DEPARTMENT OF HEALTH
BRIEFING TO PORTFOLIO COMMITTEE ON HEALTH, 7 March 2000

CLUSTER: FACILITIES PLANNING AND HOSPITAL SERVICES
There are five directorates in this cluster. They are all very relevant to hospital services, although they also have activities relevant to the rest of the health care system.

The major goals of the cluster for the next five years are to contribute to transforming hospital services and to improving the quality of patient care.

In addition to their responsibilities within their specific directorates, most managers also contribute to one or more Task Teams that address issues relevant to several clusters. Key areas of activity and strategic foci are therefore listed either under the different directorates or under the task teams.

The directorates and their budgets
· HOSPITAL MANAGEMENT = R2,5 m
· + EMS & Disaster Planning = R0,6 m
· FACILITIES PLANNING = R 1,2 m
· H. TECUNOLOGY POLICY = R0,8 m
· H. TECH. MANAGEMENT = R0,1 m
· RADIATION CONTROL = R 5,8 m
· CONDITIONAL GRANTS = R5135 m

Hospital Management
It is this directorate that is responsible for taking forward the ideas generated in the Hospital Strategy Project. Specific responses to the issues raised by the Portfolio Committee are given after the overview of the activities of the cluster as a whole.

The main focus of this directorate is to promote and facilitate decentralization of management authority and responsibility to hospital level. This involves helping to develop appropriate systems as well as building understanding and capacity in hospitals and provincial health departments. At present the team is working with 15 pilot hospitals but the intention is, as capacity increases, to roll out the systems and the approach to all hospitals. The work is supported by funds and several Technical Assistants from the EU and by periodic Technical Assistance from the World Bank and the UK Department of International Development (DFID). The EU funds supplement the funds available from the South African fiscus and are shown as part of the budget, but they only have to be spent by June 30, 2000.

The directorate is also responsible for monitoring the use of the conditional grants for Central Hospital Services and for Health Professional Training and Research. These and other conditional grants are discussed in a separate section at the end of this briefing document.

One major activity of this directorate is to assist provinces and hospitals to develop explicit annual Performance Management Agreements (PMAs). These can be quite simple initially, and will become more complex in succeeding years as capacity at that hospital increases. Each PMA should specify the budget available for that hospital for that year, and give specific targets for types and levels of activity, for quality standards and for minimum levels of information that will be provided. There is strong support for the concept but at present legal advisors are battling to overcome the problem that a province cannot technically sign an agreement with a hospital because they are the same legal entity.

Another major focus is the development of cost centers and cost center accounting at the 15 pilot hospitals. This is being done in close collaboration with the Finance cluster and with the Department of State Expenditure as it rolls out the LOGIS system.

A third focus is the development of simple and appropriate hospital information systems. This is being done in collaboration with the Health Information, Evaluation and Research cluster which is responsible for developing the National Health Information System for South Africa (NHISSA). At present the team is concentrating on developing common definitions as part of a data dictionary, and on collecting a regular, reliable, minimum set of data from every hospital.

A fourth and very large component of the programme is building the capacity of existing managers and management teams in the hospitals, starting with the 15 pilot hospitals. Development workshops, twinning programmes with hospitals in the UK and specific programmes for women managers are all already part of this component, and learning sets for peer review and support are planned for 2000.

A fifth component is the development of Emergency Medical Services (EMS). The aim here is simply to improve the quality and coverage of EMS. Norms and standards are being developed, and appropriate regulations drafted. In addition, work is starting to promote much greater integration of pre- and in-hospital EMS.

Finally under this directorate is the component of Disaster Management. The main activity here is contingency planning. The Deputy Director coordinated contingency planning throughout the health sector for Y2K, and ensured the availability of contingency plans and services for such events as the NAM Summit, the Commonwealth Heads of Government Meeting and the Inauguration of the President. He is currently heading the Department of Health task team set up to coordinate health sector responses to the floods in Northern Province, Mpumalanga and Mozambique.

Facilities Planning
The major focus for this directorate over the next five years will be the Hospital Reconstruction and Rehabilitation (Hospital R & R) programme. This is necessary because of grossly inadequate maintenance of public hospitals over many years, but it is also an opportunity to restructure the entire hospital sector. With proper strategic planning, bold decision making and the money that is needed for any rehabilitation, it is possible for South Africa to develop a network of modern, efficient hospitals appropriate for the 21st century.

