North West Province
NORTH WEST PROVINCE
BUDGET HEARING PRESENTATION

SECTION 1
A. INTRODUCTION
During the last four years of its existence, the Department of Health and Developmental Social Welfare in the North-West Province has applied several strategies as identified to realise its vision. Difficulties, constrains and challenges like in any other country that is going through economic and political restructuring were encountered and dealt with accordingly.

This paper presents the Department's report for the past four financial years as follows:

A.1 VISION
OPTIMUM HEALTH AND WELFARE FOR INDIVUALS AND COMMUNITIES IN THE NORTH WEST PROVINCE, SOUTH AFRICA

A.2 MISSION
TO CO-ORDINATE AND DELIVER ACCESSIBLE, EQUITABLE, AFFORDABLE, EFFlCIENT AND EFFECTIVE SERVICES THROUGH COMMUNITY PARTICIPATION

A.3 STRATEGIC OBJECTIVES
To develop capacity in order to deliver the full range of health and welfare services within the province.

To rationalise and redistribute resources (personnel, equipment, facilities) in order to achieve equity, accessibility and cost-efficient delivery of services.

To decentralise all aspects of administration and management of services in order to allow local democratic participation in the control of health and welfare services.

To achieve strategic, functional and managerial integration of health and welfare services at both Provincial and local authority institutions.

To deliver quality health and welfare services to all communities of the North-West Province in line with Batho Pele principles.

A.4 POLICY GUIDELINES
> CONTINUING RESTRUCTURING
> REALLOCATION OF RESOURCES TO PHC
> QUALITY IMPROVEMENT AT ALL LEVELS
> COST RECOVERY FOR HOSPITAL CARE
> AFFIRMATIVE ACTION
> FREE PRIMARY HEALTH CARE

A.5. PROVINCIAL PRIORITIES
· HIV/AIDS
· JOB CREATION
· CREATION & UPGRADING OF INFRASTRUCTURE
· TO TACKLE LOW SKILLS AND LITERACY RATES

A.6. DEPARTMENTAL PRIORITIES
· HIV/AIDS
· TB
· CHILD & WOMEN SERVICES
· MENTAL HEALTH & SUBSTANCE ABUSE
· POVERTY ALLEVIATION/ERADICATION
· EMS
· TRANSPORT
· RESTORATIVE JUSTICE
· FINANCIAL MANAGEMENT
· IT AND DHIS
· SERVICE RATIONALIZATION/STRUCTURES
· SERVICE STANDARDS/QUALITY
· POLICY & PLANNING
· LEADERSHIP

B. OPERATIONALIZATION THROUGH PROGRAMS/SUB PROGRAMS
B.1. PROVINCIAL BUDGET

Information on:
a) Budget and actual expenditure by program and standard item for 98/99.
(Transparencies)

b) Provincial health budget for 98/99 by program and standard item.
(Transparencies)

c) Causes for variance for 97/98 financial year
(Transparencies)

B.1.2 Budgets and expenditure in relation to specific policy issues
a) Revenue
Revenue raised during 1995/96, 1996/97 and 1997/98 was not separated in terms of public and private. Only revenue collected during 1998/99 is being separated.
1998/99 R 322 623.74
1997/98 R
1996/97 R11 502.50
1995/96 R31 118.73
TOTAL R366 705.40

a) HIV/AIDS
Budget 1998/99 R 1 050 000
1999/00 R 1 780 000
2000/01 R2400000

b) HIV/AIDS allocation for NGOs
1997/98 R1 500 000
1998/99 R 840 000

P/S Specific policy areas for HIV/AIDS are provided in Annexure 1

ANNEXURE 1
· a) 8 940 000 condoms were distributed in the NWP in 1998.
One cannot calculate specific reductions of infections as HIV is a long term illness. However it suffices to say our IDS surveillance keeps on going up by roughly 3%. Whereas in 1990 it was 1.1% by 1998 it was 21.2%. Three AIDS cases were diagnosed in 1987, by 1998 more than 3 000 people were living with AIDS.

· b) Many CBOs and NGOs are involved in HIV/AIDS prevention and control, counselling and care. In 1998 NGO funding was to the tune of 1.5 million Rands. The national level gave the province NGO funding assistance of 840 000 Rands and the rest was funded by the province. If funds were available many more CBOs and NGOs could get funding. In 1999 the National Directorate HIV/AIDS gave the NWP over Two million rands for NGO funding. The Province is presently

· c) An inter-departmental committee was formed since October 1998. The committee comprises of all departmental Members of the Executive Council and they signed pledges to be serious partners of the fight against HIV/AIDS. They pledged to set aside a percentage of their budgets to HIV/AIDS prevention and control.

