.1(d) 1999/2000 (-7,2% deviation)

The anticipated deficit for the 1999/2000 financial year is R30m. The deficits are currently being funded from savings in other departments as well as provincial debt and are a result of over-expenditure in two programs viz. District Health Services and Provincial Secondary Hospital Services.

• The budget for the provision of AIDS/HIV is part of the integrated services provided at district level.
• Management and co-ordination is done at provincial level.
• In addition to the Provincial allocation, funds were made available by both National and the Provincial Executive Council for the 1998/99 and 1999/2000 financial years
• Accessing funds from National for specific programs will further strengthen the Provincial budget for AIDS for the 2000/01 financial year.

 Table 2: HIV/AIDS Allocations

• NGO's involved in AIDS/HIV programmes are funded by the National Department of Health. Therefore no allocations are made from the provincial budget.

Funding for the capital development plan will emanate from the Hospital Rehabilitation and Reconstruction Grant and the Works budget. A further allocation of R16,458m has been made available as a conditional grant for the Redistribution of tertiary services.

The Department welcomes the reforms that have taken place with regard to the budget process. There is however room for capacity building in performance based budgeting in order to make an entire shift away from historical based budgeting.

Despite the constraints faced by the Department, national objectives were generally achieved.

Revenue generated from hospital fees amounts to R6,6m and constitutes 1,7% of the total health budget. Declining trends in revenue generation does not justify retention in revenue at this stage. Discussions with the Provincial Treasury have commenced, but no formal proposals have been tabled yet. This can only be done once an upward trend in revenue generation is established. Several strategies have been embarked upon to enhance the revenue generating capacity of the Province such as:

• The implementation of the HIS;
• The implementation of the Uniform Patient Fee Schedule for private patients;
• Strict control measures for debt recovery;
• Public-private partnerships have successfully been implemented in 2 District Hospitals.

The anticipated deficit for the 1999/2000 financial year amounts to R30m(7,6%deficit)

• As raised previously to the Committee, the issue of cross-boundary flows for primary health care services as well as hospital services continues to add pressure on the resources of the Province. The matter has still not been resolved between the Northern Cape and North-West provinces (R10m).
• The restructuring of the District Health system has resulted in the provincialisation of PHC and Emergency Medical Services. However, S20 of the health Act stipulates that local government is obliged to make a contribution toward health services. Currently, most local authorities in the Province are not in a position to meet this obligation. The Department is currently bearing the full cost of the provision of health services.
• Patient trends for Kimberley hospital continue to show a decline in in-patient days as a result of shorter length of stay. However, casualty cases have shown an 8% increase compared to the same period last year. This significantly contributes to increased expenditure patterns.
• Personnel expenditure for the 1999/2000 financial year showed a 22% increase compared to the previous financial year. This has largely resulted from the provincialisation of services where staff are now on the provincial establishment. A corresponding decrease is reflected in the amount expended on transfer payments. However, personnel budgets are being constrained by "wage-drift. Whilst personnel numbers are not growing, the increase in the wage bill continues to have a negative impact on other recurrent expenditure.
• The conditional grant allocated for NITER for the 1999/2000 financial year has resulted in the baseline of the Department being significantly reduced. As a result the program could not be fully implemented.
• The amount for security services was centrally negotiated on behalf of the Department. Payments were subsequently decentralised to the Department with no corresponding budgets (R10m).

Various strategies have been implemented toward rendering a more effective, efficient and integrated health service, which will bring about efficiency gains in the system without impacting negatively on the level of service currently being rendered. These include:

• The process of provincialising emergency medical services, provincial aided hospitals as well as some PHC services is complete.
• The district surgeon system has been restructured in its entirety. Doctors are now appointed on a sessional basis.
• The process of layering services rendered at the only Secondary facility in the Province and the development of a policy for referral pathways within the province, enabling more efficient use of facilities as well as reduced referrals to Kimberley Hospital is on-going.
• The tender for the outsourcing of the procurement, warehousing and distribution of pharmaceutical services has been awarded. The lead times have been reduced from a 6-week period to less than a week from date of requisition. The maintenance of just-in-time stock will significantly contribute toward the appropriate management of working capital.
• The Hospital Information System is currently being implemented in the Province at 6 nodal sites. Four sites have already gone live, whilst the rest will be implemented within the next 2 months. This would complete the first phase. Investigations for the second phase have already commenced and should be fully implemented by the end of October 2000. The improved billing systems will significantly contribute toward improving revenue generation.