Another focus for this directorate is the development of appropriate regulations for private hospitals, and the exploration of better public-private partnerships.

Health Technology Policy
This is a new directorate which is tasked with developing a policy framework and a whole range of specific policies related to the efficient and cost-effective use of health technology. Health Technology policies are now recognized as being vitally important for the rational planning of any health system, but it is a relatively new field even in developed countries and South Africa is one of the first developing countries to give it serious consideration. Specific sub-systems of the overall Health Technology system include.
· Health Technology Assessment
· Health Technology Acquisition
· Health Technology Management
· Health Technology Planning

This directorate has also recently taken over responsibility for the coordination of Highly Specialised Services such as organ transplants, and the Conditional Grant for the Redistribution of Specialized Services.

Health Technology Management
This is another vital area of work. South Africa has at least R6 billion worth of equipment in its public hospitals, and generally procures and manages this equipment very badly. A director was appointed to this post in October 1998 and with the restructuring of the Department in April 1999 this directorate was linked with the directorates of HT Policy and Radiation Control as part of what was envisaged as a Health Technology Unit. Unfortunately, progress in this area has been very slow to date, but Technology Management will have to develop rapidly over the next five years.

Radiation Control
This unit is based in Belville, Cape Town, but also has small inspectorates in
Pretoria and Durban. Their work is concerned with the safety and control of both
the medical and industrial applications of certain technologies.

Their main areas of activity include the control of Electronic products that produce ionising radiation, Radioactive material, Listed non-ionising radiation devices and Listed high and medium risk electromedical devices.

They also ensure compliance with the provisions of the Hazardous Substances Act, liaise with national and international organizations and regulatory authorities, and provide technical assistance, advice and training to industry, professional users, the public and neighbouring states.

Strategic goals for the next five years include maintaining high standards of safety in the fields of radiation and electromedical devices, revising regulations to bring them up to date, helping to develop appropriate legislation to cover all medical devices and finding ways to make the technical staff of this directorate more representative of the South African population.

Task Team on the National Planning Framework
This technical task team is chaired by the cluster manager and besides three directors and two technical assistants from this cluster, includes staff from three other clusters.

Main areas of work to date include re-examining the capital and maintenance funding requirements of the present and currently projected health facility infrastructure, exploring a conceptual framework to integrate the many different elements of current health service planning, and gathering data from both public and private sectors on the volumes and costs of Highly Specialized Services.

A consultancy, funded by the World Bank, to assist in the critical Assessment of the Affordability of Hospital Services in South Africa is also contributing to this work on a National Planning Framework.

The technical task team reports to a sub-committee of the PHRC, chaired by the Director General and including four provincial Heads of Health.

It is envisaged that a draft National Planning Framework for Hospital Services will be ready by July 2000 to be tabled to the Minister and MinMEC for their comment. Once discussed, amended and accepted by MinMEC, it should then be circulated more widely for discussion, and be updated on an annual basis.

Task Team on Certificates of Need
This task team is also chaired by the cluster manager. It includes officials from three other clusters, as well as people from two provinces. Their main task has been to draft regulations that could replace the rather vague concept of "in the public interest" in the current regulations (R158) governing private hospitals At the same time, they have been addressing the issues of defining different types of hospitals or health services, and different types of equipment that may require "Certificates of Need". Contrary to some rumours in the media, the task team has NOT even EXPLORED the possibility of applying a "Certificate of Need" approach to the distribution of individual provate practitioners.

It is envisaged that aspects of this work on Certificates of Need for facilities and for certain specified services and equipment, will be included in a new National Health Bill and its regulations. However, further work will be required over the next few years.

Other Task Teams
Other task teams in which officials from this cluster participate include those on
the Uniform Patient Fee Structure (UPFS), Cost Centres, Organizational
Development, Management Training, District Hospitals, National Electrification
Programme, Academic Health Service Complexes and Public Private Partnerships.

SPECIFIC ISSUES RASISED BY THE PORTFOLIO COMMITTEE

HOSPITAL DEVELOPMENT
The recommendations of the Hospital Strategy Project are being implemented in several hospitals to varying degrees. The National Hospital Co-ordinating Committee which includes senior officials from all provinces and SAMHS, is the forum that monitors progress and provides support when necessary.

