NORTHERN CAPE PROVINCE
REPORT TO PORTFOLIO COMMITTEE
NATIONAL ASSEMBLY

B1 BUDGET INFORMATION
B1.1 General
B1.1 (a)
1996/97 Budget per programme & sub-programme

1996/97 Expenditure per programme & sub-programme

1997/98 Budget per programme & sub-programme

1997/98 Expenditure per programme & sub-programme

1998/99 Budget per programme & sub-programme

1998/99 Expenditure per programme & sub-programme

1998/99 Budget per standard item

1998/99 Expenditure per standard item

B 1.1(d) 1997/98 deviation (-1.49%)
The deficit incurred by the Department was funded from under-spending of other Departments in the Province.
The 1997/98 financial year closed with a deficit of R5, 516m. This arose mainly from over-expenditure in personnel as a result of the elevation of salaries for nursing professionals, notch increases and leg promotions.

B1.2Budget and Expenditure in relation to specific policy issues
a) Revenue raised from private patients using public hospitals

b) HIV/AIDS budget
The budget for the provision of AIDS/HIV is part of the integrated services provided at district level. Management and co-ordination is done at provincial level. Additional funds from National were made available as per the table. The allocation of future resources from National for the outer years is not known at this stage.

c) HIV/AIDS allocation for NGO's 1997/98 and 1998/99
NGO's involved in AIDS/HIV programmes are funded by the National Department of Health. Therefore no allocations are made from the provincial budget.

d) TB programme allocation for the years, 1998/99, 1999/2000, 2000/01

e) Planned expenditure on information systems

f,g,h) Planned new capital expenditure

Funding for the capital development plan will emanate from the Hospital Rehabilitation Grant and the Works budget.
B 1.3 Narrative Report

(a) Key problems experienced in relation to the budgeting process
• no link between budget making and policy formulation, since budgets are determined provincially.
• Additional funds made available during the year, makes resource planning very difficult and often results in the "hockey stick syndrome" prior to the close of the financial year.

(b) Ability to realise national objectives generally
Despite the constraints faced by the Department, national objectives were generally achieved.

(c) Implementation of revenue retention policy
Revenue generated from hospital fees amounts to R4,026m and constitutes 1,15% of the total health budget. This is not substantial, and declining trends in revenue generation does not justify retention in revenue at this stage. Discussions with the Provincial Treasury have commenced, but no formal proposals have been tabled yet.

Medium Term Expenditure Framework
MTEF fair reflection of envisaged health policy
The following table represents the increase/decrease per programme for the MTEF.

The budget allocated to the Department for the 1999/2000 financial year constitutes 16,1% of the provincial budget and is representative of a stagnant budget. This is inclusive of the conditional grant of R22,360m for the Training and Research programme that was not top-sliced from the budget resulting in a decrease of 1% in the budget for health services If an average inflation rate of 7% percent is used it results in a real decrease in the budget of 8% (R1,8m) for 1999/2000. This is a significant cut in the budget, if compared to current levels of expenditure, making it very difficult for the Department to remain within budget, despite various restructuring and drastic cost-containment measures being implemented. The financial implications for the outer years are also represented per the table.
• Medium Term Planning
The 1999/2000 budget process was a first step toward linking the budget process to the operational plans of the Department. The planning cycle focused on priority-setting, which involved the determination of goals, objectives and targets. The second phase also involved the assessment of various options available in achieving the set objectives and targets within the limited resource envelope.

B2 POLICY ISSUES
B2.1 General
B2.1.1 Over/under expenditure
The anticipated projection for the 1998/99 financial is R17,9m (-4,9% deviation). In line with National health policy, a definite move toward District Health Care was reflected in the budget allocations. This resulted in the budget for Provincial Secondary Hospitals being seriously constrained, whilst the service demands are increasing. The budget for provincial secondary services constitutes 32% of the total budget and is anticipated to close with a deficit of R15m (12% deviation) for the current financial year. The main reasons for this deficit are a result of:
• Casualty cases are on the increase at the Kimberley Hospital. Statistics show that visits to the casualty have increased by 17% from April 1998 to October 1998. Increased trauma has a direct correlation to increased expenditure, since it results in a high level of medical interventions.
• Statistics also show that inpatient days have shown a downward trend. Declining inpatient days are a result of decreased average length of stay, resulting in a higher patient turnover. However, whilst the average cost per patient day has been reduced as a result of this, the cost to the hospital has increased overall, since bed occupancy continues to be very high. Several cost containment measures have been implemented but will have a limited impact for the financial year under review.

