS admissions TB Admissions

Total admission

rate96/97 104.41 7.59 112.00 97/98 102.13 10.47 112.60 98/99 89.57 14.11 103.67 99/00 76.04 17.59 0.35 93.63 00/01 94.29 22.31 0.39 116.61 2010 95.00 91.00 0.68 186.68 Drop in non AIDS admission rates must be transferred to PHC

Comment: Potential effects of changing demographic composition and trend to lower admission rates with more day surgery and high tech OPD procedures modelled as follows:

a) 99/00 data used as baseline. b) Fall in "without AIDS" admissions transferred to OP visits at rate of 3.00 visits per admission.c) No adjustment for higher OP costs for day surgery or minimally invasive techniques

99/00 data may exclude trauma visits

OPD headcounts / population predictions

without AIDS visits / 1000 pop

with AIDS visits / 1000 pop

Total Visits / 1000 pop

96/97 526.18 118.21 644.39 97/98 533.05 163.18 696.23 98/99 570.72 219.84 790.56 99/00 324.28 287.02 611.30 00/01 267.40 193.86 461.26 2010 267.40 208.44 475.84

Ratio of 2010 total visits to 99/00 total visits 0.78

Comment Home Based Care

AIDS admissions calculations Total team cost from HBC costing paper 555,840 (R 2000/01)Team capacity 32 patients per month

384 patients per annumExcludes HIV co-infected TB admissions

1,540 Cost per admission equivalent

Selected Total admissions Excluding TB admission HBC Stepdown District Regional Tertiary 20% HBC % of AIDS Admissions:% by level of care 20% 15% 37% 18% 3%1996/97 56,185 56,185 11,237 8,147 20,620 10,282 1,686 17,302,2681997/98 80,289 80,289 16,058 11,642 29,466 14,693 2,409 24,724,9401998/99 110,397 110,397 22,079 16,008 40,516 20,203 3,312 33,996,7931999/00 146,541 139,974 29,308 21,248 53,781 26,817 4,396 45,127,3432000/01 188,202 179,989 37,640 27,289 69,070 34,441 5,646 57,957,0472001/02 229,517 219,536 45,903 33,280 84,233 42,002 6,886 70,679,8502002/03 271,793 259,994 54,359 39,410 99,748 49,738 8,154 83,698,9142003/04 313,132 299,546 62,626 45,404 114,920 57,303 9,394 96,429,2222004/05 351,605 336,352 70,321 50,983 129,039 64,344 10,548 108,277,0132005/06 385,560 368,831 77,112 55,906 141,500 70,557 11,567 118,733,2652006/07 413,899 395,938 82,780 60,015 151,901 75,744 12,417 127,460,3762007/08 436,259 417,333 87,252 63,257 160,107 79,835 13,088 134,346,0552008/09 452,804 433,171 90,561 65,657 166,179 82,863 13,584 139,441,2112009/10 464,174 444,059 92,835 67,305 170,352 84,944 13,925 142,942,7552010/11 471,842 451,402 94,368 68,417 173,166 86,347 14,155 145,303,965

Option 1 AbTYear Admission Rate HBC Stepdown District Regional Tertiary% by: 20% 15% 37% 18% 3%1996/97 7.6 1.52 1.10 2.78 1.39 0.231997/98 10.5 2.09 1.52 3.84 1.92 0.311998/99 14.1 2.82 2.05 5.18 2.58 0.421999/00 17.6 3.68 2.67 6.76 3.37 0.552000/01 22.3 4.67 3.38 8.56 4.27 0.702001/02 26.9 5.63 4.08 10.33 5.15 0.842002/03 31.6 6.60 4.79 12.11 6.04 0.992003/04 36.1 7.56 5.48 13.87 6.91 1.132004/05 40.3 8.43 6.11 15.48 7.72 1.272005/06 44.0 9.21 6.67 16.89 8.42 1.382006/07 47.1 9.85 7.14 18.08 9.01 1.482007/08 49.6 10.36 7.51 19.02 9.48 1.552008/09 51.4 10.75 7.79 19.72 9.83 1.612009/10 52.7 11.02 7.99 20.22 10.08 1.652010/11 53.7 11.22 8.13 20.58 10.26 1.68

