Western Cape
HEALTH DEPARTMENT:
PROVINCIAL ADMINISTRATION WESTERN CAPE
RESPONSE TO WRITTEN QUESTIONS OF THE PORTFOLIO COMMITTEE ON HEALTH

1 March 1999

Introduction
This document contains written responses to questions posed by the Portfolio Committee on Health for its Budget Hearings to be held from 1-3 March 1999.

It should be noted that the time given to respond is unsatisfactory. The document contains almost a hundred sub-questions over 7 pages covering many substantial and complex aspects of departmental functions. Yet the document was only faxed to the Department late on the 22 February and a deadline for responses being given as 10 am on the 26 February. This has not allowed the departments sufficient time to do justice to the important and penetrating questions posed. A strong request is therefore made to allow adequate time for this process in future years.

B.1. BUDGET INFORMATION
B.1.1. GENERAL
a and b) Budget and expenditure data
Budget and expenditure data by program and standard item for 1996/97, 1997/98 and 1998/99 are attached in annexure 1 (16 pages). The format is not exactly identical to that prescribed in the table for the following reasons:

• The format makes no provision for Standard Items.
• Capital funding in respect of Buildings is part of the Works allocation and not the Health Department.
• Capital funding on the Health allocation consists of allocations to Equipment and the purchase of ambulances against Transfer Payments only.
• Allocations for Bursaries are made against Transfer Payments in the Provincial Management sub-programme.

Table 1 compares expenditure in 1996/97 with adjustments estimates budgets for 1998/99, modified to reflect deferred payments. This data suggest a fairly small expenditure shift towards primary health and regional hospitals away from tertiary hospitals.

Table 1. Comparison of expenditure 1996/97 with 1998/99*

* Deferred payments have been included

c) The data given is for Health only and not Welfare.

d) Reasons for deviations, how deficits were funded, what happened to surpluses etc. is described in the last column of the annexure.

B.1.2. Budget and expenditure in relation to specific policy issues
a) Revenue
Revenue raised from private patients using public hospitals cannot be extracted from the FMS. However, revenue in respect of Hospital Fees can be submitted and is attached at the back of annexure 1. It is disturbing to note that revenue from hospital fees has declined from R89 million in 1996/97 to R75 million in 1997/98 and is projected to be R64 million in 1998/99. Furthermore in each year revenue was below budgeted levels.

b and c) HIV/AIDS budgets
HIV/AIDS budgets are not isolated. Budgets are allocated according to FMS objectives and HIV/AIDS are treated at clinic, district hospital, regional hospital and central hospital level and expenditure in this regard forms part of the total health care expenditure of the institution.

National funding for NGOs has been approved for R 1. 7 million for 1999 / 2000. As mentioned above this constitutes only a small proportion of total expenditure on HIV/AIDS.

d) TB program allocations
Expenditure in respect of the treatment of TB can also not be extracted for the reasons as stated above. The following clinics/hospitals are dedicated TB institutions and the information in respect of the 1998/99 allocations are as follows :

Table 2. Budgets for TB hospitals 1998/99

Data from the FMS states that expenditure on TB medications was R8 million in 1996/97, R4.5 million in 1997/98 and R5.1 million in 1998/99. However expenditure is sometimes misclassified within the FMS and these figures should be viewed with caution.

e) Planned expenditure on information systems
Planned expenditure on hospital information systems is contained in annexure 2. Total cost of the hospital information system is R90 million with maintenance costs increasing to around R15 million per year by year 5-6. The annexure schedules the prospective allocations divided over a 5 year period.

f, g and h) Planned new capital expenditure
The table below shows planned capital expenditure for 1998/99, 99/00 and 2000/01. The data is presented by source of financing and level of care.

Table: Provincial capital budget

* Projects not finalised.
** Allocation unknown.

B.1.3. Narrative report
a) Key problems experienced in relation to the budgeting process
The MTEF process has in general worked fairly well. Some of the problematic issues have been:

i) Rapid changes in the global amounts. Although less dramatic than in previous years, the new census results and a range of other national and provincial factors have led to several rounds of changed indicative allocations, the outer year being particularly fluid. This makes the process more difficult - particularly if one wishes to utilise participative processes in budget development.
ii) Difficulty in synchronising budgeting and planning processes. The budget process starts very early in the financial year and many months before managers are seriously planning for the following year.
ii) In this province maintenance and capital works budgets are part of the Works Vote rather than the Health Vote which makes long term capital planning more difficult.

b) Ability to reach national policy objectives generally
The Department generally has made substantial efforts to realise national policy objectives.

A large practical constraint on the department over the past three years has been that our attention has been centrally focussed on a downsizing process to come within budget. This has at times distracted us from optimal fulfilling national objectives. For example, while we have implemented the free primary care policy, this has been done at a time of staff losses and shortages, and this has placed tremendous pressure on PHC services. For example PHC services in the Cape metro are dealing with over a million additional new PHC visits annually despite a loss of 200 primary care staff.

The current constitutional framework provides the national level with a central role in legislation and policy formulation but almost no say in the budgetary process. This obviously has the potential to be problematic. Policies generally need to be associated with quantitative objectives and plans with budgetary implications. This highlights the need for proper involvement of provinces in policy formulation.

c) Implementation of revenue retention policy
There has been some progress in this area in that the Provincial Executive Committee has decided that 50% of revenue generated above the MTEF revenue budget levels may be retained. Although Treasury has approved the policy they have not put in place processes to formally implement the system so revenue retention is not yet in place.

We see revenue retention as being absolutely critical for the long term financial viability of this department.

Given the current constitutional framework, national legislation is required to facilitate this issue. We would value the support of the Portfolio Committee in helping to get this approved.

d) MTEF Framework
Some comments on the current MTEF budgeting process have been discussed in (a) above.

The MTEF is a fair reflection of envisaged health policy. A summary of our MTEF budget for 1999/2000 to 2001/02 is attached as appendix 3. This shows budgets for primary health care (subprogram 2.2.) increasing from R499 million in 1998/99 to R602 million in 2001/02. This reflects our policy shift towards primary health care which has increased from 14,7% of the budget in 1995/96 to 19,1% in 2001/02. The budget shows the limiting of expenditure on academic hospitals whose budget is effectively capped through the MTEF period.

