Kwadukuza
2007/2008 Year review Focus area PHC: Increase Access (measure total Head Counts Strategies to increase head count were: • Down referral hospital chronic medication • Down referral hospital pts on ARV medication • Quality, friendly facilities, better staffing • Opening on Saturday and Sunday (KDC, Groutville, Kearsney?) • Extending hours of services: KDC, Ballito • Wellness clinic (all HIV considered as ‘chronics’ and pink card system • Doctor support for clinics: at least twice a week to daily (KDC, Groutville, Ballito, Shakaskraal) Overview of Population Major Categories
Population Population Main Break Down for 2007 / 8 Main Break Down for 2008 / 9 1 year 3,720 1 year 3,728 < 1 yr 3,914 < 1 yr 3,904 < 5 yr 18,499 < 5 yr 18,505 male 15 yr older 67,840 male 15 yr older 69,210 female 15 yr older 60,700 female 15 yr older 61,475 15yr older 128,540 15yr older 130,685 female 15 - 49 51,276 female 15 - 49 52,468 female 30 - 49 21,808 female 30 - 49 22,069 female 30 - 59 27,855 female 30 - 59 28,145 female 30 older 33,994 female 30 older 34,365 female 15 --44 8,423 female 15 --44 44,971 Total sub district 179,063 Total sub district 180,963
Utilization Target of 3.5 per HC (total HC) Kwadukuza Sub District Means: 3.5 x 180,963 = 633,370 visits For 2008 / 9, we will be close and could make it! Overview of Total Head Counts
Kwadukuza Sub District: Total PHC Head Count Total : 534,159 58,000 Strike June 52,233 52,628 53,000 50,886 50,342 Loss 26,000 HC 48,698 48,000 45,156 45,892 45,873 43,398 43,000 39,849 40,687 38,000
33,000
28,000
23,000 18,517 18,000 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Head Count Overview (2)
< 5 years: 90,331 Kwadukuza Head Count 2007 / 2008 > 5 years: 443,828 155,203 180,000 136,921 140,271 160,000 140,000 101,764 25,318 17% 18%23,813 16% 120,000 24,001 100,000 17,199 17% 80,000 129,885 60,000 112,920 116,458 40,000 84,565 20,000 0 Q1 Q2 Q3 Q4
PHC headcount 5 years and older PHC headcount under 5 years Focus area PHC: Increase Access (measure utilization rate)
Kwadukuza Utilization Rate 2007 / 8
Target < 5 Yrs: 5 6.0 5.5 5.2 5.1 Target : Overall 3.5 5.0 3.7 4.0 3.5 3.1 3.2 2.8 3.1 2.9 3.0 2.1 2.3 2.0
1.0
- Q1 Q2 Q3 Q4
Utilisation rate < 5 years 3.7 5.2 5.1 5.5 Utilisation rate > 5 years 2.1 2.8 2.9 3.2 Utilisation rate overall 2.3 3.1 3.1 3.5 A historical overview + projections (stretched)
Reminder: we lost 26,000 Head Counts in Kwadukuza Sub District: Total Head Count 07 /08 a as result of June Strike. So, we should have 700,000 We could make 630,000 Total Head Count in 2008 / 9! booked 560,000 HC. We conservative projected 600,000 but now already above 630,000 52,000 per month! Projects on the go: 600,000 •ART roll out 534,129 •ART down referral •HIV wellness clinic 500,000 474,744 •Increased MO visits •Opening on Sundays 404,805 •Extended Hours 400,000 360,081 •More Mobile Points •Health Allied outreach 300,000 227,724
200,000 Yr 2003/4 Yr 2004/5 Yr 2005/6 Yr 2006/7 Yr 2007/8 Yr 2008/9
Total PHC Head Count 227,724 360,081 404,805 474,744 534,129 630,000 Perc. change per annum 58.1% 12.4% 17.3% 12.5% 17.9%
Kwadukuza Clinic opened Total PHC Head Count Perc. change per annum Overview per clinic: Ballito
kz Ballito Clinic
16,000 Projections: 60,000 (2008 / 9)? 14,838
14,000 11,884 11,923 12,000
10,000
8,000 6,785
6,000
4,000
2,000
0 Q1 Q2 Q3 Q4
Total Head Count: 45,430 Overview per clinic: Darnall
kz Darnall Clinic
9,000 Projections: 30,000 (2008 / 9)? 7,646 8,000 7,197 7,000 6,029 6,000
5,000 4,352 4,000 3,000 2,000
1,000 0 Q1 Q2 Q3 Q4
Total Head Count: 25,224 Overview per clinic: Glenhills
kz Glenhills Satellite Clinic
12,000 Projections: 36,000 (2008 / 9)?
9,745 10,000
8,000 7,077 6,545 5,849 6,000
4,000
2,000
0 Q1 Q2 Q3 Q4
Total Head Count: 29,216 Overview per clinic: Groutville
kz Groutville Clinic
30,000 Projections: 100,000 (2008 / 9)?
23,976 25,000 21,216 20,288 20,000 18,479
15,000
10,000
5,000
0 Q1 Q2 Q3 Q4
Total Head Count: 83,959 Overview per clinic: Kearsney
kz Kearsney Clinic
9,000 Projections: 32,000 (2008 / 9)? 8,469 8,000 6,679 7,000 5,749 6,000 5,000 4,047 4,000 3,000
2,000 1,000 0 Q1 Q2 Q3 Q4
Total Head Count: 24,944 Overview per clinic: Kwadukuza
kz Kw aDukuza Clinic
60,000 53,202 53,255 52,194 50,000
38,358 40,000 Projections: 200,000 (2008 / 9)? 30,000
20,000
10,000
0 Q1 Q2 Q3 Q4
Total Head Count: 197,009 Overview per clinic: Mpumelelo
kz Mpumelelo Clinic
8,000 7,039 7,226 7,000 6,406
6,000 5,615
5,000
4,000 Projections: 30,000 (2008 / 9)?
