1. BRIEFING TO SELECT COMMITTEE ON APPROPRIATIONS Expenditure on National Health Insurance Grant and NHI Pilot sites 2014 /2015
9 JUNE 2015

2. Outline
Focus areas for the National Health Insurance Conditional Grant (NHI-CG) in 2014/15
GP Contracting
Expenditure on Schedule 5 and Schedule 6 CG 2014/15 FY
Expenditure and activities (Donor funding and Global Fund)
2014 / 2015 NHI Rapid Appraisal

3. NHI Pilot Districts

4. GP Contracting
The following two slides show the number of GPs by NHI Pilot District as well as NHI pilot district doctor coverage.
Three options were being tested:
Direct contracting through NDOH
Service Provider
Western Cape option

5. Total Number of Contracted GPs (working as at 31 March 2015)No
Province
District
No of signed contracts
No of GPs working 1
Western Cape
Eden 17 15 2
Mpumalanga
Gert Sibande 36 35 3
North West
Dr Kenneth Kaunda 23 4
Eastern Cape
OR Tambo 5
Northern Cape
Pixley ka Seme 11 10 6
Free State
Thabo Mofutsanyana 24 7
KwaZulu-Natal
uMgungundlovu 41 32 8
uMzinyathi 14 12 9
Limpopo
Vhembe 26
Gauteng
Tshwane 94 80
TOTALS
287
256

6. GP PHC facility coverage - March 2015 versus March 2014
No of Clinics
Clinics with doctor service 2014
% coverage 2014
Clinics with doctor service 2015
% coverage 2015
Pixley Ka Seme 38 26
68.42% 31
81.58%
Vhembe
115 68
59.13% 71
61.74%
Gert Sibande 42
73.81% 39
92.86%
Kenneth Kaunda 32
76.19% 35
83.33%
OR Tambo
143
0.00%
Umzinyathi 34 14
41.18% 17
50.00%
Umgungundlovu 59 40
67.80% 47
79.66%
Tshwane 89
42.70% 51
57.30%
Thabo Mofutsanyana 67 28
41.79%
50.75%
Eden 58
81.03% 57
98.28%

7. Composition PHC Facility Doctor Coverage - March 2015
Districts
Type of Contract/ Employment
National Contracted GPs
Doctors on Full time employment
Doctors doing Outreach from Hospitals
Provincially contracted doctors
NGO doctors
Total
Pixley Ka Seme
22.73%
27.27%
4.55%
45.45%
0.00%
100.00%
Vhembe
28.57%
1.79%
32.14%
37.50%
Gert Sibande
55.81%
9.30%
6.98%
4.65%
23.26%
Kenneth Kaunda
30.00%
42.50%
7.50%
11.43%
OR Tambo
Umzinyathi
75.00%
25.00%
Umgungundlovu
46.51%
11.63%
18.60%
Tshwane
84.29%
15.71%
Thabo Mofutsanyana
79.07%
20.93%
Eden
32.08%
47.17%
3.77%
9.43%
7.55%

8. GP/Doctor Contracting
The introduction of an independent service provider to recruit and place GPs in facilities has increased the number of GPs contracted.
The contract only came into effect in November 2014,
Prior to the introduction of the independent service provider, just over 150 doctors were recruited during the 21 months of the project.
Since November 2014, a further 150 doctors have been recruited increasing the number of doctors to 256.
The service provider has a further 300 doctors in the recruitment pipeline however this is contingent on funding
During 2015/16 the intention is to supply a minimum of 180,000 hours to clinics in 9 pilot districts.

9. District by District Placement

10. Placement limited to 156 FTE (Due to the budget cut for FY 15/16 only 156 Full Time Equivalent (FTE) doctors could be contracted)
Original target was to recruit 450 FTE’s
i.e. 50 doctors/district for the 9 participating NHI districts.
(Eden district elected not to participate)

11. Western Cape approach
The Western Cape DOH is excluded as they are implementing a different framework.
The WCDOH is using a principle of deploying existing medical officers employed by the WCDOH to clinics in the Eden district, and using the grant funding, they are employing doctors on sessional basis in hospitals to cover the gap left by the medical officers deployed to clinics.
According to the WCDOH, this has proved to be highly effective strategy as attracting private GPs to hospitals is easier than to clinics.
The team is assessing the impact of this model against the NDOH and the service provider model.