There are some issues where a simple reading of the MTEF budgets contained in the White Books does not reveal underlying complexities.

i) The White Book budgets do not give an indication of regional funding and shifts to inter-regional equity.
ii) While budgets reflect intended policy shifts, actual changes in expenditure patterns often lag several years behind. For example, expenditure on academic hospitals has exceeded original White Book budgets substantially in this province over the past 3 years. This has not allowed other parts of the service to operate at the levels originally budgeted. This situation is however progressively improving, with this provincial department now hopefully (after having downsized 8000 personnel) having reached a position of budgetary stability.
iii) Personnel expenditure increases over the past three years have far exceeded anticipated amounts. Most of these increases have been centrally determined in the Central Bargaining Chamber. This has required unexpected cuts in all parts of the service to pay for unexpectedly large personnel expenditure increases.

Medium term planning is occurring to some extent and there is a progressive shift to multiyear thinking. The department has based its strategic planning in our quantitative normative model on the medium term MTEF figures. This has allowed medium term hospital bed, personnel and other forms of planning. However the instability in the outer years budget levels (which change constantly) have led managers to distrust outer year estimates and led them to focus on the first year of the MTEF. Associated with this is a sense among many managers that the inner year is real and important and that the outer years are pure speculation.

Requirements to improve the process include:
i) Greater stability in the indicative allocations.
ii) Departments to be given their indicative allocations earlier.
iii) Departments to integrate their service planning and budgeting better.

B. 2 POLICY ISSUES
1. Over and underexpenditure by the department
Over and underexpenditure is detailed in annexure 1 together with reasons therefore, how deficits and surpluses were handled.

In summary:
i) In 1998/99 the deficit is a result of difficulty in shedding supernumerary staff (because of limitations of the VSP process) and the adjustment of housing allowances. The over-expenditure (R28 million) will be carried over as the first debt to the 1999/2000 allocation.
ii) In 19978/98 a surplus (R11 million) was paid over to Provincial Treasury. In the 1996/97 year over-expenditure of R18 million was funded by provincial Treasury.

This analysis does not however reflect the fact that the adjustments estimate was substantially higher than the original White Book budgets. This has largely been because of the difficulty in downsizing Health Departments rapidly (this department has reduced in excess of 8000 personnel over the past 3 years), the limitations of the VSP tool, the costs of severance and most importantly because of very large increases in average personnel cost, negotiated in the central bargaining chamber. Provincial Treasury has in each of the last 3 years substantially increased allocations in the adjustments estimates to cover the projected deficit. Now that the department has substantially downsized, the province is likely to come into budget in the 99/00 year.

No disciplinary action has resulted.

B. 2.1 .2 Benchmarks and performance targets for 98/99
BUSINESS PLAN 1998/99
The Department developed a Business Plan for 1998/99, which was adopted by cabinet on the 20/5/98. The major projects are summarized below:

1. Communication strategy
There has been consultation and information sharing with a range of stakeholders including Standing Committee on Health, senior management of universities, staff, unions and Heads of Health in other provinces. There has been inadequate communication with the public and staff on an ongoing basis. A Public relations unit has been set up recently directly under the Head : Health to improve the situation.

2. Reporting :
The Head: Health took personal responsibility of monitoring the implementation of the Business Plan on a monthly basis. He regularly reported to the Provincial Treasury Committee, the D-G and the Minister: Health and Social Services.

3. Institutional Rationalization :
3.1 Psychiatric Hospital Services
A single management structure has been created across the psychiatric hospitals. This has helped to create a single service platform with the sharing of resources across institutions. Programme and portfolio managers have been put in place. There has been a significant loss of management cadre at the institutional level, but this is being currently addressed.

It has been agreed that the mental handicap services will be based at Alexandra and part of Lentegeur Hospital. The acute and chronic psychiatric services will be based at Valkenberg, Stikland and Lentegeur Hospitals. The forensic unit will be moved from Valkenberg to Lentegeur. The adolescent service will be reopened at Lentegeur hospital. Capital funds will be made available to facilitate the structural alterations required.

All inpatient services have been relocated from the Pinelands side to the Observatory side of Valkenberg Hospital. Approximately 400 chronic patients have been discharged; many into group homes over the last two and half years. 279 beds have been closed since Nov 97 at the psychiatric institutions. The staffing levels have been very low in psychiatric hospitals i.e. approximately 1 staff : 1 bed. From Feb ' 98 - Feb ' 99, 269 staff have left the service from psychiatric hospitals, the majority being nurses. However, 40 nurses have been appointed recently.

3.2 Princess Alice Orthopedic Hospital (PAOH)
Sixty beds have been closed and sixty beds transferred to Groote Schuur hospital. Sixty staff were declared supernumery. The service was transferred to Groote Schuur on the 1/8/98.

3.3 DP Marais Hospital
This is a TB hospital run by a SANTA contract. The buildings have been in a poor state of disrepair. The hospital was vacated as the area was being developed by the South Peninsula Local Authority as a housing complex for the informal settlement in the area. The service and all the staff were transferred to the PAOH by the 21/12/98. The developer carried the costs of structural alterations that were needed.

3.4 Westlake Hospital
This hospital is being vacated for the same reasons as in 3.3 above. The developer has agreed to fund the structural alterations at Conradie hospital (R10m) to house the patients from Westlake. This project is targeted to be complete by the 1/1/2000. The Provincial Health Plan and further investigations into the future of Conradie have recommended that Conradie Hospital would be the main rehabilitation hospital for the province.

3.5 Nelspoort Hospital
This hospital forms the economic lifeline for the local community. While the health Department is prepared to close this hospital, it has been agreed with all the role players that this would happen in a phased manner and with the development of an economically viable alternative for the survival of the local community.

The beddage has been reduced from 242 to 126; 17 staff have accepted the VSP and 20 staff have agreed to be transferred to other institutions. There have been no new admissions to the hospital.