3,000
2,000
1,000
0 Q1 Q2 Q3 Q4
Total Head Count: 26,286 Overview per clinic: Nandi
kz Nandi Satellite Clinic
8,000 Projections: 30,000 (2008 / 9)? 7,133 7,000 6,421 5,944 6,000 5,362 5,000
4,000
3,000
2,000
1,000
0 Q1 Q2 Q3 Q4
Total Head Count: 24,860 Overview per clinic: Shakaskraal
kz Shakaskraal Clinic
18,000 Projections: 72,000 (2008 / 9)? 16,006 16,000 13,453 14,000
12,000 10,670 10,000 9,035 8,000 6,000 4,000
2,000 0 Q1 Q2 Q3 Q4
Total Head Count: 49,164 Overview per clinic: Gateway Stanger Hospital
kz Stanger Hospital
2,500 Projections: 8,0002,326 (2008 / 9)?2,351
1,981 2,000
1,500
1,000 679
500
0 Q1 Q2 Q3 Q4
Total Head Count: 7,337 Overview per clinic: Mobile 1
kz Stanger Mobile 1
3,000 2,775 2,646 2,630
2,500
2,000 Projections: 16,000 (2008 / 9)? 1,500 1,317
1,000
500
0 Q1 Q2 Q3 Q4
Total Head Count: 9,368 Overview per clinic: Mobile 2
kz Stanger Mobile 2
4,000 Projections: 16,000 (2008 / 9)? 3,359 3,500 3,065 3,052 3,000
2,500 1,886 2,000
1,500
1,000
500
0 Q1 Q2 Q3 Q4
Total Head Count: 11,362 New Financial Year: 2008 / 9 • The trend is upwards and we project > 600,000 per annum (range 600,000 – 630,000) • ALL clinic will be open on Sunday, besides Saturday • Extend hours for Shakaskraal, KDC (earlier and maybe later) • More Friendly service offering on Saturday to decongest the week • Better Doctor coverage for clinics not receiving daily support from doctors: Glenhills, Nandi as priority with daily doctor visits; Mpumelelo, Kearsney, Darnall 3 times a week • Increased Outreach Services Health Allied and Professional staff • ALL clinics to have pharmacy assistant and nutrition advisor! • More Professional Nurses (OSD assisting?) • Clinics to prepare for EMS transfer of D/V patient to clinics during opening time (strengthening resuscitation) Mobile Health Services 2008 / 9 • Both mobiles to increase total head count to above 16,000 per annum • Monday to Saturday Services • More frequent visits to busy points, 3 times a week and 2 times a week less busy service points • Increase in mobile points (where?) • Additional Resources required (vehicle, staff) • Tracing units to be established (dedicated), but also to work on tracing activities from clinics in new financial year Work Load Prof. Nurse
Kwadukuza Prof Nurse Work load 2007 / 2008
70
60
50
40
30 61 55 54 50 20
10
0 Q1 Q2 Q3 Q4
Actions: recruitment to be intensified! Critical gaps to be resolved. Prof Nurse Workload per Quarter
Facility Q1 Q2 Q3 Q4 Year kz Ballito Clinic 37 55 62 61 54 kz Darnall Clinic 38 33 56 62 47 kz Glenhills Satellite C 49 43 40 48 45 kz Groutville Clinic 63 81 42 55 60 kz Kearsney Clinic 81 244 42 52 105 kz KwaDukuza Clinic 50 61 57 54 55 kz Mpumelelo Clinic 95 132 42 46 79 kz Nandi Satellite Cli n 55 39 34 45 43 kz Shakaskraal Clini c 50 44 72 76 61 kz Stanger Hospital #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! kz Stanger Mobile 1 #DIV/0! 100 41 42 46 kz Stanger Mobile 2 #DIV/0! 118 31 54 51 1) Shakaskraal highest 2) Data Kearsney and Mobile to be corrected 3) Kwadukuza downward trend Doctor Consultations
PHC patient seen by doctor at clinic and % total head count
12,000 11,125 14.4% 7.4% 10,000 12.1% 8,0006,559 6,208 5.6% 5,945 6.2% 6,000 2.4% 5.5% 6.0% 4.8% 4,000 1,819 1,379 1,578 617 1,204 2,000
0 c ic ic ini in n c c Cl ini ini ito Clinic l Clinic lle linic ll i a Cl C a rnal tv ney Cli o Cl a u lel llite D ro ars kuz aal Clinic kz B e me te r kz G u a k kz kz K waDu Mp di S z akas kz K k h kz Glenhills Satellite Cl kz Nan kz S
* Referral rate to doctor: 2.9 per annum * Workload 33 pts: Quarter 4 and 26 per annum. Target > 35 per day Chronic Diseases: Hypertension, DM, asthma, epilepsy, mental
Kwadukuza Chronic Disease 2007 / 8 + prevalence above 15 years
15,000 12,172 11,111 11,403 Increase result 10,000 8,604 of down referral 8.9% 9.5% Hospital + new 5,000 6.7% 8.6% cases 0 Q1 Q2 Q3 Q4
Total Chronic Disease per 8,604 11,111 11,403 12,172 Month prevalence > 15 years (all 6.7% 8.6% 8.9% 9.5% chronics) Burden of Disease …
Prevalence of Diabetes (> 15 years) 2.3% Prevalence of Hypertension (> 15 years) 6.0% Prevalance of Asthma(> 15 years) 0.70% Prevalence of Epilepsy (> 15 years) 0.37% Prevalance of Mental Health (> 15 years) 0.38%
Chronic Non Comunicable Disease Hypertension 8,029 Total HIV /Aids on Treatment Diabetes 3,013 (ART) : 5,104 Asthma 1,058 Wellness Clinic: HIV positive Epilepsy 559 on pink card Mental Health 582 to follow! Total 13,241
Still a lot of work outstanding to update registers and to reduce the defaulter rate from 10% to a more acceptable rate of 5% Chronic Disease: growth
Kwadukuza Yr 2007/8 Newly Diagnosed Hypertension and DM BP: 852 p.a 300 DM: 246 p.a 256 250 229 187 200 180
150 78 100 60 63 45 50
0 Q1 Q2 Q3 Q4
New ly Diagnosed Hypertension New ly Diagnosed DM
Hypertension: 12% and Diabetes : 8% Chronic Disease: issues 1. The defaulter rate seems to come down to 10% 2. Pharmacy got data 3. New targets to be set e.g. < 5% for 2008 / 9 4. Registers for Chronic Diseases updated on time? 5. Outreach services for Chronic Diseases? • The plans: CHW activated? • List of needs in catchment area available? • Data Element to be added? 6. Basic Equipment for services at facilities (DM, hyper- tension, asthma, epilepsy, mental health? 7. Booklets to be given to individual patients to assist (ME) 8. Chronic Review at clinics 9. Referral guidelines hospital and to obtain date and time appointment at MOPD (doctor to doctor referral) 10. Emergency to casualty (to notify casualty) Diarrhoea and Pneumonia < 5 years
Kwadukuza Diarrhoea and Pneumonia < 5 years : incidence per 1000
288 375 How do 400 237 245 348
we do? 300 270 232 116 C – IMCI? 200 100
0 Q1 Q2 Q3 Q4
Diarrhoea incidence per 232 270 375 348 1000 < 5 years Pneumonia incidence per 116 237 245 288 1000 < 5 years
Action was: to offer VCT to all with Diarrhoea and Pneumonia Monitor and Evaluate: % new HIV and / or with HIV Not Gaining Weight < 5 years Kwadukuza Not Gaining weight % < 5 years
10.0% 9.3%
8.0% 6.3% 6.0%
3.5% 4.0% 2.6% 2.0%
0.0% Q1 Q2 Q3 Q4
Not gaining w eight under 5 2.6% 3.5% 6.3% 9.3% years perc.