Option 2 - Higher demand 57.6 7.3% above option 1 AbtOption 3 - Lower demand 49.7 7.3% below option 1 Abt

OutpatientsYear Outpatient Visits HBC Stepdown District Regional Tertiary% by: 0% 0% 49% 36% 15% 100%1996/97 875,592 0 0 429,040 315,213 131,3391997/98 1,251,277 0 0 613,126 450,460 187,6921998/99 1,720,580 0 0 843,084 619,409 258,0871999/00 2,283,951 0 0 1,119,136 822,222 342,5932000/01 1,563,624 0 0 766,176 562,905 234,5442001/02 931,476 0 0 456,423 335,331 139,7212002/03 1,081,179 0 0 529,777 389,224 162,1772003/04 1,224,865 0 0 600,184 440,951 183,7302004/05 1,356,989 0 0 664,925 488,516 203,5482005/06 1,472,429 0 0 721,490 530,074 220,8642006/07 1,567,846 0 0 768,245 564,425 235,1772007/08 1,642,301 0 0 804,727 591,228 246,3452008/09 1,695,727 0 0 830,906 610,462 254,3592009/10 1,730,734 0 0 848,059 623,064 259,6102010/11 1,753,615 0 0 859,271 631,301 263,042

0.21(n.b. 50% of OP visits are directly allocated to primary care)

TuberculosisTB Assumptions:Workload: Best case - taken directly from Abt Report

Medium case - mid-pointWorst case - Abt estimate scaled up to estimated national caseload (2000), from South African Health Review 2000

Composition of TB casesNew cases 79.2%Retreatment 19.2%MDR (Multiple Drug Resistant) 1.6%

Care requirements Hospital stay (days) DOTS (days) Drug cost per courseNew cases 0 180 256Retreatment 60 120 Consider an alternative scenario of 30 days stay 523MDR (Multiple Drug Resistant) 180 0 Not negotiable given current drugs 31322

Mid Case is used as it gives best match with 1999/00 observed TB cases

Total Incident TB cases in: Best Case Mid Case Worst Case % HIV Coinfected1999/00 11,842 13,565 20,775 41% 48%2000/01 13,462 15,209 23,618 48% 54%2001/02 15,210 16,978 26,684 54% 59%2002/03 17,012 18,799 29,846 59% 63%2003/04 18,786 20,588 32,958 63% 66%2004/05 20,444 22,258 35,867 66% 69%2005/06 21,910 23,734 38,439 69% 70%2006/07 23,132 24,962 40,582 71% 72%2007/08 24,088 25,922 42,260 73% 73%2008/09 24,785 26,620 43,482 74% 74%2009/10 25,257 27,091 44,311 75% 74%2010/11 25,569 27,402 44,858 76% 75%

KwaZulu Natal ProvinceTotal TB Admissions Best Case Mid Case Worst Case

Retreatment MDR Retreatment MDR Retreatment MDR1999/00 2,274 189 2,604 217 3,989 332 2,8222000/01 2,585 215 2,920 243 4,535 378 3,1632001/02 2,920 243 3,260 272 5,123 427 3,5312002/03 3,266 272 3,609 301 5,730 478 3,9102003/04 3,607 301 3,953 329 6,328 527 4,2822004/05 3,925 327 4,274 356 6,886 574 4,6302005/06 4,207 351 4,557 380 7,380 615 4,9372006/07 4,441 370 4,793 399 7,792 649 5,1922007/08 4,625 385 4,977 415 8,114 676 5,3922008/09 4,759 397 5,111 426 8,349 696 5,5372009/10 4,849 404 5,201 433 8,508 709 5,6352010/11 4,909 409 5,261 438 8,613 718 5,700

Input data as predicted by Abt Associates, provincial data isstill to be obtained from the Abt reportInput data from the scenario sheet

Inflation (CPI)

CPIConversion to

99 prices

Conversion to 2001 prices

1996/7 101.583 1.26 1.381997/8 109.858 1.17 1.281998/9 118.125 1.08 1.191999/00 128.058 1.00 1.102000/01 131.983 0.97 1.062001/02 140.395 0.91 1.002002/03 149.099 0.86 0.942003/04 156.853 0.82 0.90

Comment: Based on SSA CPI for metro areasData from SSA websiteData recalculated for financial years. Year average calculated from difference in average index between 2 years.