 
Other important events or goals not identified above

• In June sixty delegates from the province will be given an opportunity to attend an international conference in Durban. This conference will give government officials and community members the exposure to engage in global debates on HIV/AIDS.
• A youth coordinator has been employed to focus on behavior modification strategies. This decision is based on the conclusion's in the latest antenatal survey, which clearly indicate an upward trend amongst the age group 19 – 29 years
• The next financial year has been earmarked for the formation of a Provincial AIDS council.
• We will increase the establishments of workplace clinics aimed at STD/HIV/AIDS management amongst the labour force.
• Approximately 132 testing sites has been identified within the province, these are mostly clinics
• We recognize the need for expansion of testing sites, therefore this financial year we will focus on establishing non-medical testing sites and augment the current number of counselors throughout the province. This process will be sustained by a provincial-counseling forum chaired by a psychologist.
• Two multi-purpose centres, one in Kimberley and De Aar will be operationalized to ensure that our province respond to the needs of persons infected and affected. This includes services for children.
• In addition there is a continuous flow of HIV/AIDS/STD promotional articles in the province. We will ensure that this effort is sustained through implementing an effective communication strategy.

• Social mobilization
• Prevention
• Counseling and testing
• Care for the infected and affected including children
• Women and youth programmes
• Surveillance and research

1. Primary Care Services

1. District Health System

1. District Management Structure.

Districts have established management teams consisting of :

• District Health Managers
• Administration Support
• Hospital Managers
• Clinic Co-ordinators
• Emergency Care Practitioners
• Pharmacist

1. Process for achieving equity in the allocation of primary health care services.

• Budget allocations are done on per capita basis but taking into account geographic distribution of people, case mix etc. 59% of the budget allocated to districts.
• The use of the nationally developed norms and standards for the implementation of PHC will ensure equity.

1. Relationship with local government structures

• Local government representatives sit on all health structures.
• The new process of establishing provincial and district health authorities will also ensure full participation.

d) new fixed clinics since 1995/1996

1. Future Strategic Direction

A strategic plan for hospital services is being prepared in the form of a working and informative document. The first draft is expected at the end March 2000 and final draft for authorization by June 2000. Presently no such document exists.

2. Improved Management

• In September 1995 the management structure for Kimberley Hospital was changed from the traditional Medical Superintendent, Chief Matron and Hospital Secretary, to the appointment of a CEO and accompanying support structure and Clinical Director.
• This structure created the enabling environment for the implementation of decentralized management and flattening the structure.
• The organogram for the co-ordination of the delivery of hospital services needs to be formalized for all hospitals in the province.
• Gordonia Hospital has started the process of procuring a CEO.
• The implementation of the new Hospital Information Service (HIS) will have a direct effect on patient registration, uniform patient fee structure and make available relevant patient information modules which will be decided by key stakeholders.

1. Service Reprioritization

• In the NCP Kimberley Hospital has been identified and accredited for the development of Tertiary Care provision. Currently, KH is classified as a level 2 facility with no level 1 facility in close vicinity leading to inappropriate bed occupancy in Kimberley Hospital.
• In addition, Gordonia Hospital in Upington has been identified for the development of limited Secondary Care in order to facilitate referrals from the western half of the province.

1. Retention of Revenue Policy

See B1.3.c

2. Rationalization of Staff

• A rationalized service delivery plan for hospital services is being prepared in the form of a working and informative document. The first draft expected at the end March 2000 and final draft for authorization by June 2000.
• Future rationalization will be based on the content of this document. Once this plan has been approved on provincial as well as on national level the staff in hospitals will be rationalized accordingly.