3.6 Somerset hospital
The North Block of the Hospital has been vacated. 57 beds have been closed. Plans have been developed for structural alterations to the West Block of the Hospital to accommodate the services from the North Block. A CHC is being developed at City Hospital to accommodate the PHC patients. The property section in Public Works has been requested to commercialize the North Block. A Cabinet resolution has been adopted to secure the funds from this commercial venture for the building of a 250 bed Phillipi East Hospital on the Cape Flats.

3.7 Rationalization of Dental hospitals
A task team report has been produced. Programme and portfolio managers have been appointed to integrate and coordinate the services. The joint agreements have been rewritten ; previously PAWC provided a 100% subsidy to joint staff. The rewritten agreements provide for 51% PAWC : 49% University contributions. This is a major saving for the Health Department.

3.8 Rationalization of Academic Hospitals
126 beds have been closed and 1292 staff have been lost in the 1998/99 year. 5025 staff have been lost to the AAH since April 1996. See section 3.1 for details on the central hospitals.

4. Capital and maintenance projects
A total of R22m from the capital and maintenance budgets for health facilities were reduced as part of the savings to come within budget.

5. Part time District Surgeons (PTDS) Expenditure
The target of a R3m saving on the part time district surgeons expenditure has been achieved by capping patient numbers and medicines. In some areas, the PTDS service is being phased out and replaced by a PHC nurse driven service.

6. Nursing Colleges
Final proposals for the rationalization of the four nursing colleges culminated in a cabinet submission. The cabinet has supported the proposal of two campuses at Nico Malan and Otto Du Plessis. The Carinus Campus has been vacated and a lease has been signed by UCT for the use of the premises.

7. Review of Hospital Staff establishments
The large losses of staff from the service over the last few years have resulted in gross distortions in the mix of staff categories. The Department has embarked upon an exercise to analyze staff establishments for each of the provincial hospitals by post classes; compare these to standardized normative guidelines weighted for workload; identify the corrections that need to be made within an affordability framework.

8. Conversion of Boilers from Steam to Electrical operations
This was meant to happen at Red Cross, Paarl, George, Karl Bremmer and Somerset Hospitals. Progress has been slow because of reduced capacity at Public Works and Tender Board procedures.

9. Reduce expenditure on equipment
The equipment budget was cut by R20m in this financial year to come within budget. This has exacerbated the backlogs in the provision of proper functional equipment. This would be regarded as a priority in the next financial year.

10. Reduce Commuted Overtime
The target was to reduce claims for overtime by 10% per institution. There has been great difficulty in negiotating the terms for commuted overtime at a national level which has impacted locally. Remuneration from overtime has come to be regarded as an integral part of the medical personnel salary. There has therefore been great resistance from the medical staff to reduce overtime claims. The phasing out of Limited Private Practice (LPP) has added to the resistance from health professionals. In addition, the salary increases granted to medical staff has increased the overtime claims.

11. Outsource Pinelands laundry
This was achieved in 1998. The full benefit of the savings would be gained in the following financial year.

12. Public Private Partnerships (PPP)
There has been in principle support to engage in PPP where the ventures strengthen the public sector e.g. maximize the optimal utilization of currently under utilized infrastructure in the public sector; generate revenue for the public sector; retain skills in the public sector; improve access to private sector resources; sharing of expensive high tech equipment etc.

The department is at an advanced stage of discussions with the universities to lease out 125 beds at Groote Schuur to UCT and 125 beds at Tygerberg Hospital to the University of Stellenbosch to be used as private beds. The financial implications and staffing arrangements are still being negotiated. The provincial cabinet has supported the investigation of such opportunities. The PHRC has been kept informed.

13. Revenue Augmentation
A range of measures to augment the Departments revenue was planned (See details in annexure). The main measures were outsourcing of Debt Collection; adjustment of hospital tariffs from the 1/9/98 and the collection of outstanding revenue from the Universities. There has been a delay in awarding the tender for debt collection. The contractor will begin with his service from the 1/3/99. This will result in a loss of income for this financial year of approximately R16m? High level representations have been made to resolve the collection of outstanding revenue from universities.

14. Rationalization of staff
The department had 26 988 filled posts on the 1/4/98 and set a target of 24 840 on the 1/4/99 i.e. a net loss of 2148 staff through natural attrition and VSPs. While the personnel targets have been numerically met, the loss of experience, clinical and corporate memory and its impact on the quality of care from exit of staff from the service should not be underestimated.

15. Financial Targets
The original budget allocation for 1998/99 is R2901. A business plan to provide savings for R147m was developed which included deferred payments into the following financial year. The deferred payments are to prevent the further loss of staff and reduction in services to address the cash flow problem being accounted for in this financial year. The carry through savings from the loss of 2148 staff would be in the range of R135m to R150m in the next financial year. No further reduction in staff and services would be required.

The adjustments estimate budget (including ICS) is R3013 million and this is our current target expenditure level.

Performance targets by directorate
Appendix 4 summarises some objectives and performance targets by directorate.

B.2.2. SPECIFIC POLICY ISSUES
1. HIV/AIDS
1a. Targets set for 1999/2000 :
• To develop plans of action with specific target groups within various ministries / sectors.
• To develop a joint programme of implementation for peer group education for military and paramilitary personnel
• Capacity building for NGO’s
• Increased NGO funding ( an amount of R 1.7 million has been approved by the National Department)
• To establish a task group to deal with specific PWA issues.
• To train primary school teachers in the province ( 2 per school )
• Increased partnership with traditional healers to encourage the use of condoms, improved STD management
• Increased distribution of condoms by 30 %
• Implementation of a specific projects with sex workers
• To establish structures to support the lay counsellor programme, accreditation procedures.
• Integration of HIV and TB programmes ( specific project in Langa)

1b. The HIV subdirectorate currently works in partnership with 50 NGO’s.
Funding has been approved for R 1. 7 million for 1999 / 2000.
This year capacity building workshops will be held for NGO’s who do not usually include HIV issues as part of their work. This will strengthen our partnerships with NGO’s

1c. An Interministerial Campaign had been launched last year with all Ministeries in the province. This will ensure better interdepartmental co – operation and collaboration.

