DISTRICT HEALTH PLAN 2015/2016
UMKHANYAKUDE DISTRICT
KWAZULU-NATAL
[UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16
1. ACKNOWLEDGEMENTS
I would like to express my appreciation to District Health Management Team and Program Managers who contributed to development of the DHP 2015/16. The support from the Provincial Planning Unit during the development of this document was of great value.
The M&E Team worked tirelessly in co-ordination of the document so that it meets the legislative mandates of the department. The team went beyond their call of duty to ensure that the document is meaningful. The efforts of the district Data Management team are acknowledged as they continued to verify data that was submitted.
A special word of appreciation goes to Dr. Immelman who was able to carry dual roles and participated fully in this exercise.
Our word of gratitude also goes to the supporting partner (MatCH) who gave technical support to the team. Their contribution kept the team focused to the entire process.
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2. OFFICIAL SIGN OFF
It is hereby certified that this District Health Plan:
Was developed by the district management team of Umkhanyakude Health District with the technical support from the provincial district development directorate and the strategic planning unit. Was prepared in line with the current Strategic Plan and Annual Performance Plan of the Department of Health of KZN
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3. TABLE OF CONTENTS
1. ACKNOWLEDGEMENTS ...... 2 2. OFFICIAL SIGN OFF ...... 3 3. TABLE OF CONTENTS ...... 4 4. LIST OF ACRONYMS ...... 6 5. EXECUTIVE SUMMARY BY DISTRICT MANAGER ...... 9 PART A - STRATEGIC OVERVIEW ...... 12 VISION, MISSION & CORE VALUES ...... 12 6. SITUATIONAL ANALYSIS ...... 12 6.1 MAJOR DEMOGRAPHIC CHARACTERISTICS...... 14 6.2 SOCIAL DETERMINANTS OF HEALTH ...... 17 6.3 EPIDEMIOLOGICAL (DISEASE) PROFILE OF THE DISTRICT ...... 20 7. DISTRICT SERVICE DELIVERY ENVIRONMENT ...... 22 7.1 DISTRICT HEALTH FACILITIES ...... 22 7.2 TRENDS IN KEY DISTRICT HEALTH SERVICE VOLUMES ...... 26 8. DISTRICT PROGRESS TOWARDS THE ACHIEVEMENT OF THE MDG’S ...... 31 9. PROVINCIAL AND DISTRICT CONTRIBUTION TOWARDS THE HEALTH SECTOR NEGOTIATED SERVICE DELIVERY AGREEMENT (NSDA) ...... 33 10. SUMMARY OF MAJOR HEALTH SERVICE CHALLENGES AND PROGRESS MADE FOR THE PREVIOUS THREE FINANCIAL YEARS ...... 35 10.1 INTRA DISTRICT EQUITY IN THE PROVISION OF SERVICES ...... 45 11. ORGANISATIONAL ENVIRONMENT ...... 50 11.1 Organisational Structure of the District Management Team ...... 50 11.2 Human Resources ...... 51 12. DISTRICT HEALTH EXPENDITURE ...... 55 PART B - COMPONENT PLANS ...... 62 13. SERVICE DELIVERY PLANS for district health services ...... 62 13.1 Sub-Programme: District Health Services ...... 62 13.2 Sub-Program: District Hospitals ...... 72 14. HIV & AIDS & TB CONTROL (HAST) ...... 81 14.1 Programme Overview ...... 81 14.2 HIV & AIDS, STI & TB CONTROL (HAST): Strategies/ Activities to be implemented 2015/16 ...... 89 15. MATERNAL, NEONATAL, CHILD AND WOMEN’S HEALTH AND NUTRITION ...... 90 15.1 Programme Overview ...... 90 15.2 Strategies/ Activities to be implemented 2015/16 ...... 106 16. DISEASE PREVENTION AND CONTROL (Environmental Health Indicators) ...... 108 16.1 Programme Overview ...... 108 16.2 STRATEGIES/ Activities to be implemented 2015/16 ...... 114 17. INFRASTRUCTURE, EQUIPMENT AND OTHER SUPPORT SERVICES ...... 115 18. SUPPORT SERVICES ...... 117 18.1 PHARMACEUTICAL SERVICES ...... 117 18.2 EQUIPMENT AND MAINTENANCE ...... 123
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18.3 EMERGENCY MEDICAL SERVICES (EMS) ...... 124 SUB PROGRAMME OVERVIEW ...... 124 19. HUMAN RESOURCES ...... 127 20. DISTRICT FINANCE PLAN ...... 131 PART C: LINKS TO OTHER PLANS ...... 133 21. CONDITIONAL GRANTS (Where applicable) ...... 133 22. PUBLIC-PRIVATE PARTNERSHIPS (PPPs) and PUBLIC PRIVATE MIX (PPM) ...... 135 PART E: INDICATOR DEFINITIONS ...... 137
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4. LIST OF ACRONYMS
Abbreviations Description
A
AIDS Acquired Immune Deficiency Syndrome
ANC Ante Natal Care
APP Annual Performance Plan
ART Anti-Retroviral Therapy
ARV Anti-Retroviral
B
BAS Basic Accounting System
BLS Basic Life Support
BUR Bed Utilisation Rate
C
CARMMA Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa
CCG’s Community Care Givers
CEO(s) Chief Executive Officer(s)
CHC(s) Community Health Centre(s)
COE Compensation of Employees
D
DCST(s) District Clinical Specialist Team(s)
DHER(s) District Health Expenditure Review(s)
DHIS District Health Information System
DHP(s) District Health Plan(s)
DHS District Health System
DOH Department of Health
DQPR District Quarterly Progress Report
E
EMS Emergency Medical Services
ETB.R Electronic Tuberculosis Register
ETR.net Electronic Register for TB
F
G
G&S Goods and Services
H
HAST HIV, AIDS, STI and TB
HCT HIV Counselling and Testing
HIV Human Immuno Virus
HOD Head of Department
HPS Health Promoting Schools
HPV Human papilloma virus
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Abbreviations Description
HR Human Resources
HTA High Transmission Area
I
IDP(s) Integrated Development Plan(s)
IPT Ionized Preventive Therapy
J
K
KZN KwaZulu-Natal
L
LG Local Government
M
M&E Monitoring and Evaluation
MDG Millennium Development Goals
MDR-TB Multi Drug Resistant Tuberculosis
MEC Member of the Executive Council
MNC&WH Maternal, Neonatal, Child & Women’s Health
MO Medical Officers
MOU Maternity Obstetric Unit
MTEF Medium Term Expenditure Framework
MTSF Medium Term Strategic Framework
MUAC Mid-Upper Arm Circumference
N
NDOH National Department of Health
NCS National Core Standards
NGO(s) Non-Governmental Organisation(s)
NHI National Health Insurance
NIMART Nurse Initiated and Managed Antiretroviral Therapy
O
OSD Occupation Specific Dispensation
OSS Operation Sukuma Sakhe
P
P1 Calls Priority 1 calls
PCR Polymerase Chain Reaction
PCV Pneumococcal Vaccine
PDE Patient Day Equivalent
Persal Personnel and Salaries System
PHC Primary Health Care
PN Professional Nurse
R
RV Rota Virus Vaccine
S
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Abbreviations Description
SCM Supply Chain Management
SHS School Health Services
SLA Service Level Agreement
Stats SA Statistics South Africa
STI(s) Sexually Transmitted Infection(s)
T
TB Tuberculosis
U
V
VCT Voluntary Counselling and Testing
W
X
XDR-TB Extreme Drug Resistant Tuberculosis
Y and Z
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5. EXECUTIVE SUMMARY BY DISTRICT MANAGER
UMkhanyakude District is one of the most socio-economically deprived districts in the country. It is bordered by Mozambique and Swaziland resulting in treatment of foreign clients, with unbudgeted costs.
The District is striving towards elimination of Malaria epidemic since 2012. The malaria case fatality rate is 1.9%. The District will continue with residual house spraying, and the monitoring of mosquito insecticide resistance, and parasite resistance to the antimalarial medication which was shown to be so important in the late 1990s.
HIV/AIDS remains the biggest challenge to the healthcare system in the District. HIV/AIDS adversely affects life expectancy, maternal mortality, perinatal mortality, child nutrition, child mortality, tuberculosis incidence and cure, and incidence of MDR-TB and XDR-TB, impeding progress towards Millennium Development Goals (MDG) 4 (child mortality), 5 (maternal health), and 6 (combating HIV/AIDS and malaria).
Though maternal mortality is decreasing but the child health indicators show increase both in mortality and morbidity. The district has embarked on implementing MDG Countdown strategies to improve MCWH indicators. Strategies identified to help accelerate achievement of the MDGs include: promotion of early antenatal care (ANC) booking, ambulances based at hospitals and clinics with high numbers of deliveries for rapid transfer of critical patients, improved provision of antenatal calcium carbonate, promotion of contraception including use of intrauterine devices (IUDs) and hormonal implants, continuing promotion of male medical circumcision (MMC), and health counselling and testing (HCT), improved condom distribution including male and female condoms, improved tuberculosis screening and use of isoniazid preventive therapy.
The District has made a good progress in management of HIV and AIDS. 58,643 persons are now taking antiretroviral drugs in the District. Prevention of maternal to child transmission (PMTCT) is at 1.7%. There is evidence that life expectancy has increased by about ten years since 2007 as a result of the HIV&AIDS programme. The District HIV/Aids Antenatal prevalence has dropped from 41% to 35.2%
Teenage pregnancy remains a major challenge despite a collaborative efforts made with other departments such as Department of Education, Social development and NGOs. The district increased the number of School health teams from 5 to 10. This will assist in Health promotion at schools.
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SERVICE DELIVERY PLATFORM:
There are five district hospitals, 56 clinics including four Gateways, and 17 mobile clinics servicing 251mobile stopping points.
The first CHC in the district is currently under construction at Jozini LM and it is expected to be completed by 2015/16. Commissioning processes for the CHC have started. Hluhluwe clinic (Big Five False Bay) has been completed awaiting hand over. The construction of Mpophomeni clinic under UMhlabuyalingana LM is behind schedule. There is unevenness in the distribution of these resources throughout the District. The most glaring deficiency is the lack of higher level care in Mtubatuba local municipality. A community health centre for Mtubatuba is planned, but has been delayed by difficulty acquiring a site, followed by a shortage of funds.
Medical clinic coverage will continue to increase, with the ultimate aim of achieving weekly medical visits to all clinics.
No Ward based health teams appointed as yet. The district has planned to appoint at least five teams by end of 2014/15 financial year.
The District will continue to strive for full recruitment District Clinical Specialist Team (DCST), which presently has only four out of seven posts filled.
All five hospitals and Clinics are striving to implement National Core Standards but none is compliant due to structural challenges and insufficient essential equipment in all service areas. Procurement of essential equipment is prioritised in the next financial year.
Monitoring committees in hospitals and at District will be strengthened, including perinatal mortality meetings, child health forums and pharmacy and therapeutics committees and audit committees.
SUPPORT SERVICES:
Pharmaceutical support to clinics will improve through increasing deployment of pharmacist assistants to clinics, improving clinic stock management. Through a full complement of pharmacy managers in the District, pharmaceutical management in hospitals and clinics is anticipated to improve.
At present the District has only three obstetric ambulances, but needs at least six to have one for each hospital and clinic where more than 500 deliveries per year occur. EMRS challenges are still persistent with serious adverse events.
INFRASTRUCTURE:
Construction of new wards was finalised such as new Peads ward at Bethesda, female ward at Manguzi and Mosvold these has improved hospital image.
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HUMAN RESOURCES (HR):
There is high staff turnover within the district. This is attributed to the rural nature of the district.
FINANCES:
Strengthening of institutional cash flow committees, including clinic committees, with compulsory attendance, should improve financial management in the next financial years. The District Principal Accountant will continue to support institutions.
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PART A - STRATEGIC OVERVIEW
VISION, MISSION & CORE VALUES
Vision
To achieve optimal health status for all persons in UMkhanyakude District
Mission
To develop an integrated, coordinated, comprehensive and sustainable health system at all levels of care based on the Primary Health Care approach through the District Health System.
Core Values
Trust built on truth, integrity and reconciliation
Open communication, transparency and consultation
Commitment to performance
Courage to learn, change and innovative
DISTRICT HEALTH PRIORITIES FOR 2015/16
1. Strengthen Primary Health Care Services 2. Strengthen health system effectiveness 3. Reduce and manage the burden of disease and promote health 4. Strengthen human resources for health 5. Improve quality of health care 6. Improve quality of data
6. SITUATIONAL ANALYSIS
UMkhanyakude district is the northernmost district in KwaZulu-Natal. The district stretches from the UMfolozi River, near Mtubatuba in the south, to the Mozambique and Swaziland borders in the north. To the east it borders the Indian Ocean with 175km of pristine beaches. In the west it is bordered by Zululand District; and UThungulu District to the south. Geographically, uMkhanyakude is the most sparsely populated district in the province. The district is deep rural, a presidential node and is ranked number 51/52 of the most deprived districts in the country. There are five local municipalities with 68 wards.
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The platform for service delivery in the District consists of five district hospitals, 56 PHC facilities including 4 Gateways (18 Jozini, 18 UMhlabuyalingana, 12 Mtubatuba, 5 Hlabisa and 3 The Big Five False Bay Local Municipalities). There are 17 mobile teams (2 Hlabisa, 2 Mtubatuba, 6 Jozini and 7 UMhlabuyalingana). There is unevenness in the distribution of these resources throughout the District. The most glaring deficiency is the lack of higher level care in Mtubatuba local municipality. Despite holding 28% (179 378) of the District population (638 011), the municipality has no hospital or Community Health Centre. A Community Health Centre for Mtubatuba is planned, but has been delayed by difficulty in acquiring a site, followed by a shortage of funds.
The PHC cost per headcount is R108 (range R82.5 -Hlabisa to R116.4 -UMhlabuyalingana) which is below the national average of R210 due to incorrect linking of expenditure. The district hospitals and clinics spent 52.4% and 46.7% of the budget respectively. The district PHC expenditure per capita is R388 and only 3.9% of the district population belongs to medical aid schemes, which indicates that bulk (96.1%) of population is uninsured and utilizing public health services.
The PHC utilization rate for the district is 3.6 UMhlabuyalingana Local Municipality remains the highest with the rate of 4.2 and Hlabisa being the lowest with 3.0. The average PN workload in the district is 46, it ranges between 39.3 at The Big 5 False Bay and 52.5 at Hlabisa.
Access to PHC services in the district is limited due to long distances between where communities reside and facilities’ location (not all facilities are within 5km radius), poor road infrastructure, transport flow and cost as well as shortage of clinics.
The district has 5% tarred road and 95% gravel or sandy which contributes to regular breakdowns of motor vehicles that affects the transport fleet and leads to poor EMRS response time. The majority of the community rely on public transport in order to access health facilities. During rainy seasons some areas and facilities are inaccessible.
Doctors from all 5 hospitals within the district visit clinics at least once a month as there are no doctors allocated in the clinics. More than half of the clinics are visited by the doctor at least once a week. The doctor work load is 34.2 patients; it ranges between 27.2 in Jozini and 43.3 in UMhlabuyalingana. The expenditure for these doctors was incurred by hospitals but now they are linked to PHC support. Other Allied Health Professionals visit clinics at least once a month.
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6.1 MAJOR DEMOGRAPHIC CHARACTERISTICS.
Table 1: District Population 2013/14
% pop Uninsured Sub-District Total Population uninsured Population
Hlabisa LM 73 059 96.1 70 209
Jozini LM 189 966 96.1 182 556 Mtubatuba LM 179 378 96.1 172 382 The Big 5 False Bay LM 36 172 96.1 34 761 UMhlabuyalingana LM 159 438 96.1 153 220 District 638 011 96.1 613 129 Source: DHER 2012/13
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Figure 1: Population Pyramid Umkhanyakude District 2011 Stats SA
Graph 1: Population distribution per Municipality
Hlabisa LM 25% 11% Jozini LM 6% 30% Mtubatuba LM
28% The Big Five False Bay LM
Umhlabuyalingana LM
Source: DHIS
UMkhanyakude has a total population of 638 011 with a population density of 46 per km2. 53.3% are females and 46.7% are males. 38.5% of the total population are less than 15 years old and 12.5% are between 15 – 19 years old highlighting the need for Youth Friendly Services.
54% of households are headed by females, while 46% are headed by males, which might be due to males migrating to bigger cities for employment opportunities and dying early due to a delay in seeking medical help.
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The population is unevenly distributed among the five local municipalities with Jozini LM having the highest population of 30% and is the second biggest sub-district with an area covering 3 057km2, UMhlabuyalingana LM has the third highest population 25% and the biggest sub-district covering 3 621 km2, Mtubatuba LM and Hlabisa LM have a total population of 28% and 11% respectively and The Big 5 False Bay LM has the lowest population of 6%. The district is sparsely populated which has an impact on service delivery in terms of infrastructure. (The population to clinic ratio under UMhlabuyalingana LM indicate fair distribution of PHC facilities, but due to low density population not all clinics are within 10km radius compared to Mtubatuba LM. UMhlabuyalingana requires additional PHC facilities to be constructed. Mtubatuba LM is more densely populated and infrastructure required is less than in a sparsely populated area.
PHC services in The Big Five will be enhanced by the opening of Hluhluwe Clinic in 2014/15. Jozini Community Health Centre (CHC) is under construction and will be opened in 2015/16. Commissioning of the CHC has started in third quarter 2014/15 financial year. This CHC will be the first in the District, and should increase accessibility to PHC services. UMhlabuyalingana LM despite having the highest PHC utilisation rate of 4.2 and number of clinics per population still has underserved pockets of population due to its large area.
Demographic data indicates high percentage of household headed by <19 years old by 2.8%. It points to a high number of orphans with no extended families; this could be attributed to HIV and aids that is prevalent in the district. This may have contributed to high teenage pregnancy (11.3%) and illiteracy rates (25%) which could also lead to high incidence of malnutrition. There is a need to strengthen collaboration with other sector departments through (Oss) operation Sukuma Sakhe and other departmental initiatives such as Phila Mntwana centres.
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6.2 SOCIAL DETERMINANTS OF HEALTH
Table 2 (A1): Social Determinants of Health Name of Data source Development Indicators Sub-district Unemployment rate Percentage of population living below poverty line of per month R283 Percentage Households with portable access to water(inside) dwelling) households of in Number Informal dwelling households of in Number traditional structures Percentage of Households sanitation to access with Percentage of Households with accesstoelectricity rate (if Adult literacy available) Hlabisa Census 2001 76.1% 33.5% 2.2% 253 5259 - 28.7% 43.0% Community 83% 24% - 409 10 913 70% 35% 67% Survey 2007 Census 2011 52.6% 16.1% 12.5% 97 4075 - 55.4% 21.7% Jozini Census 2001 60.0% 43.0% 3.3% 502 18 649 - 11.8% 50.7% Community 65% 25% - 359 17 863 60% 32% 63% Survey 2007
Census 2011 44.1% 22.3% 10.9% 1446 8 308 - 29.1% 21.7% Mtubatuba Census 2001 59.7% 27.2% 8.2% 819 9 074 - 45.6% 37.3 Community 38% 22% - 105 1 024 90% 89% 69% Survey 2007 Census 2011 39.0 11.6% 22.1% 1394 5 172 - 65.1 19.7%
The Big Five Census 2001 47.1% 36.0% 13.9% 336 2 760 - 21.9% 39.7% False Bay Community 64% 23% - 100 2 643 86% 33% 61% Survey 2007 Census 2011 26.5% 17.5% 23.5% 98 1 392 - 65.1% 25.0% UMhlabuyali Census 2001 69.0 48.9% 1.8% 1019 15 698 - 7.0% 53.7% ngana Community 56% 27% - 195 14 679 63% 13% 59% Survey 2007 Census 2011 47.1 29.5% 5.3% 130 13 865 - 14.2% 30.2% District Total Census 2001 53.9 37.7% 4.7% 3873 51 441 - 21.2% 46.3% Community 63% 29% - 1 168 57 140 68% 34% 63% Survey 2007 Census 2011 42.8 19.4% 13.7% 2092 32 811 - 38.4% 25.0%
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The Health Systems Trust estimates UMkhanyakude to be the second most socio-economically deprived district in the country.
