NHI Pilot Districts 12 months progress report Presentation to the Portfolio Committee on Health Committee Room 514, Marks Building 24 July 2013

Background August 2011: NHI Green Paper – action plan April 2012: NHI pilot districts to prepare for: – Purchasing of services; – Engaging the private sector; – Introducing a district health authority; April 2013: Rapid appraisal to: – Assess progress in preparing for NHI – Provide a framework for monitoring

NHI domains appraised 1.NHI management 2.Hospitals 3.Quality 4.Primary Health Care re-engineering 5.Infrastructure & Equipment 6.Human Resources 7.Health information 8.District Management Teams 9.Conditional Grant 10.Referral 11.Contracting Private Providers

Key Nearly or completely achieved (where numerical data available >75%) Partially achieved (where numerical data available %) Minimally, or not achieved (where numerical data available <25%) No data available Tabular summary per District

NHI management & coordination Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Full-time NHI Project Managers (NB interim managers in all other districts)

Hospital Reform Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana District hospitals re-designated 6\63\39\97\95\53\3 no data 4\4 0\39\9 Full-time CEOs in post 6\63\32\94\95\51\3 no data 3\4 3\33\9 CEOs orientated at Leadership and Management Academy 0\63\31\22\42\51\162\3 0\3

Quality Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Facility Improvement Team in place OSC overall score for PHC facilities inspected in 2013 (%) 55%57%48%51%70%56%58%62%32%47%72% OSC overall score for hospitals inspected in 2013 (%) 68%50%55%56%73% No data 68%63% No data 86%

PHC facility OSC inspections Baseline and 2013 follow-up scores and differences for each district Eight districts showed a fall in scores (five less than 5%) Two districts showed significant improvements (17% and 8%) District Number of PHC facilities inspected Baseline Score % 2013 follow- up Score % Score difference % Vhembe %32.0%- 21.1% Oliver Tambo %48.1%- 15.8% Dr Kenneth Kaunda %47.2%- 13.0% City of Tshwane %69.8%- 8.5% Amajuba %55.5%- 4.4% Umzinyathi 766.4%62.4%- 4.0% Eden 156.9%54.7%- 2.2% uMgungundlovu %58.4%- 0.2% Thabo Mofutsanyana %72.7%4.6% Pixley ka Seme 648.4%56.8%8.4% Gerte Sibande %51.2%17.2%

PHC Re-engineering Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana District Clinical Specialist Teams: members in post (7 posts) Ward-based Outreach Teams: Required number of teams in place 61%22%6%3%16%28%17%36% 11% School health: Required number of teams in place 100%0%6%28% No data 92%100%32%12%60%29%

Infrastructure Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Facility maintenance plans in place Hospitals: Major refurbishment over past 12 months 6\60\33\92\92\83\3 No data 4\4 No data 2\50\9 PHC facilities: Major refurbishment over past 12 months No data

Equipment Audit in Primary Health Care Facilities Summary of facilities assessed in NHI pilot districts DistrictTotalCompleteRemaining OR Tambo Thabo Mofutsanyana City of Tshwane60 0 Amajuba, Umzinyathi, uMgungundlovu Vhembe Gerte Sibande Dr Kenneth Kaunda27207 Pixley ka Seme29236 Eden Total

Human Resources for Health Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Hospital: Doctors 92%72%60% 58% No data 80%89%69%29%97%63% PHC Facilities: Nurses 95%85%37%58% No data 95%93%95%30%99% No data Requisite no data capturers in post 100% 86% No data 74%96%59%36%83%

Health Management Information Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Time for DHS data to reach province (target 15 days) District officers trained in use of NHIRD Districts with access to NHIRD

National Health Information Repository and Data warehouse (NHIRD) Rollout Process A 2 day workshop in each district The team will comprise of the Planning Unit from the National Department of Health, a software developer and facilitators from HISP The purpose of the visits are to: Ensure that the NHIRD reporting system is available for use to the District Management Team Ensure that the District staff are able to maintain and utilise the NHIRD system so that data is accessible. During the visits the team are proposing to meet with the following : The District Management Team to orientate them on the basic use of the NHIRD reporting system Senior staff from the DHS, planning/information or M&E units as decided by the Province

District Preparation for the Roll-out In preparation for the provincial roll-out of the NHIRD, the following need to be addressed: Each participant should have access to a computer, with internet access and the latest version of Internet Explorer installed, need to be available in the office of the HOD and the NHIRD support office. As these computers will be used to access the national server, the latest version of Google Chrome must be installed and computers must have reliable internet access. The computers should be connected to printers, ideally colour printers so that reports and graphs can be printed from the NHIRD database; The team will need access to these computers during the rollout visits.