1d. The subdirectorate currently provides funding to hospice organisations in the province for adults and children; ( this includes NGO’s / 3 in total who provide hospice care ). We will extend the amount of support given for hospice care this year.

1e. Home based care for is being provided by three big organisations in the province. A committee has been established for home based care in the office of the Minister of Health.

1f. The lifeskills school has trained a total of 129 master trainers, who in turn trained 816 teachers in 433 schools. There are also NGO’s who provide support to schools in terms of lifeskills / HIV / issues around sexuality.

1g. Regular HIV training courses are held for Department of Health clinic and hospital staff where issues such as HIV discrimination are tackled. The AIDS Training and Information Centre (ATICC) also provides training for NGO’s and CBO’s and provides a counselling service for communities. Through the Interministerial Campaign this year, we hope to deal with discrimination amongst all public sector employees.

1h. The province is part of the Beyond Awareness Campaign (National) which had set specific timeframes. In addition by June, we would have published AIDS awareness material in Afrikaans.

1i. The sub-directorate has provided additional funding to sustain the Lay Counsellor project which is aimed at extending counselling services at primary care level.
Voluntary testing services are offered at all primary care facilities.

A more detailed progress report from the HIV/AIDS directorate is attached as appendix 5.

2. PRIMARY CARE SERVICES
2.1. District health system
Progress has been made in negotiating and planning the implementation of the district health system but progress has been much slower than we would have hoped.

A Bi-ministerial task team has been established by the MECs for Health and Local Government to negotiate the formal establishment of the system. The 2nd interim report of this task team has recommended that district health services be managed by local government. Sub task teams have been set up to examine the detailed financial and personnel issues involved in staff transfers.

Key problems which we are facing include:
i) The lack of a legislative framework for districts, since the National Health Bill is not law.
ii) The lack of finalisation of municipal boundaries.
iii) Confusion on the ground around the constitutional term "municipal health services".
iv) The potential annual loss of R10million per year in improvements of conditions of service should personnel be transferred to local government. We will attempt to negotiate with State Expenditure but this problem has for years been unresolved for provincially aided hospitals.

a) District management structure
Since districts are not yet formally legally established in the Province we remain with interim coordinating structures at district level. These District Management Coordinating teams have been only of limited success given the continuing fragmentation of provincial and local government services.

Although draft organograms for DHAs were contained in the Provincial Health Plan further work on this has been put on hold until resolution of the governance issues within the Biminsterial Taskteam. However as part of its work the Personnel Task will examine some aspects of the microdesign of the amalgamated establishments.

b) Process for achieving equity in the allocation of primary care services
Appendix 6 details the degree of interregional inequity in the province, progress made in addressing equity and future plans. In summary the process has, over the past 3 years, largely focussed on the building of new clinics in areas without services. We are now starting to focus more on explicit financial analyses of inter-regional equity and the MTEF budget makes provision for progressive shifts to the relatively under-resourced Boland Overberg and West Coast- Winelands regions. Inter district equity has not yet been systematically addressed from a provincial perspective, but regional directors have been given decentralised authority to budget for their regions in an optimal manner and are progressively addressing equity issues.

c) Relationship with local government structures
At provincial level a Bi-ministerial Task team has been established to negotiate the establishment of the district health system.

At regional level management co-ordinating committees exist between the Regional Director and local authority health heads. For example in the metro a Health Advisory Management committee (HAM) meets monthly. Local authorities are also represented on the all party Metropolitan Health Forum.

At district level, interim co-ordinating committees exist in most districts to co-ordinate management of provincial and local government services.

d) New clinics constructed
Appendix 7 lists all new clinics constructed since 1994. 52 new clinics have been built and 29 upgraded. All of these are operational although 2 clinics are not fully commissioned (Delft and Kraaifontein).

2.2. Primary care core package
The national Department of Health has put the core package on hold while it awaits the Ministers approval. This has not yet been given to date.

There has been gradual progress in providing integrated preventive and curative services in facilities, with local authorities progressively increasing the curative services they offer.

2.3. Management of pharmaceuticals
Institutions at all health care levels may prescribe only according to established treatment guidelines, utilising only drugs listed in the Western Cape’s Catalogue of Approved Pharmaceuticals and the Essential Drug List for that particular level.

Community Health Centres may only place orders with the Day Hospital Organisation’s Central Depot in Woodstock. This ensures strict adherence to provincial policies by monitoring requirements.

Demanders are encouraged to make use of the Direct Delivery Voucher (DDV) system for procuring drugs so that deliveries from Pharmaceutical suppliers can be made directly to the demander, where possible. This relieves the State from re-routing orders via the Cape Medical Depot, resulting in a decreased potential of stock pilferage.

A tender has been approved for a new health information system to be implemented. The Academic Hospitals’ dispensaries will, as part of this tender, be fitted with computers and identical dispensing software. This will ensure coordinated drug distribution within the hospitals. Patient profiles will be established which will favor rational prescribing as well as economic dispensing.

The linking of hospitals to the Medical Stock Administration System - MEDSAS - is in an advanced stage. This will ensure tighter control over drug utilisation in the Western Cape.

At the Auditor General’s recommendation, the use of stock cards by all institutions in the Western Cape for internal stock control, will become compulsory. Although most hospitals and clinics are making use of one system or another, the monitoring of stock movement within certain institutions could be improved. A new stock card has been designed and institutions are in the process of implementing them.

3. HOSPITAL SERVICES
3.1. CENTRAL HOSPITALS
a) Future strategic directions
Following upon the Kings Fund report and months of negotiations, the three central hospitals were brought together under the Associated Academic Hospitals (AAH) on the 14/1/98 as a single teaching and service platform under the AAH Executive and an Acting CEO.

The AAH plays an important role in the delivery of services at a national as well as a provincial level. The hospitals are teaching hospitals and there are contractual obligations with the Universities in this regard. However, deliberate attempts are being made to shift teaching to other levels of care and seek opportunities beyond the teaching platform provided by the academic hospitals.