Result of better ME? Or a real increase? How many are HIV positive? Severe Malnutrition rate Kwadukuza Severe Malnutrition rate (per 1000) < 5 years
20.0 15.4 15.0 12.1
10.0 5.0 5.0 3.7
0.0 Q1 Q2 Q3 Q4
Severe malnutrition under 5 15.4 3.7 5.0 12.1 years - new ambulatory p 1000 < 5
Any interpretation possible? Vitamin A coverage 6 –11 mths
Kwadukuza Vitam A 6-11 months coverage
140% 133% 116% 120% 105% 100% 87%
80%
60%
40%
20%
0% Q1 Q2 Q3 Q4
Vit A coverage 6-11 months 87% 105% 116% 133%
Result of better recording? Food Supplements – underweight children < 5 years
Kwadukuza Food Supplements to underweight children
700 591 600 500 377 400 360 300 200 128 100 0 Q1 Q2 Q3 Q4
Food supplements to 128 377 360 591 underw eight children under 5 years Food Supplements
Kwadukuza Food Supplements underweight child < 5 years and above 5 years
4,680 5,000 4,038 4,000
3,000 2,126 2,247 2,000 591 1,000 128 377 360 0 Q1 Q2 Q3 Q4
Food supplements to 128 377 360 591 underw eight children under 5 years Food supplements to clients 2,126 2,247 4,038 4,680 5 yrs and older
ME: HIV/Aids, TB, Chronic Condition, etc. Æ done? BCG coverage < 1 year
Kwadukuza BCG dose < 1 year and coverage
Child < 1 year: 2,000 3,904 1,600 1,605 1,622 1,407 1,500
1,000 164% 164% 144% 166% Total: 6,234 500
0 Q1 Q2 Q3 Q4
total BCG dose under 1 year 1,600 1,605 1,407 1,622
BCG coverage under 1 year 164% 164% 144% 166% Estimate deliveries outside of sub district
Kwadukuza Difference between BCG (mainly given at hospital (delivery)) and 1st immunization at 6 weeks at clinics.
700 Total per annum: 590 1,285 600 Thus about 500 4,949 in Kwadukuza 400 314 Sub District (babies) 300 ÆPopulation estimates 201 180 to low … 200 3,904 not accurate .. 100 0
Q1 Q2 Q3 Q4
Difference betw een BCG 590 201 180 314 and OPV 1st dose Drop Out rate DTP-Hib
Kwadukuza Drop Out Rate DTP-Hib (1st and 3rd)
16% 14% 14% 12%
10% 8% 8% 8% 8% 6% 4% 2% 0% Q1 Q2 Q3 Q4
drop out rate DTP-Hib 14% 8% 8% 8%
Target was below 10; Strike June result in 14% Fully Immunized
Kwadukuza Fully Immunized < 1 year
140.0% 123.6% 120.0% 104.9% 102.6% 100.0% 80.0% 73.2% 60.0% 40.0% 20.0% 0.0% Q1 Q2 Q3 Q4
percentage fully immunized 73.2% 104.9% 102.6% 123.6% < 1 year
As expected above 100% (overall 101%) due to higher population < 1 year in our sub district Antenatal
Kwadukuza Antenatal Visits < 20 weeks Trend is downwards: Target 40%
1,600 1,494 Dual 1,400 1,183 Therapy 1,200 1,040 Assist? 1,000 800 640 467 600427 443 409 Average 400 visit: 2.7 200 Q1 Q2 Q3 Q4 0 Antenatal 1st visit before 20 427 443 409 467 weeks Antenatal 1st visit 20 w eeks 640 1,183 1,040 1,494 or later Percentage < 20 w eeks 40% 27% 28% 24% Antenatal tested +ve for Syphilis
Kwadukuza Antenatal Positive for syphilis - new
200 180 176 160
140 120 100 80 60 44 41 39 40 20 Q10 Q2 Q3 Q4 Antenatal client tested 44 176 41 39 positive for syphilis - new Antenatal HIV accepting rate
Kwadukuza Antenatal HIV accepting rate
110% 108%
105% 101%
100% 96% Overall: 99% 95% 90% 90%
85%
80% Q1 Q2 Q3 Q4
Antenatal HIV accepting rate 101% 108% 90% 96%
Why a decline? Antenatal HIV prevalence
Kwadukuza Antenatal tested HIV positive and percentage
800 594 567 600 399 447 400
200
0 Q1 Q2 Q3 Q4
Antenatal client tested HIV 399 594 447 567 positive - new Percentage pregn w omen 36.9% 33.9% 34.1% 30.0% HIV pos
A decline in prevalence? Hospital data higher, but trend is something to monitor closely! Antenatal – NVP dose
Kwadukuza Antenatal Nevirapine dose
600 407 400 304 289 251 200
0 Q1 Q2 Q3 Q4
Nevirapine dose to w oman 251 304 289 407 at antenatal or labour % NVP given to HIV positive 63% 52% 66% 72% w omen in labour
The trend is upwards, but … (28% on HAART?) Post Natal (babies): PCR testing
Kwadukuza PCR testing at 6 weeks
600 464 Overall: 67% 404 400 325
200 150
0 Q1 Q2 Q3 Q4
HIV 1st test of baby born to 150 325 464 404 HIV positive w oman % babies tested for PCR at 38% 55% 104% 71% 6 w eeks
Percentage likely influenced by formula used Æ 4th quarter increase in pregnant women. We have done well! Post Natal PCR test positive
Kwadukuza PCR positive and percentage
60 49
40 30 16 20 5 0 Q1 Q2 Q3 Q4
HIV 1st test positive of baby 5163049 born to HIV positive w oman % babies postive born to 3.3% 4.9% 6.5% 12.1% HIV positive w oman
The outcome is influenced by the PCR tests that return .. Overall: 6.1% likely that last Quarter is most accurate. HIV testing at clinics