There are about 128 195 households (according to Stats SA) in the District of which 53.9% headed by females and only 9.9% households have flush toilets connected to sewerage. Only 13.4% of households have piped water inside the dwelling and 38.4% have electricity for lighting. The average household size is 4.7 people per household. 55.3% of the population is between the ages of 15-64; 25% of the population has no education; 25.4% has matric, and only about 5% has higher education. The District unemployment rate is 42.8%, with youth unemployment rate at 51.2%. An inter-sectorial approach, including ward-based structures such as Operation Sukuma Sakhe (OSS), and the Integrated Development Plan (IDP) forums, will be used to tackle many of the socio-economic challenges in the District, which impact on health and healthcare delivery.
Due to the rural nature of the District, households are far apart from each other, and people travel long distances to the nearest clinic. Transport scarcity and the influx of clients from neighbouring countries (Swaziland and Mozambique) justify construction of additional clinics to meet these demands.
Geographically UMkhanyakude District is rural and sparsely populated which has a negative impact to PHC accessibility. In addition, poor road and transport infrastructure and poor ambulance response times impede accessibility of health facilities, thus increasing mortality. Only 4% of the population are covered by a medical aid scheme, and there are no private hospitals in the District, so most of the population rely on public health facilities for healthcare.
The high illiteracy and unemployment rate and long distances to health care facilities have a negative impact on health seeking behaviour. The high unemployment rate leads to high psycho-social illnesses and difficulty affording travel to health facilities. The high illiteracy rate leads to high level of poverty in the District which aggravates the non-communicable diseases of lifestyle such as TB and HIV/AIDS. The first health contacts for most patients are traditional health practitioners which may delay seeking formal medical health assistance.
The high illiteracy rate impairs understanding of information, education, and communication (IEC) material distributed to the community, thus posing a challenge to changing life styles and health behaviour.
The severe malnutrition <5years incidence is 6.4/1000 which is above the district target of 6/1000. TB incidence is 832/100 000, which is largely attributed to a high HIV prevalence, poverty and unemployment.
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Data shows that there is a high diarrhoea incidence for under-5 years within the district (123/1000 population), especially in the Jozini Local Municipality where it is 152/1000 population. This is mainly attributed to the unavailability of potable water and malnutrition. These co-morbidities are being addressed through implementation of Operation Sukuma Sakhe and the Food for All campaign.
There is inadequate electricity supply in many parts of the District, particularly in the UMhlabuyalingana Municipality, resulting in high use of generators, candles, gas stoves & wood fires, which are health hazards. All PHC facilities are connected to electricity.
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6.3 EPIDEMIOLOGICAL (DISEASE) PROFILE OF THE DISTRICT
Figure 2: Disease Profile
HIV/AIDS 29.4 TB 20.5 Diarrhoeal Disease 8.3 LRI 5.1 Cerebrovascular Disease 3.6
DC 27 Hypertensive Heart Disease 2.5 Transport Injuries 2.4 Meningitis & Encephalitis 1.9 Interpersonal Violence 1.9
10987654321 Diabetes Mellitus 1.9
0 5 10 15 20 25 30 35
Maternal Mortality
Indicator 2011/12 2012/13 2013/14 Maternal Mortality rate 68/100k 95/100k 60/100k Maternal Death in facility 10 14 9 Live Births in Facility 14 695 14 683 14 946
Infant and child mortality
Indicator 2011/12 2012/13 2013/14 Inpatient infant mortality rate 8/1K 10/1K 8/1K Inpatient Death under 1year 124 146 141 Population estimated Live Births 15 418 14 601 18 649 Inpatient child mortality rate 66/1K 59/1K 50/1K Inpatient Death under 5 years 171 213 192 Inpatient Separation under 5 years 2 577 3 584 3 847
District HIV & Aids Profile
Indicator 2011/12 2012/13 2013/14 Antenatal HIV prevalence 41.9% 41.1% 35.2%
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District TB Profile
Indicator 2011/12 2012/13 2013/14 TB cure rate 71.2% 68.0% 72% TB (new pulmonary)client cured 1 275 1 530 1 399 TB(new pulmonary) client initiated on treatment 1 793 2 257 1 935 TB Smear conversion rate at 2 months 65% 68% 62.3% Smear converted at 2months (negative) 1 191 1 305 1 073 New smear positive cases 1 831 1 918 1 721 TB(new pulmonary) defaulter rate 4% 2.5% 3.% TB(New pulmonary) treatment defaulter 72 58 59 TB(New pulmonary) client initiated on treatment 1 793 2 257 1 935 TB AFB Sputum results turnaround time <48 hours rate 61% 56% 63.9% TB AFB Sputum results received within <48 hours 39 618 42 151 35 111 TB AFB sputum sample sent 67 752 75 105 54 910 TB Death rate 6.3% 3.9% 4.7% TB client died during treatment 113 89 90 TB client started on treatment 1 793 2 257 1 935
The table and graph above shows HIV infection to still be the leading cause of mortality in the District, which also affects TB morbidity and mortality, maternal mortality, and child mortality. The antenatal HIV prevalence is at 35.2%. Despite the high HIV and TB burden, the District maternal mortality ratio (MMR) remains low. Infant and child mortality indicators are showing an increase this financial year (2014/15). The TB cure rate has improved since 2008; however more effort is needed to achieve the target of 85%.
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7. DISTRICT SERVICE DELIVERY ENVIRONMENT
7.1 DISTRICT HEALTH FACILITIES
7.1.1 PRIMARY HEALTH CARE FACILITIES
Table 3 (NDoH 1): PHC facilities (Provincial and LG combined) per Sub-District as at 31 March 2014
Sub-Districts Health Posts Mobiles Satellites Clinics Community Community Standalone District Day Centre1 Health MOU3 Hospitals Centres (24 x 7)2 LG P LG P LG P LG P LG P LG P LG P
Hlabisa LM 0 0 0 2 0 0 0 5 0 0 0 0 0 0 1 Jozini LM 0 0 0 6 0 0 0 18 0 0 0 0 0 0 2 Mtubatuba LM 0 0 0 2 0 0 0 12 0 0 0 0 0 0 0 The Big 5 False Bay LM 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 UMhlabuyalingana LM 0 0 0 7 0 0 0 18 0 0 0 0 0 0 2 District 0 0 0 17 0 0 0 56 0 0 0 0 0 0 5
Source: DHIS There are no Health posts, CDCs, Satellites, Stand Alone MOU and Local Government facilities in the district. One CHC at Jozini is under construction, planned to be opened next financial year May 2015. There are 56 PHC clinics (including 4 Gateway clinics) and 17 mobile teams servicing 251 points in the district.
1 There are no Community Day Centres in KwaZulu-Natal 2 All Community Health Centres (CHC’s) in KwaZulu-Natal do not have MOU’s according to the definitions used in the DHER 2011/12. All KZN CHC’s operate on a 24 hour, 7 day a week basis. 3 Accordingly to the DHER 2011/12 definitions for Stand Alone MOU’s, there are no Stand Alone MOU’s operational within KwaZulu-Natal
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The construction of Mpophomeni clinic under UMhlabuyalingana LM is behind schedule due to challenges with the awarded contractor. The construction of Hluhluwe clinic has been completed; and may be operational before the end of 2014/15 financial year. Future planned clinics on the STP include construction of Mpanzakazi and Mfekayi in Hlabisa and Emfihlweni in Manguzi.
Table 4: Provincial Clinic Facility to Population – 2013/14
Sub-Districts/ District PHC facility per pop ratio - PHC facilities per pop - PHC facilities per pop ratio PHC facilities per pop ratio Health Post Mob provincial - Clinical provincial - CHC provincial 0 Hlabisa LM 36 529 14 612 0 0 0 Jozini LM 29 994 10 554 0 0 Mtubatuba LM 89 689 14 948 0 0 The Big 5 False Bay LM 0 12 057 0 0 UMhlabuyalingana LM 22 777 8 858 District 0 37 530 11 393 0 Source: DHER 2013/14 Customised District Report
The population under UMhlabuyalingana LM indicates fair distribution of PHC facilities, but due to low density population not all clinics are within 10km radius. Hlabisa and Mtubatuba LMs need additional clinics according to population. There are no mobile teams under The Big 5 False Bay LM; this LM is serviced by Mtubatuba and UMhlabuyalingana LMs mobile teams. 14 mobile points at The Big 5 False Bay are supported by Mseleni hospital and 3 supported by Mtubatuba LM mobiles, their data are inclusive under Mseleni and Mtubatuba mobiles respectively.
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Table 5 (NDoH 2): District Hospital Catchment Populations 2013/14
Name of District Hospital 2012/13 2013/14 Hlabisa Hlabisa Hlabisa Mseleni Mseleni Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Mosvold Mosvold Manguzi Manguzi Manguzi Bethesda Bethesda Bethesda
Catchment Population of District Hospital 108 124 249 395 110 885 116 065 82 052 88 039 252 436 100 487 109 726 87 322 Source: DHER 2013/14 (GIS)
Note: District Hospital Catchment Populations are calculated according to the catchment population of referring clinics.
Table 6: Beds per population, BUR and ALOS District Hospitals Population Inpatient Beds Average Beds Per Beds Utilization Length of population Rates Stay Bethesda 88 039 222 48.3 5.5 1:397 Hlabisa 252 436 275 65.6 6.0 1:918 Manguzi 100 487 284 59.1 5.6 1:354 Mosvold 109 726 244 60.2 6.4 1:450 Mseleni 87 322 219 63.8 4.3 1:399 District 638 011 1 244 60.7 5.5 1:513
Four hospitals are distributed evenly in the north of the district (60-80 kilometres apart) but only1 hospital at Hlabisa on the south of the district. There is no hospital in Mtubatuba and Hluhluwe. With the establishment of Mtubatuba CHC the situation will improve. There is a difference in population figures for 2012/13 and 2013/14 due to census 2011. Hlabisa and Mseleni population increased by 1% and 6% respectively in 2013/14, while there was a decrease in the other hospitals. Hlabisa hospital is serving two sub districts Mtubatuba LM and Hlabisa LM and Mseleni serving
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part of UMhlabuyalingana LM and The Big Five False Bay LM. Even with the population increase the bed status has not changed. Mosvold hospital is serving patients from Swaziland and Manguzi is serving patients from Mozambique.
All the hospitals especially Bethesda is also serving cross boundary patients from adjacent districts. According to the table there is an unequal distribution of beds to population and also unequal utilization of beds.
The cross border and cross boundary movements have a negative impact on service delivery such as poor monitoring of treatment outcomes, tracking of defaulters and tracking of patients.
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7.2 TRENDS IN KEY DISTRICT HEALTH SERVICE VOLUMES
7.2.1 PRIMARY HEALTH CARE SERVICE VOLUMES AND UTILISATION
Table 7 (NDoH 3): PHC Headcount Trend
Sub-District 2012/13 2013/14 Variation PHC PHC Total PHC Total PHC PHC Total PHC Total PHC PHC Total PHC Total Headcount Headcount Utilisation Headcount Headcount Utilisation Headcount Headcount Utilisation – Provincial Rate – Provincial Rate – Provincial Rate Hlabisa LM 211 375 211 375 2.1 221 145 221 145 3.0 0.05 0.05 0.43 Jozini LM 652 528 652 528 3.0 699 187 699 187 3.7 0.07 0.07 0.23 Mtubatuba LM 552 737 552 737 3.8 563 149 563 149 3.1 0.02 0.02 -0.18 The Big 5 False Bay 116 690 116 690 3.1 129 783 129 783 3.6 0.11 0.11 0.16 LM UMhlabuyalingana 660 784 660 784 4.0 677 732 677 732 4.2 0.03 0.03 0.05 LM District 2 194 114 2 194 114 3.2 2 290 996 2 290 996 3.6 0.04 0.04 0.13
Source: DHIS downloads
There is a consistent increase of 4% per year (from 2011/12 to 2013/14) in total PHC headcount. The increase of 18% and 11% for The Big 5 LM is due to better staffing and improved monitoring of utilization rate. Mtubatuba LM has a decrease of 6% in 2011/12 and a slight increase in 2013/14 this could be due to data clean-up.
The district utilization has increased from 3.2 to 3.6 (from 2011/12 to 2013/14); the biggest increase was at The Big 5 False Bay (0.9) which is due to improvement in staffing followed by UMhlabuyalingana (0.8) and Jozini (0.7). There has been a decrease of 0.4 at Mtubatuba LM, partially due to increase in population.
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Graph 2: PHC Utilisation (Provincial Clinics) vs. Population to PHC facility (Provincial clinics) – 2013/14
16000 4.5 14000 4 12000 3.5 10000 3 2.5 8000 2 6000 1.5 4000 1 2000 0.5 0 0
Population to PHC facility (avg) PHC utilisation Rate
Source: DHIS & DHER 2013/14 Customised District Report
Graph 3: PHC Utilisation rate in relation to PN Workload Provincial Clinics
4.5 60.0 4 50.0 3.5 3 40.0 2.5 30.0 2 1.5 20.0
1 Workload Rate PHC Utilisation Rate UtilisationPHC 10.0 0.5 0 0.0 Hlabisa LM Mtubatuba LM Umhlabuyalingana LM
PHC Utilisation rate PN Workload
Source: DHIS, DHER
Hlabisa LM has the highest workload of 52.5 and the lowest utilization rate of 3.0. The workload of 52.5 at Hlabisa is not a true reflection of what is happening because of poor recording of workload for the relieving PNs. Training on recording clinical workload has been conducted and linking of staff is in progress
Jozini LM has a PN workload of 50.7 and utilization rate of 3.7. This is due to high vacancy rate at PHC and highest population of this local municipality. HR assessments were conducted by the District Office with MatCH support which revealed high staff turnover due to dissatisfaction on management style and personal problems, and remedial action plan for high staff turnover has been developed and implementation will be monitored.
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UMhlabuyalingana and The Big Five False Bay LMs are well staffed (workload 39.9 and 39.3 respectively) compared to other LMs. UMhlabuyalingana LM has the highest PHC utilization rate of 4.2 which means PHC services are well utilised. The district PHC workload is 46 which is above the target of 35.
It is recommended that vacant PNs posts be filled to reduce the district PN workload. PHC supervisors should conduct quarterly productivity reports to determine PNs workloads for PHC facilities.
Table 8 (NDoH 4): District Hospital activities
District Hospitals Year Bethesda Hlabisa Manguzi Mosvold Mseleni District Hospital Hospital Hospital Hospital Hospital Totals
1. Inpatient 2012/13 45 282 64 274 58 037 49 812 50 851 268 256 Days – total 2013/14 39 168 65 844 61 267 53 598 50 898 270 775
Variation -0.1 0.02 0.06 0.08 0 0.01
2. Day patient 2012/13 158 84 1 582 24 75 1 923 – total 2013/14 0 30 1 7 157 195
Variation -1 -0.6 -1 581 -0.7 1.1 -0.9
3. OPD 2012/13 4 374 5 106 36 987 4 586 13 707 64 760 Headcount 2013/14 6 011 7 930 39 683 8 547 8 985 71 156 not referred new Variation 0.37 0.55 0.07 0.86 -0.34 0.1
4. Inpatient 2012/13 8 129 10 841 10 555 8 517 10 874 48 916 Separations 2013/14 7 148 10 904 10 939 8 398 11 877 49 266
Variation -0.12 0.01 0.04 -0.01 0.09 0.01
5. Inpatient 2012/13 417 772 440 439 357 2 425 Deaths 2013/14 366 761 397 389 382 2 295
Variation -0.12 -0.01 -0.10 -0.11 0.07 -0.05
6. OPD 2012/13 46 115 85 671 78 425 41 899 57 617 309 727 Headcount 2013/14 52 490 100 221 89 392 46 242 49 712 338 057 – total Variation 0.14 0.17 0.14 0.10 -0.14 0.09
7. Emergency 2012/13 3 182 3 305 4 787 1 016 3 019 15 309 headcount 2013/14 1 636 622 5 773 653 973 9 657 total Variation -0.49 -0.81 0.21 -0.36 -0.68 -0.37
8. Patient Day 2012/13 61 793 93 975 86 565 64 129 71 100 377 563 Equivalent 2013/14 57 192.0 9 9439.7 92 957.4 69 217.5 67 854.6 386 661.2
Variation -0.07 0.06 0.07 0.08 -0.05 0.02
9. Cost per 2012/13 R1 582 R1 592 R1 389 R1 630 R1 391 R1 513
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District Hospitals Year Bethesda Hlabisa Manguzi Mosvold Mseleni District Hospital Hospital Hospital Hospital Hospital Totals
PDE 2013/14 R1 828 R1 733 R1 610 R1 589 R1 697 R1 675
Variation 0.16 0.09 0.16 -0.03 0.22 0.11
10. Delivery by 2012/13 23.3 25.9 16.7 20.1 16.6 21.2 caesarean 2013/14 25.5 24.2 16.9 19.6 20.7 21.6 section rate Variation 0.09 -0.07 0.01 -0.02 0.25 0.02
11. Average 2012/13 5.7 6.0 6.6 5.9 4.7 5.7 length of 2013/14 5.5 6.0 5.6 6.4 4.3 5.5 stay - total Variation -0.04 0 -0.15 0.08 -0.09 -0.04
12. Inpatient 2012/13 56.4 65.3 57.6 55.9 63.4 59.8 bed 2013/14 48.3 65.6 59.1 60.2 63.8 60.7 utilisation rate – total Variation -0.14 0.004 0.03 0.08 0.01 0.02
13. Total 2012/13 49 297 88 976 83 212 42 915 60 636 325 036 Ambulatory 2013/14 54 126 100 843 95 165 46 895 50 685 347 714 (OPD Headcount Variation 0.10 0.13 0.14 0.09 -0.16 0.07 Total + Emergency Headcount total)
14. Ratio of 2012/13 1.0 1.3 1.4 0.8 1.1 1.2 Ambulatory 2013/14 1.3 1.5 1.5 0.9 1.0 1.2 to Inpatient Days Total Variation 0.3 0.2 0.1 0.1 -0.1 0
Source: DHIS Downloads 2012/13 & 2013/14
Graph 4: District Hospitals Cost per PDE vs. IPD and OPD
90% R 1 850 80% R 1 800 70% R 1 750 60% R 1 700 50% R 1 650 40% R 1 600 30% 20% R 1 550 10% R 1 500 0% R 1 450 Bethesda Hlabisa Manguzi Mosvold Mseleni
Total IPD as % of PDE Total OPD as % of PDE Cost per PDE
Source: DHER 2012/13 Customised District Report
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The district expenditure per PDE is (R1 675) below the provincial target R1 854. The highest is Bethesda at R1 828 due to low PDE followed by Hlabisa at R1 733 and Mosvold being the lowest at R1 589. There was 11% increase in cost per PDE compared to 2012/13. Mosvold cost per PDE has decreased with 3% due to shortage of staff especially doctors and pharmacists.