The bed capacity of the AAH has been steadily reduced over the past few years. In the 1998/99 financial year, a further 126 beds were closed by June 1998. However, this has lead to an inefficient, sub-optimal use of the infrastructure of these hospitals. Discussions are at an advanced stage with the universities for the creation of private facilities within the unutilized sections of these hospitals. This will result in expanding the teaching platform, provide a more balanced, clinical profile of patients for teaching purposes, revenue generation for the public sector and retention of skilled staff in the public sector which we could possibly lose with the phasing out of limited private practice.

Proposals have been developed and are currently being discussed by all the relevant role players to address an equitable distribution of resources between the AAH hospitals on the basis of outputs.

b) Impact of the Conditional Grant
There has been agreement at a national level between health and finance to maintain the conditional grant funding levels for the next two years of the MTEF while a range of issues get investigated to refine the allocation of these funds. This has brought stability to these hospitals, which have carried the brunt of the rationalization measures in the Western Cape over the last few years.

c) Retention of Revenue Policy
While the principle of revenue retention has been discussed for many years, progress has been slow in the adoption and implementation of this policy. The Provincial Cabinet in the Western cape has supported the principle of revenue retention and decided that fifty percent of the revenue generated in excess of the revenue budget of the Department could be retained within the department. The Provincial Treasury is currently developing the procedures necessary to implement this policy. The Department of Health is still to develop its policy on what proportion of the retained revenue could be kept at the institution and what proportion of the revenue will be available for redistribution within health.

d) Inter-provincial arrangements for the use of specialist services
There has been a long-standing arrangement for the referral of patients requiring unique services provided by our central hospitals. This has been further enhanced by the recent installation of telemedicine communication between Groote Schuur Hospital and the Eastern Cape. This is going to make the expertise at Groote Schuur hospital more easily available to the Eastern Cape and will reduce the number of patients requiring referral and result in significant savings for the Department of Health in the Eastern Cape as well as the patient and his/her family.

The Conditional Grant compensates provinces providing the tertiary service for patients from other provinces for expenditures incurred. Cross border billing remains in place for formal secondary level referrals from other provinces. However, no mechanism exists to compensate for patients crossing borders on their own accord to receive hospital care (unreferred).

Billing of other provinces for services rendered outside central hospitals has been unsuccesful. It is unlikely that other Provinces will pay unless we can prove that patients have been referred. Proof of referral requires close liaison between clinicians and reception staff for which mechanisms will have to be put in place. A recommendation to PHRC has been formulated for consideration.

e) Improved management
The formation of an AAH executive is allowing better management and coordination of services in the central hospitals. The AAH executive comprises an Acting CEO, the three Chief Medical Superintendents and a Deputy Director: Administration.

Decentralized management has been accepted in principle. The specifics around powers to be devolved, revenue retention, capacity and training requirements at institutional level, cost centered accounting etc are being investigated with the help of the National Department of Health and the European Union Consultants.

New management processes and structures to ensure the stable and coordinated management of clinical services across the AAH service platform are discussed under (f) Service Reprioritization.

f) Service Reprioritization
A structure has been created with portfolio and programme managers for each discipline across the AAH hospitals to enable better coordination, rationalization and prioritization of services from the 1/7/98. Plans are being developed to increase day cases/ day surgery; reduce the length of stay of patients in hospitals and "step down " facilities which are staffed at lower levels for observing patients before they can be safely discharged. The objective is to provide a more efficient and smarter service to patients. Waiting lists have been addressed for cataracts, hernias etc.?

Tertiary paediatric orthopaedic services from Lady Michaelis have been relocated to vacant wards at Tygerberg Hospital. Adult and paediatric orthopaedic services from Princess Alice Hospital have been relocated to Groote Schuur Hospital since August 1998.

g) Movement of services from central to regional hospitals
There has been a successful shift of resources from the central to the regional hospitals. In 1996/97, 713 posts were shifted. The patient attendance at central and secondary hospitals over the last three years has shown a clear shift: increase at secondary hospitals and decrease at tertiary hospitals. Specific shift of services include delinking of Mowbray Maternity from Groote Schuur Hospital and its placement under the metro region, shift of much of Red Cross Hospital General OPD to Community health Centres and shift of emergency and trauma load to GF Hospital away from Groote Schuur.

However, the central hospitals continue to provide a major component of the provincial tertiary and secondary services.

h) Rationalization of staff:
There has been a large loss of staff from the AAH. Between April 1996 to April 1999 5025 staff have left the AAH. This is equivalent to 34,58% of the total staff establishment of the AAH. The loss of clinical and corporate memory, skills and experience is not quantifiable but would undoubtedly impact on the quality of care and the general functioning of the institution.

i) Future of Academic Function
The AAH provides a teaching platform for Universities, Technikons and other Higher Education Institutions. The recommendations of the Kings Fund Report have been amended and adopted by cabinet i.e. development of goals and an emergent strategy; maintain the two undergraduate schools; increased cooperation at the post graduate level and delink the AAH from individual universities.

Discussions are far advanced to investigate the transfer of professional staff onto the university conditions of service. The provincial Administration would then buy the quantum of services it requires for the AAH from the universities through a cooperative framework and performance contracts. This has been accepted in principle and the implications are being currently investigated.

A new cooperative framework is at an advanced stage of development. This would address the historical inequities in arrangements between universities and PAWC. Future agreements would cover all levels of the service and not be confined to tertiary hospitals only. The management of academic staff would be simplified by having a single employer i.e. universities.

j) Serious Problems encountered in 1998/99
A huge equipment backlog has developed at the AAH. The budget for equipment in 1998/99 was significantly reduced to come within budget. This situation aggravates the frustration of clinicians in providing a good service to patients. The clinical engineering department has been decimated through the loss of staff from VSPs. The has added to the delays in repairing equipment; reduced the capacity of the AAH to do repairs in house and the added costs of outsourcing this function on a regular basis.

As part of the rationalization process, approximately 1600 staff were declared supernumery. Most of the clinical staff have been absorbed at other parts of the service. Currently, 324 staff are still on the supernumery lists and have to be paid. They have not taken the VSP nor were they able to be absorbed into any other part of the health service or administration. The management is unable to do anymore in the absence a negotiated retrenchment tool in the public service. However, this has made it difficult for the AAH and the Department to come within budget and has resulted in the freezing of posts generally within the service because of the high personnel expenditure.