Kwadukuza HIV testing Total: 4,554 positive: 37.3%
2,000 1,447 1,500 1,151 1,160 1,000 796
500
0 Q1 Q2 Q3 Q4
Total tested HIV positive 796 1,151 1,160 1,447 Percentage HIV positive 37.8% 36.3% 37.6% 37.8% (non pregnant) HIV testing (male / female)
Kwadukuza HIV testing Accepting rate: 98%
1,000 884 800 679 662 563 600 470 472 498 326 400 200 0 Q1 Q2 Q3 Q4
HIV test positive - new 470 679 662 884 (excluding antenatal) - Female HIV test positive - new - 326 472 498 563 Male
More Females check HIV status than men. Women Year Protection
Kwadukuza Women Year Protection
Marketing services? More friendly? 35% 30% 30% 30% 27% 26% 25% 23%
20%
15%
10%
5%
0% Q1 Q2 Q3 Q4 year
Women Year protection 23% 30% 26% 30% 27%
(contraceptive use .. Room for improvement?) ARV data 31 March 2008
Down Referred to Clinic or roll out at Clinic in 2007 / 8
No. of patients on ART at PHC facilities Last Quarter : 584 new on ART Total: 2,524
1000 918 900 Hospital: 3,489 and to be down referred during 2008 / 9 800 New roll out from clinics at least 150 per month for all 697 700 clinics 600 500 All clinics ready to start in April 2008 400 We anticipate to increase from 5,104 Æ 7,000 in 2008/9 300 200 125 126 133 137 108 130 99 51 100 0
i c c c ic c c ic c c lini ni n lin lin li li lini Clini C C Clinic l Clini o C e C a y C el lls ito ra za C sne nhi ku Ball Nandi Cliniandeni r le kask a pumel Darnall Du a M e G Groutvill a h K M S Kw Nurse Outreach Support to Assist Clinics with the challenges! HIV/Aids Management at PHC facilities .. 1. All clinics ready from 01 April 2008 to roll out ARVs (implementation in progress)! 2. All clinics ready from 01 April 2008 implementing dual therapy on Friday 11, April 2008 already 68 on treatment 3. All clinics to continue with project: – Wellness clinic (HIV positive on pink card system); support groups to be set up and strengthened (most have already 300 on register) – VCT offering to all children < 5 years with diarrhoea and pneumonia 4. Keep up the good work with PCR testing (6 weeks post delivery) 5. NOTE: Hospital will focus on fast tracking very ill HIV positive patient and setup a referral HAAST clinics 08/09 6. Support outreach team to be strenghtened 7. All clinics to have champion (dedicated) nurse for ARVs, dual therapy, IMCI and chronic medication! Condom distribution / uptake
Kwadukuza Condoms (hospital and PHC) Target: > 12 (males 15 years and older) Bins at 10.0 Shopping 7.7 8.0 Centers? 6.5 6.5 5.7 5.9 6.0
4.0 67,840 2.0
0.0 Q1 Q2 Q3 Q4 year
Condoms per male 15 years 5.7 5.9 6.5 7.7 6.5 older
We failed to do implement dedicated condom distributor! Increase the Condom Availability • Contact all shopping centers to place condom bins + information pamphlet for STI • Approach all hotels in sub district and place condom bins, etc. • Approach all big companies, private sector and place condom bins • Ensure that all public toilets close to taxi ranks have condom bins, etc. • Traditional Healers is another opportunity! Etc. • Therefore we need a dedicated staff member to manage this process! Let us try again So new target can be definitely above 12 condoms per male per for 2008 / 9 Cervical smear
Kwadukuza Cervical Smear
1,500 Total: 3,631 1,196 11% overall 935 1,000 847 558
500 Q1 Q2 Q3 Q4 0 Total Cerv smear 30 558 1,196 847 935 years older Percentage covered 7% 14% 10% 11% w ith smear > 30 years
Well done! MUS rate per 1000 males > 15 years
Kwadukuza Male Urethritis Syndrome
1,000 738 785 783 800 725
600 400
200 42.7 43.5 46.3 46.2 0 Q1 Q2 Q3 Q4
Male Urethritis 725 738 785 783 Syndrome treated - new episode MUS rate per 1000 42.7 43.5 46.3 46.2 above 15 years STI: 13,127 STI Partner Treated: 3,031 Notification rate: 118% Kwadukuza STI STI incidence: 10.2
4,138 5,000 3,541 3,237 4,000 3,000 2,211 2,000 1,357 702 847 1,000 322 0
Q1 Q2 Q3 Q4 STI treated - new episode 2,211 3,541 3,237 4,138
STI partner treated - new 322 1,357 702 847
STI incidence 15 yrs older 6.9 11.0 10.1 12.9
Treatment rate 15% 38% 22% 20%
Partner Treatment rate remains low … TB smear positive clinics Kwadukuza TB smear positive clinics Sputum sent: 6,713 Pos: 7 % of sent 250 202 Total positive: 577 More data to follow .. 200 For next meeting 151 141 150
100 83
50
0 Q1 Q2 Q3 Q4
Suspected TB case smear 83 202 141 151 positive % positive total sputum sent 8.5% 11.0% 7.0% 8.1%
Hospital data not included Pharmacy data (script, item, etc.)