12. NHI-CG Schedule 6 Focus Area GP Contracting
GPs were slow in signing up for the GP contracting initiative because of concerns that the state of our health facilities will hamper their quality of work
Their concerns about the state of our PHC facilities are being addressed through the Ideal Clinic programme and while the working environment in many of our clinics is still being attended to, the GPs who have signed on have reported that they have been pleasantly surprised by the good working conditions in some of clinics. As result many have since increased the working hours they spend working in public health facilities
Contracting numbers improved with the appointment of an external service provider

13. NHI-CG Schedule 6 Focus Area GP Contracting
This feedback is gathered through interactions with the GPs during orientation sessions and during support visits to the health facilities where they are providing services
This positive trend has also been demonstrated by the constantly increasing number of GPs who have signed on
At the end of March 2014 we had 119 GPs working to complement permanent staff in public health facilities. This number increased to 256 at the end of March 2015
The number of GPs on contract now will expend 100% of the budget for 2015/16

14. National Health Insurance Grant 2014/15 (Schedule 5)
4/22/2017
National Health Insurance Grant 2014/15 (Schedule 5)

15. National Health Insurance Grant 2014/15 (Schedule 6)
4/22/2017
Grant Name
Adjusted Budget
2014/15
Expenditure
Budget Available
% Spent of Budget
R'000 % 
NHI-Indirect Grant
82 261
21%

16. Project Deliverables in NHI Pilot Districts using donor funds during 2014-15

17. NHI Green Paper Phase 1: Focus Areas
NHI White Paper and Legislative Process
Management reforms and designation of Hospitals
Establishment Office of Health Standard Compliance
Public Health facility audit, Quality Improvement and Certification
Building capacity to manage NHI Through the strengthening of District Management
Costing Model
Establishment of NHI Fund
Accreditation and contracting of private providers by NHI Fund

18. NHI Green Paper Phase 1: Focus Areas
Hospital Reimbursement reform
Appointment of District Clinical Specialists Support
Municipal Ward-based Primary Health Care Outreach Teams
School -Based PHC services
Public Hospital Infrastructure and Equipment
Human resources for health
Information management and systems support
NHI Conditional Grant to support piloting of initial work in 10 Districts
Population Registration
ICT
Accreditation and contracting of private providers by NHI Fund

19. Hospital Reimbursement reform

20. Hospital Reimbursement reform
Fist phase for developing and testing of a Diagnosis Related Grouper (DRG) as an alternative reimbursement tool for hospitals was completed
This involved developing a base DRG tool for the 10 central hospitals across the country.
As at March 2015, the Department had managed to extract clinical and financial data from central hospitals.
The data has been categorised into 25 Major Diseases as part of the preliminary technical work to develop and apply a disease algorithm.
Technical work on case mix and actuarial analyses has been undertaken on the data that has been aggregated and a triangulation process has been undertaken with regards to data from other third party sources.

21. Hospital Reimbursement reform
A group of 10 professional nurses with extensive clinical (diagnostic and procedural) coding experience were employed to collect the data.
The coding team was deployed to 8 of the 10 central hospitals in South Africa.
The team was supported onsite by a team supervisor, project management assistant and project management team.
The clinical data collection tool was developed, tested and approved for use.
From 17 June 2014 until 6 March 2015, a total of more than files were coded (final total in verification process). This exceeded the target of files expected.
All data is maintained in the secured database

22. Appointment of District Clinical Specialists Support

23. National DCST Recruitment Status
Province
Ad Midwife
Anaesthetist
Family Physician
Obstetrician
Paediatric Nurse
Paediatrician
PHC Nurse
Total EC 8 5 1 6 3 7 30
Free State 2  1 23
Gauteng 4 29
KZN 11 47
Limpopo 24 MP 13 NW 20 NC WC 14 46 37 41 22
446
220
Source: National DCST Database: 31 March 2015