Policy consequences as a result of the deficit
An amount of R21,2m was allocated for the Training and Research programme for health, which was included in the global allocation to the budget. The formal implementation of the training grant commenced on 1 January 1999, when Registrars commenced duties within two units, Pediatrics and Anesthetics. The anticipated deficit does not take into account the full implementation of this program. If the entire amount of R21,2m were to be utilised for training and research, this would have a serious impact on services at the hospital as termination of certain services would have to take place. The closure of services however, would be contrary to the policy regarding the development/strengthening of tertiary health services in provinces where these are not provided. A conditional grant of R3,6m has been received for the redistribution of tertiary services in the 1998/99 financial year.

Cross boundary flows continue to put an added burden on the resources of the province. The financial impact of cross boundary patients accessing health care in the Northern Cape is conservatively calculated at approximately R11 million p.a (approx. 65% of deficit).

Strategies to deal with the deficit

Various strategies have been implemented toward rendering a more effective, efficient and integrated health service, which will bring about efficiency gains in the system without impacting negatively on the level of service currently being rendered. These include:
• The provincialisation of ambulance services.
• New agreements between the Province and Local authorities for the rendering of Primary Health Care services
• The termination of old contracts of provincial aided hospitals resulting in either the provincialisation of certain hospitals or the entering of new agreements with those that chose not to Provincialise.
• The restructuring of the district surgeon system.
• The layering of services rendered at the only Secondary facility in the Province and the development of a policy for referral pathways within the province, enabling more efficient use of facilities as well as reduced referrals to Kimberley Hospital.
• The submission to Treasury to consider alternative financing mechanisms for the acquisition of capital equipment (mainly medical equipment) that will assist the Department in addressing some of the backlogs that exist with regard to the replacement of obsolete and/or redundant equipment.
• The tender for the outsourcing of the procurement, warehousing and distribution of pharmaceutical services is in the evaluation phase.
• Intersectoral collaboration between Departments of Welfare, Education and Health to co-fund facilities which have overlapping responsibilities.
• The Department is currently in the evaluation phase of awarding the tender for a new Hospital Information System, which will address some of the collection problems, currently being experienced.
• Overtime and absenteeism studies, which are directly linked to productivity.
• Various strategic moves have been made to enhance the efficiency and effectiveness of the Kimberley Hospital Complex. These include the strengthening of the management structure by appointing clinical managers as well as introducing a cost-centre approach to budgeting and accounting. In-house training is being provide for clinical and unit managers by the Swedish Support programme. 600 employees of the Complex have been trained to date.

B2.1.2 Specific benchmarks and performance Targets
• Establishment of a well functioning departmental policy and planning unit (achieved through appointment and functioning of appropriate personnel)
• Stabilisation of Kimberley Hospital by appointment of CEO (not achieved, post advertised but not filled )
• Provincialization of emergency services (achieved - in line with decentralisation, emergency services now resort under the management of district health managers)
• Re-negotiation of contracts with local authorities, provincial aided hospitals and part-time medical officers (partly achieved)
• Re-engineering of financial management system (achieved)
• Establishment of an internal fraud unit ( This unit has been successfully established, but the officer has resigned from the department at the end of February 1999 and the process of appointing someone else has to be commenced)
• Research priorities
• Establishment of formal co-operative agreement between the department and the Medical Research Council (MRC) (achieved).
• Twinning agreement with Oxford university.