Kwadukuza Pharmacy Data
350,000 323,174 322,241 306,204 300,000
196,865250,000
200,000 121,430 109,605 120,161 81,733150,000 Q1 Q2 Q3 Q4 100,000
50,000 Prescription issued 81,733 109,605 120,161 121,430 (439,929) Item dispensed (1,148,484) 196,865 323,1740 306,204 322,241 Number of items 1.9 2.4 2.2 2.1 dispensed per Head Count (2.1) Average item per script (2.7) 2.4 2.9 2.5 2.7 Stanger Hospital
Selected Data Stanger Hospital – Inpatient Day
Stanger Hospital Total Inpatient Days over the Years
140,000 125,059 120,007 120,000 112,349 101,161 101,229 98,373 100,000 92,972 90,929 88,141
80,000
60,000 461 beds 40,000 415 beds 20,000 385 beds 0 99-00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
Major change: conversion from district hospital to regional hospital Year 2008 / 9: start with 501 beds Æ expanding close to 600 beds. Overview Medical Inpatient Days
Stanger hospital Inpatient Days - all medical
60,000
50,000
40,000
30,000
20,000
10,000 99-00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
Female Medic al 15,648 16,857 15,456 18,486 16,810 18,950 21,971 21,868 25,240 Male Medical 17,045 18,681 14,709 15,661 15,079 14,682 16,459 18,639 23,204 Total Medical 32,693 35,538 30,165 34,147 31,889 33,632 38,430 40,507 48,444 % change (total medical) 9% -15% 13% -7% 5% 14% 5% 20%
Female Medical Male Medical Total Medical % change (total medical) 2 per. Mov. Avg. (Female Medical) 2 per. Mov. Avg. (Male Medical) 2 per. Mov. Avg. (Total Medical ) Women Delivered Stanger Hospital
Stanger Hospital No. of Women Delivered The trend
6,500 6,298
6,000 5,832 Change in referral pattern 5,582 5,500 Started in 2003/4 5,275
5,000 4,502 4,500 3,984 3,859 3,863 3,911 4,000
3,500
3,000 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 C/S rate – over years
C/S rate over the years
Change in referral 31.0 pattern 30.4 Started in 2003/4: 30.2 29.7 29.6 more regional OG 28.9 29.0 28.3 27.5
27.0 25.9 25.2 25.0 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
caesar rate 28.9 25.2 25.9 27.5 30.2 30.4 29.7 28.3 29.6
We set as target a 10 % reduction for 2007- 2008 Stanger Hospital – Percentage C/S 07/08
Stanger Hospital Percentage C/S Year 2007/8
33.0% 31.7% 32.0% 30.9% 31.0% 29.6% 30.0% 29.2% 29.0% 28.0% 27.0% 27.0% 26.0% 25.0% 24.0% Q1 Q2 Q3 Q4 Yr
Quarter 1: June strike influence the results. Maternal Mortality – trend
Stanger Hospital Maternal Mortality Rate per 100,000 w omen
652 630 530 430 330 270 233 230 151 104 129 113.7 130 51 67 30 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
MMR 104 129 51 151 67 113.7 233 652 270 Maternal Deaths 4 5 2 6 3 6 13 38 17
We set as target a 50% reduction for 2007- 2008 Maternal Mortality 07 / 08
Maternal Mortality Rate / Maternal Deaths 2007 / 8 per quarter
600 563 550 500 422 450 400 350 270 300 250 200 150 100 61 63 50 1 1 8 7 17 0 Q1 Q2 Q3 Q4 Yr
Maternal Deaths 118717 MMR 61 63 563 422 270
We set as target a 50% reduction for 2007- 2008 : less than 19 Maternal Deaths Low Birth Weight – The Trend
Low Birth Weight Rate - the trend over the years
17.5 18.0 16.8 15.4 15.2 14.9 14.8 14.4
13.0 12.1
10.4
8.0 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 low B weight R 16.8 15.2 14.8 17.5 14.9 14.4 15.4 12.1 10.4 Live Birth data & % underweight Total Live Hospital data Birth(LB): 6,248 Live Birth Data Stanger Hospital 2007 / 2008 Total LB > 2,5 kg: 5,580 2,000 1,444 1,400 1,487 Total LB < 2,5 1,500 1,249 kg: 668 1,000 11.2% 10.7% 11.4% 9.6% Overall % 500 182 168 160 158 Underweight: 10.7% 0 Q1 Q2 Q3 Q4
percentage live birth < 11.2% 10.7% 11.4% 9.6% 2.5kg
percentageNumber live live birth birth > < 1,444 1,400 1,249 1,487 2.5kg2,5 kg No live birth < 2.5 kg 182 168 160 158
Quarter 1: June strike influence the results, but last quarter promising! Perinatal and Neonatal Mortality 3 year trend
Stanger Hospital Include < 1 000 gram
60.0 50.2 43.0 38.0 40.0
16.4 19.1 20.0 12.5
-
year 05/06 year 06/7 year 07/08 perinatal mortality 43.0 50.2 38.0 neonatal mortality 16.4 19.1 12.5
perinatal mortality neonatal mortality Poly. (neonatal mortality) Poly. (perinatal mortality) Perinatal and Neonatal Mortality Rate 07/08
Perinatal and Neonatal Mortality Rate
50.0
40.0 30.0
20.0 10.0
0.0 Q1 Q2 Q3 Q4 Yr PNMR (all) 27.1 43.5 43.4 39.1 38.0 PNMR > 1kg 19.9 38.7 31.1 31.9 30.3 Neonatal Death Rate (all) 4.9 18.5 14.2 12.8 12.5 Early Neonatal Death Rate 4.3 13.4 10.6 10.3 9.6 Late Neonatal Death Rate 0.6 5.1 3.5 2.4 2.9
June Strike influenced data. Trend is down for all Still Birth – trend over year
Still Birth Rate - trend over the years
35.0 34.0 33.7 31.7 30.7 29.5 30.0
26.5 26.4 25.9 24.9 25.0
20.0 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
Still birth rate 29.5 34.0 30.7 26.5 33.7 26.4 24.9 31.7 25.9 Still Birth & Still Birth Rate 07 / 08
Total Live Still born data Stanger Hospitall 2007 / 2008 Birth: 6,248