The key recommendation of Hospital management decentralisation is being piloted in fifteen pilot hospitals around the country. All ten central hospitals and in those provinces without central hospital, a provincial/tertiary hospitals was identified as pilots. Extensive work was done on:
· Developing appropriate management structures to support decentralisation.
· Identifying core management competencies for the senior management teams
· Developing personal development plans for the existing management teams in each of the pilot sites.
· Training workshops on development of Performance management Agreements.
· Reviewing current systems and implementing news financial and information systems that support improvement financial management and better planning and monitoring.
· Introduction of cost centre accounting systems and LOGIS as a procurement system
· Introduction of a new uniform patient fees schedule and a Patient administration and billing system.
· Workshops for senior women managers in hospitals.
· Introduction of performance management agreements to ensure transparency, better accountability, improved efficiency and increase quality.

A Ministerial Task Team of experts on Decentralisation was set up in April 1999 to advise the minister. This task team reviews progress and makes recommendations when obstacles are encountered with the implementation of aspects of the project. The team will also develop draft policy on hospital reforms. The task team is currently developing a document of revised roles and responsibilities of national and provincial departments with the implementation of full decentralisation.

Giving powers of hospitals CEO’s to management hospitals better is key to the success of the project. Work was done on the levels and types of delegations that will be given to CEO's to enable then to do the job better. Hospitals now and in the future will be headed by general management trained CEO's, supported by the Medical director nursing manager, Human resources, financial and Information manager.

Progress on revenue retention Systems for public hospitals
It is agreed in principle that hospitals will retain all of a part of revenue generated from fees and other sources. At this time only two provinces have agreed to implement the policy of revenue retention. The departments of finance nationally and all provinces support this principle, but we are still to agree on the mechanisms needed to implement this. A system of Trading Accounts is being piloted in Karl Bremmer in Western Cape and Johannesburg Hospital in Gauteng. We are working closely with the National departments of Finance and State Expenditure to ensure that the requirements of the Public Finance Management act is adhered to and the necessary checks and balances are in place.

Current performance of hospitals
Some information on bed occupancy and length of stay, by month, has been collected from every public hospital for 4 years, and has been reviewed periodically by the PHRC. The Department also collates an extensive monthly data set on patient activity in private hospitals. This information has drawn attention to some problems, which have then been addressed, but overall these data sheets have not been particularly useful. There are gaps in the information, some provinces have submitted more information than others, and there are also issues about definitions which may vary between provinces or even between hospitals in the same province.

For this reason, a new hospital form has been developed through a long process of consultation, and is to be introduced in April 2000. There is an agreement that all private, public and military hospitals will return the form on a monthly basis. This will provide the Department with bed capacity, patient throughput and performance information (length of stay and bed occupancy) in a much more detailed and comprehensive manner than is currently available. The form also includes indicators to monitor the quality of maternity and neonatal care. Standard reports will be generated from the data, and made available to the national and provincial departments.

Human resources and financial data are routinely collected as part of operational systems such as PERSAL and FMS. The use of indicators taken from these systems is also being investigated.

CLINIC BUILDING
·
41 new clinics built in 1999/2000
· 32 operational
· 37 others under construction
· 40 clinics major upgrading in 1999
· 26 mobile clinics acquired
· 3170 total of operational clinics. Major need is for upgradings & replacement

For details per province, see attached schedule.

CONDITIONAL GRANTS
1. Central Hospital Services R3,1 bn
The purpose of this grant is to fund services which cannot be provided in all provinces but to which all South Africans should have equitable access.

They are Highly Specialised Services which are usually expensive, and to be cost effective they require teams of people with scarce skills. They also require long term planning and adequate funding. Because they can only be provided in a limited number of hospitals in the country, and must serve patients from all provinces, they should be planned collectively.

When this grant was first introduced, there was very little data that could be used to determine how much money was or should be used for such services, and how it should be distributed. The majority (but not all) of these services are provided at ten central hospitals situated in Gauteng (4), W Cape (3), KwaZulu-Natal (2) and Free State (1). An amount and a distribution was agreed upon, and it was further agreed that the grant should run initially for three years, while further data was collected. This is now the second year of this grant and data is being collected that could influence the size and distribution of the grant in 2001/02 and subsequent years.

The grant goes mostly to the four provinces with central hospitals, with a small amount now going to E Cape in order to open the maximum security section of Fort England Hospital which will take dangerous mentally ill patients from all provinces. There are two main conditions attached to this grant. The first is that plans for how it will be used must be submitted to the DG Health so that they can be shared with other provinces. The second condition is that patients referred to the central hospitals from other provinces must have equitable access to the services and nothing will be charged to the referring province.

