“What counts in life is not the mere fact that we have

lived. It is what difference we have made to the lives of

others that will determine the significance of the life we

lead.” – Nelson Mandela on the 90th birthday

celebration of Walter Sisulu, Walter Sisulu Hall,

Johannesburg,18 May 2002

Collaborating towards better health outcomes in Klerksdorp

Prof Binu Luke

Chief Physician

Coordinator of Tertiary Services

Klerksdorp/Tshepong Hospital

University of Witwatersrand

North West Province

Area[2]:9

Population (2011)[2]:18[3]

• Total 3,509,953

• Estimate (2018) 3,979,000

• Rank 7th in South Africa

• Density 33/km2

(87/sq mi)

• Density rank 7th in South Africa

Population groups[2]:21

• Black African 89.8%

• White 7.3%

• Coloured 1.8%

• Indian or Asian 0.6%

Languages[2]:25

• Tswana 63.4%

• Afrikaans 9.0%

• Southern Sotho 5.8%

• Xhosa 5.5%

• Tsonga 3.7%

• English 3.5%

• Zulu 2.5%

• Northern Sotho 2.4%

Dr Kenneth Kaunda District

Population (2011)[2]

• Total 695,933 ? 780000 (2018)

• Density 48/km2

(120/sq mi)

Racial makeup (2011)[2]

• Black African 80.3%

• Coloured 4.1%

• Indian/Asian 0.7%

• White 14.5%

First languages (2011)[3]

• Tswana 44.8%

• Afrikaans 18.4%

• Sotho 15.3%

• Xhosa 11.5%

• Other 10%

Public Hospitals in Dr KK District

• Klerksdorp/Tshepong: Provincial tertiary

• Potchefstroom: Regional

• Nic Bodenstein(Wolmaranstad): District

• Ventersdorp: District/Large CHC

Klerksdorp/Tshepong• In Matlosana sub district• Two hospitals :7 kms apart• One management• Departmentalised facility thus avoiding duplication of services since

1999• Regional hospital upgraded to provincial tertiary• Mandated to provide primary, secondary and T1 tertiary services• 890 beds• 96 bedded provincial MDR/XDR TB Unit

Funding streams 19/20

• Equitable share :R 917 149 130

• NTSG: R 192 273 000

• HPTDG: R 73 599 685

• HIV: R 20 000 000

• Netcare R 2 085 000

• Total budget R1 205 106 815

Tertiary Services (T1)• Nephrology• Neurosurgery• Thoracic surgery• Medical Oncology• Radiation oncology• Radiology: MRI,2 CT Scans, Mammography• Cardiology: Non Invasive• Arthroplasty and spine surgery

Tertiary Services• Maxillofacial

• Vascular Surgery

• Rheumatology

• ICU

• MDR TB/XDR TB

• Gynae oncology

• Laparoscopic surgery

• Neonatology

• Urology

Academic platform

• Faculty of Health Sciences , University of

Witwatersrand

Registrar Programme• Internal Medicine: 9• General Surgery:2• Paediatrics:2• O&G:2• Orthopaedics:2• Radiology:2• Neurosurgery:2• Family Medicine:2• Emergency Medicine:3• Psychiatry:2• Urology:1

• Anaesthesia:2 Total : 33( Satellite and full training)• Oncology :2

Medical Students

• Final year Wits Students

• Internal Medicine: 8

• IPC : 8

• NMFCC Students under Wits: 30

• Medicine, Surgery ,Paeds, O&G, Anaesthesia, FM, Orthopaedics, Psychiatry

Other Students• Attached to other universities as well• Occupational therapy• Radiography• Radiotherapy• Nursing• Pharmacy• Elective students: Local and International