The most expensive cadre of staff i.e. the medical staff have not applied for VSPs in any significant numbers. This has resulted in a bloated medical cadre with serious shortages in nursing and admin staff. This has contributed to the difficulties in reducing personnel expenditure, which accounts for approximately 76% of the total expenditure.

3.2. REGIONAL HOSPITALS
a) Future Strategic Directions
There are six hospitals in the metropolitan region and one in each of the rural regions that provide secondary level care in the province. The academic AAH also provide a large amount of secondary level care in the metro region. In addition, the concept of sub-regional hospitals are being implemented in some eof the rural regions. These are district hospitals providing some components of regional level care e.g. Mossel Bay Hospital in the Southern Cape provides the ENT specialist services for the region. This helps to spread the capacity and skills outside regional hospitals as well as improves accessibility to patients.

The Provincial Health plan states that regional hospitals need to be strengthened. The rural regional hospitals are seen as priorities for capital upgrading. Phase I at George Hospital has been completed.

In the metro region, improving accessibility to regional hospitals on the Cape Flats, where the majority of the population lives has been an important objective. The GF Jooste hospital has been converted to an acute trauma and emergency hospital in the Manenberg area. The hospital is currently being expanded to provide a specialist outpatient department and facilities for training of students. The north Block of Somerset has been vacated with the closure of 57 beds. Plans are far developed to relocate the services from the North Block to the West Block of the Hospital. There is a cabinet resolution supporting the proposal that the funds from the alienation of the north block of Somerset Hospital could be used to build a new 250 bed Phillipi East Hospital. 50% of the funding for this hospital would come from the iSLP (RDP project).

Given the well-developed PHC infrastructure in the Metro region, the focus for development of hospital services has been secondary level care as opposed to district hospital care.

b) Improved management
• A large number of middle management have been sent to management courses viz. the Oliver Tambo Fellowship and the PAWC Senior Management courses.
• The Health Information System (HIS) tender has been signed. The first phase is going to be the academic hospitals and the second phase is going to be a roll out of the programme to regional hospitals. (See Section 6)
• A cost centered accounting system is being developed within regional hospitals to allow better expenditure control and performance management.
• Clinical protocols are being developed to standardize management of common conditions and improve the quality of care. Quarterly meetings between clinicians and the medical superintendents within specific disciplines from both the regional hospitals and the tertiary hospitals take place to better improve and coordinate the delivery of services.

c) Service reprioritization
Regional Hospitals are meant to provide secondary level of care in the basic specialties i.e. medicine, surgery, paediatrics, obstetrics and gynecology, anesthetics, orthopedics and psychiatry. Currently, not all of these specialist services are available at all regional hospitals. However, significant progress has been achieved in getting specialists to work in the rural regional hospitals specifically.

Clear referral routes have been developed for patients from PHC facilities and district hospitals to regional and tertiary hospitals. A communication strategy was operationalised to convey this message to the public.

A normative model has been developed, based originally on the methodology of the Hospital strategy project (HSP), but within affordability limits of the Western Cape Health Department. The model recommended norms on beds/1000 population and staff/beds for each level of hospital care. These norms were adopted on the 6/3/98 by the Department and provided guidelines for the restructuring and reorganization of hospital services on an equitable basis within the province. The model was weighted for ruralness by adding 10% to the populations of the West Coast/Winelands and Boland /Overberg regions and 12% for the Southern Cape/Karoo given the vastness of the latter region.

The model is currently being updated with the new census figures and the average cost per staff. Further work is being conducted to define the extent of inequity between regions and refine the mechanism to address such inequities.

d) Revenue Retention Policy
See previous sections B.1.3 and 3.1.

e) Rationalization of staff
Clinical staff on the supernumery list from the AAH have been largely absorbed within vacant posts at regional and primary care services. However, non-clinical staff have remained on the supernumery list and the resultant personnel expenditure has blocked the filling of more posts at regional and primary care level.

The large losses of staff from the service over the last few years have resulted in gross distortions in the mix of staff categories. The Department has embarked upon an exercise to analyze staff establishments for each of the provincial hospitals by post classes; compare these to standardized normative guidelines weighted for workload; identify the corrections that need to be made within an affordability framework.

f) Serious problems during 1998/99
These would be similar to those stated under section 3.1 (j).

4. TUBERCULOSIS
A report on the achievements, objectives, outputs and outcomes of the TB control program is contained in appendix 8.

5.1. GENERAL
a) Human resource restructuring since 1996/1997:
• The department has downsized by over 8000 personnel since May 1995. This is shown in the table below.

Table 2. Reductions in personnel

• In terms of the Provincial Health Plan a shift of posts from the academic institutions to regional and community service institutions took place during 1996 in order to extend/implement services on the periphery. Fourteen projects were identified for the shift process from academic to secondary/primary level of which the opening of the GF Jooste and the Michael Mapongwana Community Service Centre during the course of 1996 were major projects. The shift process commenced early in 1996 until October 1996 and during this period a total of 713 posts with a monetary value of R36 964 863,30 were abolished at the academic institutions and a total of 617 post were created on primary and secondary level with a monetary value of 36 874 717,40.

• The Provincial Laboratory for Tissue Immunology was closed during 1996 and the functions together with the staff were taken over by Groote Schuur and Tygerberg Hospitals.

• The Department is presently in the process of rationalising the four Nursing Colleges and in place thereof to establish one School of Nursing for the Western Cape.

• During June 1997 a total of 7000 vacant posts were abolished on the establishment of the Department of Health of the Western Cape.

• During 1998 the rationalisation based on the normative model of the academic hospitals, Princess Alice Orthopaedic Hospital and Somerset Hospital took place and a total number of 1076 filled posts across the board of the Associated Academic Hospitals were identified for abolition. The personnel occupying these posts were declared supernumerary and in many cases redeployed in PAWC. Certain of the staff opted to take the voluntary severance packages. The staff were declared supernumerary during September 1998 and at this point in time there are only 328 personnel supernumerary.