Funds from this grant flow smoothly according to an agreed schedule, there will be no over- or under-expenditure by the national Department, and the provinces do comply with the conditions set. However, until good information systems are in place that can capture and analyse data on the province of origin, diagnosis and management of every patient, it will be difficult to monitor exactly who benefits most from this grant. In the meanwhile, data is now being collected on the numbers of patients receiving specific Highly Specialised Services, and the estimated costs.

2. Health Professional Training and Research R1,1 bn
The purpose of this grant is to compensate provinces for the additional service costs associated with training or providing research opportunities for undergraduate and postgraduate health professionals who would then be available to work anywhere in South Africa.

This grant was also introduced using the best available data (which related to undergraduate medical students), with a clear commitment to collecting data on other groups of health professionals in training, and on any extra costs associated with having them in the service.

The grant has been used to assist provinces to implement the nationally agreed policy of shifting undergraduate teaching out of central hospitals and away from tertiary care, into regional and district facilities providing secondary and primary care.

Again funds from this grant flow smoothly according to an agreed schedule, there will be no over- or under-expenditure by the national Department, and the provinces comply with the conditions set. Again however, much more information is needed in order to be able to monitor accurately the cost effectiveness of this grant.

3. Redistribution of Specialised Services R176 m
This grant is the mirror image of the grant for Central Hospital Services and goes to the five provinces that do not have central hospitals. It is being used to build up specialised services in one or two hospitals in each of these provinces and so to reduce the numbers of patients that need to be referred out of the province.
Particularly good progress in this regard has been made at Witbank, Pietersburg-Mankweng and Kimberley Hospitals.

4. Hospital Reconstruction & Rehabilitation (Hospital R & R) R400 m
The purpose of this grant is to try and ensure that South Africa develops a network of modern public sector hospitals that is appropriate and affordable for the 21st century This will involve some major decisions on the numbers of hospital beds of different types that are needed, and are affordable, in South Africa in the next 20 years. These decisions will be guided by the affordability assessment and the national planning framework that are currently being developed.

Because it is a capital works programme involving many projects in all nine provinces, and because any project may be subject to unforeseen delays of a month or more, it is difficult to come in exactly on budget at the end of one particular month. In 1998/99 a total of 87% of the R100 million available for that financial year was spent by 31 March, and the rest was fully committed. In the current financial year, about the same percentage of the R213 million available will have been spent by 31 March 2000, and the rest will be committed. For the year 2000/01 projects worth more than R400 million have already been approved.

5. Inkosi Albert Luthuli Academic Central Hospital (Durban) R273 m
Construction of this hospital is going ahead rapidly, several members of the
Commissioning Team have been in place for at least six months, and a Chief
Executive Officer has recently been appointed. The first patients are expected
to be admitted early in 2001.

It is worth noting that although the project is well managed and major construction companies are involved, nevertheless there has been some slippage and about R80 million of the R200 million available in 1999/2000 will have to be rolled over into 2000/01.

6. Nelson Mandela Academic Regional Hospital (Umtata) R Nil
Construction on this hospital is also now going ahead well, after some significant delays in 1998/99. Most of the R100 million budgeted by the national Department for that year will be spent this financial year, and the remainder plus the R63 million originally budgeted for this year will be spent in 2000/01. The total approved budget is now R367 million, to which the national Department is contributing R163 million. The reason for the 50.50 split between the national and provincial contributions to the original budget of this project is that this will be the main teaching hospital for the UNITRA Medical School, but it will serve patients almost exclusively from the Eastern Cape.

 

Eastern Cape

Free State

Gauteng

KwaZulu Natal

Mapumalanga

Northern Cape

Northern Province

North West

Western Cape

Total

Number of clinics completed in 1999/2000

7

6

4

4

3

0

12

1

4

41

Of the above, how many of the clinics were operational

6

6

3

3

3

0

6

1

4

32

Total number of clinics operational

724

212

333

365

221

96

506

373

340

3170

Number of clinics upgraded in 1999

0

3

3

17

0

0

12

0

5

40

Number of mobile vehicles purchased and converted from other vehicles in 1998/9

21

0

0

3

0

0

?

?

2

26

Number of clinics under construction

13

4

3

3

2

0

8

2

2

37