50 43 45 41 Total Still 37 Birth: 166 40 29.6 30 25.5 26.6 Still Birth Rate 22.2 (overall): 25.9 20
10
0 Q1 Q2 Q3 Q4
Total still born 37 41 43 45 Still Birth Rate per 1000 22.2 25.5 29.6 26.6 births (still and alive)
Quarter 1: June strike influence the results Pregnancy: Teenage and > 34 – trend over the yrs
Teenage pregnancy rate - trend over the years & Pregnancy > 34 years
12% 11.5% 11.3% 11.0%
9.7% 10.0% 10% 9.2% 9.4% 8.3% 7.6% 7.9% 8% 7.3% 6.7%
6% 02/03 03/04 04/05 05/06 06/07 07/08
Perc. Teenage Pregnancy 11.5% 9.2% 11.0% 11.3% 10.0% 9.4% Perc. Elderly Pregnancy 7.3% 7.6% 8.3% 9.7% 7.9% 6.7% Teenage Delivery and > 34 years (%)
Teenage Delivery and Delivery above 34 years Stanger Hospital 2007 / 8 Total Delivery: - < 18 yrs: 593 - > 34 yrs: 424 11.0% 9.9% 10.1% 9.2% 9.4% 9.0% 8.6% 8.3% 7.5% 6.7% 7.0% 5.5% 5.7%
5.0% Q1 Q2 Q3 Q4 Yr
% Deliveries < 18 years 9.2% 8.6% 9.9% 10.1% 9.4% % Deliveries > 34 years 5.5% 5.7% 7.5% 8.3% 6.7%
Quarter 1: June strike influence the results. Financial Overview Expenditure per PDE
Year 2007 / 8 Q1 Q2 Q3 Q4 Yr Cost per PDE for District Hospital 619.10 588.40 610.71 484.00 572.82 Cost per PDE for Regional Hospital 1,442.28 1,238.72 1,243.33 991.95 1,213.74 Cost per PDE for District and Regional Hospital 1,047.83 943.49 961.38 764.72 921.75 (interesting is above calcuation based on old method! I split District Hospital PDE further down in TB, Psych and Stepdown Year 2007 / 8 Q1 Q2 Q3 Q4 Yr Total District Hospital PDE 19,051 21,704 20,246 22,370 83,370 Total TB Hospital PDE 3,810 4,340 4,049 4,474 16,673 Total Acute Psychiatric PDE 1,124 1,281 1,195 1,320 4,920 Total Stepdown PDE (Under HIV/Aids) 1,905 2,170 2,025 2,237 8,337 Total Adjusted PDE District Hospital 12,212 13,913 12,977 14,338 53,440 Acute TB Hospital Expenditure 3,642,276 3,943,655 3,818,133 3,343,393 14,747,456.74 Acute Psychiatric Expenditure 1,283,165 1,389,340 1,345,119 1,177,869 5,195,493.67 Stepdown Expenditure 1,242,749 1,389,340 1,345,119 1,177,869 5,031,851.23 District Hospital Expenditure 11,794,687 12,770,633 12,364,158 10,826,823 47,756,301.59 Cost per PDE TB Hospital 955.96 908.59 942.96 747.31 884.49 Cost per Acute Psychiatric Hospital 1141.28 1084.73 1125.75 892.18 1,055.95 Cost per PDE Stepdown Hospiital 652.35 640.19 664.40 526.55 603.58 Cost per PDE for adjusted District Hospital 965.84 917.92 952.78 755.09 893.64 Cost per PDE for Regional Hospital Services 1,442.28 1,238.72 1,243.33 991.95 1,213.74
This overview will definitely result in change how we approach budgeting and ME of expenditure. Financial Data .. comments
• We have worked out the PDEs for TB, Psychiatric and Step Down services • The result a significant change in expenditure per PDE. • In past hospitals, including ourselves just booked expenditure for TB, psychiatric and step down hospital services without looking at PDE to justify expenditure. • The result is that if all hospitals do this Æ expenditure per PDE for district hospital will be higher than reported on budgets shift can be justified for in particular TB Hospital services, a conditional grant • For 2008 / 9: – 72 dedicated TB beds – 36 dedicated Hiv/Aids Step down Beds (including terminal care beds – All discharges to be managed e.g. TB resolved / HIV resolved (fast tracking, transfer to clinic with sound hand over process to CBC, etc.) Æ result in lower re- admission rates – Gaps in staffing to be addressed in 2008/9 year … is now! Question
• Carry over orders for 2007 /8: for Stanger Hospital R 11,4 Million (15% of operational budget passed over) • What is the amount for the whole Province? – Likely R 300 – R 400 Million – New budget leaves us with less R 200 Million, if we ignore inflationary pressure – Result is that we have to cut services, or motivate better for additional funds! – Where is the additional money for PHC ? Medical OPD – down referral project Average HC: Medical OPD Head Count •2006 / 7 : 4,078 •2007 / 8 : 2,839 Less: 1,240 pm 60,000 Down Referred to 48,939 50,000 Clinics
40,000 34,063
30,000
20,000 14,876
10,000
0 Yr 06.07 Yr 07.08 variance
Yr 06.07 Yr 07.08 variance
From Financial perspective: Expenditure from Hospital to PHC: R 300 per Head count Æ R 4,4682,000.- Medical OPD Month to Month Average HC: Overview Medical OPD •2006 / 7 : 4078 •2007 / 8 : 2839 Less: 1,240 pm 5,000 4,570 4,537 4,528 4,315 4,305 4,216 4,146 4,151 4,120 4,123
4,000 3,912 3,697 3,606 3,499 3,332 3,255 3,244 3,215 3,224
3,000 2,943 2,685 2,599 2,352 2,132
2,000 1,771 1,552 1,322 1,273 1,273 1,071 1,092 921
Head Counts 1,000 618 208 159 0
-88 y e ly t r y a n u er er e r ch J us b b b a ary r -1,000 April M Ju g m to m u ru a Au e vember an M pt Oc ce J No Feb Se De Month
Yr 06.07 Yr 07.08 variance 2 per. Mov. Avg. (Yr 06.07) 2 per. Mov. Avg. (Yr 07.08) 2 per. Mov. Avg. (variance) Medical OPD – other issues
Medical OPD - Total Head Count Only able to sustain 3 months?