• The Lady Michaelis Hospital was closed in March 1998 and the rehabilitation functions were taken over by Conradie Hospital. Some of the staff were redeployed to Conradie Hospital whilst others transferred to other hospitals within the Department.

• The outsourcing of the laundry service of the Central Laundry, Pinelands and the closure thereof. The rationalisation of laundry and linen control services in PAWC which will be finalised during mid-1999.

b) Overview of intended medium-term HR strategy:
Human resources will be linked to the Department’s strategic plan and service delivery improvement plan. Based on the normative model the staff establishment of all hospitals will be determined whereafter an analysis of the human resources required to perform the various functions at each institution will be made. With regard to the foregoing the following human resource planning process will be implemented over the next three years:

• Develop/review of the Department’s human resource management and affirmative action policies/programmes (including those focusing on gender and disability issues)

• Assess human resources in terms of: (i) Numbers (ii) Competencies (iii) Employment capacities

• Assess existing human resources by race, gender and disability as per occupational category, organisational component and grade

• Develop an integrated human resources/affirmative action plan which is linked with MTEF and which contains goals/targets for achieving representativeness and to train personnel.

• Address position of employees affected by elimination of posts no longer required.

• In line with human resource and affirmative action planning, establish when and for what jobs permanent/temporary/full-time/part-time employees are needed.

• Ensure that jobs with health and security requirements are identified in advance and be advertised as such.

5.2 Students and training
Final year medical students (not on staff establishment): 329

Medical Interns: 180

Dental Interns: 0 (Please note that Dental Interns do not exist – Dentists after the completion of their university training are immediately appointed as Dentists - they do not undergo intern training)

Nurses students (student nurses appointed as nursing assistants on establishment): 941

Allied staff Students: Student Medical Technologists 6; Clinical Technologists 6; Intern Clinical Psychologists 21 and Student Radiographers 158; Intern Pharmacists 10

6. INFORMATION SYSTEMS
a) Minimum reporting requirements for hospitals
• Authorised beds
• Actual beds
• Inpatient admissions
• Inpatient days
• Deaths
• Discharges
• Deliveries
• Operations
• Detached outpatient headcounts
• Detached outpatient visits
• Outpatient headcounts
• Outpatient visits
• Emergency cases

Minimum reporting requirements for clinics
• Total attendance
<6 years
=>6 years

• Development assessment
Babies examined for 1st time up to and including 6 weeks
Children <6 who had development assessments done
Children <6 with developmental delay

• Immunisation
Primary Course completed <1 year

• Growth monitoring
<3rd%ile & =>60% EWA
<60% EWA
Growth faltering/failure

• Curative services
Cases seen by Medical Officer
Cases seen by Professional Nurse
Cases seen by PN and referred to MO
Children <6 years
Cases of children <6 with diarrhoea
Cases of children <6 with Acute Chest Infection
Cases of STD (new cases)
Cases Penile Urethral Discharge (new cases)

• Reproductive health
Couple Year Protection Rate
Oral contraceptives dispensed
Depo Provera injections given
Nuristerate injections given
IUCD’s inserted
Sterilisations performed
Vasectomies performed
Condoms issued
Emergency contraception cases
Patients referred for TOP

• Laboratory
Cervical smears 30 – 59 years

• School health
Grade 1 children seen

• Mental health
Visits
New clients seen
Clients referred to 2nd level
Clients referred to 3rd level

• Rehabilitation services
Assistive devices required
Assistive devices issued
Home visits done
Referrals to 2&3 levels

• Maternal health
Antenatal visits
Booking visit
Booking visit <20 weeks
Live births
Still births
Unbooked deliveries
Deliveries <18 years
Live births <2500gms
Women who deliver >34 years
Women who deliver with parity > 4

b) Hospital Performance Indicators
• Authorised beds
• Actual beds
• Bed occupancy rate
• Average length of stay
• Inpatient days
• Inpatient admissions
• Outpatients – attendance’s and head counts
• Emergency attendance’s
• Expenditure
• Admission rates per staff
• Cost per patient day equivalent
• Cost per PDE
• Cost per bed per day
• Posts per bed
• PDE per post
• PDE per day
• Nurses per bed
• Beds per nurse
• Beds per medical officer & registrar
• Beds per specialist
• Inpatient admissions per day
• Inpatient admissions per post
• Hospital income

c) Clinic Performance Indicators
• % Child Attendance
• % children with development delay <6 years
• % children with Primary Course Completed
• % of children seen for curative purposes
• % of Clinical Nurse patients referred to MO
• % of curative patients seen by MO
• Antenatal visits per delivery
• Clinical Nurse Workload
• First contact rate (expected births)
• Incidence of Acute Chest Infection <6 years
• Incidence of diarrhoea cases <6 years
• Incidence of emergency contraception among women of fertile age
• Incidence of males with new PUD
• Incidence of mental illness
• Incidence of new STD cases
• Incidence of referral for TOP among women of fertile age
• Incidence rate of underweight children
• Mental health as % of total attendance
• Proportion of booking visits <20 weeks
• Proportion of deliveries to women >34 years
• Proportion of deliveries to women with parity >4
• Proportion of low birthweight babies
• Proportion of new cases in Mental Health
• Proportion of pregnant women booking
• Proportion of unbooked deliveries
• Rate of growth faltering / failure
• Rate of severely underweight children
• Secondary level referral rates for Mental Health clients
• Still birth rate
• Teenage pregnancy rate
• Tertiary level referral rate for Mental Health clients
• Utilisation Rate

d) Health Status Indicators
• Number of cases and deaths from notifiable medical conditions, per district and province
• TB case findings per age, race and sex per reporting area
• TB treatment outcomes, cure rate, deaths, treatment discontinued, treatment failed per area.
• Immunisation coverage

e) Computer Systems and their Utilisation
Computerised patient registration systems exist in all acute hospitals, excluding provincial aided hospitals. The systems range from comprehensive, integrated systems at the tertiary hospitals, to basic patient registration systems at the district hospitals. The systems are being replaced with a year 2000 compliant system over the next three years.