Research

• Led by Internal Medicine

• PHRU, Wits

• John Hopkins

Medical Staff Component

• Over 250

• Over 50 specialists : Joint staff of Wits

• Accredited for 112 interns

District Health

• CHC

• Primary Health Care Clinics

Challenges in provision of service• External• Type, Volume and Severity of illnesses: • Medical, Surgical, Maternal and Paediatrics• Infectious, Non Infectious ,Trauma• High burden of HIV and related illnesses• Strength of Primary care platform • Referral network and capacity of referring institutions to

fulfil their mandate• Family and social support

Challenges in provision of service• Internal

• Hospital infrastructure: Acute, Chronic and specialised care

• Human resource : Medical Staff

Nursing Staff

Support staff

• Supply of pharmaceuticals and consumables

• Overall budget allocation for staff, services and equipment

• Supply chain processes: Centralisation

• Duplication and wasteful expenditure

• Availability of palliative and rehabilitation services

• Laboratory service support

• Introduction of new services with or without adequate funding

Addressing challenges• Reorganisation of services• Introduction of new services• Development of a teaching platform• Revitalisation projects• Look at measures to reduce wastage and lean

management• Lobby for additional funds• Collaborate with private sector

Private Sector Collaborations

Collaboration in primary health care

• Broad Reach project (2005-2015)

• Down referral of virally supressed patients on ARVs to local GPs from wellness clinic of Tshepong Hospital

• Broad Reach accessed PEPFAR funds

• Capitated fee to GPs

• Protocol drawn up

• Monitoring and evaluation

ACCESS TO HEALTH CARE SERVICESFROM DOH PRESENTATION ON NHI

• Population coverage

– the fund will purchase services on behalf of SA citizens; permanent residents; refugees; inmates and specific categories of foreign nationals.

– asylum seeker or illegal migrants – EMS, notifiable conditions, basic health services for children,

– Foreign Nationals – travel insurance

• Registration as users

Eligible person must register (incl children) with accredited healthcare provider/establishment. Biometrics and such other prescribed information

• Health care services coverage

– User must enter at the PHC level, and follow referral pathways as condition of entitlement

– Minister must designate central hospitals as semi-autonomous - government components

– Treatment will not be funded if – no medical necessity, not cost effective or not included on the formulary. If the fund declines a benefit – provide reasons and allow for appeal process

.

Steps followed in the project……• Beneficiary defined : HIV positive patients stable on ARV

without other comorbid illness• Entry point defined: PHC Level • Registration of Patient: With GP near patients home• Services defined: HIV and opportunistic infection follow

up• Drug supply defined: ARVs from formulary packed and

delivered by local pharmacy on a named patient basis to GP practices based on a script

• Lab investigations defined: NHLS

Steps followed in the project……• Frequency of consultation defined• Referral criteria to hospital/clinic defined• Funding defined: Capitated fee paid by Broad Reach .

Funder: PEPFAR• Monitoring and evaluation: Broad Reach• Governance: DOH , GP reps and Broad Reach• Many aspects of the project involved data capture from

paper based data

Outcomes• Project ran for 10 years: 2005 to 2015• 4129 patients enrolled• 2759 remained on treatment • Retention rate: 95% ??• Viral load suppression: 93%• Was expanded to Mahikeng and Potchefstroom in

2009/2010• Project terminated when funds dried up• Patients transferred to clinics

Strengthening of primary health care

Medical Internship training

INTERNSHIP ACCREDITED POSTS : JAN 2019

No Province Accredited posts No of Facilities

1 Eastern Cape 318 4

2 Free State 216 5

3 Gauteng 1182 17

4 Kwazulu Natal 956 10

5 Limpopo 222 8

6 Mpumalanga 144 4

7 Northern Cape 66 1

8 North West 228 4

9 Western Cape 564 12

Total South Africa 3896 65

HPCSA Decision on medical internship 2020

and beyondInternship period to remain 24 months

Extended training in the primary health care platform

Equal emphasis on preventative and promotive care

along with curative care

Out put of the programme :Competent general

practitioner

Monitoring and evaluation system to be developed

New training model

Rotation within tertiary ,regional and or large district hospital

(departmentalised facility) for

18 months

and district hospital ,CHC and primary health care clinics for

6 months

Training model

18 month rotation in the differentiated facility

The rotation in the departmentalised facilities(differentiated facility) will

focus in training of core clinical skills

Internal Medicine : 3 months

General Surgery : 3 months

Obstetrics and Gynaecology: 3 months

Paediatrics and Neonatology : 3 months

Orthopaedics : 2 months

Anaesthesia : 2 months

Psychiatry : 2 months

Training model

6 month rotation in the district health platform(Family Medicine/Primary

Care)

Led by the Department of Family Medicine

Includes outpatient, emergency and inpatient care for adults and children,

chronic care, theatre training, preventative and promotive care including

immunisation, community outreach etc .