B2.2 Specific policy areas
B2.2.1 HIV / AIDS
Performance outputs
In the last two years the HIV prevalence in our province has risen from 8.6% in 1997 to 9.9% in 1998 as reported in the annual national HIV sero-pervelance survey. In response to the rising epidemic the priorities for the provincial Department of Health has been to:
• strengthen integration between HIV/Aids and TB programmes.
• strengthen collaboration and coordination between all government sectors, CBOs/NGOs, in the private sector and other relevant stakeholers.
• provide counselling, care and support to those infected with HIV/AIDS.
• co-ordination of the high-transmission project.

Interdepartmental Committee on HIV/Aids
• Establishment of Interdepartmental Committee on HIV/AIDS in order to engage all government departments extensively in HIV/AIDS mobilization campaigns. All government departments have shown commitment towards this initiative. Each department is currently embarking on their own mobilization strategy. They have been central in all mass mobilization campaigns as well as contributing financially to these campaigns e.g. condom week advertisements. We envisage strengthening this relationship and engage in extensive dialogue with departments to allocate a HIV/AIDS budget for the next fiscal year.

Welfare and HIV/AIDS Collaboration
Currently the two units meet on a by-monthly basis and have discussions at length around the following issues:
• Welfare strategy for AIDS orphans.
• Recruitment of foster parents.
• Social worker involvement in supporting health promotion.
• Capacity building of social workers in dealing with HIV/ AIDS issues (15 social workers will be trained in March – 6 from the department of Welfare and 9 from Correctional Services. An additional 12 in September 1999)
• Dissemination of information on current HIV/AIDS trends or issues on the impact of AIDS on Health and Welfare

NGO/CBO Partnership
A structural relationship between civil society and the HIV/AIDS programme has been established. An agreement has been reached on systematic monitoring and evaluation tool for funded NGOs. This tool has been used to assess outputs and support for funded organizations. This approach allows the department to have on-hand information, regarding usage of NGO funding and enable the department to link outputs to HIV/AIDS provincial intervention. Funded NGOs submit quarterly progress and financial reports to the sub-directorate.

Capacity Development for NGOs/CBOs
Clear communication channels between NGOs/CBOs and the HIV/AIDS Programme have been established. A Departmental/NGO forum is in place that meets on a monthly basis. This forum address issues such as:
• NGO/CBO operational needs
• Overlaps
• Planning for mass/targeted activities

Lay Counselor Project
The Department of Health has developed and implemented an institutionalized lay counselor programme model. This model is unique recognizing that other provinces use an approach whereby lay counselors are not on their permanent establishment. Thus far, 17 lay counselors have been trained for pre and post test counselling. They are placed in 5 of our 6 regions. A caseload monitoring system has been designed. This enables the Department to trace existing needs for counselling. Our mental health practitioners within these five regions have been partially absorbed wthis programme. They fulfill a supportive and supervisory role to lay counselors.

We are in the process of developing the mental health practitioners’ counseling/supervisory skills as well as employing a sessional psychologist to render overall support and technical input on advanced cases. An impact assessment of this programme is currently in the process. In conclusion, lay counselors will be accredited in order to meet national requirements. This was also a prerequisite for using the minimum standards framework of their training.

Home Based Care
As an initiative from the Department of Health, Hospice and a departmental HIV/AIDS official received "train the trainer" training for home caregivers. This led to Hospice training 30 caregivers for home care. These caregivers were awarded certificates in December 1998. Additional caregivers will be trained in March 1999 in one of our semi rural areas (Barkley West).

High Transmission Area
A base-line study has been completed aimed at interventions for sex workers and truck drivers on major commercial routes in the province. This study has informed the Department of Health of the high transmission commercial routes. This study has led to interventions in De Aar, Colesberg and Hanover area. The approach used for this programme is based on full partnership of all role players and peer educators model intervention.

Needle Prick Policy
A needle prick policy has been formulated and implemented. Drugs are secured and administered at all health facilities in the event of an injury.