Proposed Schedule ProvinceProposed Dates Support Team Northern Cape – Pixley ka Seme12 and 13 August Free State – Thabo Mofutsanyana5 and 6 August KwaZulu-NatalCOMPLETE Western Cape - Eden19 and 20 August Mpumalanga – Gert Sibande15 and 16 August Limpopo - Vhembe22 and 23 August Gauteng - Tshwane10 and 11 September Eastern Cape – OR Tambo27 and 28 August North West – Dr K Kaunda3 and 4 September

District Management Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Annual district health expenditure review completed District NHI project plan in place NHI Conditional grant: % spent up to 30 th March 2013 (inc. commitments) 86%114%95%55%52% 78% 50%77% 88%

Referral systems Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Referral system protocols in place Planned patient transport system in place Emergency transport system in place

GPs in districts on national contract Eden Pixley ka Seme OR Tambo Gert Sibande City of Tshwane Amajuba uMgungundlovu Umzinyathi Vhembe Dr Kenneth Kaunda Thabo Mofutsanyana Facilities identified by District Facilities assessed as being ready for GPs 80%65%2%20%23% No data 76% 15%45%22% As at 31 March 2013

Assessment of PHC Clinics in NHI PILOT DISTRICTS The facility visits focus on infrastructure, personnel, equipment, access to drugs, and other system processes. This information will allow the NDOH to determine which facilities do not meet the minimum requirements and the process to bring them to standard. – In total, there are 764 PHC facilities in the 11 Pilot Districts. 669 PHC Clinics 67 CHCs

Overview of Method of Assessment The Assessments focus on all NHI pilot districts with a combination of quantitative data and qualitative observations, as well as conducting interviews with facility staff. Facilities were assessed in terms of various aspects relating to their functionality and were scored or assessed in terms of the following areas: – Human Resources: – Relative comparison of workload with Professional Nursing staff – Range of Services rendered against the PHC package – Physical Space – Infrastructure conditions such as broken windows, locks on doors, cracks on walls, leaking roofs etc. – Can they physically accommodate a doctor in the existing premises? – Pharmacy services – System and process elements – Essential Equipment

Overview of Approach Human Resources: – What are the current staffing levels by professional grouping? – Do they have access to services of a Medical Officer or General Practitioner on sessional basis? Relative comparison of workload with Professional Nursing staff – Patient Data – Clients seen on average in a day, week, month and over the past 12 months – Range of Services rendered against the PHC package – What services are current offered?

Overview of Approach continued Physical Space – Number of consulting rooms – Storage and filing – Access to utilities such as piped water, sanitation, electricity Infrastructure conditions such as broken windows, locks on doors, cracks on walls, leaking roofs etc. – Major Infrastructure challenges including requiring major repairs, lack of adequate space, can the building be extended or requires a temporary (park home) structure. – Can they physically accommodate a doctor in the existing premises? Pharmacy services – Availability of a pharmacy or dispensary – Availability of medicines trolleys in consulting rooms – Access to qualified pharmacist or pharmacy assistant – Drug stock outs – Issues with routine and continuous supply of medicines

Overview of Approach continued System and process elements – Access to telephones, fax, internet – Data capturers – Filing systems – Patient scheduling – Availability of key communication and information materials – Availability and understanding of SOPs, guidelines and policies Essential Equipment – Availability of essential equipment required for services rendered – Ordering and accessing missing equipment

Overview of Approach continued Each element above is scored on the basis of (i) acceptable, (ii) fair or adequate and (iii) poor condition and categorized as follows: – Staffing – Space – Building Condition – Do they have a pharmacy? – Equipment – If yes to the question above, is there space for the GP? – When can they start contracting a GP?

PROGRESS As of 1 st June 2013, 556 of the facilities in the 10 Pilot Districts have been prioritized. Amajuba will be completed after the 10 pilots

Preliminary Analysis Criteria – Staffing – Space – Building Condition – Equipment – Would you like a GP to come in part-time? – If yes to the question above, is there space for the GP? How many facilities are “READY”? – Of the 556 the facilities were scored as being ready as follows: Only 125 facilities scored YES to all the questions; If you remove staffing, then 164 facilities are classified as ready

SCORING INDICATING CHALLENGES CRITERIAGOODFAIRPOORTOTAL Staffing Space Building Condition Equipment CRITERIAYESNONOT SURETOTAL Would you like a GP to come in part-time? Is there space for the GP?

Next Steps Most facilities do not have a service improvement plan to address areas of weakness arising from the assessments. Support from NHI coordinators and District Managers in order to develop, and implement service improvement plans and thereby meets deadlines important. NDOH has begun to engage the Province on specific feedback sessions and will develop and monitor progress following these initial facility assessments The placement of GPs in facilities should be directly linked to service needs and then informed by the state of facility readiness.

Summary NHI management and coordination in place and DHMTs realigning their priorities NHI Conditional Grants have contributed to progress Quality improvement interventions underway Hospital reform being introduced Referral mechanisms are in place PHC Re-engineering: Three streams (DCSTs, WBOT and School Health) teams not yet complete Health staff is insufficient; WHO WISN norms and standards being used to motivate for increased funding Private providers – districts ready for private GPs to work alongside nurses in primary health care facilities Challenges – these are identified per facility and are being addressed specifically