Department of Health Northern Cape Key Challenges in Health

1. Department of HealthNorthern CapeKey Challenges in Health Presentation to Select Committee on Social Services Parliament of RSA 23 June 2015

2. Overview • The department has made strides in improving the service delivery despite many challenges that we will outline later in the presentation. • The NHI pilot is a priority district and work is being carried out as planned. • Reduced maternal mortality is a major improvement but a lot still needs to done. • There is also a reduction on the number HIV positive babies

3. Vision & Mission • Vision • Health Service Excellence for All • Mission • Working together, we are committed to provide quality health care services. We will promote a healthy society in which we care for one another and take responsibility for our own health. Our caring, multi-skilled professionals will integrate comprehensive services, using evidence-based care-strategies and partnerships to maximize efficiencies for the benefit of all.

4. Strengthening Health Systems Effectiveness • For the public health care system to be effectively strengthened, there is a need to overhaul the health delivery platform from one that is based largely on a curative high-cost care model, to one that promotes prevention and low cost primary health care, delivered as close to peoples’ homes as possible • In an attempt to improve proactive preventative health care we will conduct health profiling of all citizens in the NHI district, to proactively identify the risks patients might have and consider early treatment • The Department is collaborating with other provinces on the tertiary and quaternary platform

5. Dependency on the Public Health Care System • 85% of the population is without medical aid and therefore rely on the public health services for their health care needs and treatment • The number of individuals who are reliant on the public health system has been increasing steadily between 2010 and 2012, ranging from 14.2% to about 19%. • The consequence is that public facilities are over-burdened

6. Access to primary health care • Primary Health Care services are provided by 130 clinics, 29 mobile units, 46 satellites and 33 Community Health Centres • The vastness of the province leads to a need for more health facilities, especially in far-lying and hard-to-reach areas, to cater for all citizens • However, a big challenge is the under-utilization of many primary health facilities due to the by-passing of these services and referral (including self-referral) to higher levels of care • The Department has prioritized selected Community Health Centres for 24-hour operationalization to help address this

7. Maternal mortality • The Province has shown a marked improvement in reducing maternal mortality with a substantial reduction from 247/100 000 in 2010/11 to 167/100 000 in 2011/12 and an even further decline to 127/100 000 in 2013/14). • Although all facilities provide Antenatal Care late bookings by pregnant women continue to pose a major challenge. Nevertheless, it is quite within the capability of the province to achieve the national target set for the maternal mortality rate by 2014/15.

8. Reduction in HIV+ve babies • The Prevention of Mother to Child Transmission (PMTCT) coverage for HIV positive antenatal patients has resulted in a significant decrease in the number of HIV+ve babies. • Babies that tested HIV+ve (using PCR) at 6 weeks decreased from 7.5% in 2010/11 to 5.3% in 2011/12 and with a further drop to 2.7-3.0% in 2012/13/14. • (The province has also rolled out ART service points to all Primary Health Care facilities to increase access to ARV treatment, care and support.)

9. TB treatment success rate between 2008/09 & 2013/14

10. Functionality of primary health care facilities • The Northern Cape does not currently conform to the national standard definitions for health facilities • For instance, most community health centres do not operate for 24 hours due to staff shortages and poor infrastructure • This places strain on the day staff as many have to be on call during the night, while having a full shift during the day

11. Functionality of District Hospitals • Another situation giving effect to inefficiencies at district level, is the incapacity of Level 1 Hospitals to function at the correct level • More that 60% of the 11 district hospitals are not rendering the required package of services, resulting in the confidence in the primary health care system being undermined by the community • This also places undue strain on the higher level of care; the regional (Level 2) hospital in Upington and the tertiary (Level 3) hospital in Kimberley

