NHI Spending Progress Report Standing Committee on Appropriations 22 February 2013

NHI Grant Framework Overview R 150 million for 2012/13 financial year –Each pilot district allocated R11.5 million –Each of the 7 selected central hospitals received R5 million Focus: –To provide strategic resources for supporting the pilot districts in implementing selected health service delivery interventions –To undertake health system strengthening initiatives in identified districts –To test innovations that are necessary for the implementation of NHI –Strengthen revenue collection and revenue management systems at selected Central Hospitals 2

NHI Allocation per Province, 2012/13 ProvinceBudgetAllocation% Eastern Cape 11,500,0008% Free State 16,500,00011% Gauteng 31,500,00021% KwaZulu Natal 33,000,00022% Limpopo 11,500,0008% Mpumalanga 11,500,0008% Northern Cape 11,500,0008% North West 11,500,0008% Western Cape 11,500,0008% TOTAL 150,000,000100% 3

Provide Strategic Resources for Supporting the Pilot Districts Provided unemployed graduates to hospitals for revenue collection Mobilised support from the World Bank Technical assistance from DfID and EU Financial support from EU Sent Health Facility Improvement Teams from National to NHI pilots Appointment of Provincial NHI Coordinators 4

Undertake Health System Strengthening 1.Health service delivery – PHC re-engineering 2.Health workforce – determining the staffing norms and needs using the WISN tool 3.Health information – first phase roll-out of the business intelligence system i.e. NHIRD 4.Medical products, vaccines and technologies – pilot sites purchased equipment for PHC facilities; introduction of non-negotiables framework 5.Health system financing – costing work on a service package based on services rendered in NHI pilot districts 6.Leadership and governance – district managers from 8 NHI pilot districts on leadership in health, health policy transformation, and health policy reform 5

Test Innovations that are necessary for the implementation of NHI Different contracting models for GPs specifically for PHC services – Introduce active purchasing of services Roll out of the PHC streams, specifically the community specialists approach Mobile Units for School Health 6

School Health Services 7

Strengthen Revenue Management Systems at selected Central Hospitals Joint project with World Bank in Gauteng – Appointment of interns Purchase of equipment i.e. Computers, servers Improved systems of revenue collection Improvement of patient filing systems in 3 central hospitals Improved claim processes to medical schemes Positive impact on actual revenue collection 8

NHI Grant Framework Outputs Improved management of district health offices and facilities within selected pilot districts Strengthening the districts health system and establishment of a functional district health authority (DHA) model that integrates health service provision and management functions and institutional and administrative implications for such arrangements is developed for scaling up Enhancement of managerial autonomy, delegation of functions and accountability in districts and health facilities implemented for selected pilot districts 9

NHI Grant Framework Outputs Innovative models for contracting private providers that include innovative arrangements for harnessing private sector resources a primary health care level A rational referral system based on a re-engineered primary health care platform with a particular focus in rural and previously disadvantaged areas of the selected pilot districts Revenue collection and management model for the 7 selected central hospitals 10

NHI EXPENDITURE YTD (JANUARY 2013) ProvinceBudgetExpenditureFunds Available Eastern Cape 11,500,0001,241,000 10,259,000 Free State 16,500,0005,692,000 10,808,000 Gauteng 31,500,0004,370,000 27,130,000 KwaZulu Natal 33,000,0001,174,000 31,826,000 Limpopo 11,500,000491,000 11,009,000 Mpumalanga 11,500,0002,320,000 9,180,000 Northern Cape 11,500,000509,000 10,991,000 North West 11,500,0001,662,000 9,838,000 Western Cape 11,500,0003,441,000 8,059,000 TOTAL 150,000,00020,900, ,100,000 11

NHI Committed funds by Province per District (January 2012/13) 12 ProvincesBudgetExpenditure Commitments for the district Variances Total including commitments % Eastern Cape Free State ( ) Gauteng ( ) KwaZulu Natal ( ) Limpopo Mpumalanga (27 000) Northern Cape ( ) North West Western Cape ( ) Total ( )