There was an increase of 9%in the district OPD headcount. The biggest increase was at Hlabisa hospital at 17%, Manguzi and Bethesda at 14% and Mosvold at 10%. The increase was due to the increased number of patients attending PHC facilities and more of them were referred to hospitals. OPD patients not referred ratio at Mosvold hospital increased from 11% (2012/13) to 19% (2013/14) due to decreased visits by medical officers to PHC facilities which led to self-referral of patients to OPD. Certain services such as; dental, rehab services, social services etc. are available on daily basis at hospitals and only once a month at PHC facilities.
There was a decrease of OPD headcount by 14% at Mseleni hospital; this could be attributed to the establishment of a Gateway clinic as a cost centre.
Mosvold and Mseleni hospitals have high IPD than OPD headcount (53 598- IPD; 46 242-OPD and 50 898-IPD, 49 712-OPD respectively). This is attributed to waiting mothers being admitted as inpatients in both hospitals (Mosvold uses lodger beds for waiting mothers and Mseleni they are included in the usable beds). Manguzi hospital has high IPD headcount due to high number of MDR patients (catered for the whole district except for Hlabisa) and high OPD headcount due to monthly MDR follow-ups. There are high self-referrals as there is no Gateway clinic. The other reason for the increase OPD headcount at Manguzi is due to road construction leading to Mosvold and sometimes shortage of water supply for services like X-ray and poor medicine supply (stock out) at PHC facilities which lead to number of patients channelled to hospitals for medication. Data quality has been a challenge at Manguzi hospital with regards to emergency headcount 2013/14 due to poor understanding and this has been corrected from June 2014 after in-service education.
Overall there was 2% increase of PDE in the district with the highest increase of 8% at Mosvold hospital (10% increase of OPD headcount and 8% increase in-patient days) and a decrease of 7% at Bethesda and 5% at Mseleni hospitals.
The district BUR (60.7%) is below the provincial target (63%-69%). Hlabisa and Mseleni remained constant, Manguzi and Mosvold slightly increased in BUR due to change in admission criteria. There was a decrease in BUR at Bethesda hospital, it needs an investigation.
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8. DISTRICT PROGRESS TOWARDS THE ACHIEVEMENT OF THE MDG’S
Table 9 (NDoH 5): Review of Progress towards the Health-Related Millennium Development Goals (MDG’s) and required progress by 2015
MDG Target Indicator Provincial progress Source of data District progress District targeted 2013/14 2013/14 progress 2014/15
Goal 1: Halve, between 1990 Prevalence of underweight DHIS 0.4% 0.7% Eradicate Extreme and 2015, the children under 5 years of age Poverty And Hunger proportion of people who suffer from hunger Severe malnutrition under 5 years DHIS 5.6/1K 6/1k incidence )
Goal 4: Reduce by two-thirds, Under-five mortality rate – use DHIS 50/1k 70/1k Reduce Child between 1990 and proxy “Inpatient death under 5 Mortality 2015, the under-five years rate” mortality rate Infant mortality rate – use proxy DHIS 67/1k 97/1k “Child under 1 year mortality in facility rate”
Goal 4: Reduce by two-thirds, Measles 2nd Dose coverage DHIS 70.1% 90% Reduce Child between 1990 and Immunisation coverage under 1 DHIS 74.6% 85% Mortality 2015, the under-five mortality rate year
Goal 5: Reduce by three- Maternal mortality ratio (only DHIS 60.2/100K 70/100k Improve Maternal quarters, between 1990 facility mortality ratio) Health and 2015, the maternal mortality rate Proportion of births attended by DHIS 74.5% 87% skilled health personnel (Use delivery in facility as proxy indicator)
Goal 6: Have halted by 2015, HIV prevalence among 15- 19- National HIV Not reported Difficult to set a target Combat HIV and and begin to reverse year-old pregnant women Syphilis according to ages.
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MDG Target Indicator Provincial progress Source of data District progress District targeted 2013/14 2013/14 progress 2014/15
AIDS, malaria and the spread of HIV and Prevalence Survey other diseases AIDS of SA
HIV prevalence among 20- 24- National HIV Not reported Difficult to set a target year-old pregnant women Syphilis according to ages. Prevalence Survey of SA
Contraceptive prevalence rate DHIS 32.7% 50% (use Couple year protection rate as proxy)
TB Cure Rate ETR.Net 72% 83.3%
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9. PROVINCIAL AND DISTRICT CONTRIBUTION TOWARDS THE HEALTH SECTOR NEGOTIATED SERVICE DELIVERY AGREEMENT (NSDA)
The National Development Plan 2030 was adopted by government as its vision for the health sector. It will be implemented over three electoral cycles of government. The MTSF 2014-2019 therefore finds its mandate from National Development Plan 2030.
Table 10: (NDoH): Alignment between NDP Goals 2030, Priority interventions proposed by NDP 2030 and Sub-outcomes of MTSF 2014-2019 NDP Goals 2030 NDP Priorities 2030 Sub-Outcomes 2014-2019 (MTSF)
Average male and female life a. Address the social HIV & AIDS and Tuberculosis expectancy at birth determinants that affect prevented and successfully increased to 70 years health and diseases Managed Tuberculosis (TB) prevention and cure progressively d. Prevent and reduce improved; the disease burden and promote health Maternal, infant and child mortality reduced
Prevalence of Non- Maternal, infant and child Communicable Diseases mortality reduced reduced by 28%
Injury, accidents and violence reduced by 50% from 2010 levels
Health systems reforms b. Strengthen the health Improved health facility completed system planning and infrastructure delivery
Health care costs reduced
c. Improve health Efficient Health Management information systems Information System for improved decision making
h. Improve quality by Improved quality of health using evidence care
Primary health care teams Re-engineering of Primary deployed to provide care to Health Care families and communities
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NDP Goals 2030 NDP Priorities 2030 Sub-Outcomes 2014-2019 (MTSF)
Universal health coverage e. Financing universal Universal Health coverage achieved healthcare coverage achieved through implementation of National Health Insurance
Posts filled with skilled, f. Improve human Improved human resources for committed and competent resources in the health health individuals sector Improved health management and leadership g. Review management positions and appointments and strengthen accountability mechanisms
The NDP 2030, together with the MTSF 2014-2019, forms the umbrella goals for the health sector. These goals are specific but also generic enough to allow District management to develop their own plans in order to achieve the health sector goals but also incorporate priorities, which respond to localised challenges
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10. SUMMARY OF MAJOR HEALTH SERVICE CHALLENGES AND PROGRESS MADE FOR THE PREVIOUS THREE FINANCIAL YEARS
IMBALANCE IN SERVICE DELIVERY PLATFORM:
District health services are provided at five district hospitals with 56 PHC Facilities including four gateway clinics and 17 mobile clinics servicing 251 points. Multi-sectoral Teams from District hospitals are supporting PHC Facilities which relieves congestion in OPD. Five clinics (Mbazwana, KwaMsane, Jozini, Sipho Zungu and Ndumo) offer 24 hour open door services; 36 clinics offer after hours on-call services; seven clinics do not offer on call services and delivery services due to lack of space; four do not offer on call services due to shortage of staff; four gateway clinics are open from Monday to Friday, but do not offer after hours on- call services. Maputa clinic has been regarded as a gateway clinic whereas in reality it is a day clinic. Maputa clinic has started to operate on weekends and extended hours of operation from 16H00 to 18H00 in August 2014 and this has decreased number of patients in OPD. This is the best practise of decongesting OPD by ±20 patients per day. The full comprehensive package of services is not offered at all clinics due to space constraints.
Mpembeni clinic was established as a cost centre in April 2014 which will improve spending patterns in terms of COE. Mobile teams have increased from 14 to 17 and points from 208 to 251 in the past three financial years. There has been a steady increase (4%) in total PHC headcount, from 2 099 757 in 2011/12 to 2 194 114 in 2012/13, and 2 290 996 in 2013/14, indicating an overall improved PHC access throughout the District.
The PHC supervision rate is fluctuating for past three years. In 2011/12 it was 97% and declined in 2012/13 to 89%, in 2013/14 to 85%. Although the PHC supervision rate was high, the outcome was not satisfactory, based on continuing quality and efficiency challenges persisting in PHC facilities such as shortage of basic equipment, data quality, etc.
There are no CDCs, Satellites, MOUs and Health posts in the district. A Community Health Centre (CHC) in Jozini Local Municipality is under construction; Mpophomeni clinic under UMhlabuyalingana LM (Manguzi) and Hluhluwe clinic under The Big 5 False Bay LM are under construction. The population under UMhlabuyalingana LM indicate fair distribution of PHC facilities, but due to low density population not all clinics are within 10km radius. Hlabisa and Mtubatuba LMs need additional clinics according to population. There are no mobile teams under The Big 5 False Bay LM; this LM is serviced by Mtubatuba and UMhlabuyalingana LMs mobile teams. 14 mobile points at The Big 5 False Bay are supported by Mseleni hospital and 3 supported by Mtubatuba LM mobiles, their data is inclusive under Mseleni and Mtubatuba
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mobiles respectively. Construction of Mtubatuba CHC is on hold due to budgetary constraints for the next MTEF period. Future planned clinics on the STP include construction of Mpanzakazi and Mfekayi in Hlabisa and Emfihlweni in Manguzi.
PROBLEMS IN REFERRAL CHAIN:
There are no ward based outreach teams appointed as yet in the district, this compromises supervision of CCGs. The referral system starts with Community Care Givers and Phila Mntwana Centres which are based in the community. They refer to mobile clinics then mobiles refer to fix PHC Facilities. PHC Facilities refer to district hospitals, hospital if necessary refer to regional hospital. There is no Specialized and Regional hospital in the district which poses a challenge in the transfer of emergency patients. Emergency patients are transferred to Ngwelezane hospital and Obstetrics emergency referrals to Lower Umfolozi Memorial hospital which is about 260 km (single trip) away and Inkosi Albert Luthuli hospital is about 410 km from Mosvold hospital.
The referral hospital for Mental Health Care Users is Ngwelezane which has got a Psychiatric wing however, there is a space challenge at Ngwelezane and patients are referred to Madadeni hospital which is about 500km away (single trip from Manguzi hospital). There are cost implications in transfer to and back of these patients because sometimes there is only one case that needs transfer. On discharge of these patients again to fetch one patient at a time has high transport cost implications
INTRA-DISTRICT REFERRAL: Bethesda hospital - TOP and Colposcopy services Manguzi hospital - MDR services for 4 hospitals except for Hlabisa hospital and TOP services Mosvold hospital - Cataract surgery Mseleni hospital - Hip replacements The services mentioned above are for the entire district.
STAFF MIX AND PROVISION OF CARE: The district has a challenge in recruiting certain categories of staff; Medical Officers, Pharmacists, Allied Professionals, Clinical Nurse Practitioners and Specialised Nurses. The district has a high staff turnover which affects service delivery. Bursaries and training programmes are offered to train staff and local youth to increase the pool of required skills.
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Due to the rural nature of the district retention of some categories of staff remains a challenge as they don’t honour their contractual obligation of serving back the number of years trained. The hospitals rely on Community Service Officers for sustaining service delivery.
The vacancy rate for Doctors grossly increased from 9% (2012/13) to 32% (2014/15 Q1). At a glance, the increased vacancy rate is misleading as the actual number of posts increased from 79 to 97 in this financial year. The district has reviewed the accommodation strategy and provided more capacity building efforts to retain doctors.
Vacancy rate for Pharmacists improved from 42% (2012/13) to 35% (2014/15 Q1). This is attributed to absorption of Bursary holders and retention of Community Service Pharmacists. The vacancy rate for Pharmacist Assistants improved from 38% (2012/13) to 16% (2014/15 Q1), because Mosvold and Mseleni hospitals have appointed 11 and 4 respectively.
There was a 6% vacancy rate of PNs in 2012/13, this increased to 9% in 2014/15, Q1.
DISTRICT HOSPITALS AND PHC INFRASTRUCTURE REVITILIZATION: There is much improvement in infrastructure development in all district hospitals. New wards and some of staff residences were constructed according to the specifications of DoH such as paediatric ward, female ward and Doctors residence at Manguzi, theatre at Hlabisa, Maternity ward at Mosvold, Peads ward at Bethesda and female and multi-disciplinary therapy department at Mseleni. Clinics upgrade includes Gwaliweni, Gateway, Makhathini, Ophansi, Bhekabantu, etc. Hlabisa hospital is under revitalization program.
The aesthetic improvement of some physical facilities has improved staff morale, infection prevention & control and dignity of patients.
QUALITY OF CARE IMPROVEMENTS: All facilities are implementing National Core Standards, Infection and Prevention control policy and developing QIPs (Quality Improvement Plans). Bethesda and Manguzi were assessed by the Office of Health Standards Compliance and they scored above 70% which is a remarkable milestone in rural hospitals. There is still a challenge in gap assessments and implementation of quality improvement plans in all hospitals which needs strengthening. Five hospitals were assessed in 2013/14 and were all found compliant in IPC.
There is a still a challenge in the implementation of National Core Standards in PHC facilities and this is attributed to poor supervision and unavailability of basic equipment that is not in the provincial PHC equipment list e.g. defibrillator. Four clinics (Mboza, Mnqobokazi and
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Zamazama) were visited by office of Health Standards Compliance. Mboza scored 58%; Zamazama scored 51%, Mnqobokazi scored 43% and Mabibi scored 43%
Complaints mechanism is a challenge at PHC facilities because of complaint boxes not opened, and when opened not resolved despite support visit. Continuous monitoring will be conducted to ensure that suggestion boxes are opened at least monthly and complaints should be resolved within 25 days. The Operational Managers to take full responsibility.
PUBLIC/PRIVATE INTERACTIONS
In the past three financial years Umkhanyakude has been supported by various development partners concentrated on Health Systems Strengthening, and Priority programs. This has assisted the district in trainings for certain programs and improvement in some indicators e.g. TB cure rate, ANC 1st visit before 20 weeks, Orientation on data management, MMC uptake, PMTCT dashboard indicator monitoring, nurses trained on NIMART initiation, etc.
TUBERCULOSIS (TB)
TB treatment outcomes have improved over the last three financial years due to improved management and monitoring of the programme. The TB cure rate for the district has slightly improved from 71% in 2011/12, 68% in 2012/13 to 72% in 2013/14. The TB death rate slightly decreased from 6.3% in 2011/12, 3.9% in 2012/2013 and 4.7% in 2013/14. The increase of new MDR confirmed cases from 198 in 2011/12 to 284 in 2012/13 and 328 in 2013/14 is attributed to improved active detection and surveillance, attributed to the use of the GeneXpert machine; improved data management; and increase in primary MDR cases. MDR-TB patients began to be initiated on treatment at Hlabisa Hospital in June 2013.
MATERNAL CHILD AND WOMEN’S HEALTH (MCWH)
The district continues to improve in MCWH indicators. The maternal mortality trend declined from 68/100 000 in 2011/12, 95.3/100 000 in 2012/13 to 60/100 000 in 2013/14. The ‘1st ANC attendance before 20 weeks rate’ improved from 48% in 2011/12, 54% in 2012/13 and 61% in 2013/14. Under-1 year facility mortality decreased from 8/1000 in 2011/12, 10/1000 in 2012/13 and 8/1000 in 2013/14. Child under-5 years facility mortality rate was 66/1000 in 2011/12 then decreased to 59/1000 in 2012/13 and 51/1000 in 2013/14.
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The decrease in child mortality under-1 year is attributed to:
implementation of new PMTCT guidelines,
ESMOE trainings, emergency obstetric drills and continuous monitoring of the programme.
A slight improvement is noted in vitamin A supplementation for children 12 to 59 months, which was 30.3% in 2011/12, 33.9% 2012/13 and 51.1% in 2013/14. There is still a challenge in administering vitamin A to children in pre-schools and crèche’s. The Phila Mntwana Campaigns should improve vitamin A uptake and detection of malnutrition. There are still areas that are affected with severe malnutrition within the district. Severe malnutrition case fatality rate under 5 years was 8.2/1k in 2011/12, increased to 9.2/1k in 2012/13 and decreased in 2013/14 to 5.6/1k.
HIV AND AIDS
The district is still having a challenge of Antenatal HIV prevalence which is very high for the past three years in the District being 41.9% in 2011/2012, 41.1% in 2012/13 and 35.2%in 2013/14. All five hospitals and All 56 clinics are now implementing the 3-TIER Strategy. 53 Clinics have been signed off on TIER.net. All PHC clinics have at least one nurse trained on NIMART and all are initiating. The total number of patients on ART continued to increase from 43 332 in 2011/12, 53 373 in 2012/13 to 58 643 in 2013/14.
In total 236 (2012/13) PNs have been NIMART trained in the district. In 2013/14 additional 144 PNs were trained on NIMART.
The STI programme management remains a challenge in the district. The incidence of STI remains high at 84/1k in 2011/12, 80/1k in 2012/13 and 84/1k in 2013/14. The STI partner treatment rate has increased from 14% in 2012/13 to 14.9% in 2013/14. Condoms are distributed by the health facilities, and through private distributers. Total number of condoms distributed in 2013/14 is 3 852 193 by health facilities and private distributers.
Mkuze High Transmission area (HTA) site is functional and Mtubatuba HTA is not yet functional.
The district has never reached MMC target set by the Province. Male Medical Circumcision numbers are increasing with the support from partners. From 3 890 circumcisions performed in 2011/12, 6 275 were performed in 2012/13 and10 153 for 2013/14. Mobilisation strategies need to be reviewed.
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NON COMMUNICABLE DISEASE:
In line with output 1 of the NSDA, the district provides services to promote a healthy lifestyle, prevent, detect early and manage non communicable diseases. There is a very slight decrease in the incidence of hypertension over the past three years. In 2011/12 it was 25.9/1000(2737), 24.5/1000(2622) in 2012/13 and 22.2/1000(2588) in 2013/14. The incidence of diabetes mellitus in 2011/12 was 08.3/1000(545), 0.63 /1000(423) in 2012/13 and 0.8/ 1000(527) in 2013/14. Whilst the incidence of diabetes mellitus seems to be fluctuating, the number of diabetic amputations is escalating. In 2011/12 there were 15, 17 in 2012/13 and 25 in 2013/14. The increase could be attributed to late case detection and sub optimal management. The district needs to strengthen promotion of healthy lifestyle.
There are two sight saver sites in the district, one at Hlabisa and The other at Mosvold. There is one Ophthalmic Medical officer who roves between the two sites for cataract surgery. The Cataract Surgery Rate in 2011/12 was 679/1mil, 735/1mil in 2012/13 and 798/1mil in 2013/14.
DISABILITY & REHABILITATION:
The District continues to offer disability and rehabilitation services. There has been a steady increase of people with disabilities accessing disability services for the past three years from 63 544 in 2012/13 to 71 783 in 2013/2014. Issuing of hearing aids was 174 in 2011/2012 and decreased to 80 in 2012/2013 financial year, this was due to shortage of audiologists in the district. In 2013/2014 financial year the number of hearing aids issued increased to 316 due to an increase number of community service audiologists in the district. The issuing of wheelchairs also continued to increase from 322 in 2011/2012 to 480 in 2012/2013 due to an improved procurement processes and a huge backlog at Hlabisa hospital. In 2013/2014 financial year there was a decrease in the issuing of wheelchairs to 387. The district has six functional wheelchair repair sites which help in recycling of wheelchairs. The recruitment of permanent appropriate Rehabilitation Therapists staff of all 4 categories in all District hospitals remains a major challenge especially of Audiologists and therapy assistants due to difficulty in recruiting this category and one year program is being offered for Therapy assistants to be bridged as Therapy Technicians. Bursaries are also offered for prospective candidates.