12. Quality improvement • Quality improvement initiatives as part of developing NHI are focused on reducing waiting times, improving cleanliness, reducing infection, ensuring drug availability, ensuring the safety of patients and staff, and improving staff attitudes • The initiatives are driven through the following programmes: • National core standards compliance • Permanent Perfect Team for Ideal Clinic Realisation and Maintenance • Ministerial non-negotiables • Management Performance Assessment Tool • Risk management • Primary care reengineering, including WBOT, DCSTs and School Health

13. National Health Insurance • Pixley-Ka-Seme District is one of the ten NHI pilot Districts in the country • The following teams are critical for the introduction of the NHI: • District Health Specialist Teams (DCST) which comprise a Gynaecologist, Paediatrician, Physician, Midwife and Paediatric Nurse. • School health teams • Ward based outreach teams • These teams are in place however the chalenge is still the high turn over and shortage of specialised staff.

14. Reducing Waiting Times • Patient waiting time in clinics goes up to 5 hours, with almost 79% of time in the clinic spent by the patient waiting • Interventions are being introduced to address the challenge: • Introduction of Integrated Chronic Disease Management and the Integrated Services Management Model • Support to clinics to adjust hours of operation to increase accessibility • Implementation of queue management processes and a Patient Booking System • Communication of clear expectations for Waiting Times and process of care

15. Ideal Clinic Initiative (part of Operation Phakisa) • The National Health Council has resolved that all clinics in all provinces should reach the status of Ideal Clinic by 2018/19 • This Project is central to the success of the National Health Insurance and as a results provinces are expected to commit to delivering this goal by end of 2018/19 • The province has developed a 3-year Roll-out plan, however the availability of resources remains a challenge

16. Ideal Clinic: What is expected? • Transform 100% of clinics in the 5 districts to qualify as Ideal Clinics by 2018/19; up from a base of zero in 2014/15 • Create a blueprint and active mentoring approach to unblock bottlenecks that hamper quality service delivery • Develop a detailed scale-up plan for the Ideal Clinic realisation and maintenance • Optimise processes within facilities to increase patient throughput • Manage clinics volumes at clinics by offering alternative service points • Monitor, evaluate, communicate and respond to patient feedback

17. Key to an effective Emergency Medical Service • Sufficient staff for two-person crewed ambulances • Properly staffed and equipped control rooms • Skill mix in the order of 40% basic, 40% intermediate and 20% advanced • Appropriate number of ambulances deployed across the province • Roadworthy and properly equipped ambulances • New national training programmes for new recruits • Education migration programmes, including recognition of prior learning, for existing personnel • Continuous professional development

18. EMS: Improvements and challenges • Staff numbers increased from 720 to 830 in 2014/15. Plan is to increase numbers to 1,800 over the 5 years to achieve 2-person crews and fully staffed control rooms • Rolling programme to replace each ambulance after 3 years (or 300,000km) introduced in 2012/13. 60 ambulances are replaced each year. Shortfall in ambulances: 108 against 184 • New control rooms constructed in Upington and Kimberley. A business case to procure and install computer aided despatch and control ICT system is being developed.

19. EMS Training College • A new EMS College building (pre-fabricated) was completed in record time and opened in May2015 • A business case for additional teaching staff has been submitted to Treasury • New 1 year, 2 year and 4 year qualifications have been developed nationally for EMS. The College is working with the new Sol Plaatje University to develop a partnership arrangement

20. Mental Health • Plan is 199 specialised beds in the new NC Mental Health Hospital, 209 acute beds in general hospitals and 108 community-based beds – significant budget constraints in achieving this. • Currently 107 specialised beds at West End Hospital. There are no dedicated beds in general hospitals or in the community (Province does provide 72 hour assessment in several general hospitals) • State patients housed within prisons remains a big challenge. Current position is 25 in prison, 16 in hospital and 17 on approved leave of absence from hospital

21. Regional Hospital: Dr Harry Surtie in Upington • This new state of the art regional hospital opened in 2014 to service the western half of the province • Budgetary constraints require us to phase opening over 3-5 years • Currently 210 of the 327 beds are open • 45 doctors employed (incl. 15 locums), the plan is 72 • 259 nurses employed, the plan is 478 • Recruitment within the available budget is also a challenge – semi rural town with no rural allowance, industrial boom resulting in unaffordable housing for new entrants