· d) There are a few hospices that care for people living with HIV/AIDS. The well established one being Klerksdorp and Moretele. Many people living with AIDS end up with their families when they are terminally ill or end up in hospitals.

· e) Home based care has not yet really been introduced in the province. There is no policy in the province on home based care. However some officers have been sent for capacity building. If the trend continues as it is, Home based care will definitely be part of care and support. It is therefore imperative that the province start putting structures in place.

· f) The introduction of 30 Lay AIDS counsellors in the province is one intervention to offer on-going counselling, care and support to people living with AIDS.
Home based care has however not really taken off. There are a few hospices, the well established ones been Klerksdorp and Moretele. Many patients still spend their last lap of their lives in hospitals or at home. Access to these facilities is available by means of a telephone call or referral from a hospital or clinic.

Patients are however not institutionalised because of lack of funding. The procedure is that the hospital phones the hospice and the latter reaches out to the terminally ill person.
The patient and his family are counselled.
There are no written policy guidelines available.
Lay counsellors are in the process of establishing support groups in the various districts.
NGOs are also involved in the rendering of care and support. With the partnership against AIDS we wish to draw in the church and other stakeholders.
Education is the key strategy to destigmatise this disease and to change the attitudes of the peoples.
Sixty five tutors and one thousands six hundred and fifty secondary school teachers trained in life skills. Plans to train out of school youth are in place.

· g) No strategies is in place in the province to deal with discrimination against HIV positive people.
· h) The province embarked on a media campaign from July 1998 to December 1998 for TV and Radio programs.
· i) The province has developed minimum standards for training, mentoring of HIV/AIDS Counsellors and trainers. Furthermore Circular No. 16 of 1996 stipulates clearly procedures 10 be followed by the health care settings where HIV testing is being conducted.
· j) The proper management of sexually transmitted diseases play a major role in the prevention of HIV/AIDS. In order to ensure that clients receive quality and efficient care syndrome management was introduced in the Province. The following strategies were embarked on:

Capacity Building: 200 nurses have undergone training in syndromic management of STDs.

Development of Treatment Guidelines: Treatment protocols for the province are in situ and have been distributed to all health care facilities. So far 1000 have been distributed.

Partner Management: The standard format of tracing partners of sexually transmitted diseases is in situ. This will ensure that most of these clients are traced and treated thus ensuring proper control of STDs.

Surveillance: The standard format of reporting syndromes as experienced by the STD clients is in place and 80% of the districts are using it to record STDs

B.1.2. (cont.)
d) TUBERCULOSIS PROGRAMME (TB)
Allocation for 1998/99 R 1 452 000
1999/2000 R 1 444 .406
2000/001 R 1 480 787

Achievements of the Tuberculosis Programme is provided in Annexure 2 (i.e. item B.4)

e) Planned Expenditure on Information Systems in 1999/2000 Item

WAN & LAN installation ( Health sites) 8 500 000
Computers & Program for the District Health Information System 300 000
PAAB system implementation 4 210 000
Computer Training 400 000
Publications and dissemination of information 300 000
TOTAL 13 710 000

f) Planned new capital expenditure on Hospital Services and Clinics
1998/99 R29 million
1999/2000 R40, 5 million
2000/01 R40, 5 million

This excludes hospital rehabilitation and reconstruction program funding and RDP
funding.

SECTION 2 PRIMARY CARE SERVICES
2.1 District Health Systems
a) Five Regions and which include 18 districts have been established in January 1996. The management of these structures include Chief of Health Services of Local authorities where available.

b) An Equity Task Team has been established for redistribution of resources. Allocation of resources has been based on the following variables:
· Patient days
· length of stay
· bed occupancy
· weighted population
· phamarcutical supplies
· personnel expenditure

c) The local councilors formed part of the interim district health forums. A Provincial Governance Act has been developed. The provincial organized local government structure called NORWELOGA through its health technical teams has been involved in a concerted consultative process in regards to decentralization process.

2.2 Primary Care Core Package

2.3 Management of Drugs
Presently the only official policy document in use is the National Drug Policy with all other documents on the Essential Drugs Program.

lnternal/ local documents have been prepared on the actual Procurement and Distribution Procedures. Training on and the principles of Drug Supply Management are being encouraged throughout the Province.

Preparations are under way for the integration of the Central Depot System and the Management of the procurement storage and distribution will be outsourced with effect from 1st April 1999.