Mass mobilization
• All government departments, community based organisations, parastatals and the media have been central to the organization of major events e.g.
- Political commitment against AIDS campaign,
- World AIDS Day,
- Condom week
Barrier methods
600 000 male condoms have been distributed between April 1998 – January 1999.

B2.2.2 Primary Care Services
1. District health system (DHS)
a) District Management Structure
All six regional offices are fully operational with fully functional community participation structures in place. Local Interim Co-ordinating Committees (LICC) and Regional Interim Co-ordinating Committees were established in all regions.
b) Process for achieving equity in allocation of PHC services.
The process of rationalisation of PHC services is well advanced. The budget allocation is done on a per capita basis with a view of moving towards a more equitable resource allocation. This exercise will address the issues of inequity between districts.
c) Relationship with local government structures
• Bi-monthly Provincial District Health Systems Committee meetings have been held during the past year. The MEC chairs these fostering interactions between officials and politicians through this forum. Local Government has representation through their own organised structure (NOGLOGA) in this forum.
• Financial difficulties of various forms in local government have somewhat offered an opportunity to facilitate integration of services as last year has seen the handing over to province of some local authorities' health services.
• The Department has terminated service contracts with District Councils in November 1998, while Provincial Aided (PA) Hospitals, have been made an offer to hand over services to the province.
• In order to formalise the service rendering relationships with part time doctors, a format for the allocation of sessions and remuneration of part-time doctors was finalised in October 1998. The contract for a relationship with PA hospitals wishing to enter into negotiations with the Department for the rendering of services, is also completed from the service point of view and has been forwarded for legal scrutiny. This relationship will be entered into, as necessary, on 1 April 1999.

d) Clinic Building Programme
Since April 1994, the following construction/purchases have been made to improve service delivery to the people of the province.

• Renovations are being carried out to make all clinics and hospitals accessible to the physically challenged person.
• A physical audit of all hospitals and clinics has been conducted. The upgrading/planned maintenance costs approximate R50m over the next 5 years.

2. Primary Care Core Package
A consultative workshop was held in July 1998 in order to define this package for the rendering of PHC services in the province. Full implementation of the package is envisaged with the finalisation of the "provincialization of services" process and the revised part time doctors' remuneration framework already being implemented.

3. Management of Drugs
Policy to improve drug distribution and procurement
Aim:
• to ensure an adequate supply of safe drugs of good quality to all people. This aim will be achieved by promoting cost effectiveness.
• Procurement and distribution
• done on an agency basis by the Cape Medical Depot. This excludes tuberculostatics, vaccines, family planning drugs and specialist coded medicines which are supplied from the mini depot in Kimberley.
Plans for future
• envisaged termination of the contract with Western Cape. The directive from Senior management is to outsource procurement and distribution to a private company.
• successful tenderer will manage procurement and distribution on behalf of the province . The successful company will ensure that supplies of drugs are managed according to provincial policies.
• it will be the prerogative of the company to decide on modes of transport, security and manage all risks associated with procurement and distribution up to the point at which drugs are delivered ( hospitals and clinics ).
• drugs will be procured using the public sector tender system.
• Depending on the availability of funds stocks will be managed using computers. Stock cards will be used at institutions where computers may prove expensive.
• Supplier performance will be monitored on a regular basis.

B2.2.3 Regional Hospital
The Northern Cape has no tertiary level facilities. However, Kimberley Hospital being the only secondary level hospital in the province also renders some tertiary level services e.g. renal and oncology.

Future strategic direction

B2.2.4 Tuberculosis
TB services at district and clinic level are integrated within the primary health care services offered by professional nurses, with the exception of West-End Hospital which falls under secondary level care. All health facilities in the province are using the recommended standardized treatment regimens. It is worth noting that the South African Health Review 1999 reflects that "The Northern Cape was the only province where all surveyed clinics has all TB drugs available." Inspite of these notable achievements however, surprisingly, the incidence rate of Tuberculosis in the province has bee noted to have increased from 417/100 000 in 1993 to 523/100 000 in 1997. In response to this increasing incidence rate, as a first phase to addressing the problems posed by this deadly disease, Lower Orange health region was identified as the model district to use in order to arrive at workable solutions aimed at bringing this incidence rate down. To date, tremendous progress has been made which has resulted in increased TB cure rate from 27% in 1997 to 62% currently. It is now necessary to spread these achievements to other regions of the province and work towards further reducing the incidence rate of Tuberculosis in the Northern Cape. Currently, there is also a drive towards increased operational research on Tuberculosis in the Province which will further serve as a means of documenting achievements and hence lead to improvement in delivery of TB care in all regions in the Province.