1. Serious Problems encountered during 1999/2000

• The relationship between the allocation of conditional grants and the baseline provided by Provincial Treasury for the Health budget.
• The AIDS related illnesses which is starting to have a serious impact on the ALS in hospitals, and this is not yet reported accordingly in order to measure and do adequate projections
• Logistical – Overnight stay of patients from the periphery is still causing inappropriate bed occupancy and ALS reporting.
• The development of PMA between the hospital facilities and the Provincial Head Office
• Available resources within the top management of hospitals as well as overall co-ordination
• The high incidence of TB (highest in the Country) and the cost of MDR

Implementation authorized thus far:

• Cure rates of new positive patients were 27% in 1997 and increased to 74% of 1999.
• Bacteriological coverage increased from 71% in 1997 to 99% in 1999.
• Persons receiving directly observed treatment increase from 90% - 92%
• A number of events have been organized to raise awareness of community members regarding TB
• Farmers have been bought on board and a structured well functioning TB programme is in place on the farms in Lower Orange.

This unit plans to rapidly expand the strategy applied in the Lower Orange district to other districts.

Outcome indicators for Kalahari district between 1998 and 1999 were:

- Cure rates of new patients treated were 57% in 1998 and increase to 69%

- Interruption rates were 19% and decrease to 11%.

- Bacteriological coverage was 91% now 99%. This addresses the constraints of over diagnosis experienced in the region.

Central to our efforts to reduce the Tuberculosis incidence rate are those individuals that develop multi drug resistant tuberculosis due to various reasons.

- Two multi-drug resistance TB management referral facilities with specialized management teams have been established. One, at West End Hospital in Kimberley and the other at Gordonia Hospital in Upington. - Currently 118 persons with multi-drug resistance TB have hospitalized and treated at a cost of R25 000 per person compared to R250 if treated effectively and correctly for TB. Therefore stronger measures will be put in place to treat Tuberculosis more effectively at health centres and clinics

1. Human Resources

1. General

• By 2003/4 the department is to be representative of the people it services namely:

- Asians 0.27%

- Africans 33.6%

- Coloured 52.5%

- White 13.5%

• 50% of posts in the middle and senior management level should be occupied by women. White women are viewed as a disadvantaged group.
• Recruitment is to be guided by the following preferences:

- 1^st: personnel presently serving the government departments within the Province

- 2^nd applicants outside the Public Service but within the province

- 3^rd applicants outside the Province

1. Students and Trainees

Monthly reports are expected to reach the provincial office via the district health manager’s office

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

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

1. clinic performance indicators

attendance

< 5 yrs

5 to 59 years

60+ yrs

maternal and reproductive health

child health

curative services

obstetric care

protein energy malnutrition (PEM) scheme

sexually transmitted diseases

medication

no prescriptions

no items dispensed

laboratory services

no patients seen by a doctor

no referrals to next level of care

d) health status indicators

infant and child mortality and morbidity

maternal mortality

incidence of oral diseases

quality of life of older persons

nutritional status of population

incidence of diseases of lifestyle

incidence of environmental health related risks

rate of intentional and unintentional injuries

among youth and adolescents

incidence of injury on duty

incidence of occupation related mortality, morbidity and disability

incidence of sexually transmitted disease including HIV/AIDS

incidence of mental illness

2. e) computer systems and their utilization

The HIS became functional in Kimberley Hospital in December 1999. Patient registration, admission and patient billing system module . System will go live in the following hospitals at indicated periods:

• Upington – mid march 2000 (has gone live)
• Calvinia and Springbok – mid April 2000
• Kuruman and De Aar – mid May 2000

To improve and enhance the revenue generation aspect of the hospital.

To provide effective management and decision support information.

To improve the administration of health care in the hospital.

To provide readily available clinical data (e.g. Hospital/Clinical performance indicators) to the health care professionals to facilitate the effective patient care and treatment.

To provide effective patient management.

To relieve professional staff of tedious clerical functions.

All patient information must be transferable between hospitals. This will enable the collection of bills at various points in the province.