Physical accessibility still remains a challenge especially in PHC Facilities and several toilets for the disabled were non-functional due to poor maintenance. It needs to be prioritised on annual maintenance plans. There are only two Community based Rehabilitation workers (CBRs) in the district as per Disabled Persons’ South Africa (DPSA) and Department of health Service Level Agreement; one based at Kwa-Ngwanase and Mtubatuba Municipalities. Ideally each Local Municipality will need to have one CBR as these two CBRs are unable to
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service the whole district. The district will continue to liaise with the Provincial office to review this issue.
MALARIA:
The District is moving towards elimination of Malaria with an incidence of 0.33/1000 population per year. A threat to malaria control in the District is the cessation of insecticide spraying on the Mozambique side of the border, as well as the emergence of mosquito resistance to insecticides. Increased entomological surveillance is required with an improved insectary at Malaria Control and this matter has been referred to entomologist. The current first line treatment of malaria, artemether-lumefantrine still appears to be effective, supported by an audit of its efficacy in 2012. Malaria elimination in South Africa is aimed for 2018. Malaria case fatality rate was 1 % in 2011/12, 1% in 2012/13 and 1.9% which indicates that there are still clients that delay in seeking medical help. Indoor spraying coverage has decreased over the past 3 years due to certain individuals refusing to have their houses sprayed. The coverage has decreased from 93% in 2011/12, 82% in 2012/13 and 75% in 2013/14.
EMERGENCY MEDICAL SERVICES (EMS):
EMS response time has not improved in the past three years, contributing to adverse events and negative publicity. Poor road infrastructure further hinders response time. The District has 18 operational ambulances but the response time is not improving. Response time is presently 29% ambulances arriving within 60 minutes. The Turn-Around-Strategy was developed but EMRS challenges are persistent.
INFRASTRUCTURE:
Unreliable water supply, especially in Bethesda, Mosvold, Hlabisa and some of their clinics contributes to service delivery challenges, including non-functioning laundry, X-ray and autoclaving machines. Lack of water also increases likelihood of machine breakdown, increased staff overtime with unbudgeted costs.
An improvement is noted in delivery of capital projects; however, there are still backlogs, especially with clinic building, including Mtubatuba CHC, Ezibayeni and Mpembeni clinics.
HUMAN RESOURCES
The overall vacancy rate has improved from 20% in 2011/2012 to18% 2012/13 and to 14% in 2013/14. Although this indicates improvement but the challenge still remains in the
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recruitment of critical (Artisans) and clinical personnel (Pharmacists, Medical Officers). There is high staff turnover in the district which compromises service delivery. HR assessments were conducted which revealed dissatisfaction on management style and social personal problems to be the leading causes of staff turnover. Turnaround strategies have been developed and their implementation to be monitored.
There is increased absenteeism due to ill health of staff that ends up in prolonged sick leave which affects service delivery and high COE for staff that does not render services as was appointed to. Staff wellness programmes are implemented in all hospitals and PILLIR procedures to be implemented.
The total of 129 employees benefited on training programmes in 2011/12 and massively improved to 781 in 2012/13 and 415 in 2013/14.Theses training programmes are intended to capacitate the employees to improve service delivery. 19 Local youth has been awarded prospective bursaries to study Health sciences in SA and 35 Cuban Doctors bursaries have been awarded in 2012, 17 prospective bursaries, 27 Cuban Doctors bursaries awarded in 2013 and 6 prospective bursaries, 12 Cuban Doctors bursaries and 3 Manipal Phase 1 bursaries have been awarded in 2014. These bursaries are intended to increase the pool of the required skills that are currently scarce to improve service delivery.
Although training of Local youth is seen as a solution in retaining staff, some of them fail to honour their contractual obligation due to departmental policy on bursary holders. This matter has been brought to the attention of the department.
The district managed to retain 12 bursary holders in 2012, 7 in 2013 and 21 in 2014. 29 CCGs have been trained as Nutritional advisors in 2012 and 26 in 2014 and all clinics have one nutritional advisor.
FINANCE:
The district spent 100.09%, 100.01% and 100.81% in 20011/12, 2012/13 and 2013/14 respectively. This is attributed to regular movements of funds and balancing of expenditure. 1% of the allocation was for Management, 47% for PHC and 52% for District Hospitals in 2013/14. There has been an increase in percentage spent by PHC from the district total expenditure (45% in 2012/13 to 47% in 2013/14), this improvement is noticeable, but it could be more than this if journaling and staff linking was accurate.
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There has been a slight increase in cost per headcount in the past three years (R94, R97 and R108 in 2011/12, 2012/13 and 2013/14 respectively. Expenditure per PDE shows an increase when comparing the past three years; R1 295 in 2011/12, R1 539 in 2012/13 and R1 675 in 2013/14.
Medical supplies are high cost driver at R45.90 followed by medicines at R36.80 in the non- negotiable items. This is attributed to unavailability of storage space, poor stock management and journaling. Continuous training and support are conducted to all institutions with a minimal change. Computerised stock management system will be introduced. The district is still struggling with the linking of staff especially in nursing category where Nurses are allocated under PHC facilities and their salaries paid from hospitals. Finance and HR sections are not informed about these movements so as to channel expenditure accordingly. This gives a skewed picture in terms of expenditure management. Collaboration between HR, Finance and Nursing management needs to be strengthened.
DATA MANAGEMENT
Data quality remains a challenge in the district despite trainings and support given to health facilities. The information management teams meet infrequently. The data quality audits reveal that there is poor understanding of certain data elements and data collection tools are not used. 44/56 clinics have data capturers. Training of PHC Operational Managers has been conducted. A plan is to train all Operational Managers and Area Managers at hospitals in Monitoring and Evaluation.
25 Data capturers have been trained by Enhance Strategic Information (ESI) on DHIS, data quality and indicators.
PHC RE-ENGINEERING DISTRICT CLINICAL SPECIALIST TEAM (DCST)
The District has so far appointed four members of the DCST: Specialist Family Physician, Specialist Midwife, Primary Healthcare Nurse, and Specialist Paediatric Nurse. There have been no applicants for the posts of Obstetrician, Paediatrician or Anaesthetist. Three of the first-appointed team members underwent induction training.
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SCHOOL HEALTH TEAMS
School health teams in the District have increased from five to ten, each containing two- three nurses. Seven school health teams are linked to PHC facilities. Clinics have school health components in their structure but lack transport for school health nurses to travel to schools from clinics. Vehicles are presently a limiting factor for proper functioning of school health teams as there is no budget for school health team vehicles. Motivation for vehicles budget will be sent to Head Office by the District. It is hoped that these teams can reduce teenage pregnancy and HIV infection in teenagers, particularly females. The introduction of the HPV vaccine has increased the awareness of cervical cancer to learners and parents.
COMMUNITY CARE GIVER (CCG) PROGRAMME
The number of Community Care Givers has increased from 686 in 2011/12 to 749 in 2012/13 and 783 CCGs in 2013/14.The increase is not according to the demand of the programme because of limited budget. All 68 Municipal wards have CCGs but some areas do not have CCGs as 1 CCG is allocated 60 homesteads .Over the past 3 years 125 CCGs were career pathed as enrolled nurses and 22 as Enrolled Nursing Assistants.55 CCGs were career pathed as Nutritional Advisors They are performing community health functions including: home based care, community profiling, and referral of pregnant women to health facilities, vitamin A administration and administration of directly observed treatment (DOT) of tuberculosis medication. They attend weekly war-rooms at ward level. The TB cure rate and vitamin A coverage in the District has improved in recent years due to their involvement. Antenatal booking rate before 20 weeks gestation has also improved. CCGs are also allocated to work in Phila Mntwana centres where they weigh babies, administer vitamin A and do health education. The appointment of CCG is centrally done at the District Office which poses a challenge in the management of their HR related matters such as leaves and service termination. Proposal has been made to Head Office to link the CCGs to their mother hospitals.
FAMILY HEALTH TEAMS:
No family health team has yet been appointed in the district and no vehicles allocated for the service. A family health team consists of a PN, clinical nurse practitioner, EN, ENA, and six CCGs per team. It is planned to appoint five teams in the District in the 2014/15 financial year. The teams are intended to provide healthcare in the community.
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10.1 INTRA DISTRICT EQUITY IN THE PROVISION OF SERVICES
Table 11 (NDoH 6): PHC Expenditure
Sub-District PHC Expenditure / PHC Utilisation Rate Patient to PN % Share of District Uninsured Capita Provincial clinics Population
Hlabisa LM R259.70 3.0 7 224.2 11%
Jozini LM R417.10 3.7 5 286.4 30%
Mtubatuba LM R346.60 3.1 6 869.8 28%
The Big 5 False Bay LM R412.20 3.6 6 830.7 6%
UMhlabuyalingana LM R514.80 4.2 5 343.8 25%
District R390.08 3.6 7 250.0 100%
Source: DHER 2013/14 Customised District Report, DHIS
Graph 5: Equity of resources vs population and headcount – 2013/14
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
% Share of PN's % Share of Population % Share of Expenditure % share of PHC headcount
Source: DHER 2013/14 Customised District Report
UMhlabuyalingana LM has the highest PHC expenditure per uninsured population (R514.8), utilization rate of 4.2 and cost per headcount (R116.40) compared to Hlabisa with the lowest PHC expenditure per uninsured population (R259.7), lowest cost per headcount (R82.5) and lowest utilization rate of 3. This shows that UMhlabuyalingana LM has more focus on PHC than district hospital.
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There are still instances of staff deployment from Hospitals to PHC facilities for service delivery demands and vice versa due to poor communication about staff allocation. This results in the number of filled posts not matching with the number of actual staff working in the facilities. This is problematic since it skews the expenditure which requires constant journaling. The main reason for staff deployment is poor management. This happens in all cadres of staff but nursing being the mostly affected component. Working relationships between Finance, HR and component Managers especially nursing must be encouraged as this is not happening at institutions. Unfreezing and filling of posts to be done to ensure proper allocation of staff.
The above graph indicates low % share PN in Hlabisa (7%) compared to population, expenditure and headcount. It must be taken to account that Mpembeni clinic is completely staffed by Hlabisa hospital nurses and journaling not done.
Jozini and UMhlabuyalingana LMs have high % share PN (31.3% and 31.6% respectively) compared to population and headcount, but a little bit more expenditure due to demographics and topography. Mtubatuba LM has high population with low % expenditure due to population density that may be corrected with the construction of the CHC in future. The Big 5 False Bay has a relatively low expenditure compared to population and headcount, but that will be corrected by the opening of Hluhluwe clinic in the near future.
Proper linking of staff as per staff establishment is recommended and implementation of Workload Indicators of Staffing Needs (WISN).
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Table 12 (NDoH 7 (a)): Number of patients to staff type (Sub-District) – PDoH PHC Clinics
Sub-District
Administrat or Staff Clinical Other Counsellor Data Capturer General / Worker Cleaner Medical Officer Nurse Assistant Pharmacist Assistant Basic Pharmacist Assistant Basic Post Pharmacist Professional Nurse Nurse Staff Specialist 0 0 0 0 0 Hlabisa LM 36 121.0 11 287.8 60 201.7 20 067.2 0 90 302.5 7 24.2 5 826.0 0 0 0 0 0 0 Jozini LM 81 561.9 15 430.6 51 903.0 21 145.7 28 547.7 5 286.4 5 437.5 0 0 0 0 0 Mtubatuba LM 47 464.4 15 356.1 47 464.4 30 712.2 174036.0 522 108 6 869.8 7 566.8 The Big 5 False Bay 0 0 0 0 0 0 43 261.0 21 630.5 6 4891.5 43 261.0 6 4891.5 6 830.7 7 210.2 LM UMhlabuyalingana 0 0 0 0 0 0 80 157.1 12 197.8 35 068.8 12 197.8 35 068.8 5 343.8 5 906.3 LM District 71 593.6 0 16 722.6 545261.1 22 683.1 0 57 274.9 2 290 996 0 0 5 862 7 687.9 0
Source: DHER 2013/14 Customised District Report, DHIS
The above table indicates a huge discrepancy amongst sub-districts and in all categories of staff. It is difficult to compare because of unavailability of staffing norms; fast tracking of WISN implementation could assist. Nevertheless Jozini and UMhlabuyalingana have high patient to Admin staff ratio compared to other sub-districts, because of the lack of support staff at PHC facilities. High patient to Counsellors, Data Capturers and General Worker’s ratio at The Big 5 False Bay will be improved with the opening of Hluhluwe clinic.
There are 5 Pharmacist Assistants in the clinics one at KwaMsane clinic in Mtubatuba LM and four appointed at Mosvold clinics under Jozini LM. The province is planning to create Pharmacist Assistants post in remaining PHC facilities. The patient to PN ratio is high at Hlabisa LM however this is not taking into account PNs deployed from the hospital. Mtubatuba LM has high patient to SN ratio, but again these officials are deployed at clinics by Hlabisa hospital. There are NAs at some clinics throughout the district, but their scope of practice is limited.
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There are reviewed PHC structures but budgetary constraints hinders filling of posts. PHC support expenditure (COE) is linked to hospital but render services to clinics, but all other goods and services items e.g. transport are paid from district hospital. This is not giving the true picture of goods and services expenditure and it affects planning and budgeting. It is recommended that cost centre management be improved to allow accurate costing of all PHC activities.
Table 13 (NDoH 7 (b)): Number of patients to staff type (Sub-District) – CHC’s
Sub-District Specialist Counsellor Data Capturer General / Worker Cleaner Medical Officer Nurse Assistant Pharmacist Assistant Basic Pharmacist Assistant Post Basic Pharmacist Professional Nurse Staff Nurse Administrator Administrator Staff Clinical Other
Sub-District 1
Sub-District 2
Source: DHER 2013/14 Customised District Report, DHIS
Note: There are no CDC’s operational in KwaZulu-Natal. Note: There are no Stand-Alone MOU’s in KwaZulu-Natal.
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Table 14 (NDoH 8): Population to Staff per sub-district – 2013/144
Sub-District Population to Medical Officers Population to Professional Nurses
Total Population Uninsured Population Total Population Uninsured Population
Hlabisa LM 12 021 11 552 415 399
Jozini LM 5 817 5 590 760 730
Mtubatuba LM 0 0 2 360 2 268
The Big 5 False Bay LM 0 0 1 904 1 830
UMhlabuyalingana LM 5 076 4 878 571 549 District 6 935 6 664 798 766
Source: DHER 2013/14 Customised District Report, DHIS Note: The National Table A12 has been combined to incorporate both Medical Officers and Professional Nurses.
Hlabisa LM has the lowest ratio of Medical Officers compared to UMhlabuyalingana LM. Hlabisa employed eight sessional Doctors who only take calls and work on weekends instead of appointing full time doctors. This has a negative impact on clinical service delivery like medical coverage at clinics and continuity of care. There is a need to review the appointment of Sessional Doctors in the district.
Hlabisa has the highest number of PNs 154, some of these PNs are allocated at PHC facilities to sustain services and the expenditure is not the true reflection because they get paid from the hospital budget. This number is inclusive of Operational Managers. There is an improvement in staffing compared to previous years and improved health outcomes like decreased Maternal Mortality Rate (MMR) and improved TB cure rate. However there is a need of staffing norms for appropriate interpretation of the tables. There are 125 PNs per 100 000 population in the district, this is lower than 2013 figures for KZN Province of 171 PNs per 100 000 population and is lower than the National average which is at 147 PNs per 100 000. (Source: http://indicators).
4 District hospital plus PHC
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11. ORGANISATIONAL ENVIRONMENT
11.1 ORGANISATIONAL STRUCTURE OF THE DISTRICT MANAGEMENT TEAM
The post of Hospital Manager at Mseleni remains vacant, having been so since 2010. It is in the process of being filled and there is hope of attracting a suitable candidate because the requirements cover a wide spectrum of health professionals. The District Clinical Specialist Team (DCST) is still incomplete, requiring an obstetrician, paediatrician and anaesthetist. The Manager: Medical Service: Senior is acting as the DCST Family Physician. The post of Manager Emergency Medical Services (EMS) is presently vacant, having been vacated in December 2013. EMS is a vertical programme and the District Office provides oversight.
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11.2 HUMAN RESOURCES
The 2015/16 to 2017/18 Human Resource Plan has the following priorities:
- To reduce skills shortage for the clinicians and critical skills e.g. the artisans (review and implement employee retention strategies)
- To strengthen the capacity of employees in the district through HRD initiatives
- To strengthen leadership and governance by training and mentoring
- To reduce high absenteeism and increased labour turn over
- To recruit and fill critical post including non-clinical post according to the approved structure
The district had a challenge in recruiting and retaining clinical and critical support staff, which is still persistent in this financial year. This was more evident in recruitment of DCST, PHC Outreach and School health teams, Pharmacists, Artisans, Specialized Nurses, Clinical Nurse Practitioners, Medical Officers (especially at Hlabisa hospital) and Allied Health Professionals. There is an uneven distribution of Community Care Givers and there is no coordination between DoH and DSD- CCGs. Regular audits on the implementation of PHC and District hospital service delivery packages are not done.
It is difficult to address staff shortage since staff is not properly placed according to staff establishment (see annexure B). Necessary corrective measures such as correct linking of staff, training programs, bursaries and recruitment will be instituted.
Organisational review has been done but it is not realistic since it’s a one size fits all. Individual institutional assessments were not conducted resulting in the organisational structure not talking to the organisational needs in terms of service demands. It has a lot of medical specialist’s posts, Medical Officers posts and inadequate PNs posts for wards coverage yet all wards should be under the PNs supervision. Budget limitations stagger the process of creating and filling of posts thus resulting in high overtime expenditure. There are delays in migration of staff from the old hospital organizational structures to the new (head office is facilitating the process). There is no consistency in the filling of high level posts in the institutions which results in cost inefficiency and affects service delivery.
There is a small margin of extra capacity to allow the district to absorb additional patients activity at all levels of care. The high turnover of staff put the district at higher risk.
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The district has a high labour turn-over rate in certain categories of staff e.g. Doctors, Professional Nurses, Allied Health Professionals and District Office Staff. This affects service delivery in that there is no consistency, continuity, and reliability in the provisioning of the health services. The exit interviews should be strengthened to determine and address main concerns.
While the district has taken the initiatives to train several speciality nursing posts such as PHC nurses, advanced midwives, theatre nurses, paediatric nurses and orthopaedic nurses, and more capacity building efforts to retain doctors, long term retention still remains a challenge.
The district is creating opportunities for career-pathing. Thus far, 125 CCGs have been trained as ENs, 22 as ENAs and 55 as Nutrition Advisors. Mseleni Hospital is offering courses for Enrolled Nursing Assistants to be capacitated as Enrolled Nurses. Hlabisa and Bethesda Hospitals are offering bridging courses for Enrolled Nurses to be trained as Registered Nurses.
A number of training programs have been conducted to capacitate managers on leadership and governance. This includes the Advanced Management and Development Program (AMDP), Khaedu, Albertina Sisulu Training Program, Evidence Based Decision Making, APSTAR and Mentoring for Growth.
Absenteeism is a continued challenge as there is a weak system regarding leave monitoring at Hospitals and PHCs. This has been worsened by the disease profile of the staff which is suffering from chronic diseases and HIV/AIDS. More staff is sickly thus increase absenteeism. Strategies to be implemented to reduce high absenteeism include strengthening of Employee Assistance Programme (EAP), Employee Health and Wellness Programme, Improved management and supervision with emphasis on the EPMDS, timeous implementation of PILIR for prolonged sicknesses and institute disciplinary measures for unauthorized absence.