24. Municipal Ward-based Primary Health Care Outreach Teams

25. WBPHOT in NHI Pilot Districts
WBOT Required based on 1:1500 households
Number of WBOT registered March 2014
Number of WBOT registered January 2015
Amajuba DM 74 10
Dr K Kaunda DM
139 49 93
G Sibande DM
182 9 64
Oliver Tambo DM
199
223
Pixley ka Seme DM 33 41 44
T Mofutsanyane DM
145 29 68
Tshwane MM
608 19
155
uMgungundlovu DM 17
Umzinyathi DM 76 20 22
Vhembe DM
229 54
Eden
109 -
Grand Total
1976
434
752

26. CHWs trained in Cellphone Technology to Improve Reporting
DISTRICT
Teams trained
No of CHWs
uMgungundlovu 4 63
Thabo Mofutsanyana 30
178
Dr Kenneth Kaunda 18
158
Gert Sibande 12 99
Cacadu 16 81
Total 80
579

27. WBOT being trained on the mHealth:
 Those teams reporting to DHIS have received basic orientation to use of cell phones
Scheduled training on the full mHealth manual

28. School -Based PHC services

29. School Health Services
To improve access to school health services additional School Health Mobile Vehicles were purchased and distributed in the NHI Pilot Districts
27 Mobile PHC Trucks
17 Oral Health Mobiles
3 Eye Care Mobiles

30. Appointment of school-based teams led by a nurse
PROVINCE
NO. OF TEAMS
Eastern Cape 65
Free State 20
Gauteng 62
KwaZulu-Natal
147
Limpopo 47
Mpumalanga 32
Northern Cape 3
North West 25
Western Cape 43
Total
444

31. PHC Facility Renovations

32. PHC Facility - Renovations

33. PHC Facility - Renovations

34. Photo’s of Dr Consulting Rooms Boiketlo Clinic (FS)

35. Photo’s of Dr Consulting Rooms Delekile Khoza clinic (NW)

36. Human resources for health

37. Information management and systems support
Patient Administration Rationalisation of Registers Assesment of PHC Patient Information systems

38. PHC Facilities Patient Administration

39. Rationalisation of Registers

40. Background
The Health Systems Trust (HST) has been commissioned to coordinate and manage the national roll-out of the rationalised set of registers in all PHC facilities and provide technical support to provinces during this process.
Reducing the 56 Registers used in PHC facilities to 6 Registers
The set of rationalised registers that was implemented is as follows:
PHC comprehensive daily tick register + reception daily headcount register
TIER.net: ART for all HIV positive patients (including TB, Pregnant women, HIV+e babies)
TB registers (case identification and treatment registers)
Theatre register ( for facilities performing MMC and TOPs)
Delivery register
Midnight census for PHC facilities providing inpatient services

43. Registers: Delivery status
Provinces
Total number of registers delivered to facilities
Total number of surplus registers to districts
Grand Total
Eastern Cape
8302
11480
19782
Free State
2442
7560
10002
Limpopo
4862
5100
9962
North West
3561
6840
10401
Northern Cape
2069
1440
3509
KZN and GP
(see next slide)
Total
21 236
32 420
53 656

44. New set of Registers

45. Findings: positive perceptions
Waiting time reduced.
Reporting on fewer elements and workload is less
Uniformity of data collection tools leading to less administration and more better recording
More time spent with patients
Removal of duplications
Easy to collet correct data elements as layout on one page
Better reporting

46. Health Patient Registration

47. Primary Health Care Patient Information System
In preparation of the development of an automated patient based information system the HNSF work was extended to include the assessment of patient-centric primary healthcare (PHC) systems currently in use in the country, inlcuding systems used in the private sector and aimed at primary healthcare. Open Expression of Interest yielded 37 responses;
23 systems were shortlisted based on eligibility criteria;
1 Vendor retracted their submission;
Rigorous evaluation process including:
Definition of PHC system requirements;
Collection of detailed information from system vendors;
Representations from each system vendor;
Site visits where each of the systems were deployed;

48. Primary Health Care Patient Information System
This assessment culminated in recommendations on the most appropriate PHC Patient based information system to be deployed in PHC facilities
The outcome of this assessment is Automated PHC Patient Information systems - implemented in the NHI pilot districts
( 700 facilities) and be linked to the second phase of the scale up (1400 facilities)

49. Health Patient Registration System (HPRS)
Secure central database on a web based platform available to public health facilities to capture and verify beneficiary identification via bar coded identity documents and biometric methods. It also records patient visits to facilities.
Patient registry – a critical component to implement electronic health records nationally.
Planning tool because beneficiaries are linked to facilities based on the their demographic details.
Currently implemented at PHC facilities in NHI Pilot Districts.
Auto-generates a unique Health Patient Registration Number (HPRN) and assigns to registered and successfully verified beneficiary.
HPRN is an internal system number that could be able to uniquely identify health beneficiaries for all other patients (including Foreign nationals).
South African National ID Number remains the primary identification for South African citizens.