Exposure to basic Urology, ENT, Ophthalmology

New logbook

Medicine, Surgery, Paediatrics and O&G are done in the first year and

the rest in the second year

Internship accredited posts : January 2020No Province Accredited

posts

No of

Training

Comp

New

District

Hosp

CHC/PHC

1 Eastern Cape 432 3 7 9

2 Free State 276 5 8 22

3 Gauteng 1592 16 12 64

4 Kwazulu Natal 1128 10 21 110

5 Limpopo 340 7 8 17

6 Mpumalanga 200 5 5 11

7 Northern Cape 80 1 1 6

8 North West 344 5 11 38

9 Western Cape 660 12 13 38

Total South Africa 5052 64 86 315

Private Sector hospitals :Matlosana

• Life Anncron Clinic: 153 beds• Wilmed Park: 144 beds• Sunningdale: 62• Park Med ( Mental health): 50 beds• Mine Hospitals: not functional•

Total: 409 beds

Comparison of beds

• Primary drainage population of Matlosana: 500000• 20% medical aid /self funded: 100000• 1 bed for 250 ( 4 beds for 1000)• 80% indigent: 400000• 1 bed for 450 (2.2 beds for 1000)• Overall: 2.6/1000• This excludes accommodation for referrals from the province • State has significantly sicker patients needing inpatient care• UK: 2.3 acute beds/1000 EU: 3.7/1000

Use of GPs and Specialists

• Sessional appointment

• Clinics and Hospital

• Defined role during and after hours

• Predominantly supplementary role

• Visiting consultants from Wits: Teaching and service

Collaboration in tertiary care

• Cardiology

• Cardiothoracic services

Fee structure• Procedures defined• Maximum time for each procedure determined and capitated• Fee determined per unit time for procedures in theatre and

cath lab• Negotiated fee for hospital bed, high care and ICU• Facility fee includes nursing cost• Consumable cost borne by the state• Remuneration of technical and professional staff borne by the

state.

CARDIAC PATIENT FLOW

PRE-OP

• Presentation & Diagnosis

• Operative Work-up

• Pre-Op Admission

INTRA-OP

• Anaesthetic

• Surgical

• Perfusion

POST-OP

• ICU

• High Care

• Ward

DISCHARGE

• Rehabilitation unit

• Home

FOLLOW-UP

• Cardiology Clinic

• Cardiothoracic Clinic

• INR Clinic

PUBLIC PARTNER

•Presentation

•Diagnosis

•Operative Work-Up

•Pre-Op Admission/Anaesthetic work-up

•Transfer to Private Facility

PRIVATE PARTNER

•Pre-Op Admission

•Cardiac Surgery Operation

• ICU Admission

•Step Down to High Care

PUBLIC PARTNER

•Transfer to Public Facility

•Ward Admission

• ICU Re-Admission & High Care

•Ward Readmission

•Discharge & Follow-Up

PRE-OP WORK UP IN PUBLIC FACILITY

OPERATIVE WORK UP & SELECTION IN PUBLIC FACILITYCardiology – Cardiothoracic Surgery Meeting

LOW RISK SELECTION CRITERIA

- LOW OPERATIVE RISK (EUROSCORE II)

- SINGLE VALVE AVR OR MVR

- SINGLE CORONARY

- ASD

- NO PULMONARY HYPERTENSION

- MILD TO MODERATE PHT (REVERSIBLE)

- LOW COMORBIDITIES

- YOUNG PATIENTS (<65 yrs)

- GOOD EJECTION FRACTION (>50%)