4,500 4,059 4,000 3,577 3,384 3,204 3,271 3,327 3,500 3,058 3,000 2,332 2,500 2,222 2,026 1,869 2,000 1,500 1,000 324 500 - Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov - Dec- Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 The challenge at MOPD was January 2008 with also no community service Officers Æ result: January 14 doctors less. Problem to balance HR with demand MOPD: Disability Assessment
Disability Grant - Patients Assessed at MOPD
120 106
100 83 80 62 58 59 60 51 42 40 30 32 24 20 7 10
- Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov - Dec - Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 MOPD: Referred for Voluntary Counseling and Testing Total VCT: 3.280 Issue: shortage of consult rooms? MOPD : VCT 2007 - 2008 • Average : 15 new a day • Mostly to be done in morning? 400 373 353 331 350 320 311 302 293 300 277 251 250 215 193 200
150
100 61 50
- Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov - Dec - Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 MOPD: Voluntary Counseling and Testing
Percengate VCT / Total MOPD Head Count 2007 - 2008
20% 19% 18% 16% 14% 14% 13% 12% 12% 10% 11% 9% 9% 10% 10% 8% 9% 7% 8% 6% 4% 2% 0% Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov- Dec - Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08
We could also look at referred for VCT and accepted for VCT Dental – decline in visits .. Average HC: Dental •2006 / 7 : 728 •2007 / 8 : 543 Head Count Less: 185 pm
Down Referred to 10,000 Strike less : 410 8,733 Clinics(June 07) 9,000 8,000 7,000 6,514 6,000 5,000 4,000 3,000 2,219 2,000 1,000 0 Yr 06.07 Yr 07.08 variance
Yr 06.07 Yr 07.08 variance
Is this the result of limiting access at dental clinic? Dental clinic – month to month
Dental Clinic- Total Head Count
800 712 700 647 605 596 597 564 600 552 538 548 504 500 434 400
300 233 200
100
- Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov - Dec - Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 Skin clinic – month to month
SKIn Clinic- Total Head Count
300 278 268 275 250 250 217 194 200 165 152 144 150 127
100
50 - - - Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 OPD: Stoma and Wound Care 07 / 08
Outpatient Stoma and Wound Care Stoma and wound care to be rationalized to PHC 300 Evidence for stoma care, but not for wound care 263 250 200
150 146 124 120 100 86 105 96 50 91 86 79 67 50 48 46 54 55 58 32 48 36 23 25 17 0 0 07 y- 7 Apr-07 7 Ma Jun-07 -0 Jul-07 p t-0 -07 Aug-07 Se c c 8 O Nov-07 e -0 D Jan-08 Outpatient-Wound Outpatient StomaFeb-08 CareMar Variance in OPD visits
Specialist Clinics OPD Variance Year 2006 /7 - 2007/ 8 Corrections for June 2007 strike effect
15,000 9,692 10,000 -377 1,083 5,000 814 384 0 Ortho Surgery Eye Clinic Peads Gynae MOPD gen. spec MOPD MOPD (all) Dental ARV Casualty
-5,000 -1,809 -784 - 377 -10,000 -1,619 -177 -12,047 -15,000 -10,964 TB clinic data (OPD) - 1
TB Clinic (repeat and new ): 2007 - 2008
900 800 763 743 679 700 653 648 583 610 600 553 558 464 500 444 400 300 200 106 100 - Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 TB clinic data (OPD) - 2
TB Clinic (repeat and new ): 2007 - 2008 Total New TB cases: • 2,413 • average: 201 pm. 900 • follow up: 4,391 800 763 743 679 700 653 648 583 610 600 553 558 500 485 464 500 444 421 431 447 396 375 400 357 337 306 254 278 300 106 221 232 217 243 232 235 190 196 187 200 82 158
100 24 - Apr- May - Jun- Jul-07 Aug- Sep- Oct- Nov- Dec - Jan- Feb- Mar - 07 07 07 07 07 07 07 07 08 08 08 TB clinic data – New TB
Stanger Hospital Year 2006 / 7: 2,753 Year 2007 / 8: 2,422 New TB clients - overview per Quarter
900 NB. June 2007 strike 766 800 708 701 661 700 618 648 634 600 500 439 400 300 200 100 0 q1 q2 q3 q4
Year 2006/7 Year 2007/8
A decline in TB incidence observed, but not that significant. TB clinic data – Retreatment
Stanger Hospital Year 2006 / 7: 376 Year 2007 / 8: 207 TB Retreatment - overview per Quarter
120 106 108 NB. June 2007 strike 100 87 75 80 64 65 54 60
40 24 20
0 Q1 Q2 Q3 Q4
Series1 Series2
A decline in TB re-treatment is noted in all quarters!. TB – % HIV positive tested
Percentage TB patients --> tested HIV positive 77.9% 78.0% 77.4% 77.4%
76.8% Acceptance rate for HIV testing: Year 2006 / 7: 80%Year 06.07 Year 07.08 Year 2007 / 8: 73% (significant decrease!)