B2.2.5. Human resource issues
2.2.5.1. General
Personnel in service

JANUARY 1996

JANUARY 1999

• Personnel increase of 414

• Coloured persons received 50% of appointments to bring in line with demographics of Province.

• Females continued to enjoy the higher % of appointments namely 73%.

• Increase in white male appointments is due to the appointment of white Medical Officers.

Profile of personnel appointments assistant director and upwards

JANUARY 1996

JANUARY 1999

Increase of 5 personnel in management cadre from January 1996 to January 1999.

• Profile of representivity improved by the addition of 1 African, 5 Coloured and 2 Asian appointments. Decrease of White management personnel by 3.

Reduction in supernumerary personnel
• Severance Packages
• Retirement
• Resignation
• Placement on establishment due to vacancy arising
• Promotion
• Job alteration

1996/97 total supernumerary = 208

1998/99 total supernumerary = 49

Continues to have a negative impact on personnel budget of R2, 493,016 per year.

B2.2.5.2 Student nurses and trainees
In the Northern Cape the only Training Institution for health workers is the Henrietta Stockdale Nursing College.

B2.2.5.3 Medium Term Human Resource Strategy
• Re-evaluation of organogram and staff establishment to meet strategic objectives of Department.

• Provincialisation of State-Aided Hospitals, Emergency Medical and Rescue Services and selected Local Authority Health Services.

• Implementation of Public Service Regulations and associated policy.

B2.2.6 Information Systems
a) minimum reporting requirements
Monthly reports are expected to reach the provincial office via the district health manager’s office
b) hospital performance indicators

Private Hospitals
• total no of day patients and total no of patients staying overnight categorized in medical, surgical and obstetric specialties
total no of registered theatres
• total no operations under general anaesthesia
• total no of admissions to the following intensive care units:
• standard
• neonatal
• high care
• cardio-thoracic
• total no of casualties
• total no of infectious admissions
• total no of admissions
• total no of discharges
• total no of deaths
• maternal
• stillborn
• other

Provincial hospitals
• Admissions in hours
• Admissions after hours
• Discharges
• Deaths
• Referals to next level of care
• Theatre cases
• Post operative infections
• Out-patients
• Casualty cases
• Maternal health services
• Child health services
• Bed capacity
• Approved beds
• Actual beds

a) clinic performance indicators
• attendance
• < 5 yrs
• 5 to 59 years
• 60+ yrs
• maternal and reproductive health
• child health
• curative services
• obstetric care
• protein energy malnutrition (PEM) scheme
• sexually transmitted diseases
• medication
• no prescriptions
• no items dispensed
• laboratory services
• no patients seen by a doctor
• no referrals to next level of care

a) health status indicators
• infant and child mortality and morbidity
• maternal mortality
• incidence of oral diseases
• quality of life of older persons
• nutritional status of population
• incidence of diseases of lifestyle
• incidence of environmental health related risks
• rate of intentional and unintentional injuries
• among youth and adolescents
• incidence of injury on duty
• incidence of occupation related mortality, morbidity and disability
• incidence of sexually transmitted disease including HIV/AIDS
• incidence of mental illness

b) computer systems and their utilization
• Hospital Information System(HIS)
The department has undertaken to procure a hospital information system. The computer system will be implemented in six nodal provincial hospitals viz. Kimberley, Gordonia (Upington), Kuruman, Springbok, Calvinia and De Aar hospitals in that order. The IT operational centre will be based at the Kimberley hospital.
In line with the department’s strategy of a phased implementation, the HIS will initially comprise of the below modules with the scope to add additional modules in the future.
• Master Patient Index
• Patient registration with admissions, discharges and transfers included
• Patient billing.