3. Hospital Services
3.2. Regional Hospitals
a) Future Strategic Directions:
· This Province has 6 Provincial / Regional Hospitals. We have just restructured these hospitals into complexes and appointed 3 Chief Executive Officers (CEO's) to manage them.
The hospitals will be divided as follows:
- Mafikeng General and Bophelong Psychiatric Hospital as a complex
- Klerksdorp / Tshepong - / Potchefstroom/ Witrand Hospital as a complex
- Rustenburg Hospital
· For the Odi - Vryburg Region there are presently no designated Regional Hospitals. The Vryburg region is currently referring to Klerksdorp complex. Odi Region refers to GaRangkwa and Pretoria Academic Hospitals. We intend to develop a Regional Hospital in Vryburg over the next 5-10 yrs depending on feasibility studies.
· The above-mentioned 3 complexes renders Level 1 and Level 2 services and regarding Klerksdorp , Tshepong-/Potchefstroom/ Witrand Hospital Complex certain Level 3 services ire rendered.
· Strategically the above mentioned hospitals are in the process of merging to form complexes. The reason for the mergers are for:
- Better management and control
- The elimination of duplication of services
- The building out of services presently not rendered
· Regional hospitals would like to form some private public interfaces regarding unused beds. This process is still in its early development.

b) Improved Management
· The Klerksdorp / Tshepong-/Potchefstroom/ Witrand Hospital Complex is taking part in the pilot project of the National Department of Health regarding:
"Decentralization of Hospital Management". This project is funded by the European Union and DFID. It consist of:
- Drawing up of Performance Management Agreements between the Provincial Department of Health and the Complex
- Skills assessment and development of the complex management
- Appointment of Provincial and Institutional technical assistance by the Health Systems Trust
- Twinning arrangement with a National Health Service Trust in the United Kingdom for learning purposes
· The above-mentioned will again be twinned with the other Regional hospitals in the Province.
· All 3 complexes have been engaged in improving quality of services delivered through the COHSASA Hospital Accreditation process. Klerksdorp/ Tshepong was the first Public Hospital in the country to be accredited by COHSASA

c) Service Reprioritization
· After the Departmental Work-Shop Lekgotla 15 priorities were decided on of
which Regional hospital.; will concentrate on:
- Service rationalization
- HIV/AIDS/TB
- Child and Woman's health
- Termination of pregnancy
- Financial management
- Decentralization of hospital management
- Extension of services by using the Re-distribution of Specialized Hospital
Services Conditional Grant for establishing specialized hospital services in our province

d) Retention of Revenue Policy
This is still a debate between the National Department of Health and State Expenditure and the Provincial Health Departments and Treasuries. The implementation of this policy will provide an incentive for hospitals to collect revenue more effectively.

e) Rationalization of Staff
· All Regional hospitals received new post establishments in 1997. Although all management are not satisfied, consistency was obtained
· All institutions went through the absorption phase. Supernumerary staff were identified and are mainly on the lower rank, i.e. Cleaners, kitchen staff etc.
· Management structures were restructured and the approach was changed from appointing Medical Superintendents to Hospital General Managers and CEO's

f) Serious problems encountered during 1998/99 financial year
· Serious problems were encountered regarding cash flow on the Walker System. This lead to hospitals and clinics running out of essential medicine.
· The tender process in the Province is a major problem and institutions ran out of available tenders to buy from which had the implication that we had to buy out stock on price quotations.
· The total budget allocated to Regional hospitals is not enough as the flow of patients to Primary Health Care is not complexed yet.
· Increased patient load regarding HIV/AIDS/TB with the increase in mortality rate for these patients and a higher percentage of unclaimed corpses.
· Hospitals experienced a major increase in the percentage theft cases in our institutions. Security is the therefore a major problem that needs intervention.

4. Tuberculosis (Annexure 2)

5. Human Resource Issues
Students and training (See Annexures)

6. Information Systems
Systems is one of the strategic priorities of the Department of Health and Developmental Social Welfare. This section of the report outlines the 3 strategies that will be used to achieve this strategic priority.

STRATEGY 1: Developing the Department's Information Technology (IT) infrastructure
Developing the Department's the IT infrastructure will focus on the following:
1. Connecting the remaining 6 district offices, 12 hospitals, and major health centres to the wide area network (WAN)
2. Installation of local area networks (LAN) at priority sites
3. Conducting an audit of IT infrastructure, including computers, printers, etc to assess their utilisation and possible redeployment This audit will also include assessing IT equipment and medical equipment for Year 2000 compliance
4. Purchasing computer equipment to facilitate the running of essential systems.