50. KZN Beta Implementation September 2014
Focus on Patient Registration
Reception Desk Support
Integrated Team Approach
RIPDA
Daily Data Capture Onsite Training
HPRS Certification of Competency

51. Imported from registers
Number of Patients Registered in 50 Beta Sites in the NHI Pilot Districts
As at 31 May 2015
Province
Captured at Beta Sites
Imported from registers
Total
OR Tambo District
27 355
6 856
34 211
Tabo Mofutsenyane
47 348
4 191
51 539
Tshwane
29 002
18 182
47 184
Umzinyati and Umgundlovu
28 067
Vhembe
44 335
7 731
52 066
Gert Sibande
1 014
12 085
13 099
Pixley ka Seme
4 008
1 805
5 813
Dr K Kaunda
37 590
2 133
39 723
Grand Total
81 050

52. Health Patient Registration
Nancefield
Morara
Masisi
Health Patient Registration
The Patients Unique Identified are being used to register the Patient at the Health Facility and to do verification at follow-up visits
The system allow for tracking patients between different facilities
The Map Demonstrates the testing of this by the implementation team using the Green ID book of one of the Team members
First Registration at Masisi
And the person could be picked up at Morara and Nancefield clinics in Vhembe
And Tebang, Marakang, Harrismith and Hobhouse in Thabo Mofutsenyane
Tebang
Marakang
Harrismith
Hob House

53. Health Provider Registry
Software development completed
Infrastructure hardware established
Next step is to develop an implementation plan in consultation with health professional organisations

54. Accreditation and contracting of private providers

56. GP PHC facility coverage - March 2015 versus March 2014
No of Clinics
Clinics with doctor service 2014
% coverage 2014
Clinics with doctor service 2015
% coverage 2015
Pixley Ka Seme 38 26
68.42% 31
81.58%
Vhembe
115 68
59.13% 71
61.74%
Gert Sibande 42
73.81% 39
92.86%
Kenneth Kaunda 32
76.19% 35
83.33%
OR Tambo
143
0.00%
Umzinyathi 34 14
41.18% 17
50.00%
Umgungundlovu 59 40
67.80% 47
79.66%
Tshwane 89
42.70% 51
57.30%
Thabo Mofutsanyana 67 28
41.79%
50.75%
Eden 58
81.03% 57
98.28%

57. Central Chronic Medicines Dispensing and Distribution Program

58. Central Chronic Medicines Dispensing and Distribution Program
CCMDD aims to decongest public healthcare facilities and improve access to chronic medicines in South Africa.
The program contracts the dispensing and distribution of repeat prescriptions for stable chronic patients to private sector service providers.
The program of two program components, Central Chronic Medicines Dispensing and Distribution (CCMDD) and Pick-up Points (PuPs).
The first relates to individual patients’ medicines being centrally dispensed and distributed to the point of service delivery.
The second relates to the provision of pre-dispensed medicines at private sector pharmacies, or ‘Pick-Up-Points’ (PUP), that is conveniently located for patients.
CCMDD is currently being rolled out in 10 districts, as well as in 2 hospitals that are not in the NHI districts.
Combined both models have in excess of 380,000 patients; with current enrolments in the private distribution model half at around 190,000.

59. Project Specific Expenditure 2014-15

60. Project Specific Expenditure 2014-15
Source
School Health Service Mobiles EU
District Clinical Specialist teams
PHC Ward Base Outreach Teams
Ideal Clinic – Operation Pakhiso
Health Information support including expansion of the NHIRD
Assessment of PHC Information Systems
Patient Administration –Rationalisation of Registers
Health Patient Registration
NHI Project Management
Support for Human Resource, Financial and Health Information Management
Broadband Connectivity for 50 PHC Facilities
Global Fund
Central Chronic Medicines Dispensing and Distribution Program

61. NHI Pilot Sites Appraisal