PRE-OP ADMISSION IN PUBLIC FACILITY

WARD ADMISSION

- History & Exam

- Bloods: FBC, U&E, INR, PT, PTT, LFT HIV, HBV, HCV, RPR

- Lung Function Test

- ECG

- CXR

- ECHO

- ANGIO

- Cross Match 2 UNITS PACKED CELLS

- ± OTHER BLOOD PRODUCTS

- Consent

- Anaesthetic Assessment Completed

TRANSFER TO PRIVATE

FACILITY

POST-OP IN PUBLIC FACILITY

TRANSFER INTO HIGH CARE IN PUBLIC FACILITYADMISSION CRITERIA FOR HIGH CARE

- EXTUBATED

- OFF INOTROPES

- INVASIVE MONITORING NOT REQUIRED

- NO FURTHER BLEEDING

- CONTINUOUS NON INVASIVE MONITORING

TRANSFER TO WARD

WARD ADMISSION

-HEMODYNAMICALLY STABLE

- STABLE RESPIRATION

- NORMALIZED BLOOD GASES

- DRAINS OUT

- CXR

- MOBILIZING

DISCHARGE AND

FOLLOW-UP IN

PUBLIC FACILITY

Distribution of Service Responsibilities

OPEN HEART

SURGERY

Private Partner

Nursing Staff and other Ancillary

Staff

Facility, Equipment, Instrument

s,

Public Partner

Technical Staff

Consumables, Disposables, Medicines,

Prosthesis, Blood Products,

Investigations

Summary of Cost of Cardiac Surgery

Valve Replacement

Surgery

Pre-op

Hospital Stay Investigations

Blood tests

Imaging

Human Resource Medication Consumables

Intra-op

Anaesthetic

Surgical

Perfusion

Human Resource

Post-op

ICU Stay

Surgical Ward Stay

Human Resource

Logistic Aspects/Challenges• Transportation of Patients to the Private facility in Rustenburg

• All team members informed of:– Admin team informed of date and demographic details of patient and

proposed operation– Clinical details shared with clinical team

• Hospital Transport– First few patients were taken directly to JST, Rustenburg despite giving

specific instructions– Had to transfer early morning as the hospital needed the transport later

in the day

• Private hospital needed to be pre-informed– Of arrival of patient in order to authorize admission

Logistic Issues• Observations

• Routine investigations repeated for 1st few patients despite being told not to, as this was part of routine activities within the private unit

• JST Anaesthetist reviews the patient the day before at Ferncrest and orders blood products

• ICU team does some routine investigations that were costly• Step down from ICU to high care was a grey area until nurses informed

to step down formally • Transfer of patients back was a challenge as information got lost

between EMRS and Buthelezi• EMRS and Buthelezi shift changes caused challenging logistic issues

Name Age Residence Diagnosis Date of Op Operation Status Invoiced by NETCARE

1 46 Klerksdorp Left Atrial Myxoma 23-Sep-16 Open Heart Excision of Myxoma Back at Work 86919,72 –Paid

2 36 Leeudoringstad Mitral Regurgitation 04-Nov-16 Mechanical Mitral Valve Replacement Back at Work 84299,75 – Paid

3 66 Joberton Mitral Regurgitation 04-Nov-16 Bioprosthetic Mitral Valve Replacement Back at Work 129946,21 – Paid

4 60 Klerksdorp Triple Vessel Coronary Disease 04-Dec-16 Triple Vessel Coronary Artery Bypass Graft Back at Work 138766,88 – Paid

5 33 Stilfontein Mitral Regurgitation/Submitral Aneurysm 10-Feb-17 Submitral Aneurysm and Mitral Valve Repair Full Functional Status 97486,87 – Paid

6 46 Wolmeranstad Double Vessel Coronary Disease 10-Feb-17 Double vessel Coronary Artery Bypass Graft Full Functional Status 81975,79 – Paid

7 33 Stilfontein Recurrence of Mitral Regurgitation 03-Mar-17 Redo Mitral valve replacement and Repair of Aneurysm Full Functional Status 117216,46 – Paid

8 23 Klerksdorp Severe Aortic Regurgitation 03-Mar-17 Aortic Valve Replacement Full Functional Status 94321,46 – Paid