Developing the department's infrastructure is necessary to run essential systems and applications such as PERSAL, Walker, the financial system, Patient Administration and Billing System (PAAB) in hospitals, and the District/Primary Health Care information system.

Indicators that will be used to monitor and evaluate the implementation of this strategy
· Number/% of sites connected to the WAN
· Number of institutions with Persal/Walker/PAAB system/ District/PHC system/E-mail/ Internet access
· Number of institutions where an audit of IT equipment has been conducted.

Budget required to implement this strategy
Item Yr 1999/2000
WAN installation (Health & Welfare sites) 11500000
Computers & Program for the District Health Information 300000
PAAB system implementation 6210000

STRATEGY 2: Training staff to use of IT resources (including programs) and information

This strategy will focus on training staff on the following:
1. Basic computer training.
2. Training staff on specialised programs such as PAAB, PHC information system and Epi Info, which is used for disease surveillance.
3. Training staff in data collection and data analysis and basic research and basic epidemiology competencies.

Indicators that will be used to monitor and evaluate the implementation of this strategy
· Number staff who have undergone basic computer training.
· Number of staff trained on how to used specialised programs such as Persal/Walker/PAAB/Clinic/PHC system/Epi Info.
· Number of staff trained in data collection/data analysis/ epidemiology/basic research
· Number of people trained who actually use the programs on which they were trained.

Budget required to implement this strategy

R163 000 required for training staff in data collection/data analysis/ epidemiology/basic research/ Epi Info

R 90 000 required for training staff in specialised IT programes , the transversal systems such Persal, Walker (budget under HR/Finance)

R150 000 required for basic computer training.

STRATEGY 3: Improving the flow of information, collection of data, dissemination and use of information
This strategy will focus on the following:
1. Strengthening district information offices to ensure that they coordinate all key district information. This strategy will involve nominating/appointing district health/welfare information personnel.
2. Consolidating the Provincial Information Office as the contact point for all key provincial health and welfare information.
3. Ensuring that data that is collected is analysed and used at all level.
4. Ensuring that information is disseminated as widely as possible to key stakeholders so that information is used in decision-making.

Indicators that will be used to monitor and evaluate the implementation of this strategy
· Number of districts/institutions with information coordinators.
· Number of statistics/analytic reports produced quarterly or annually.
· % of clinics or social work offices which have information displayed based on their activities within the previous 3 months.
· Web page development for the Department.

Budget required to implement this strategy

R155 000 required for dissemination of information.

R250 000 required for developing Department's web page (1st Phase).

Reporting mechanisms and indicators
Attached are the forms that are used to collect information from hospitals and clinics. A standard form is used to report data from all the hospitals. The main hospital indicators that are used in the province are:
1. Bed occupancy rate (for acute and chronic beds)
2. Average length of stay
3. Cost per Patient Day Equivalent
4. Outpatient headcount
5. Fatality rates
6. Number of operations
7. Number of deliveries
8. Post-operative infection rates (not measured currently)

The province has not yet introduced uniform method of collecting data from clinics.
However, all clinics are supposed to report the following information on a monthly basis:
1. Total headcount
2. Number of deliveries
3. STD visits
4. Ante-natal visits
5. Post-natal visits
6. Mental health visits
7. Family Planning visits
8. Minor ailments

In 1999, the province will implement a standard system of collecting data from clinics. The province has decided to use the Health Information System Project (HJSP) software, which will be implemented with support from the EQUITY project. The new system will mainly build on the data elements for PHC that were endorsed by the NHIS/SA committee.

Health status indicators will mainly be monitored used surveys, such as the Demographic and Health Survey.

7.Women's Health Issues
In addition to providing information that has been required for Women Issues, the North-West province's Department of Health and Developmental Social Welfare has gone beyond and highlighted the framework for a public policy that aim at making a difference in reducing reproductive morbidity and mortality in the province. The framework is guided by the principle that if the root causes of reproductive morbidity and mortality are addressed, high rates of reproductive morbidity and mortality will decline. It suggests that the empowerment of women in terms of strengthening their socio-economic means could reduce their vulnerability to risks of morbidity and mortality. This level could be addressed through an integrated approach and inter-sectoral mechanisms to meet the Strategic Reproductive Health Needs. Practical Reproductive Health Needs could be met through the provision of accessible, equitable, quality reproductive health care services. This task should be ensured by the Department of Health, in the North-West Province, by designing and operationalising concrete action plans.

8. SPECIFIC PROBLEM AREAS AND CONCERNS
a) Financial
b) Control, management and administration
c) Institutional