NHI Commitments in FS: Thabo MofutsanyanaCategoryCommitment Amount Spent Variance Explanation Strengthening the District Referral Systems including linkages to PHC streams R800,000R316,178 Delays in appointment of suppliers; lack of appropriately skilled service provider Supply Chain Management interventions e.g. Training, employment of temporal staff; etc R1,440,000R633,000 Delays in appointment of Chief User Clerks Integrated procurement of basic equipment at health facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R5,086,110R1,260,250 Delays in issuing orders; Delays in delivery of ordered equipment Maintenance of identified PHC facilities focusing mainly on infection control R526,196R316,118 District will achieve 100% spend – no variance anticipated at end of year Strengthening of the District Health Management Teams through procurement of computer and related equipment for improved performance of health districts R600,000None Yet Delays in delivery of ordered equipment Capacity building for managers & PHC supervisors on HR, Finance and SCM R831,500R470,126 Delays in service providers submitted invoices for work done Total Spend To-date R9,283,806R2,995,672 13

NHI Commitments in GP: TshwaneCategoryCommitment Amount Spent Variance Explanation Innovative models for contracting private practitioners that include arrangements for harnessing private sector resources at the primary health care level (Three months GP contracts for 12 GPs) R960,000 R272, No variance is anticipated – district will spend all the allocated money by end of the year Strengthening the PHC teams (Three months contracts for 49 CHW for ward based outreach teams) R332,661 Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R10,075,770 R37, District encountered challenges in placing and processing orders; suppliers not willing to deliver due to non- payment on previous invoices; Total Spend To-date R11,368,431 R310,

NHI Commitments in KZN: Umzinyathi CategoryCommitment Amount Spent Variance Explanation Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R7,885,964- The processes for obtaining approvals are tedious; district faces huge delays in getting requests processed through SCM; limited delegations that hinder activities to be undertaken; delays in submission of invoices by suppliers (especially for training) Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R309,820 - Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R638,380- Strengthening District patient referral information systems R398,980- Capacity building for managers & PHC supervisors on HR, Finance and SCM R1,133,428- Total Spend To-date R10,366,

NHI Commitments in KZN: UmgungundlovuCategoryCommitment Amount Spent Variance Explanation Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R6,143,354 None (awaiting SCM processes at Provincial Office) Delays in getting requests processed through SCM Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R635,000- Equipment and furniture have been ordered, awaiting delivery and capturing Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R555,000- Delays in getting requests processed through SCM Strengthening District patient referral information systems R460,000- Delays in appointing suitable service provider Testing models for contracting GPs at the primary health care level R2,000,000R932,000No variance is anticipated – district will spend all the allocated money by end of the year Total Spend To-date R9,793,354R932,000 16

NHI Commitments in LP: Vhembe CategoryCommitment Amount Spent Variance Explanation Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R1,811,396R301,596 Orders have been generated and the district awaits delivery of the items. Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R 9,030,604 R158,404 Orders have been generated and the district awaits delivery of the items. Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R658,000R31,000 District is struggling to attract the correct calibre of staff to take up PHC posts Total Spend To-date R11,500,000R491,000 17

NHI Commitments in MP: Gert Sibande CategoryCommitment Amount Spent Variance Explanation Enhanced managerial autonomy, delegation of functions and accountability in districts and health facilities including improved Supply Chain Management capacity to support development of frameworks R2,700,000R1,684,240 Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R2,152,000Nil It is expected that there will be no variance on this item. Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R4,385,300 Nil The district has placed orders and is awaiting delivery of the equipment; delays in delivery from suppliers Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R2,262,700R877,342 No variance is anticipated Total Spend To-date R11,473,000 R11,473,000 R2,561,582 R2,561,582 18

NHI Commitments in NC: Pixley Ka SemeCategoryCommitment Amount Spent Reasons for Variance Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R10,064,657.54None The district is awaiting the receipt of equipment and processing of payments, prior to the payment of invoices Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R509,000 None Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R246,217 None Total Spend To-date R10,819,874R755,217 19