The system must incorporate standards based (Electronic Data Interchange) EDI to allow for connections to systems viz. Medical Aid Schemes, Road Accident Fund (RAF), Workmen Compensation Act and allow for the future connections to other systems.

With the objective to establish a DHIS, partly electronic, partly paper based, in the districts as well as in the provincial office, availing timely, up to date and relevant health service information, necessary for efficient and effective district and provincial management the province has commenced with the implementation of the DHIS in cooperation with EQUITY and ISDS.

The collation, analyses, interpretation and use of data should start at facility level. The information made available through this system should adequately provide in the needs of facility district and programme managers.

Telemedicine is the practice of medical care using interactive audio, visual and data communications; this includes medical care delivery, consultation, diagnosis and treatment, as well as education and the transfer of medical data.

The vision of the department for the utilisation of telemedicine is as per the above definition.

The Telemedicine initiative has been implemented (not fully functional yet) at Kuruman and Kimberley Hospitals, with Kuruman Hospital being the send site and Kimberley Hospital being the receive site. Kimberley Hospital will thereafter be directly linked to a National Research Centre.

The project will be for TeleUltrasound antenatal Screening.

Telemedicine is also envisaged to:

Strengthen the referral system between Community Health Centers, Regional Hospitals and Central Hospitals, for effective delivery of Primary Health Care.

The development of local expertise and skills transfer to the peripheral site.

Epi/Info is utilised for the following functions;

• Compiling questionnaires for surveys.
• Capturing of epidemiology data based on the questionnaire that had been created.
• Analyse data.
• Currently the computer system is used for Anonymous AIDS, Tuberculosis, Notification of notifiable disease and Immunisation.

Word processing.

Data capturing.

Spreadsheets.

Accounting.

Presentation.

It is the departments strategy to provide every employee that has a computer with a network connection and therefore e-mail as well as.reporting requirements for hospitals and clinics.

Hospital performance indicators.

Clinic performance indicators.

Health status indicators.

Computer systems and their utilisation.

1. WOMENS HEALTH ISSUES.

A Provincial Maternal Deaths workshop planned for the next financial year having as one of its objectives the establishment of provincial and district committee on Confidential Enquiry into Maternal Deaths.

• TOP services have been provided in Kimberley and Gordonia Hospitals. The 3^rd site at Posmasburg hospital is envisaged to open in June 2000.
• Two sites have been identified (one in the Diamondfields and one in the Lower Orange districts) to introduce the Quality Improvement programme (QIP) comprising of facilitative supervision, whole site training, client oriented provider efficient (COPE) assessment techniques in the Province in collaboration with the Reproductive Health Research Unit. QIP is envisaged to commence April 2000.
• Capacity building programs are ongoing and continue to ensure that an effective referral process is in place.
• Trained mid-wives are in place at all centres to provide pre and post abortion family planning counselling.
• The following impact on attitudes to terminations:
• lack of awareness in deep rural areas re: rights and basic knowledge of the concept of TOP.
• Impact of cultural and religious attitudes.
• Labeling is a barrier.
• Internal conflicts
• The vast distance in the Province negatively contribute to the accesability of the service. More sites are recommended, but lack of resources is a definite constraint.
• A Quality Assurance Committee has been established which is aimed at determining standard guidelines and strategies for all health providers and institutions. The Batho Pele principles are applicable.

• Cervical screening is done for females over the age of 30 (once every 10 years). The lack of capacity has deterred the Province from intensifying this program.

1. SPECIFIC PROBLEM AREAS AND CONSTRAINTS.

The demands and challenges facing the Department are listed as follows:

• Budget decreasing in real terms
• Medical inflation
• Personnel related issues
• Wage Drift
• Basic Conditions of Employment
• Skills Development Act
• Trauma
• HIV/AIDS
• Tuberculosis
• Cross Boundary

1. .Control,management and administration.

Management echelon is extremely small only 52% of posts filled due to financial constraints and the need to direct more funds to PHC

Management training has been carried out intensively within the management echelon's. This training has been funded through donor funding

2. .Institutional.

hospitals are in need of upgrading as is the equipment - this process is being addressed but takes time