22. Tertiary hospital: Kimberley Hospital • Kimberley Hospital is the only Tertiary Hospital in the NC Province; officially classified as such in 2012 • 657 active beds, offers 33 different speciality disciplines, all headed by qualified specialists in their respective fields; • A satellite training facility of the University of the Free State accredited by the Health Professional Council of South Africa (HPCSA) to train interns and Registrars; • Undergraduate medical students programme commencing 2016

23. Kimberley Hospital: T1 Services to be developed

24. Kimberley Hospital: Resource Needs • A total number of 74 specialists will be required to render the complete Tertiary service package • Current specialists (tertiary services): 31 • Additional Specialists required: 43 • Technologists • Current number of specialist technologists: 4 • Additional specialist technologists required: 11 • The number of specialist nursing staff, allied health professionals, auxiliary and support staff must increase proportionally • National Core Standards Assessment - 75% Compliance achieved

25. Measures to overcome challenges • Outreach services to all 5 districts • Operationalisation of the facility leased to the private sector during the previous dispensation increasing theatre capacity from 5 to 9 • Introduction of hip and knee replacement surgery which was previously referred to the Free State – Now provided • Renal unit (PPP) • Introduction of advanced radiological services which was previously accessed from the private sector • Increase number of High Care beds to reduce pressure on ICU • Upgrade of viral haemorrhagic fever unit

26. HR: Recruitment and Retention • Occupational Specific Dispensation: The Northern Cape remains relatively disadvantaged since professionals tend to seek more attractive conditions of employment elsewhere, although the Department’s Policy on the Staff Retention makes provision for the Executing Authority to consider matching the offer made to an employee, within collective agreements. • Grade Progression: The backlog for all Grade Progressions is being urgently finalized, since this contributes negatively to the retention of critical skills. • Management of Overtime: Records for all overtime are being kept and monitored by the Human Resource Management and supervisors in charge. As a recent intervention, verification is being be done against the commuted and normal overtime performed, and hours not worked are deducted from the employees’ salary. Attendance registers are also to be signed by all employees including clinical staff.

27. HR: Rural allowance • The rural allowance percentage is not the same for qualifying Health Professionals in the Northern Cape: only certain areas in the Northern Cape are classified as rural. • It is recommended that the application of rural allowance be reviewed in favour of broadening the areas classified as rural in the Province. • Currently there are discussions underway regarding the introduction of a “deprivation allowance” in order to enable compensation in individual instances where this may be indicated.

28. Information and Communication Technology • Completing the staff complement of the IT Directorate has been a challenge that at this stage is partially resolved. • Poor connectivity remains a major obstacle to service delivery. Various solution have been identified, amongst them the implementation of dedicated virtual private network. • Under-utilisation of data and information to inform decision-making in the department has been addressed by the strengthening of the Monitoring and Evaluation competency, as well as the introduction of measures to ensure the accuracy of data captured at facilities.

29. Infrastructure: Implementing Agents • Each project is allocated to a specific infrastructure official from the NCDOH infrastructure unit who ensures that pressure is maintained on the implementing agent in order to ensure delivery momentum Two different officials from NCDOH are members of the bid evaluation and bid adjudication committees. • A specialised infrastructure SCM sub-unit is to being considered to fast-track maintenance, technical and infrastructure procurement

30. Infrastructure: Mental Health Hospital • Project Steering Committee established that reports to Joint Management Committee consisting of top management of NDOH, NCDOH, DRPW and Prov. Treasury • Initiatives include design reviews and investigating several alternatives e.g. sectional completion. • Contractor did not reach contractual completion on 27 May 2015 • In December 2014 contractor was taken over by International Company. Mota-Engil that made a proposal to add resources at a cost, in order to guarantee practical completion by end 2015/16 financial year end. Addendum to contract is at finalisation stage. Final project cost at completion is anticipated to be R1.2 billion.