Computerised systems exist at head office for the managing of information in the following areas:
• Hospital Statistics
• District Health Information System
• Routine Monthly PHC Report
• Perinatal Mortalities
• TOP's
• Immunisations
• TB Case Findings & Treatment Outcomes
• Notifiable Diseases
• Dental Statistics
• Dental Epidemiology
• Nutrition

7. WOMENS HEALTH ISSUES
a) Termination of pregnancy (TOP)
A Strategic Plan for implementation was developed in October 1997.

Designated Facilities
32 State facilities are designated of which 21 provide termination of pregnancy services and 1 NGO and 23 Private facilities.

Awareness Campaign
An extensive awareness campaign has been conducted and is still continuing.

Training
Values Clarification and Counseling Workshops.
During January and February 1997 32 Trainers were trained in value clarification. Since then, numerous health care workers have attended one day values clarification and counseling workshops and these workshops are still continuing.

Technical Training
* A Core Curriculum for the 160 hour short course for the training of midwives in manual vacuum aspiration (MVA) technique of TOP was developed and subsequently approved by the SANC in August 1998.
* The Western Cape TOP Training Business Plan was finalized in July 1998 and circulated.
* The first 4 midwives successfully completed the 2 weeks theoretical part of the MVA Course in November 1998 and have subsequently all completed the 2 week practical and some are already performing TOPs.

Services
Vertical support continues to be provided to the services e.g. in developing operational plans, dealing with problems and providing staff support.

Notification
New TOP / Abortion Notification forms which combine the information from the Gazetted Annexure A form, the GW 8/86 form, consent form and also give additional information (to measure outcomes) were piloted and implemented successfully in June 1998. Reportedly the Minister of Health would like the use of these forms rolled out to the other provinces.

Statistics
During 1998, 5008 TOPs were performed in the province, compared to 3796 TOPs during the 11 month in 1997. Of these 2/3 were done in State facilities.

b) Maternal health services
Goals for 1999 include:
• To initiate a programme of action to identify and address issues that lead to the high incidence of late bookings by pregnant women.
• To sustain and strengthen the newly implemented Maternal Death Notification System. This National initiative was implemented on 01 December 1997 with the aim of reducing maternal deaths nationally by 50% by the year 2000.
• To sustain and strengthen the outreach training programmes; the Continuing Perinatal Education (COPE), the Continuing Active Paediatric Education (CAPE) and the Perinatal Education Programme (PEP). These outreach continuing education programmes are targeted at health workers in the rural regions which are not as well resourced as the Metropole Region. Such programmes help to improve the knowledge and skills of service providers in order to uplift the standard of patient care.
• To facilitate the establishment of a Maternal Health Information System. The MCWH Sub-directorate is working closely with the Health Information Sub-directorate in updating the Perinatal Statistics form which will serve as a much more useful tool in collecting the data from the four regions.

c) Cervical Cancer
During 1998 the Department collaborated with CANSA in:
* doing a situational analysis regarding cervical cancer screening in the Province
* in having an educational drama flighted on SABC TV2.
We are currently collaborating with UCT Community Health Department in doing some research to determine the impact of the Cervical Screening Policy introduced in 1995 as well as the level of awareness.

d) Breast Cancer
The province do not have a breast cancer screening policy, but reproductive health care workers are trained to teach women self breast examination and to consult a doctor or return to the clinic/facility for assessment and referral if any unusual signs are detected.

e) Other reproductive services
Based on the goals and general findings nationally, of a 1994 national assessment and the action agenda resulting from the International Conference on Population and Development (ICPD), Cairo 1994, the Western Cape Family Planning Component decided to review and revise our vision, mission, objectives, etc This was done during two times one week (2 X 5 days) workshops held in November 1994 and February 1995

The outputs of the workshops were:
• The strategic plan 1995 – 2000.
• The quality assurance documents.
• Implementation of the Western Cape Cx Ca Screening Policy
• Changed the Family Planning Clinics into Reproductive Health Clinics. (See attached copy of circular "Revised Approach To Sexual and RPH Services).
• Trained RPH and Primary Health Care Service providers and managers in the Comprehensive and Syndromic Management Approach of STDs and implemented the syndromic management of STDs at the RPH clinics.
• Expanded Sterilization and Vasectomy Services to Community Health Centers in collaboration with AVSSA.
• Developed and introduced a flipchart to facilitate IEC of clients to enable them to make informed choices. The flipchart was officially launched on 11/7/1996 (Population day).
• Emergency Contraception
A Renewed Awareness campaign was conducted and 2 surveys were done to determine clients knowledge about emergency contraception ( 97/98).

Sterilization Act
The foundations are currently being laid for the implementation of the new Sterilization Act, 1998 (Act No. 44 of 1998) which was gazetted in September 1998 for information and became effective 1 February 1999.

A new routine monthly report (RMR) form was implemented in the primary health care services, which will hopefully provide us with an accurate minimum data set to evaluate the RPH Services and will help with future planning.

8. SPECIFIC PROBLEMS AND CONSTRANTS
a) Financial
• Fiscal drag (incomplete funding of cost increases associated with salary increases) on Housing Allowance adjustments, Medical Aid adjustments.
• Average salaries for a health worker have increased from R47000 to R84000 within three years. These increases have been centrally negotiated and not fully funded. These ICS improvements over 3 years have squeezed out other expenditure and have contributed substantially to the downsizing required. It is essential that provinces gain more control over personnel costs.
• Non-funding of Improvement of Conditions of Service of Local Authority staff (Transfer Payments) and Provincially Aided Hospitals (Subsidised Hospitals).
• The above create pressure on strained budgets and often lead to over-expenditure. In the event of the above being increased the increase should be funded by DEPSA.

b) Institutional
The department has now downsized by over 8000 personnel. Financial pressures have made filling posts very difficult, with only the most critical posts in institutions being filled. This has led to substantial staffing pressure, significant stress on personnel and declining quality of care.

The Department has as part of it’s downsizing closed approximately 3500 beds over the past three years. Pressure on beds is at times significant.

For problems in academic hospitals see section 3.1 (j).