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Table 15: Patient to Staff type Ratio in Facilities [per 10 000] – Provincial Clinics
Sub-Districts MO to PN to EN to ENA to Data General Patient Patient Patient Patient Capturer to Worker to Provinci Provincial Provincial Provincial Patient Patient al Clinics Clinics Clinics Provincial Provincial Clinics Clinics Clinics
Hlabisa LM 0 7 224.2 5 826.0 90 302.5 60 201.7 20 067.2
Jozini LM 0 5 286.4 5 437.5 28 547.7 51 903.0 21 145.7
Mtubatuba LM 0 6 869.8 7 566.8 174 036 47 464.4 30 712.2
The Big 5 False Bay LM 0 6 830.7 7 210.2 64 891.5 64 891.5 43 261.0
UMhlabuyalingana LM 0 5 343.8 5 906.3 53 068.8 35 068.8 12 197.8
District 0 5 862 7 687.9 57 274.9 545 261.1 22 683.1
Source: DHER 2013/14 Customised District Report
The table indicates that there are no Medical officer’s posts at the PHC facilities but Medical officers employed at district hospitals are visiting PHC facilities. The district needs to create Medical Office’s posts under PHC support. Hlabisa, Mtubatuba and The Big Five False Bay need to employ more PNs. Mtubatuba and The Big Five False Bay need to appoint more ENs. All LMs except for UMhlabuyalingana needs to appoint more Data Capturers.
Table 16: Cost per Headcount in relation to Workload
Sub-Districts and District Total Staff Cost per PN Workload Patient to Staff ratio at PHC Headcount Provincial Clinics - PN
Hlabisa LM R50.55 52.5 7 224
Jozini LM R76.70 50.7 5 286
Mtubatuba LM R79.12 48.8 6 870
The Big 5 False Bay LM R71.16 39.3 6 831
Umhlabuyalingana LM R85.56 39.9 5 344
District R77.08 46.0 5 862
Source: DHER 2013/14 Customised District Report, DHIS
The above table indicates that Hlabisa has the lowest COE cost per headcount, high PN workload and high patient to PN ratio This implies that Hlabisa LM requires more PNs, however the COE for some PNs are incurred by the hospital in some clinics. Moreover the full complement of Mpembeni staff is from Hlabisa hospital. This is being currently corrected as there is a signed staff establishment and staff will be appointed. Jozini and Mtubatuba LMs need to employ more PN to bring their workload to be in line with the Provincial norm of 35 – 40.
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Table 17: District Hospital Staff to PDE Ratio
Total Total Total Total Total Medical Pharmacy Support District Hospital Nursing Staff Clinical Staff Staff to PDE Staff to PDE Staff to PDE to PDE ratio to PDE ratio ratio ratio ratio
Bethesda Hospital 3011.1 312.6 6356.7 2383.7 440.1
Hlabisa Hospital 5851.4 331.6 7105.2 6217.1 588.6
Manguzi Hospital 4649.5 340.6 9298.9 3099.6 726.5
Mosvold Hospital 4945.2 329.7 5325.6 3461.7 438.2
Mseleni Hospital 3992.4 292.5 6787.1 3572.2 449.5 Source: DHER 2012/13 Customised District Report
The above table indicates adequate Pharmacy staff to PDE ratio at Mosvold hospital compared to Manguzi hospital. The district hospitals need to employ at least one Pharmacy supervisor and more Pharmacist assistants. According to the new structure Assistant Manager: Pharmaceutical Services has been replaced by Deputy Manager Pharmaceutical Services which would assist in attraction and retention of staff.
Hlabisa has the lowest ratio of Medical Officers compared to Bethesda hospital. Hlabisa employed eight sessional Doctors who only take calls and work on weekends instead of appointing full time doctors. This has a negative impact on clinical service delivery such as medical coverage at clinics and continuity of care. There is a need to review the appointment of Sessional Doctors in the district.
Mosvold and Bethesda are well staffed with Administration Support staff and Manguzi has least. Mseleni appears to be well staffed in nursing staff compared to Manguzi. Hlabisa has the lowest Allied Clinical staff to PDE compared to Bethesda who seems to be well staffed. Hlabisa must employ more Allied Health Professionals. Hlabisa has the highest number of PNs (154), some of these PNs are allocated at PHC facilities to sustain services and the PN to PDE ratio is not the true reflection. This number is inclusive of Operational Managers.
Over all for the district there is an improvement in staffing compared to previous years and improved health outcomes like decreased Maternal Mortality Rate (MMR) and improved TB cure rate. However there is a need of staffing norms for appropriate interpretation of the tables.
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12. DISTRICT HEALTH EXPENDITURE
Table 18 (NDoH 9): Summary of District Expenditure
(Budget, Transfer to (Expenditure, (Expenditure, (Expenditure, LG Data element (Budget, Province) (Budget, LG Own) LG) Province) Transfer to LG) Own)
DF - 2.1: District Management 10 605 000 0 0 10 799 016 0 0
DF - 2.2: Clinics 247 452 000 0 0 247 334 420 0 0
DF - 2.3: Community Health 0 0 0 0 0 0 Centres
DF - 2.4: Community Services 0 0 0 0 0 0
DF - 2.5: Other Community 141 182 000 0 0 140 432 723 0 0 Services
DF - 2.6: HIV/AIDS 187 431 000 0 0 186 746 261 0 0
DF - 2.7: Nutrition 3 328 000 0 0 3 327 630 0 0
DF - 2.9: District Hospitals 636 481 000 0 0 647 730 390 0 0
DF – 2.12: Donor Funding 0 0 0 0 0 0
Source: DHER 13/14 District Customised Template
The district slightly overspent overall by 0.8% (R9 891 440). This mainly occurred in District Hospital line under Goods and Services which could be attributed to poor stock management and on transfers due to unpredictable exits. Poor stock management will be addressed through implementation of electronic system and continuous training will be conducted. The hospitals overspent by R11 249 390 (1.8%) because of some
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payments for clinics (PHC management, PHC Support & School Health Services) borne by hospitals. Community Health Clinics have been underspending for the past 3 years which is a great concern. Clinics grossly underspent in minor assets especially under Equip 56 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 19 (NDoH 10): Capita PHC expenditure per sub-district – 2013/14 Total Population District Service Delivery Expenditure PHC PHC % % Cost per Cot per Sub-Districts Expenditur Expenditur Uninsured Expenditur Uninsured Uninsured and District e / Capita e / population e Capita Capita (Total Uninsured compared compared 2011/12 2012/13 Population) Capita to District to District Hlabisa LM R18 234 152 R701 R259.70 11% 7% R583 R511.6 Jozini LM R76 149 277 R791 R417.10 30% 31% R490 R347.2 Mtubatuba R59 742 537 R514 R346.60 28% 24% R350 R220 LM The Big 5 R14 327 503 R568 R412.20 6% 6% R373 R330.9 False Bay LM Umhlabuyali R78 880 275 R1 009 R514.80 25% 32% R741 R483.7 ngana LM District R247 334 420 R744.82 R390.08 100% 100% R522 R377.4 Source: DHER 2013/14 Customised District Report, DHER 2011/12 and 2012/13 Note: The PHC expenditure is inclusive of sub-programmes 2.2 to 2.7 Table 20 (NDoH 11): PHC Budget and Expenditure (%) excluding “Other Donor Funding” – 2013/14 Budget Amount Budget Expenditure Amount Expenditure District Management (2.1) 10 605 000 1% R10 799 016 1% PHC (2.2 – 2.7) 579 393 000 47% R577 841 034 47% District Hospitals (2.9) 636 481 000 52% R647 730 390 52% Source: DHER 2013/14 Customised District Report Note: The National Table for District Finance Proportional Expenditure [%] is included in Table A15 above. Table 21 (NDoH 12): PHC Cost per Headcount– 2013/14 LG PHC Facilities Provincial PHC Facilities Total Staff Cost per PHC Headcount District N/A R108 R77.08 57 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 22: District Hospital Expenditure District Hospital Expenditure per PDE ALOS BUR Proportion (%) of expenditure spent on staff (CoE) Bethesda Hospital R1 828 5.5 48.3 78% Hlabisa Hospital R1 733 6.0 65.6 79% Manguzi Hospital R1 610 5.6 59.1 80% Mosvold Hospital R1 589 6.4 60.2 81% Mseleni Hospital R1 697 4.3 63.8 82% District R1 675 5.5 60.7 80% Source: DHER 2013/14 Customised District Report Graph 6: District Hospital Expenditure in relation to Service Delivery – 2013/14 R 2 000 R 1 800 R 1 600 R 1 400 R 1 200 R1 450 R1 390 R 1 000 R1 271 R1 305 R1 413 R 800 R 600 R 400 R 200 R 378 R 343 R 339 R 284 R 284 R - Bethesda Hospital Hlabisa Hospital Manguzi Hospital Mosvold Hospital Mseleni Hospital CoE / PDE Cost / GS Source: DHER 2013/14 Customised District Report Table 18 shows high variations in cost per capita due to change in population figures and change in municipal boundaries at Hlabisa LM and Mtubatuba LM (8 clinics transferred to Mtubatuba LM from Hlabisa LM). Umhlabuyalingana has 25% share of total population and more clinics (18) due to the lower population density, whilst Mtubatuba has higher population density and fewer clinics (12). It is more cost effective to render services in densely populated area. Table 19 shows 1% of budget allocated to District Management, 47% to PHC and 52% to District Hospitals. There was a slight over-expenditure at district hospital (1.8%). A slight increase in % spent on PHC has been noted compared to previous years, in 2013/14 was 47% from 45% in 2012/13 which is encouraging. This indicates that the district is changing focus to PHC. Much as there is a substantial increase in PHC allocation and expenditure a picture may be better than this if journals and linking of staff are properly done. Table 20 indicates that PHC facilities has R108 cost per headcount and R77.08 staff cost per headcount. Percentage spent on COE is 71% which is higher than the national norm (65%). 58 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 The 71% includes rural allowance and increase on staff appointment e.g. Staff Nurses and Nutritional Advisors. The district expenditure per PDE is (R1 675) below the provincial target R1 854. The highest is Bethesda at R1 828 due to low PDE followed by Hlabisa at R1 733 and Mosvold being the lowest at R1 589. The district BUR (60.7%) is below the provincial target (63%-69%). Hlabisa and Mseleni remained constant, Manguzi and Mosvold slightly increased in BUR due to change in admission criteria. There was a decrease in BUR at Bethesda hospital, it needs an investigation. The increase in Bed Utilization Rate (BUR) and Average Length of Stay (ALOS) is noticeable at Mosvold which is attributed to availability of Doctors, but limited skills and experience contributed to the increased ALOS. The district is within the provincial target of 5.5. Table 23: Non-Negotiable Expenditure per PDE Non-Negotiable [Rands per PDE] Bethesda Hlabisa Manguzi Mosvold Mseleni Hospital Hospital Hospital Hospital Hospital Infrastructure Maintenance 2.0 0.0 1.4 0.0 1.3 Food Services 33.20 40.10 26.7 46.3 35.0 Medicine Expenditure 50.8 51.2 21.8 40.2 36.8 Medical Sundries (Supplies) 69.9 55.9 41.9 59.5 45.9 Expenditure Essential Equipment 7.7 1.1 7.3 8.0 5.6 Laundry Expenditure 0.0 0.0 0.0 0.0 0.0 Vaccination Expenditure 6.8 7.9 -0.38 4.2 -0.02 Blood Support Expenditure 16 16 10.8 15.1 12.6 Infection Control Expenditure 32.2 43.9 41.4 37.9 24.2 Medical Waste Expenditure 10 8.3 9.2 12.3 9.1 Laboratory Services Expenditure 0.0 0.0 0.0 0.0 0.0 Security Services 29.3 17.7 17.6 0.0 22.4 Source: DHER 2013/14 Customised District Report Hlabisa hospital overspent in medicines due to poor journaling of clinics mainly at Sipho Zungu and Mpembeni clinics, and misallocation of expenditure for MDR medication (allocated under district hospital instead of TB sub-program). Bethesda and Mseleni keep buffer stock for PHC facilities. 59 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 There was a shortage of blood in the whole country and this caused low cost per PDE in blood services. Monthly reviews are done. High cost for Infection control - cleaning services especially at Manguzi and Hlabisa hospitals due to exorbitant rates for outsourced companies and the provision of cleaning material & protective clothing by the hospital. The district failed to spend in maintenance remarkable underspending noted at Mosvold and Hlabisa hospitals, despite continuous support by District office. Poor planning and implementation of maintenance plans contributed to a 50% reduction of the maintenance budget by Provincial Office. As from 2014/15 financial year motivations for projects by institutions must be submitted to Infrastructure Provincial Office. There was a 73% discrepancy in food services per PDE between Mosvold and Manguzi hospitals, criteria for ordering special diets needs to be revisited. Low cost per PDE in essential equipment at Hlabisa because the institution was under revitalization program. There is a negative cost per PDE in vaccines at Manguzi and Mseleni hospitals, this attributed to over journaling of clinics compared to Hlabisa which is the highest at R7.90. Laundry services are in-house in all the hospitals. The district is experiencing challenges due to continuous breakages. This is aggravated by water shortages and electricity outage, which compromise IPC practices and unnecessary overtime and negative media publicity. A turnaround strategy is being developed by the district office. High cost of medical supplies per PDE at Bethesda (R69.9) compared to the lowest at Manguzi (R41.9) due to poor stock management. It is recommended that if a computerized stock management system could be fast tracked in order to reduce discrepancies. High cost of medical waste per PDE at Mosvold, this could be attributed to poor waste management. Continuous training and monitoring are conducted. 60 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 High cost of security services at Bethesda (R29.3) due to increased number of security officers compared to Manguzi (R17.6), Hlabisa (R17.7) and Mseleni (R22.4). No expenditure at Mosvold as security services are paid by Provincial Office. Payments of Laboratory services are centralized in the Provincial Office. 61 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 PART B - COMPONENT PLANS 13. SERVICE DELIVERY PLANS FOR DISTRICT HEALTH SERVICES 13.1 SUB-PROGRAMME: DISTRICT HEALTH SERVICES 13.1.1 PHC SUB-PROGRAMME OVERVIEW District Health Services comprise Primary Health Care, District Hospital and Programmes. The purpose of District Health Services is to ensure effective and efficient provision of health services in the district according to PHC and District Hospital package of services. There are 56 PHC facilities including four Gateway clinics, 17 mobile teams servicing 251 stopping points. Five clinics (Mbazwana, Ndumu, Kwa Msane, Jozini and Sipho Zungu offer 24 hrs. open Door services, 36 clinics offer on call services and seven are day clinics due to shortage of accommodation. The district has good medical coverage at PHC facilities with weekly coverage at UMhlabuyalingana LM (both Manguzi and Mseleni hospitals) and Bethesda. One CHC (Jozini) is under construction, to be finalised by 2015/16. Commissioning processes have been started. Hluhluwe clinic under The Big 5 False Bay LM has been completed, awaiting handing over. Mtubatuba clinic is fully congested; there is a need to fast track construction of Mtubatuba CHC. The PHC Utilisation rate (3.6) is increasing which indicates that the PHC facilities are accessed. None of the PHC facilities at the district are compliant with National Core Standards due to structural challenges but some of them are conditionally compliant. There is poor handling of complaints especially at PHC facilities. This has been emphasized with minimal change. 39/56 PHC facilities have appointed Clinic Committees by MEC for Health. The Family Health Teams are not yet appointed. There is a plan to fill these posts before the end of the financial year 2014/15. The PHC supervision rate (85%) remains good; however; performance does not match this high rate. Monitoring the quality of the supervisors visit will be done. 62 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 STRATEGIC CHALLENGES - Poor handling of complaints - Lack of implementation of SCM procedures - Poor Maintenance services - Poor quality of PHC supervision - PHC facilities not compliant to NCS - Failure to recruit Clinical Nurse Practitioners 63 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 24 (NDoH 13): Situation Analysis: Indicators for District Health Services 2013/14 Financial Year Indicators Type Hlabisa LM Jozini LM Mtubatuba LM The Big 5 False Bay LM Umhlabuyalingana LM District Average 1. National Core Standards Quarterly 40% 77.7% 83% 100% 83.3% 78.6% self-assessment rate (PHC % Facilities) National Core Standards self- No 2 14 10 3 15 44 assessment Fixed PHC clinics/fixed No 5 18 12 3 18 56 CHCs/CDCs 2. Quality Improvement plan Quarterly 50% 36% 40% 100% 73% 54.5% after self-assessment rate % (PHC Facilities) Quality improvement plan after No 1 5 4 3 11 24 self-assessment Fixed PHC clinics/fixed No 2 14 10 3 15 44 CHCs/CDCs (PHC Fac conducted Self-assessment) 3. Percentage of fixed PHC Quarterly 0% 0% 0% 0% 0% 0% facilities compliant with all % extreme measures of the National Core Standards Fixed PHC facilities compliant with No 0 0 0 0 0 0 all the extreme measures of the National Core Standards for health facilities Fixed PHC clinics plus fixed CHCs / No 2 14 10 3 15 44 CDCs (PHC Facilities conducted Self-assessment) 4. Patient satisfaction survey Quarterly 100% 72% 75% 100% 94.4% 84% rate (PHC Facilities) % Fixed PHC facilities that have No 5 13 9 3 17 47 conducted Patient Satisfaction Surveys Fixed PHC clinics plus fixed CHCs / No 5 18 12 3 18 56 CDCs 64 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Type Hlabisa LM Jozini LM Mtubatuba LM The Big 5 False Bay LM Umhlabuyalingana LM District Average 5. PHC patient satisfaction rate Annual % 80% 81% 80% 82% 84% 81.5% at PHC facilities Patient satisfied with health No 32 225 176 49 268 750 services Patients participating in PSS No 40 280 220 60 320 920 6. OHH registration visit Annual % No WBOT No WBOT No WBOT appointed No WBOT appointed as No WBOT appointed as No WBOT appointed as as yet yet yet appointed as coverage appointed as yet yet yet OHH registration visit No OHH in Population No 7. Number of District Clinical Quarterly N/A N/A N/A N/A N/A 1 incomplete Specialist Teams (DCST’s) No team 8. PHC utilisation rate Annual 3.0 3.7 3.1 3.6 4.2 3.6 No PHC headcount total No 221 145 699 187 563 149 129 783 677 732 2 290 996 Population Total No 73 058 189 965 179 378 36 172 159 438 638 011 9. Complaints Resolution Rate Quarterly 100% 57% 39% 78% 87% 72% % Complaints resolved No 19 78 47 50 292 486 Complaints received No 19 138 120 64 335 676 10. Complaint resolution within % 84% 83% 66% 96% 96% 91% 25 working days rate Quarterly Complaint resolved within 25 No. 16 65 31 48 281 441 working days Complaint resolved No. 19 78 47 50 292 486 65 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 25 (NDoH 14): District Performance Indicators – District Health Services Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Frequenc Performance Target Indicator Source y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Proportion of QA % 0% 0% 0% 0% 8.8% 17.2% 25.8% fixed PHC assessment Quarterly facilities records compliant with all the extreme measures of the National Core Standards Fixed PHC facilities QA No 0 0 0 0 5 10 15 compliant with all assessment the extreme records measures of the National Core Standards for health facilities Fixed PHC clinics DHIS No 54 55 44 56 57 58 58 plus fixed CHCs / calculates CDCs(PHC Facilities conducted Self- assessment) 2. Patient QA % 59% 64% 84% 89.2% 91.2% 95% 100% 100% satisfaction calculates Quarterly survey rate (PHC Facilities) Fixed PHC facilities OSS No 32 35 47 50 52 55 58 594 that have records conducted Patient Satisfaction Surveys Fixed PHC clinics DHIS No 54 55 56 56 57 58 58 594 plus fixed CHCs / calculates CDCs 66 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Frequenc Performance Target Indicator Source y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 3. PHC patient DHIS % 76.5% 77% 81.5% 83.3% 85.3% 87.6% 90% 75% satisfaction rate calculates Annual at PHC facilities Patient satisfied PSS results No 490 540 750 1250 1280 2190 2600 - with health services Patients PSS No 640 700 920 1500 2080 2500 2900 - participating in PSS records 4. OHH registration DHIS % WBOT Not WBOT Not yet WBOT Not yet TBD TBD TBD TBD 51.7% yet appointed appointed visit coverage calculates Annual appointed OHH registration DHIS/Tick No 62 422 visit register WBOT OHH in Population District No 113 495 Records 5. Number of Persal/ Quarterly 0 1(incomplete) 1(incomplete) 1(incomplete) 1(incomplet 1 1 2 Complete e) District Clinical District No teams and Specialist Teams Records remaining 9 teams with all (DCST’s) Nursing post filled. 