The administration has key priority areas, which the HIS needs to satisfy viz:
• Administrative
• To improve and enhance the revenue generation aspect of the hospital.
• To provide effective management and decision support information.
• To improve the administration of health care in the hospital.

• Clinical
• To provide readily available clinical data (e.g. Hospital/Clinical performance indicators) to the health care professionals to facilitate the effective patient care and treatment.
• To provide effective patient management.
• To relieve professional staff of tedious clerical functions.

• Patient billing
• All patient information must be transferable between hospitals. This will enable the collection of bills at various points in the province.
• The system must incorporate standards based (Electronic Data Interchange) EDI to allow for connections to systems viz. Medical Aid Schemes, Road Accident Fund (RAF), Workmen Compensation Act and allow for the future connections to other systems.

• Telemedicine
• Telemedicine is the practice of medical care using interactive audio, visual and data communications; this includes medical care delivery, consultation, diagnosis and treatment, as well as education and the transfer of medical data.
• The vision of the department for the utilisation of telemedicine is as per the above definition.
• The Telemedicine initiative will initially be implemented at Kuruman and Kimberley Hospitals, with Kuruman Hospital being the send site and Kimberley Hospital being the receive site. Kimberley Hospital will thereafter be directly linked to a National Research Centre.
• The project will be for TeleUltrasound antenatal Screening.
• Telemedicine is also envisaged to:
• Strengthen the referral system between Community Health Centers, Regional Hospitals and Central Hospitals, for effective delivery of Primary Health Care.
• The development of local expertise and skills transfer to the peripheral site.
• Epi/Info
• Epi/Info is utilised for the following functions;
• Compiling questionnaires for surveys.
• Capturing of epidemiology data based on the questionnaire that had been created.
• Analyse data.
• Currently the computer system is used for Anonymous AIDS, Tuberculosis, Notification of notifiable disease and Immunisation.
• MS-Office
• Ms-office is used for:
• Word processing.
• Data capturing.
• Spreadsheets.
• Accounting.
• Presentation.

• E-mail
It is the departments strategy to provide every employee that has a computer with a network connection and therefore e-mail as well.

B2.2 7 Women’s health issues
Termination of pregnancy
Objectives:
• Training of ten (10) midwives on M.V.A. and pre and post counselling in Diamondfield, Kalahari and Lower Orange regions.
• Training of two (2) in supervision of midwives practical’s at Kimberley Hospital by the year 2000.
• Designated hospitals for termination of pregnancy are Kimberley Hospital, Gordonia Hospital and one (1) Private Institution. The aim is to implement at Kuruman Hospital as well.

Maternity services
Objectives:
• To improve the basic knowledge and skills of midwives through the Perinatal Education Programme (PEP).
• Improve provision of Maternal and Newborn Care by training 50 midwives on both manuals in all 6 regions by the year 2000.
• To use PEP manuals as protocols for the regions until the provincial protocols are ready. Accurate record keeping on antenatal card, partogram and post natal observation card. The aim is to have 10% less perinatal and maternal deaths in 1999 due to preventable causes than in 1998.
• Since maternal death notification which started in Oct 1997 to date – 27 cases reported of which 6 cases are from the North West Province and 1 case from the Free State Province.

Cervical & breast cancer screening
Objectives:
• To inform women about cervical cancer - what cervical cancer is, that it is detected with a papsmear and what the procedure of a papsmear entails.
• To do cervical screening along with breast examination and do the necessary referrals and treatment.

Targets
• PAP Smears for all women above 30 years up to 50years (10 yearly only)
• Breast examination on all women
• Health promotion talks.
• To reach at least 5,000 women within 12 months in a particular region. It is envisaged to implement the programme in Diamondfields, Upper Karoo- and Kalahari regions.
• All nurses in Primary Health Care will receive in-service training in theoretical and practical demonstrations.