9 23 Klerksdorp Aortic and Mitral Valve Regurgitation 17-Mar-17 Aortic and Mitral Valve Replacement Died 1 year later after defaulting

treatment for 3 months

137632,42 – Paid

10 55 Orkney Mitral Regurgitation 05-May-17 Mechanical Mitral Valve Replacement Back at Work 123962,94 – Paid

11 42 Mafikeng Aortic and Mitral Valve Regurgitation 26-May-17 Aortic and Mitral Valve Replacement Back at Work 186719,92 – Paid

12 62 Klerksdorp Mixed Mitral Valve Disease 08-Jun-17 Bioprosthetic Mitral Valve Replacement and MAZE Full Functional Status 184043,84 – Paid

13 66 Klerksdorp Triple Vessel Coronary Disease 09-Jun-17 Triple Vessel Coronary Artery Bypass Graft Full Functional Status 123436,89 –Paid

14 33 Klerksdorp Constrictive Pericarditis 15-Jun-17 Pericardiectomy Back at Work 48574,36 – Paid

15 56 Klerksdorp Triple Vessel Coronary Disease 21-Jul-17 Triple Vessel Coronary Artery Bypass Graft Full Functional Status 104824,54 –Paid

16 34 Vryburg Mixed Mitral Valve Disease 15-Sep-17 Mechanical Mitral Valve Replacement Back at Work 118648,88 – Paid

17 56 Potchefstroom Mitral Regurgitation 22-Sep-17 Mechanical Mitral Valve Replacement Full Functional Status 146265,82 – Paid

18 44 Potchefstroom Mixed Mitral Valve disease 15-Jan-18 Mechanical Mitral Valve Replacement Full Functional status 107212,45 - Paid

19 68 Klerksdorp Mitral Valve Regurgitation and Double Vessel Coronary

artery Disease

23-Feb-18 Coronary artery bypass and Mitral Valve repair Full Functional Status 162239,22 Paid

TOTAL COST 2274494,42

Patients Operated under the SLA

Outcomes• 19 open heart surgeries• 1 mortality• Helped in figuring out the logistics• Good info towards costing• Project terminated for Klerksdorp patients as

Cardiothoracic surgeon leading the project joined the established cardiothoracic unit in Port Elizabeth Provincial Hospital.

• JST in Rustenburg hasn’t taken over the project

Life Anncron Hospital

• Agreed on the frame work

• Established the Cardiac Catheterisation facility in 2018

• New Cardiac ICU functional in 2019

• Signed SLA with NWDOH(KT) in July 2019

Technical team

• Two Interventional Cardiologists

• One Cardiothoracic surgeon

• Technologists

• Perfusionist

• Radiographers

Sessional appointments in KT • 2 Cardiologists

• Cardiothoracic surgeon

• Capitated fee for service arrangement, for the support staff

Vision: Cardiology

• Comprehensive services for cardiac patients

• Academic Unit for Cardiology: Anncron also to be a training platform for registrars and fellows under Wits

• HPCSA accreditation for the fellowship programme in Cardiology

Cardiac Surgery• Cardiac surgery unit in Tshepong

• Procurement of cardiac surgery equipment in progress

• Cardiothoracic ICU established

• Trained anaesthetists available

• Train nursing staff

• Sessional cardiothoracic surgeon and support staff to start the programme and then expand further

Service Delivery: Interventional Cardiology

• 5 Coronary angiograms done • Coronary stents inserted in three patients and

one patient referred for CABG• Billing being finalised• Logistics much easier due to proximity between

the facilities• R 2 million allocated this financial year• Increase budget to R 5 million next financial year

Challenges

• Funding for comprehensive service: Both for acute and chronic patients

• Availability and commitment of specialists

• Protected time for public patients

• Remuneration model

The future depends on what you do today.

If I have the belief that I can do it, I shall surely acquire the

capacity to do it even if I may not have it at the beginning.

You may never know what results come of your actions, but if

you do nothing, there will be no results.

Mahatma Gandhi

Thank you