6. PHC utilisation DHIS Annual 3.2 3.3 3.6 3.5 3.5 3.6 3.6 3.0 rate calculates No PHC headcount DHIS/PHC No 2 097 010 2 194 114 2 290 996 2 236 354 2 273 754 2 360 221 2 379 359 32 234 839 total tick register Population Total DHIS/Stats No 660 354 666 523 638 011 643 759 649 644 655 617 660 933 10 688 165 SA 7. Complaints DHIS Quarterly 63% 67% 72% 80.3% 81% 83% 86% 80% Resolution Rate calculates % Complaints DHIS / No 277 332 486 368 486 540 602 3 520 resolved Complaint records 67 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Frequenc Performance Target Indicator Source y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Complaints DHIS / No 438 493 675 488 600 650 700 4 400 received Complaint records 8. Complaint DHIS Quarterly 100% 100% 91% 82% 85% 90% 95% 90% resolution calculates % within 25 working days rate Complaint resolved DHIS / No. 277 332 441 300 413 486 572 3 168 within 25 working Complaint days records Complaint resolved DHIS / No. 277 332 486 368 486 540 602 3 520 Complaint s record Table 26 (Table 15): District Specific Objectives and Performance Indicators – District Health Services Estimated Audited/ Actual Performance Medium Term Targets Performance Strategic Objective Performance Indicators Data Source Frequency Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. 1.1 PHC utilisation rate DHIS Quarterly 4.7 4.9 4.8 4.9 4.9 5.0 5.1 under 5 years (annualised) calculates % PHC headcount under DHIS/PHC No 400 518 402 194 415 991 427 492 417 411 416 795 417 848 5 tick register Population under 5 DHIS/Stats SA No 82 577 81 136 86 746 86 748 85 186 83 359 81 931 years 1.2 PHC Total Headcount DHIS/Tick No 400 518 402 194 415 991 427 492 417 411 416 795 417 848 under 5 years register SHS 68 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Estimated Audited/ Actual Performance Medium Term Targets Performance Strategic Objective Performance Indicators Data Source Frequency Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2. 2.1 Expenditure per PHC DHIS/BAS Quarterly R96 R97 R108 R124 R132 R136 R145 headcount R Total expenditure PHC BAS (R’000) R’000 R201 289 R212 533 R247 333 R277 342 093 R300 756 R321 808 344 335 590 144 460 744 040 963 PHC headcount total DHIS No 2 097 010 2 194 114 2 290 996 2 236 354 2 273 754 2 360 221 2 379 359 calculates 3. 3.1 Number of School District Quarterly 5 8 9 10 11 12 13 Health Teams (cumulative) Records/ No Persal 4. 4.1 Number of accredited Health Quarterly 9 9 9 11 12 13 14 Health Promoting Schools Promotion No (cumulative) database 5. 5.1 Dental extraction to DHIS Quarterly 14:1 14:1 13:1 8:1 8:1 8:1 8:1 restoration ratio calculates Ratio Tooth extraction DHIS/Tick No 30 887 35 665 40 037 32 548 32 223 31 901 31 582 register Tooth restoration DHIS/Tick No 2 284 2 504 3 057 3 904 4 028 3 988 3 948 register 6. 6.1 Percentage of PHC QA Annual 0% 0% 66% 80% 83% 88% 93% facilities conditionally assessment % compliant to the National records Core Standards Clinics conditionally QA No 0 0 37 45 48 52 55 compliant (50%-75%)to assessment National Core records Standards CHC’s and clinics total DHIS No 54 55 56 56 58 59 59 calculates 7. 7.1 District PHC expenditure BAS / Stats R R321 R377 R403 R448 R482 R500 R520 per uninsured person SA Total expenditure on PHC BAS R’000 R201 289 R212 533 R247 R277 342 093 R300 756 R321 808 R344 335 services 144 461 333744 040 963 590 69 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Estimated Audited/ Actual Performance Medium Term Targets Performance Strategic Objective Performance Indicators Data Source Frequency Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Number of uninsured DHIS / Stats No 627 336 563 211 613 129 618 650 624 310 643 039 662 330 people in the DC27 SA (Stats SA) 8. 8.1 PHC supervisor visit rate DHIS % 97% 89% 85% 91% 92% 95% 97% (fixed clinic/ CHC/ CDC) PHC supervisor visit (fixed Supervisor No 624 589 573 612 640 673 687 clinic/ CHC/ CDC) checklists Fixed clinics plus fixed DHIS No 54 55 56 56 58 59 59 CHCs/CDCs Calculates 9. 9.1 Number of functional District No 0 0 0 3 5 9 12 Ward Based Outreach Manageme Teams (Family Health nt / Teams) (cumulative) Appointmen (Transport depended) t letters 10. 10.1 School ISHP coverage DHIS % Not Not 52% 60% 65% 70% 75% (annualised) reported reported Schools with any learner DHIS / Tick No 285 330 359 389 418 screened register SHS Schools – total DHIS / DoE No 550 550 552 555 557 database 11. 11.1 Number of Primary No 0 0 0 0 5 5 5 Health Care Clinics that qualify as Ideal Clinics 12. 12.1 Number of Primary No 50 51 50 52 53 54 55 Health Care Clinics with functional Clinic Committees 70 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 13.1.2 District Health Services: Strategies /Activities to be implemented 2015/16 Strategies Activities 1. To improve the quality of PHC - Monitor reports submitted by PHC Supervisors supervision - Review performance agreement by managers 2. To ensure that PHC facilities are - Conduct gap and self-assessments on NCS accredited to NCs - Develop and implement QIPs - Monitor QIP implementation 3. To improve complaints handling at - Standardization of complaints handling procedure at PHC level PHC facilities - Appointment of complaints handling committees - Submission of reports 4. Improve implementation of SCM - Monitoring of SCM procedures implementation procedures - Conduct on job trainings on SCM procedures - Strengthen clinics cash flow 5. Improve maintenance services - Strengthen support visit to PHC by maintenance team - Dedicated PHC maintenance team - Availability of material and working tool - Proper maintenance plan 71 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 13.2 SUB-PROGRAM: DISTRICT HOSPITALS 13.2.1 Sub-Programme Overview The purpose of the District Hospital Programme is to render level 1 hospital services to the District population. The District has five District Hospitals, all providing the full district hospital package of services and open 24 hours per day. Two Hospitals (Manguzi and Mseleni) are under UMhlabuyalingana LM, two Hospitals (Mosvold and Bethesda) under Jozini LM, one Hospital (Hlabisa) under Hlabisa LM. There are no Hospitals at Big 5 False Bay and Mtubatuba LM’s which poses a challenge especially at Mtubatuba as it is along the N2 which is a high accident zone. Hlabisa MDR site has been established and has assisted in the initiation of MDR patients. This has reduced unnecessary delays caused by unavailability of EMRS transport and shortage of beds at King Dinuzulu Hospital. This has compromised bed status at Hlabisa because medical beds were converted to MDR beds without additional facility. The Medical coverage improved in Hospitals though Hlabisa and Mosvold are slightly understaffed. More medical posts are to be filled in this current and next financial year. There is a problem in attraction of Community Service Officers at Mosvold; there is a need to strengthen exit interviews and analysis thereof. The Caesarean Section rate is at 21.6 at the district Hospital. Bethesda is the highest in the district at 25.5, which might be attributed to cross boundary movement of patients from Zululand district. However this figure does not include approximately 3000 babies born each year in District clinics None of the hospitals are fully compliant with the NCS due to infrastructural challenges. Gap assessments are conducted and QIPs developed with minimal implementation. New wards have been opened at Manguzi, Bethesda and Mosvold Hospitals, with a new Female ward at Manguzi and Mosvold, paediatric ward opened at Bethesda Hospitals and a new mortuary at Mosvold Hospital and Operating Theatre upgrade at Hlabisa. There is a new Therapy department and staff residence at Mseleni hospital Average length of stay in the District Hospitals is at 5.5 days. The bed occupancy rate appears low at 60.7%, however it is suspected that poor data quality, inflating the real number of beds available, contributes to this surprisingly low figure. 72 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 All five district hospitals are conditionally compliant with the National Core Standards. Compliance with vital and extreme measures remains a challenge. Accommodation remains a challenge at all hospitals, exacerbated by an expansion of services and staff providing those services, including dental, dietician, optometry, psychology and speech therapy services. STRATEGIC CHALLENGES: Inadequate accommodation at hospitals Poor data quality Non-Compliance with National Core Standards Shortage of Doctors including attraction of Community Service Officers 73 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 27 (NDoH 16): Situational Analysis Indicators for District Hospitals – 2013/14 Financial Year Indicators Type Bethesda Hlabisa hospital Manguzi hospital Mosvold hospital Mseleni hospital District Average hospital 1. National Core Standards self- Quarterly 100% 100% 100% 100% 100% 100% assessment rate % National Core Standards self-assessment No 1 1 1 1 1 5 District Hospitals total No 1 1 1 1 1 5 2. Quality Improvement plan after self- Quarterly 100% 100% 100% 100% 100% 100% assessment rate % Quality Improvement plan after self- No 1 1 1 1 1 5 assessment District Hospitals total No 1 1 1 1 1 5 3. Percentage of District Hospitals Quarterly 0% 0% 0% 0% 0% 0% compliant to all extreme and vital % measures of the National Core Standards District Hospitals fully compliant (75%-100%) No 0 0 0 0 0 0 to all extreme and vital measures of National Core Standards District Hospitals total No 1 1 1 1 1 5 4. Patient satisfaction survey rate 100% 100% 100% 100% 100% 100% Number of district hospitals that have No 1 1 1 1 1 5 conducted patient satisfaction surveys District Hospitals total No 1 1 1 1 1 5 5. Patient satisfaction rate Annual 80% 75% 72% 75% 75% 78% % Number satisfied customers No 116 45 43 15 45 264 Number users participated in survey No 140 60 60 20 60 340 74 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Type Bethesda Hlabisa hospital Manguzi hospital Mosvold hospital Mseleni hospital District Average hospital 6. Average length of stay Quarterly 5.5 6.0 5.6 6.4 4.3 5.5 Days In-patient days No 39 168 65 844 61267 53 598 50 898 270 775 Day patients No 0 30 1 7 157 195 Inpatient separations No 7 148 10 904 10 939 8 398 11 877 49 266 7. Inpatient bed utilization rate Quarterly 48.3 65.6 59.1 60.2 63.8 60.7 % In-patient days No 39 168 65 844 61267 53 598 50 898 270 775 Day patients No 0 30 1 7 157 195 Inpatient bed days available No 222 275 284 244 219 1 244 8. Number of District Mental Health No 0 0 0 0 0 0 Teams Established 9. Expenditure per PDE Quarterly R1 828 R1 733 R1 610 R1 589 R1 697 R1 675 R Expenditure total R’000 R106 146 720 R168 794 888 131 405 193 111 548 859 R111 476 545 R629 372 216 Patient day equivalent No 57 210 99 473 92 989 69 233 67 871 386 777 10. Complaint resolution rate Quarterly 53% 94% 93% 76% 95% 85% % Complaint resolved No 17 16 106 82 76 297 Complaint received No 32 17 114 108 80 351 11. Complaint resolution within 25 working Quarterly 71% 6% 100% 100% 97% 93% days rate % Complaint resolved within 25 days No 12 1 106 82 75 276 Complaint resolved No 17 16 106 82 76 297 Note: Indicator 9, [data element Expenditure total]: Expenditure should be for all hospital expenditure that occurs at a hospital level, not only sub-programme 2.9. Expenditure at community level is not included in this figure. 75 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 28 (NDoH 17): Performance Indicators for District Hospitals Audited/ Actual Performance Estimated Medium Term Targets Provincial Frequenc Indicator Data Source Performance Target y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1 National Core Standards QA/DHIS Quarterly 100% 100% 100% 100% 100% 100% 100% 100% self-assessment rate calculates % National Core Standards self- QA No 5 5 5 5 5 5 5 37 assessment assessment records District Hospitals total DHIS No 5 5 5 5 5 5 5 37 calculates 2 Quality Improvement plan QA/DHIS Quarterly 0% 100% 100% 100% 100% 100% 100% 100% after self-assessment rate calculates % Quality Improvement plan after QA No 0 5 5 5 5 5 5 37 self-assessment assessment records District Hospitals total QA No 5 5 5 5 5 5 5 37 assessment records 3 Percentage of District QA/DHIS Quarterly 0% 0% 0% 0% 0% 0% 0% 14% Hospitals compliant to all calculates % extreme and vital measures of the National Core Standards District Hospitals fully compliant QA No 0 0 0 0 0 0 0 5 (75%-100%) to all extreme and assessment vital measures of National Core records Standards District Hospitals total DHIS No 5 5 5 5 5 5 5 37 calculates 4 Patient satisfaction survey QA / DHIS Quarterly 100% 100% 100% 100% 100% 100% 100% 100% rate calculates % 76 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/ Actual Performance Estimated Medium Term Targets Provincial Frequenc Indicator Data Source Performance Target y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Number of district hospitals that QA No 5 5 5 5 5 5 5 37 have conducted patient assessment satisfaction surveys records District Hospitals total DHIS No 5 5 5 5 5 5 5 37 calculates 5 Patient satisfaction rate DHIS Annual 80% 87% 78% 85% 87% 88% 90% 90% calculates % Number satisfied customers PSS No 80 87 264 492 609 704 900 7 290 Number users participated in PSS No 100 100 340 582 700 800 1000 8 100 survey 6 Average length of stay DHIS Quarterly 6.3 Days 5.7 Days 5.5 Days 5.9 Days 5.7 Days 5.6 Days 5.5 Days 5.8 Days calculates Days In-patient days Midnight No 272 529 268 256 270 775 272 948 261 576 256 345 251 218 2 049 076 census Day patients Midnight No 102 357 195 86 90 95 100 11 865 census Inpatient separations DHIS No 43 327 46 993 49 266 46 612 45 898 45 767 45 685 348 922 calculates 7 Inpatient bed utilisation DHIS Quarterly 60.8% 59.8% 60.7% 60% 56.3% 55.1% 54.% 64.7% rate calculates % In-patient days Midnight No 272 529 268 256 270 775 272 948 261 576 256 345 251 218 2 049 076 census Day patients Midnight No 102 357 195 86 90 95 100 11 865 census Inpatient bed days available Manageme No 1 240 1 240 1 244 1 244 1 274 1 274 1 274 3 173 310 nt 8 Number of District Mental No 0 0 0 0 1 1 1 11 health Teams Established 77 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/ Actual Performance Estimated Medium Term Targets Provincial Frequenc Indicator Data Source Performance Target y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 9 Expenditure per PDE BAS/DHIS Quarterly R1 295 R1 539 R1 675 R1 854 R2 024 R2 210 R2 413 R 1 808 R Expenditure total BAS R’000 R504 771 573 R581 413 915 R629 372 216 703 819 607 753 086 980 805 803 069 862 209 283 5 309 057 Patient day equivalent DHIS No 389 785 377 563 386 777 379 640 372 047 364 606 357 314 2 935 044 calculates 10 Complaint resolution rate DHIS Quarterly 89% 79% 85% 47% 70% 80% 90% 75% % Complaint resolved PSS No 170 271 297 232 379 476 590 2 100 Complaint received PSS No 192 341 351 492 541 595 655 2 800 11 Complaint resolution within DHIS Quarterly 100% 100% 93% 97% 98% 98% 99% 85% 25 working days rate % Complaint resolved within 25 PSS No 170 271 276 224 371 467 584 1 785 days Complaint resolved PSS No 170 271 297 232 379 476 590 2 100 78 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 29 (NDoH 18): District Strategic Objectives and Annual Targets for District Hospitals Estimated Strategic Audited/ Actual Performance Medium Term Targets Frequency Performance Objective Performance Indicator Data Source Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. Delivery by caesarean DHIS Quarterly 22.3% 21.2% 21.6% 20.3% 20% 20% 20% section rate calculates % Delivery by caesarean section Delivery No 2 669 2 483 2 620 2 600 2 680 2 814 2 955 register Delivery in facility total Delivery No 11 541 11 960 12 140 12 756 13 402 14 072 14 776 register 2. OPD headcount- total DHIS/OPD tick Quarterly 337 166 309 727 338 057 312 252 296 645 281 813 267 722 register No 3. OPD headcount not DHIS/OPD tick Quarterly 51 437 64 760 71 156 68 002 61 198 55 078 49 571 referred new register No 4. Number of District Hospitals with functional 5 5 5 5 5 5 5 boards 5. Proportion of District Hospitals QA / DHIS Quarterly 0% 100% 100% 100% 100% 100% 100% conditionally compliant to calculates % National Core Standards District Hospitals conditionally QA No 0 5 5 5 5 5 5 compliant assessment records District Hospitals Total DHIS No 5 5 5 5 5 5 5 calculates 79 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 13.2.2 District Hospitals: Strategies /Activities to be implemented 2015/16 Strategies Activities 1. Improve Data quality - Monitor functionality of information meetings - Conduct data quality audits 2. Improve implementation of the NCS vital and - Conduct NCS audits extreme measures - Set targets for vital and extreme measures - Monitor quality improvement program on gap analysis 3. Rational use of accommodation at hospitals - Review accommodation policy at hospitals - Enforce monthly occupancy returns - Establishment of housing committee 4. Recruitment of Doctors - Advertising of posts - Attend to exits interviews findings 80 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 14. HIV & AIDS & TB CONTROL (HAST) 14.1 PROGRAMME OVERVIEW The purpose of the HAST Programs The purpose of the HAST Programme is to promote prevention of HIV, TB and sexually transmitted infections, ensure necessary treatment of persons infected with HIV, TB and STIs, and bring relief to persons infected and affected by these diseases. The district planned to test 162 160 clients for HIV in 2013/14, however, the targets set was not met and only 149 277 clients were tested. This was due to the shortage of staff and vehicles for community outreach. The target for clients to be tested for HIV in 2014/15 is 148 332. In Quarter 1 and quarter 2 of 2014/ 15, the district tested 81 218 clients and was above the target of 74 166. The 2014/15 target for High Transmission Areas (HTA) was two but only one site was functional i.e. Mkuze HTA. The second site (Mtubatuba, could not be opened due to challenges with the Local Municipality. One CNP appointed for Mtubatuba HTA, but allocated to Mtubatuba clinic. 