NHI Commitments in NW: Dr K KaundaCategoryCommitment Amount Spent Reasons for variance Strengthening the PHC streams through provision of furniture and clinical equipment for the school health teams, Family health teams and District Clinical Specialist Teams R480,000R230,100 Difficulty to attract the correct calibre of staff, and specifically GPs Strengthening of the District Health Management Team through procurement of computer and related equipment for improved performance of health districts R2,582,927R1,300,599 Orders have been placed and the districts awaits delivery and invoicing prior to payment Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R6,740,706None Awaiting deliveries and capturing on BAS Capacity building for managers & PHC supervisors on HR, Finance and SCM R1,696,367 Training will be done in full by PALAMA and invoice will be provided in March Total Spend To-date R9,838,000R1,662,000 20

NHI Commitments in WC: Eden (1)Project Committed to date Spent to date Explanation of Variance Development of an appropriate model for strengthening the District Health System R Contractor has been appointed and the work must be completed. Work is being fast- tracked Work is underway and payment will be done when the work is completed Service providers have been appointed and payment done when the work is completed Work is underway and the Revision of contract managementR R4 796 Situational analysis of the patient referral system at George Hospital R Primary Health Care patient folder management review and improvement R Community Health Worker training: Chronic Disease Management R Develop an Eye-Care model for the Eden District R Policy review and development of Home and Community Based Care (HCBC &ID) R R

NHI Commitments in WC: Eden (2) ProjectSpent to dateCommitted to date Explanation for Variance Review and improvement of consumables management R R Service providers have been appointed and the work is being done. Payment will be done when the work is completed satisfactorily. Appointment of Project Co-ordinator – DHMT strengthening R R Appointment of Project Administrator – DHMT strengthening R89 000R Purchasing of Medical Equipment R R School Health Programme R R Purchasing of computer and related equipment (support health information systems) R Audit and appraisal of private health care providers 0R Testing models for contracting by appointment of GPs at PHC facilities on sessional basis R R No variance anticipated. TOTAL R R

NHI Commitments in EC: OR TamboCategoryCommitment Amount Spent Explanation for Variance Strengthening of PHC streams (School health teams, ward- based community workers, etc) R3,700,000R1,241,000 Shortage of key HR in essential categories, particularly GPs in specified sub-districts; Supply chain hurdles; Delays in getting approvals Strengthening of the District Health Management Teams through procurement of computer and related equipment for improved performance of health districts R1,300,000 Procurement of basic equipment at PHC facilities, such as charts to conduct basic eye tests; Blood Pressure Monitoring machines; and Scales. R6,500,000 Total Spend To-date R11,500,000R1,241,000 23

Intervention Plan: NHC resolution Business plans for the financial year 2012/13 for the NHI-CG amended to, inter alia, provide for the following output / outcome areas: 1. Procurement of basic equipment at health facilities, such as: a)Charts to conduct basic eye tests; b)Blood Pressure Monitoring machines; c)Scales; 2. Strengthening the School Health Programme; 3. Procurement of computer equipment for health Districts; Furthermore, the NHC noted the presentation on the NHI Grant outputs and agreed that although a number of the interventions will take a period of up to five (5) years to implement, the outputs should be revised to ensure that they take into account all the aspects of Primary Health Care Teams and how these will be integrated into the NHI service delivery platform 24

Intervention Plan: NHC resolution Contractual employment of General Practitioners to do session duties at public health facilities should be commenced with immediately and NHI conditional grant funding should be used to defray the costs related to sessional duties performed by GPs Project managers to control and manage the NHI Conditional Grant should be appointed for each District as a matter of extreme urgency 25

Future Plan for the NHI Grant Create a National Health Grant – Perennial under-expenditure and underperformance by provinces – Gives NDOH stronger and more direct control – Develop and implement systems to overcome numerous challenges encountered by pilot sites – Integrates Infrastructure and NHI activities High-level engagements to revise DORB to adjust the purpose, focus activities and funding allocations to Provinces – Impact on programme of work to be undertaken solely at pilot site level; – Influences ultimate allocations across sites i.e. resource reprioritisation – Flexibility to reallocate between grants and between Provinces 26