Personnel Cost per PDE

Type

Cost per PDE 2000 prices-

HRPlan

negotiated increase over inflation rate

in 2010 at 2000 prices

Cost per PDE 2000 prices-

HRPlan adjusted

2000 pricesStaff per bed

ratioHSP 2000

prices

Cost per PDE* 2001

pricesDistrict<15 beds 436 477 50715-30 beds 348 381 40530-60 beds 324 354 314 1.86 377

50 0 1.80 319.0060-120 beds 369 404 355 2.13 429

100 0 2.20 357.00>120 beds 347 380 404

200 0 2.20 355.002/3 L1, 1/3 L2 (>240 PDE) 388 424 376 451

0Regional 0L1,L2 High OPD 417 456 485Mixed: 1/3 L1, 2/3 L2, low OPD 446 488 447 519 ??1+2: 250 bed 0 2.86 521.001+2: 500 bed 0 2.67 471.00Leve 2 High OPD 425 465 2.60 494 ??Pure L2, low OPD 455 498 2.50 529 ??Level 2: 250 bed 0 3.10 578.00Level 2: 500 bed 0 2.86 515.00Level 2: 1000 0 2.88 521.00

00

TB small 187 205 218TB Chronic large 173 189 160 201

0Psychiatry 0Acute 338 370 393Chronic 197 215 229Combined 252 276 243 293

0Tertiary 0Mixed L1,L2,L3 402 440 468 ??Mixed L2,3 (provincial tertiary) 447 489 474 520 ??Pure L3 (Universitas) 915 1001 1065

Notes: Data to specify at which date salary scales have been updatedAnnexures to include model establishment by type

Population

Option 1 Total Public %

Public sector users

1996 8,417,021 88.0% 7,406,9781997 8,713,578 88.0% 7,667,9491998 8,893,835 88.0% 7,826,5751999 9,042,474 88.0% 7,957,3772000 9,165,825 88.0% 8,065,9262001 9,268,914 88.0% 8,156,6442002 9,357,581 88.0% 8,234,6712003 9,417,925 88.0% 8,287,7742004 9,474,952 88.0% 8,337,9582005 9,518,173 88.0% 8,375,9922006 9,547,828 88.0% 8,402,0892007 9,566,615 88.0% 8,418,6212008 9,574,919 88.0% 8,425,9292009 9,572,619 88.0% 8,423,905 8 081 164 ABT in 20092010 9,560,153 88.0% 8,412,935 Bureau for market research

Option 2 9,480,283 88.0% 8,342,649 ABT+1%Option 3 9,386,419 88.0% 8,260,049 BMR-1%

Population - Final 1996 censusTotal population 8.42 CSS - millions, 1996

Public population 7.41 CSS updated - millions requiring public beds (non medical aid members), 20081996 rate of change 2.20% CSS data

rate of change in 2008 0.02% from AIDS consensus documentrate of decrease of change 9.09% to produce zero growth in 2010

1 2 3 4 5 6 7 8 9 10programme year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

projected rate of change 0.07431 0.01364 0.01125 0.00957 0.00645 0.00606 0.00456 0.00312 0.00197 0.00087total projected population 9.04 9.17 9.27 9.36 9.42 9.47 9.52 9.55 9.57 9.57

subsequent years 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018projected rate of change -0.00024 -0.00130 -0.00675 -0.01350 -0.02026 -0.02701 -0.03377 -0.04052 -0.04727 -0.05403

total projected population 9.57 9.56 9.50 9.37 9.18 8.93 8.63 8.28 7.89 7.46

Input data

strategicpositionstatement for kwazulu-natal · strategicpositionstatement for kwazulu-natal ......

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