54 PHC facilities (including Mosvold and Hlabisa gateway), three mobile teams (Manguzi) and 5 hospitals are initiating clients on ART and nurses have been trained on NIMART. In 2013/14, the district had a total of 58 643 clients remaining in care and this was below the target of 63 476. The figure was decreased by the implementation of Tier.net system, where clients that were already out of care were removed from the system, and this was not possible with the paper register. The target for 2014/15 for clients remaining in care is 68 606 and at the end of the 2nd Quarter, the total was 59 760. All ART sites are implementing Tier.net system and 55 facilities have been audited and Data signed off as clean. Male condom distribution in the district remains below the target. This is due to the absence of Service Providers to distribute condoms in the community. However, partnership has been formed with Family Health International to support the district in distributing male condoms as from the 3rd quarter of 2014/15. The total male condoms distributed end of quarter 2 of 2014/15 was 2 566 146 and female condoms was 62 130. 81 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 The target for Male medical Circumcision for 2013/14 was 17 848 and the district circumcised 10 737 and this was below the set target. In 2014/15, the target is 23 465.At the end Q2 of 2014/15, the district circumcised 5 014. The poor performance is due to the shortage of MMC Teams in hospitals and poor mobilization of clients for MMC. The Pulmonary Tuberculosis incidence is at 831/100k populations with a cure rate of 77%. The death rate among TB patients is at 4.7% and is above the district target of 4%. This might be attributed to co-infection, late presentation to health facilities and defaulters. 92% of clients on TB treatment have DOT Supporters; this program needs to be monitored closely in relation to TB treatment outcomes. The district is experiencing a high number of new MDR TB cases with an MDR TB initiation rate of 100%. The MDR TB 24 month cure rate is at 61% with a defaulter rate of 3%. The death rate among MDRTB clients is at 7.3% and is above the district target of 6%. The district needs to do early diagnosing and initiation on MDRTB using Gen-Xpert and contact tracing. STRATEGIC CHALLENGES Inadequate MMC teams Poor Community Mobilization for MMC High incidence of MDR TB Poor HAST data management 82 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 30 (NDoH 19): Situational Analysis Indicators for HIV & AIDS, STI’s and TB Control - 2013/14 Financial Year Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingana District Average Bay LM LM 1. Total clients remaining on ART Quarterly No 6 180 16 503 17 177 3 222 15 561 58 643 month 2. Clients tested for HIV (incl. Quarterly No 12 189 51 884 22 375 7 087 52 408 145 943 ANC) 3. TB symptom 5 years and older Quarterly % 3.2 2.3 1.8 2.8 2.0 2.2 screened rate Client 5 years and older screened for No. 5 925 12 678 8 665 3 073 11 257 41 598 TB symptoms PHC headcount 5 years and older No. 183 457 557 587 472 039 107 899 554 216 1 875 198 4. Male condom distribution Rate Quarterly 36.6 19.7 8.9 12.4 36.4 22.1 Rate per male Male condoms distributed No 709 480 1 005 056 450 236 132 480 1 554 491 3 852 193 Population 15 years and older male Population 19 370 51 085 50 444 10 700 42 694 174 293 5. Female condom distribution Quarterly 1.2 0.8 0.4 0.3 1 0.8 Rate Rate per female Female condoms distributed No 29 407 48 937 27 320 3 266 55 031 163 961 Population 15 years and older Population 24 684 63 866 61 596 12 580 55 406 218 132 female 6. Medical male circumcision Quarterly 3 905 3 195 181 484 2 972 10 737 performed – Total No 7. TB client treatment success rate Quarterly % 82.2% 86.7% 79.8% 80% 79.7% 81.7% TB client successfully No 282 360 451 76 412 1 581 completed treatment TB client start on treatment No 343 415 565 95 517 1 935 83 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingana District Average Bay LM LM 8. TB client lost to follow up rate Quarterly % 1.7% 0.5% 5.7% 4.2% 2.9% 3% TB client lost to follow up No 6 2 32 4 15 59 TB client start on treatment No 343 415 565 95 517 1 935 9. TB client death Rate Annual 6.1% 3.6% 4.8% 4.2% 4.4% 4.7% % TB client died during treatment No 21 15 27 4 23 90 TB client start on treatment No 343 415 565 95 517 1 935 10. TB MDR confirmed treatment Annual 0% 0% 0% 0% 100% 100% start rate % TB MDR confirmed client start on No 0 0 0 0 328 328 treatment TB MDR confirmed client No 0 0 0 0 328 328 11. TB MDR treatment success rate Annual % 0% 0% 0% 0% 10% 10% TB MDR client successfully No. 0 0 0 0 27 27 treated TB MDR confirmed client start on No. 0 0 0 0 278 278 treatment 84 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 31 (NDoH 20): Performance Indicators for HIV & AIDS and TB Control Indicator Data Source Frequen Audited/ Actual Performance Estimated Medium Term Targets Provincial cy Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Total clients remaining on DHIS Quarterly 43 332 53 373 58 643 64 375 82 273 95 769 106 769 1 276 200 ART month calculates No 2. Clients tested for HIV (incl. DHIS Quarterly 141 422 123 806 145 943 153 492 155 000 160 000 150 000 2 067 065 (4 ANC) calculates No 134 130 Cumulative ) 3. TB symptom 5 yrs. and older DHIS Quarterly Not Not 2.2% 2.4% 2.5% 2,6% 2,7% 20% screened rate % collected collected Client 5 years and older screened TB Register No. 41 598 43 730 47 935 52 843 58 168 6 417 887 for TB symptoms PHC headcount 5 years and older DHIS No. 1 875 198 1 808 862 1 917 394 2 032 437 2 154 384 32 089 437 calculates 4. Male condom distribution DHIS Quarterly 15 15 22.1 28 37 42 47 62.9 Rate calculates Rate per male Male condoms distributed DHIS/Stock No 2 856 684 2 969 851 3 852 193 5 042 180 6 746 528 7 755 048 8 851 839 212 000000 cards Population 15 years and older DHIS/Stats Populati 192 984 197 233 174 293 177 682 181 017 184 644 188 337 3 370 509 male SA on 5. Female condom distribution DHIS Quarterly 0.4 0.5 0.8 0.6 0.9 1 1.1 0.9 calculates Rate Rate per female Female condoms distributed DHIS/Stock No 80 035 105 900 163 961 123 368 195 536 229 181 257 142 3 500 000 cards 85 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Data Source Frequen Audited/ Actual Performance Estimated Medium Term Targets Provincial cy Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Population 15 years and older DHIS/Stats Populati 205 222 209 591 218 132 221 426 224 680 229 181 233 765 3 892 659 female SA on 6. Medical male circumcision DHIS / MMC Quarterly 3 890 6 275 10 737 9 894 29 080 34 696 41 396 631 374 performed – Total register No (Cumulativ e) 7. TB client treatment success ETR.Net % 71.2% 68% 81.7% 83.3% 85% 86.7% 88.4% 85% rate calculates TB client successfully TB Register No 1 275 1 530 1 581 1 644 1 711 1 780 1 852 32 257 completed treatment TB client start on treatment TB Register No 1793 2257 1 935 1 974 2 013 2 053 2 095 37 949 8. TB client lost to follow-up rate ETR.Net Quarterly 4% 2.5% 3% 3% 2.8% 2.5% 2.3% 3.9% calculates % TB client lost to follow up TB Register No 72 58 59 59 56 51 48 1 530 TB client start on treatment TB Register No 1 793 2 257 1 935 1 974 2 013 2 053 2 095 38 255 9. TB client death Rate ETR.Net Annual 6.3% 3.9% 4.7% 4.5% 4.3% 4% 3.8% 4% calculates % TB client died during TB Register No 113 89 90 89 87 82 80 1 140 treatment TB client start on treatment TB register No 1793 2257 1 935 1 974 2 013 2 053 2 095 28 500 10. TB MDR confirmed treatment ETR.Net Annual 100% 100% 100% 100% 100% 100% 100% 60% start rate calculates % TB MDR confirmed client start on TB Register No 198 284 328 420 400 390 350 - treatment TB MDR confirmed client TB Register No 198 284 328 420 400 390 350 - 11. TB MDR treatment success EDR Annual 62% 40% 10% 50% 60% 62% 64% 60.9% rate calculates % TB MDR client successfully EDR Register No 123 113 27 210 240 242 224 - treated 86 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Data Source Frequen Audited/ Actual Performance Estimated Medium Term Targets Provincial cy Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 TB MDR confirmed client start EDR Register No 198 284 278 420 400 390 350 - on treatment Table 32 (NDoH 21): District Strategic Objectives and Annual Targets for HIV & AIDS Estimated Strategic Audited/ Actual Performance Medium Term Targets Data Frequency Performance Objectiv Performance Indicator Source Type e 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. Number of patients that started EDR.Net Annual 334 310 328 420 400 390 350 regimen iv treatment (MDR-TB) calculates No 2. MDR-TB Six month interim outcome EDR.Net Annual 68% 52.4% 30% 60% 62% 64% 66% calculates % Number of clients with a negative EDR No 134 149 100 252 248 250 231 culture at 6 months who started Register treatment for 9 months Total patients who started EDR No 198 284 328 420 400 390 350 treatment in the same period Register 3. Number of patients that started ETR.Net Annual Reported at Reported Reported Reported at Reported Reported Reported at XDR-TB treatment calculates No King at King at King King Dinuzulu at King at King King Dinuzulu Dinuzulu Dinuzulu Dinuzulu Dinuzulu Dinuzulu 4. XDR-TB Six month interim outcome EDR.Net Annual Reported at Reported Reported Reported at Reported Reported Reported at calculates % King at King at King King Dinuzulu at King at King King Dinuzulu Dinuzulu Dinuzulu Dinuzulu Dinuzulu Dinuzulu Number of clients with a negative EDR No culture at 6 months who started Register treatment for 9 months Total patients who started EDR No treatment in the same period Register 5. TB incidence (per 100 000 ETR.Net Annual 1095/100K 955/100K 831/100K 723/100K 629/100K 547/100K 476/100K population) No per 100,000 New TB infections ETR.Net No 7 232 6 365 5 305 4751 4 257 3 813 3 418 87 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Estimated Strategic Audited/ Actual Performance Medium Term Targets Data Frequency Performance Objectiv Performance Indicator Source Type e 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Total population in DC27 DHIS/Stats SA Population 660 354 666 523 638 011 657 151 676 866 697 172 718 087 6. HIV incidence (annual) ASSA2008 Annual 2% 1.5% 1% 3.4% 3.1% 2.4% 2.5% % 7. STI treated new episode DHIS Quarterly 84/1k 80/1k 84/1k 80/1k 77/1k 74/1k 71/1k incidence (annualised) calculates No per 1000 STI treated new episode DHIS/Tick No 33 977 35 424 33 716 3 2 646 32 319 31 996 31 676 register PHC/ casualty Population 15 years and older DHIS/Stats Population 406 827 440 763 399 121 405 711 417 882 430 419 443 331 SA 8. TB (new pulmonary) defaulter ETR.Net % 4% 2.5% 3% 3% 2.8% 2.5% 2.3% rate calculates TB(new pulmonary)treatment TB Register No 72 58 59 59 56 51 48 defaulter TB(new pulmonary)client initiated TB Register No 1 793 2 257 1 935 1 974 2 013 2 053 2 095 on treatment 9. TB AFB sputum result turn-around ETR.Net % 61% 56% 63.9% 65% 67% 70% 74% time under 48 hours rate calculates TB AFB sputum result received TB Register No 39 618 42 151 35 111 36 405 38 276 40 789 43 982 within 48 hours TB AFB sputum sample sent TB Register No 67 752 75 105 54 910 56 008 57 128 58 270 59 436 10. TB (new pulmonary) cure rate ETR.Net % 71.2% 68% 72% 83.3% 85% 86.7% 88.4% calculates TB (new pulmonary) client cured TB Register No 1 275 1 530 1 399 1 644 1 711 1 780 1 852 TB (new pulmonary) client initiated TB Register No 1 793 2 257 1 935 1 974 2 013 2 053 2 095 on treatment 88 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 14.2 HIV & AIDS, STI & TB CONTROL (HAST): STRATEGIES/ ACTIVITIES TO BE IMPLEMENTED 2015/16 Strategies Activities 1. Increase MMC uptake - Appoint more MMC Coordinators - Increase the no of MMC camps - Use of OSS to market the service 2. Reduce MDR cases - Strengthen defaulter tracing at hospitals - Early screening of patients 3. Reduce STI (new) - Conduct health education in sexual reproductive health at school - Increase partner treatment 4. Improve the quality of HAST data - Monthly verification of data - Participate on monthly information team meetings - Provide monthly data feedback session 89 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 15. MATERNAL, NEONATAL, CHILD AND WOMEN’S HEALTH AND NUTRITION 15.1 PROGRAMME OVERVIEW MCWH The purpose of the program is to improve Maternal, Child and Women’s Health and Nutrition through preventive, promotive curative and rehabilitative services. Nine maternal deaths reported in 2013/14, which gave the District a Maternal Mortality ratio of 60/100k live births. Seemingly there is a projected increase in 2014/15 because up to this far (end of Q2 of 2014/15) the district has 7 of which 2 were from Mozambique. 63% Achievement in antenatal 1st visit before 20 weeks is due to regular monitoring and implementation of Dashboard indicators especially at Hlabisa and Bethesda Hospitals with the support of 20 000+. There is a high teenage delivery rate of 11.4% despite collaborative efforts with other departments. There is a need to strengthen implementation of youth friendly services and multi-sectoral approach in dealing with teenage pregnancy. Intensified trainings on the long acting reversible contraceptives are on-going and uptake of these methods in young girls will reduce teenage pregnancy. In 2013/14 the district achieved 5% in child under 5 death rate which is below a set District target of <7%. In Q2 of 2014/15 it increased to 6.3% which is above the district target of <5%. Proper audit will be conducted to identify the root cause by the DCST. 49 Phila Mntwana Centres were established at UMkhanyakude where CCGs are allocated to do health services such as administering of Vitamin A, weighing of children, referrals, health education etc. Some centres have limited resources and MatCH has committed to support. On-going trainings will be conducted. The DCST and Program Coordinators needs to monitor functionality of the Phila Mntwana Centres vs Child Health outcomes. District performance showed a decrease in all EPI indicators due to poor performance, lack of commitment and accountability at all levels of care. Continuous onsite training is being conducted. 90 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Cervical cancer screening has decreased as a result of improved understanding of this data element and poor performance. The District achieved the target of 50% (Q1 and Q2 of 2014/15) in the couple year protection rate, due to Implanon insertion. PMTCT The District successfully implemented PMTCT guidelines which contributed much in reduction of Mother to Child Transmission to 1.2% (for Q1 and Q2 of 2014/15) which is below the district target of 1.3% around 6 weeks and 1.4% at 18 months below the set target of 2%. Antenatal clients initiated on HAART rate is at 82.9% as at the end of 2nd quarter. NUTRITION The annual underweight for age incidence for children <5 years is at 27.9/k which is far above the district target of 16/k. The annual weighing rate in proportion to the headcount <5 is at 80% and which is within the target of 80% and this is due to the fact that children are visiting facilities frequently. Percentage of Children admitted with Severe Acute Malnutrition (SAM) is at 7.3% and this within the targeted range of 8% for the year. The Severe Acute Malnutrition case fatality rate for the year is at 12 above the target of 10%. All clinics have appointed Nutrition Advisors. Vitamin A coverage for 12 – 59 months increased from 43.7% to 54.4% in the 2nd quarter of 2014/15. This could be attributed to immunisation catch-up drive conducted in August 2014. INTEGRATED SCHOOL HEALTH SERVICES Integrated School Health service is offered in the District in collaboration with Departments of Education and Social Development. School health teams in the District have increased from five to ten, seven of the School Health Teams are linked to PHC facilities (Ndumo, Mahlungulu, KwaMsane, Inhlwathi, Mduku, Ntshongwe, Somkhele) and the three are linked to district hospitals (Bethesda, Manguzi and Mosvold). There is a shortage of transport resulting in teams sharing vehicles, which has negative impact on School Health coverage. 