31. Infrastructure: De Aar District Hospital • Project commissioning meetings are not attaining the intended results due to lack of budget to appoint staff for the new facility • Health infrastructure officials and In-loco monitor are involved to provide support to Public Works and operationalization team • Completion is delayed to November 2015 due to labour problems and slow delivery by contractor

32. Infrastructure: Maintenance • Maintenance policy, standard operating procedures and day-to-day maintenance is rolled out at all facilities • Maintenance Professional Service Providers now at conclusion of tender process to assist with district maintenance call centres, managing maintenance term contractors and maintenance skills development at local communities • Standby generators at all facilities are being installed, upgraded, repaired or serviced within limited budget. Remote condition monitoring units in process to be installed at all generators. Facility managers responsible for weekly inspections and half hour running of generators.

33. Financial situation: Areas to be covered • Budget, Accruals & Cashflow • Revenue • Conditional grants • Cost containment • Audit Action Plan

34. Budget v Expenditure by programme – after shifts, virement and surrenders

35. Budget v Expenditure by economic classification – After shifts, virements and surrenders

36. Budget v Expenditure by programme • Administration (R22,719 million) • Overspending & incorrect budgeting on; • Audit fees, external computer services, claims against the department • District Health Services (R25,584 million) • Overspending & incorrect budgeting on; • Medical waste, professional staff (doctors), security services, operating leases, interest, telephone, machinery & equipment and municipal services

37. Budget v Expenditure by programme (cont.) • Emergency Medical Services R0,539 million • Under spending its budget due to following; • Delays in procurement of EMS vehicles and delivery thereof • Cash Flow constraints • Submitted roll over request for committed funds • Provincial Hospital Services (R26,879 million) • Overspending & incorrect budgeting on; • COE, security services, operating leases, outsourced medical services, municipal services and machinery & equipment • Central Hospital Services 0 million • Programme break-even

38. Budget v Expenditure by programme • Health Sciences & Training (R8.392 million) • Overspending & incorrect budgeting on; • Mainly on bursary commitments • Health Care Support Services (R0,005 million) • Overspending; • Due to payment of interest • Health Facilities Management (R7,518 million) • Overspending & incorrect budgeting on, • Maintenance and payment of consultants

39. Accruals by programme

40. Revenue • The Department is faced with capacity problems at facility level resulting in under-collection of revenue • The lack of Electronic Data Interchange (EDI), at the last two facilities • Kakamas Hospital • Postmasburg Hospital • Interventions • Develop and implement revenue enhancement strategy • Strengthen the monthly revenue management forums • Prioritise connectivity in district institutions

41. Revenue

42. Revenue

43. Conditional grant expenditure

44. Conditional grant expenditure • Dept. spent 93% of the total conditional grants budget • The following grants break-even; • EPWP Incentive Grant – 100% • EPWP Social Sector Grant – 100% • Health Professions Training & Development Grant – 100% • Comprehensive HIV & AIDS Grant – 99% • Health Facility Revitalisation Grant – 85% • Slow progress on infrastructure projects particularly Mental Health project • National Tertiary Services Grant – 98% • Delay in delivery by suppliers and cash flow constraints • National Health Insurance grant – 57% • Delays in the implementation of the business plan

45. Cost containment • Department adopted the National Treasury cost containment directives. • In the process of enhancing these with departmental directives

46. Audit action plan • Purpose • To develop & implement a rectification plan designed to address the audit qualification of the 2013/14 financial year • Adopted by Executive Management • Approved by Accounting Officer • Qualifications/Projects • Immovable tangible capital assets • Movable tangible capital assets

47. Audit action plan • Intangible assets • Irregular expenditure • Fruitless & wasteful expenditure • Accrued departmental revenue • Employee related costs • Accruals • Commitments

48. Thank you