This means that 22% of patients with TB are HIV negative. TB clinic data – Various
Total on TB TB data Treament 4,000 3,417 3,000 2,821 3,000 2,426 1,751 2,800 2,000 1,032 938 992 2,600 2,446 1,000 634 496 2,400 0 2,200 Extra Pumonary Primary Total Year 06.07 Year 07.08 Pumonary TB TB TB Year 06.07 Year 07.08
TB data Kwadukuza SD Discrepancy data: total on Treatment year 06/7. 3500 3,286 2,925Which one to belief? 3000 2,821 2,446 2500 TB Year 06.07 Year 07.08 Referred to clinics 2,802 2,427 2000 Ref. Richmond 157 78 1500 Ref. Other 342 41 Totals 3,301 2,546 1000 465 479 500 0 TB prevalence : TB start at clinic TB start hospital Total Yr 2006 / 7: 1,825 per 100,000 Yr 2007 / 8: 1,625 per 100,000
Year 06.07Year 07.08 Yr 2008 / 9: >> target below 1,400? TB clinic data – Retreatment VCT data .. Last two years
VCT - Hospital and clinics combined: VCT tested and Acceptance Rate
20,000 16,63515,396 16,644 15,986
10,000
0 Year 06.07 Year 07.08
VCT Pre-Couns eled 16,635 16,644 VCT tests done 15,396 15,986 Acceptance Rate 92.6% 96.0%
So, 17,000 VCT pre- counseling sessions. Say, 220 days in year Æ 77 counseling session per day Norm is 8 clients a day Æ so, 10 counselors for pre – counseling sessions Average client require 3 to 4 counseling sessions Æ 30 to 40 counselors VCT data .. Hospital and Clinics
VCT - Stanger Hospital: VCT tested and Acceptance VCT - All Clinics Kwadukuza sub district: VCT tested Rate and Acceptance Rate
10,000 15,000 12,33912,059 6,289 5,729 10,346 4,305 9,667 5,000 3,927 10,000
- 5,000
0 Year 06.07 Year 07.08 Year 06.07 Year 07.08 VCT Pre-Counseled 6,289 4,305 VCT Pre-Counseled 10,346 12,339 VCT tested 5,729 3,927 VCT clinics 9,667 12,059 Acceptance Rate 91.1% 91.2% Acceptance Rate 93.4% 97.7%
If we require 40 counselors than distribution in line with activities 2006 / 7: 38% hospital and 62% clinics 2007 / 8 : 26% hospital and 74% clinics To cope with demand / trend and respect norms: • Hospital should have at least 12 counselors : R 774,774 for HR • PHC should have at least 30 counselors : R 1,936,935 for HR • Budget implications 42 posts at L3 -> R 2.7 Million for salaries + benefits NB. 2.7 M / 17,000 clients = R 160 per client for HR, excluding supervisors. NB this exclude counselors for ART and PMTCT. VCT data – Percentage HIV positive VCT - Percentage HIV positive : Hospital, PHC (clinics) and combined 60.0% 51.6% 49.9% 43.6% 50.0% 38.9% 37.5% 40.5% 40.0% Year 06.07 Year 07.08 30.0%
20.0% Percentage HIV positive 51.6% 49.9% - Hospital 10.0% Percentage HIV positive 38.9% 37.5% - PHC (clinics) 0.0% Percentage combined 43.6% 40.5%
Last two years: VCT data Year 06.07 Year 07.08 -average 3.7% per annum new HIV positive (VCT) No. of HIV +ve Hospital 2,958 1,958 No. of HIV +ve Clinic 3,762 We assume 30% 4,523 of population is positive Total 6,720 Æ 54,000 6,481
Likely, that we tested already > 20,000 HIV + ve VCT data % Male / Female tested HIV +ve
V CT Data: comparison % HIV positive tested males / females
65.0% PHC Male HIV tes t +v e 61.3% 60.0% Females 59.2% 56.1% PHC Female HIV test +ve 55.0% 56.0%
50.0% Hospital Male HIV test +ve Males 45.0% 44.0% 43.9% 40.0% 40.8% Hospital Female HIV test 38.0% +ve 35.0% 30.0% Year 06.07 Year 07.08 More females accept to be tested at this stage. Overall 60 % females Æ 58% Encouraging to see that trend is changing. Likely related to more males symptomatic (signs of disease). Shift from 40% Æ 42% VCT data – Inpatient VCT testing
VCT testing ratio inpatients: year 2007 / 8
25000 PMTCT data not included here. 20000 We could do better! Targets to be set for wards! 15000 10000 5000
0 Surgical Medical Paediatric Gynae ICU / High Neonatal / Total Wards Wards Wards Wards Care Mater nity Inpatient
VCT done 85 683 174 0 0 0 942 Admissions 4,569 7,012 1,664 1,613 175 6,896 21,929 VCT ratio 2% 9.7% 10.5% 0.0% 0.0% 0.0% 4.3%
1. ART admissions to be recorded & HIV positive admissions to be recorded 2. HIV negative admissions to be recorded and % offered test, % acceptance for all patients admitted; % positive males and females and CD4 distribution: < 50; 50 – <200; 200 – 350; > 350. Discharge: refer to wellness clinic (PHC). 3. AE (casualty) Æ VCT to be introduced (24 hours service). Accident & Emergency Total Head Count Total Head Count Casualty Total Headcount • YR 06.07: 33,578 9,000 8,875 • YR 07.08 : 32.043 (- 4.5 %) 8,552 8,500 8,413 8,380 8,299 8,147
8,000 7,738
7,500 7,217
7,000 1. Average of 338Q1 - patientsQ2 - lessQ3 -per monthQ4 - Q1 - Q2 - Q3 - Q4 - 2. Trauma site 06.07average06.07 less 75706.07 pts 06.07per month07.08 & 07.08 07.08 07.08 3. Medical stretcher sit average more 419 per month 4. Admissions: 5. Yr 2006 / 7: 9,157 (27.2%) ; Yr 2007 / 8 : 9,351 (29.1%) PMTCT data PMTCT data - hospital (at facility = after delivery) A significant decrease BF: 47.4% 7,000 6,298 FF: 52.6% 5,832 HIV prevalence 6,000 pregnant women PCR test: 5,000 • YR 06.07: 36.01 % PHC:1,343 4,000 Hosp.l: 93 3,000 • YR 07.08 : 32.8 % 2,103 2,063 2,000 (- 3.3 %) PCR : 100 This is in line what is Positive … 1,000 - Year 06.07 Year 07.08 observed at PHC facilities in Kwaduza NVP given to baby 2,103 2,063 Sub District. born HIV positive women Last quarter: Total Deliveries 5,832 6,298 prevalence 30 % Percentage HIV 36.1% 32.8% (down from 36.7%) positive Good News!? NVP given to babies born to HIV positive women equals HIV positive women. This is most reliable data according to me. NVP to pregnant women in labour or ANC … • Compiled by: Dr A. J. Mansvelder (Stanger Hospital CEO)