91 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 The introduction of the HPV vaccine has increased the awareness of cervical cancer to learners and parents. Challenges - Poor ANC at all levels - Increased <5 deaths due to severe malnutrition especially at Jozini LM and Diarrhoea at Hlabisa LM - High teenage delivery rate - Poor integration of SRH into other programs such as HIV and AIDS and School Health - Poor functioning of Phila Mntwana Centres 92 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 33 (NDoH 22): Situational Analysis Indicators for MCNWH & N – 2013/14 Financial Year Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingan District Average Bay LM a LM 1. Antenatal 1st visit before 20 Quarterly % 59.0% 58.4% 56.7% 61.3% 69.6% 61.2% weeks rate Antenatal 1st visit before 20 weeks No 1 193 3 133 2 592 584 3 283 10 785 Antenatal 1st visit total No 2 022 5 179 4 575 953 4 714 17 443 2. Proportion of mothers visited Quarterly % 18.2% 122.3% 151.0% 325.9% 92.5% 87.3% within 6 days of delivering their babies Mother postnatal visit within 6 days No 770 5 733 1 708 453 4 365 13 029 after delivery Delivery in facility total No 4 242 4 687 1 131 139 4 720 14 919 3. Antenatal client initiated on Annual 108% 89.0% 63.8% 37.3% 58.5% 73.1% ART rate % ANC client started on ART ART Register 579 1 193 1 020 104 611 3 507 ANC client eligible for ART initiation ART Register 536 1 340 1 598 279 1 044 4 797 4. Infant 1st PCR test positive Quarterly % 2.5% 1.6% 1.5% 1.5% 1.6% 1.7% around 6 weeks rate Infant 1st PCR test positive around 6 No 17 27 25 5 25 99 weeks Infant 1st PCR test around 6 weeks No 669 1 715 1 622 334 1 530 5 870 5. Immunisation coverage under Quarterly % 64.7% 86.1% 57.9% 69.1% 85.1% 74.6% 1 year (annualised) Immunised fully under 1 year new No 1 477 4 854 2 972 680 3 964 13 947 Population under 1 year No 2 211 5 460 4 973 952 4 510 18 106 6. Measles 2nd dose coverage Quarterly % 69% 76% 63% 70% 75% 71% Measles 2nd dose No 1 478 4 072 3 108 644 3 282 12 584 Population 1 year No 2 134 5 350 4 905 919 4 378 17 686 93 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingan District Average Bay LM a LM 7. DTaP-IPV-HepB-Hib 3 - Measles Quarterly 4.5% 4.7% 7.9% 4.3% 5.0% 5.5% 1st dose drop-out rate % DTaP-IPV-HepB-Hib 3 to Measles1st No 79 247 297 34 211 868 dose drop-out DTaP-IPV-HepB-Hib 3rd dose No 1 738 5 201 3 778 784 4 235 15 736 8. Child under 5 years diarrhoea Quarterly % 8.6% 2.8% 0% 0% 2.7% 4.5% case fatality rate Child under 5 years with diarrhoea No 26 7 0 0 12 45 death Child under 5 years with diarrhoea No 304 253 0 0 438 995 admitted 9. Child under 5 years Quarterly % 5.0% 2.5% 0% 0% 2.4% 2.9% pneumonia case fatality rate Child under 5 years pneumonia No 8 6 0 0 12 26 death Child under 5 years pneumonia No 159 237 0 0 492 888 admitted 10. Child under 5 years severe Quarterly % 12.0% 19.8% 0% 0% 4.3% 12.2% acute malnutrition case fatality rate Child under 5 years severe acute No 9 19 0 0 4 32 malnutrition death Child under 5 years severe acute No 75 96 0 0 92 263 malnutrition admitted 11. School Grade R screening Quarterly % 0% 7% 0% 5.5% 2.3% 4% coverage School Grade R learners No. 0 304 0 60 81 445 screened School Grade R learners - No. 534 4 374 1 071 1 082 3 602 10 663 total 12. School Grade 1 screening Quarterly % 44% 14% 35 59% 83% 39% coverage 94 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingan District Average Bay LM a LM School Grade 1 learners No. 885 1051 1838 503 3575 7852 screened School Grade 1 learners - No. 2033 7508 5226 851 4284 19902 total 13. School Grade 8 screening Quarterly % 11% 7% 6% 21% 61% 17% coverage School Grade 8 learners No. 259 451 262 109 1504 2585 screened School Grade 8 learners - No. 2444 6102 4103 530 2485 15664 total 14. Couple year protection rate Quarterly % 40.8% 33.6% 19.7% 21.0% 45.0% 32.7% Contraceptive years dispensed No 7 694 17 401 9 444 2 101 19 585 56 325 Population 15-49 years female No 1 907 52 218 48 789 10 126 43 933 174 083 15. Cervical cancer screening Quarterly % 21.1% 53.3% 31.4 35.3% 87.5% 51.5% coverage (amongst women) Cervical cancer screening in No 276 1 748 1 028 241 2 702 5 995 women 30 years and older Population 30 years and older No 13 328 33 444 33 400 6 972 31 459 118 603 female/10 16. Human Papilloma Virus Annual 89% 95% 96% 91% 88% 93% Vaccine 1st Dose coverage % Numerator No 705 2378 1740 456 1788 7064 Denominator No 795 2504 1808 504 2029 7640 17. Vitamin A dose12 – 59 months Quarterly % 33.9% 67.5% 29.7% 49.8% 63.7% 51.1% coverage Vitamin A dose 12 - 59 months No 5 532 28 119 11 511 3 517 21 560 70 239 Population 12-59 months No 8 168 20 843 19 179 3 534 16 918 68 642 (multiplied by 2) 18. Maternal mortality in facility Annual No 47.1/100K 63.3/100K 0/100K 0/00K 85.3/100K 60.2/100K ratio per 100K 95 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five False Umhlabuyalingan District Average Bay LM a LM Maternal death in facility No 2 3 0 0 4 9 Live birth in facility No 4 250 4 739 1 127 142 4 688 14 946 19. Early neonatal death in facility Annual 0.7/1K 4.9/1K 3.5/1K 0/1K 6.4/1K 4/K rate Per 1 000 Death in facility 0-7 days No 3 23 4 0 30 60 Live birth in facility No 4 250 4 739 1 127 142 4 688 14 946 96 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 34 (NDoH 23): Performance Indicators for MCWH&N Indicators Data Source Frequency Audited/ Actual Performance Estimated Medium Term Targets Provincial Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Antenatal 1st visits before 20 DHIS Quarterly 48% 54.2% 61.2% 60.3% 68% 69% 70% 60% weeks rate % Antenatal 1st visit before 20 weeks DHIS / Tick No 8 446 9 176 10 785 10 162 11 606 11 894 12 187 139 012 register PHC Antenatal 1st visit total DHIS No 17 545 17 075 17 443 16 854 17 067 17 238 17 410 231 686 calculates 2. Proportion of mothers visited DHIS Quarterly 60.6% 70% 87.3% 75% 77% 78% 79% 74.4% within 6 days of delivering % their babies Mother postnatal visit within 6 DHIS / Tick No 8 948 10 093 13 029 11 824 12 275 12 559 12 845 151 711 days after delivery Register PHC Delivery in facility total DHIS / No 14 756 14 443 14 919 15 776 15 942 16 101 16 262 203 910 Delivery register 3. Antenatal client initiated on DHIS Annual 84.4% 84% 73.1% 85% 87% 89% 92% 95% ART rate calculates % ANC client started on ART ART Register No 1 413 1 099 3 507 3 878 4 077 4 254 4 485 - ANC client eligible for ART ART Register No 1 674 1 313 4 797 4 550 4 686 4 780 4 875 - initiation 4. Infant 1st PCR test positive DHIS Quarterly 3.4% 3.3% 1.7% 1.2% 1.1% 1.1% 1% <1% around 6 weeks rate % Infant 1st PCR test positive around DHIS / Tick No 210 203 99 74 70 71 65 905 6 weeks register PHC Infant 1st PCR test around 6 weeks DHS / Tick No 6 182 6 226 5 870 6 260 6 351 6 414 6 479 90 535 Register PHC 5. Immunisation coverage DHIS Quarterly 102.5% 104% 74.6% 91% 92% 93% 94% 90% under 1 year % Immunised fully under 1 year new DHIS / Tick No 15 097 14 636 13 947 15 350 16 044 16 705 17 391 193 933 register PHC 97 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Data Source Frequency Audited/ Actual Performance Estimated Medium Term Targets Provincial Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Population under 1 year DHIS / Stats No 14 969 14 176 18 106 16 929 17 439 17 962 18 501 215 481 SA 6. Measles 2nd dose coverage DHIS Quarterly 88% 83% 71% 96% 96% 97% 98% 85% % Measles 2nd dose DHIS / Tick No 13 713 12 910 12 584 16 386 16 880 17 567 18 280 183 159 register PHC Population 1 year DHIS / Stats No 15 636 15 468 17 686 17 073 17 583 18 110 18 653 215 481 SA 7. DTaP-IPV-HepB-Hib 3 - DHIS Quarterly 2.9% 4.3% 5.5% 2.9% 2.8% 2.6% 2.5% 7.5% Measles 1st Dose drop-out % rate DTaP-IPV-HepB-Hib 3 to Measles1st DHIS / Tick No 461 687 868 482 474 444 432 - dose drop-out register PHC DTaP-IPV-HepB-Hib 3rd dose DHIS / Tick No 16 113 16 038 15 736 16 762 16 926 17 095 17 266 - register PHC 8. Child under 5 years diarrhoea DHIS Quarterly 4% 8% 4.5% 6.2% 5.5% 5.2% 5% 3.2% case fatality rate % Child under 5 years with diarrhoea DHIS / Tick No 17 47 45 64 55 51 47 329 death register Child under 5 years with diarrhoea Admission No 387 590 995 1 040 1 009 979 949 10 224 admitted Records 9. Child under 5 years DHIS Quarterly 5% 2% 2.9% 3.8% 3.3% 3% 2.8% 2.4% pneumonia case fatality rate % Child under 5 years pneumonia DHIS / Tick No 17 11 26 30 25 22 20 227 death register Child under 5 years pneumonia Admission No 322 590 888 788 764 741 719 9 199 admitted records 10. Child under 5 years severe DHIS Quarterly 18% 10% 12.2% 12% 10% 9% 8% 8% acute malnutrition case % fatality rate Child under 5 years severe acute DHIS / Tick No 35 21 32 32 26 23 20 256 malnutrition death register 98 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Data Source Frequency Audited/ Actual Performance Estimated Medium Term Targets Provincial Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Child under 5 years severe acute Admission No 199 209 263 266 260 256 250 3 200 malnutrition admitted records 11. School Grade R screening DHIS Quarterly Not Not 4% 6% 8% 10% 12% 40% coverage % collected collected School Grade R learners DHIS / Tick No. 445 1 005 1 380 1 777 2 196 - screened register SHS School Grade R learners - DHIS / DoE No. 10 663 16 745 17 247 17 765 18 298 - total database 12. School Grade 1 screening DHIS Quarterly Not Not 39% 41% 43% 45% 47% 55% coverage % collected collected School Grade 1 learners DHIS / Tick No. 7852 9 589 10 359 11 166 12 012 - screened register SHS School Grade 1 learners - DHIS / DoE No. 19902 23 389 24 091 24 814 25 558 - total database 13. School Grade 8 screening DHIS Quarterly Not Not 17% 20% 24% 26% 28% 40% collected collected coverage % School Grade 8 learners DHIS / Tick No. 2 585 3 603 4 453 4 969 5 512 - screened register SHS School Grade 8 learners - DHIS / DoE No. 15 664 18 015 18 555 19 112 19 685 - total database 14. Couple year protection rate DHIS Quarterly 27.8% 30% 32.7% 33% 35% 37% 39% 55% % Contraceptive years dispensed DHIS No 46 454 51 261 56 325 58 092 63 512 69 155 75 080 1 611 360 calculates Population 15-49 years female DHIS/Stats SA No 157 935 161 816 174 083 176 177 181 462 186 906 192 513 2 929 745 15. Cervical cancer screening DHIS Quarterly 90.6% 82.9% 51.5% 44% 50% 55% 60% 75% coverage (amongst women) % Cervical cancer screening in DHS / Tick No 8 667 8 152 5 995 5 376 6 271 7 105 7 984 175 671 women 30 years and older register PHC / Hospital register 99 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Data Source Frequency Audited/ Actual Performance Estimated Medium Term Targets Provincial Type Performance Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Population 30 years and older DHIS / Stats No 94 984 97 675 118 603 121 774 125 423 129 186 133 061 234 228 female/10 SA 16. Human Papilloma Virus DHIS Annual Not Not 93% 94% 95% 96% 98% 85% vaccine 1st Dose coverage % reported reported DHIS / Tick No 7064 7 215 7 511 7 817 8 220 - Girls 9 years and older HPV 1st register SHS dose Grade 4 girl learners ≥9 years DHIS / DoE No 7640 7 676 7 906 8 143 8 388 - enrolment 17. Vitamin A dose12 – 59 DHIS Quarterly 30.3% 33.9% 51.1% 54% 60% 63% 65% 60% months coverage % Vitamin A dose 12 - 59 months DHIS / Tick No 42 845 45 219 70 239 74 968 87 386 94 508 100 434 1 072 060 register PHC Population 12-59 months DHIS / Stats No 70 634 68 532 68 642 68 264 72 822 75 006 77 257 1 786 768 (multiplied by 2) SA 18. Maternal mortality in facility DHIS Annual 68.1/100K 95.3/100K 60.2/100K 70/100K 63/100K 56/100K 49/100K 120/100K ratio No per 100K Maternal death in facility DHIS / No 10 14 9 11 10 9 8 242 Midnight census Live birth in facility DHIS / No 14 695 14 683 14 946 15 672 15 841 16 158 16 481 202 473 Delivery register 19. Early neonatal death in DHIS Annual 6.7/1K 6.1/1K 4/K 5.4/1K 4.6/1K 4/1K 3.5/1K MCW facility rate Per 1 000 Death in facility 0-7 days No 98 90 60 84 72 65 58 - Live birth in facility No 14 695 14 683 14 946 15 672 15 841 16 158 16 481 202 473 100 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 35 (NDoH 24): District Objectives and Annual Targets for MCWH & Nutrition Audited/actual Performance Estimated Strategic Medium Term Targets Performance Frequency Performance Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. 1.1 Neonatal DHIS Quarterly 7.6/1K 6.5/1K 4.4/1K 6.6/1K 6/1K 5.5/1K 5/1K mortality in calculates Rate per facility rate 1000 (annualised) Inpatient death DHIS/Midnight No 115 99 68 116 108 102 95 neonatal census Population DHIS/Delivery No 15418 14601 18649 17 437 17 962 18 501 19 056 estimated live register births 2. 2.1 Infant ASSA2008 Annual 84/1K 75/1K 67/1K 108/1K 96/1K 84/1K 78/1K mortality rate Rate per 1000 Inpatient death under 1 year No 124 146 141 200 180 160 150 Inpatient separation under 1year No 1 476 1 942 2 009 1 850 1 882 1 901 1 920 3. 3.1 Child under 1 DHIS Annual 8/1K 10/1K 8/1K 11.5/1K 10/1K 9/1K 8/1K year mortality in Per 1 K facility rate (annualized) Inpatient death DHIS No 124 146 141 200 180 160 150 under 1 year calculates Population DHS calculates No 15418 14601 18649 17 437 17 962 18 501 19 056 estimated live births 101 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/actual Performance Estimated Strategic Medium Term Targets Performance Frequency Performance Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 4. 4.1 Under 5 ASSA2008 Annual 11.3/1K 14.1/1K 10.7/1K 14/k 11/k 9.7/k 8.9/k mortality Rate per rate 1000 Inpatient death DHIS under 5 years calculates No 171 213 199 244 200 180 170 Population DHIS No 15 418 14 601 18 649 17 439 17 962 18 501 19 056 estimated live calculates births 5. 5.1 Inpatient DHIS Annual 66/1K 59/1K 51.7/1K 67.5/k 57.5/k 53.9/k 53/k death under 5 Per 1 K years rate Inpatient death DHIS No 171 213 199 244 200 180 170 under 5 years calculates Inpatient DHS calculates No 2 577 3 584 3 847 3 616 3 480 3 341 3 207 separations under 5 years 6. 6.1 Child under 5 DHIS Annual 16.5/1K 17.2/1K 8.24/1K 6.9/k 6.3/k 5.9/k 5.4/k years diarrhoea calculates No per with dehydration 1000 incidence (annualised) Child under 5 PHC Tick No 1365 1393 715 592 557 529 502 years diarrhoea Register with dehydration new Population under DHIS/Stats SA No 82 577 81 136 86 746 85 189 87 745 90 377 93 088 5 years 7. 7.1 Child under 5 DHIS Annual 127.4/1K 121.8/1K 104.6/1K 84/k 77/k 71/k 66/k years pneumonia calculates No per incidence 1000 (annualised) Child under 5 PHC Tick No 10522 9885 9072 7156 6774 6435 6113 years with Register pneumonia new 102 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/actual Performance Estimated Strategic Medium Term Targets Performance Frequency Performance Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Population under DHIS/Stats SA No 82 577 81 136 86 746 85 189 87 745 90 377 93 088 5 years 8. 8.1 Child under 5 DHIS Annual 8.2/1K 9.2/1K 5.6/1K 9.5/1K 5.8/1K 5.3/1K 5/1K years severe calculates No per acute 1000 malnutrition incidence (annualised) Child under 5 DHIS/Tick No 677 745 556 808 505 474 469 years with severe register PHC acute malnutrition new Population under DHIS/Stats SA No 82 577 81 136 86 746 85 189 87 745 90 377 93 088 5 years 9. 9.1 Weighing DHIS Quarterly Not reported 89% 68.3% 81% 80% 81% 82% coverage under calculates % 1 year (annualised) Children under 1 DHIS/Tick No 151 914 153 196 164 306 167 414 174 591 182 050 year weighed register PHC/CCG records Population under DHIS/Stats SA No 14 176 18 106 16 929 17 439 17 962 18 501 1 year 10. 10.1 Child under DHIS No per Not reported Not reported 38.1/1K 59/1K 55/1K 54/1K 50/1K 2 years 1000 underweight for Annual age incidence (annualised) Child under 2 DHIS / Tick No 1 397 2 000 1 926 1 947 1 857 years register PHC underweight - new (weight between - 2SD and - 3SD new) Population under DHIS / Stats SA No 35 796 34 002 35 022 36 073 37 155 2 years 103 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/actual Performance Estimated Strategic Medium Term Targets Performance Frequency Performance Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 11. 11.1 Deworming DHIS Quarterly Not reported Not reported 37.5% 52.5% 60% 65% 70% dose 12-59 % months coverage (annualised) Numerator Tick Register No. 45885 71 654 87 386 97 508 108 160 PHC Population 12-59 DHIS / Stats SA No 70 634 68 532 68 642 68 264 72 822 75 006 77 257 months (multiplied by 2) 12. 12.1 Measles 1st DHIS Quarterly 105% 108% 82% 96% 96% 96% 96% dose under 1 % year coverage (annualized) Measles 1st dose DHIS / Tick No 15 643 15 351 14 868 16 280 16 741 17 244 17 761 under 1 year register PHC Population under DHIS / Stats SA No 14 969 14 176 18 106 16 929 17 439 17 962 18 501 1 year 12.2 PCV 3rd DHIS Quarterly 106% 107% 82% 97% 97% 97% 97% dose coverage % (annualized) PCV 3rd dose DHIS / Tick No 15 820 15 160 14 860 16 368 16 916 17 423 17 946 Register PHC Population under DHIS / Stats SA No 14 969 14 176 18 106 16 929 17 439 17 962 18 501 1 year 12.3 RV 2nd dose DHIS Quarterly 109% 113% 87% 98% 98% 98% 98% coverage % (annualised) RV 2nd dose DHIS / Tick No 16 309 15 993 15 804 16 658 17 090 17 603 18 130 Register PHC Population under DHIS / Stats SA No 14 969 14 176 18 106 16 929 17 439 17 962 18 501 1 year 104 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Audited/actual Performance Estimated Strategic Medium Term Targets Performance Frequency Performance Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 13. 13.1 Infant given DHIS Quarterly 100.5% 99% 99.6% 99.5% 99.5% 99.6% 99.7% NVP within 72 % hours after birth uptake rate 5 Infant given NVP DHIS / Tick No 4 804 5 116 4 995 5 050 5 111 5 178 5 245 within 72 hours register OPD/ after birth PHC, delivery register Live birth to HIV DHIS / delivery No 4 855 5 183 5 016 5 076 5 137 5 199 5 261 positive woman register 14. 14.1 Delivery in DHIS Annual 10.4% 11.3% 11.3% 11% 10.5% 10.2% 10% facility under 18 % years rate Delivery in facility DHIS / Delivery No 1 537 1 628 1 680 1 734 1 674 1 642 1 626 to woman under register 18 years Delivery in facility DHIS / Delivery No 14 756 14 443 14 919 15 776 15 942 16 101 16 262 total register 15. 15.1 Infants DHIS Quarterly 37.5% 66.9% 44.1% 50% 52% 53% 55% exclusively % breastfed at Hepatitis B 3rd dose Infant exclusively Tick register No 2 211 10 817 7 132 8 394 8 928 9 281 9 825 breastfed at PHC HepB3rd dose HepB 3rd Dose Tick register No 16 572 16 180 16 182 16 834 17 169 17 512 17 863 PHC 5 Baby Nevirapine uptake rate 105 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 15.2 STRATEGIES/ ACTIVITIES TO BE IMPLEMENTED 2015/16 Strategies Activities 1. Improve Antenatal care - Audit implementation of BANC - Audit all causes of still births 2. Implement KZN 5 point contraceptive - Monitor the availability of contraceptive method mix in PHC facilities strategy and to reduce high teenage - Monitor integration of SRH in HIV/TB and School Health. pregnancy 3. Improve community involvement in - Sensitise all community stakeholders on MCWH&N issues. MCWH&N issues through OSS 4. Strengthen functionality of Phila Mntwana - Ensure availability of basic equipment centres - Conduct adequate training of cadres working at Phila Mntwana Centres - Marketing of Phila Mntwana centres - Increase number of Phila Mntwana centres under Jozini and Hlabisa 5. Implement MDG Count-down to April 2015 - Train health workers in management of malnutrition - Train, monitor and conduct partogram audits in all facilities - conducting deliveries - Promote and support breastfeeding 6. Strengthen implementation of CARMMA - Monitor implementation of Mom Connect, BANC, post natal care, PMTCT, contraception and HIV & AIDS 106 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Strategies Activities - Conduct audits 7. Improve IMCI implementation - Train health workers on IMC implementation - Monitor implementation of IMCI guidelines 8. Improve access to quality skilled birth - Train, monitor and mentor maternity staff on implementation ESMOE attendants - Monitor functionality and effectiveness of EMS harmonization 9. Improve management of gastroenteritis and - Train health workers on management of gastroenteritis and pneumonia pneumonia - Audit implementation of gastroenteritis and pneumonia treatment guidelines 107 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 16. DISEASE PREVENTION AND CONTROL (ENVIRONMENTAL HEALTH INDICATORS) 16.1 PROGRAMME OVERVIEW The purpose of this programme is to prevent and control communicable and non- communicable diseases in the District. The district is aiming towards elimination of malaria. The Malaria incidence is 0.33/1k population, below the target of <1/1k population. 207 Malaria cases identified in 2013/14 financial year with four deaths reported which gives a case fatality rate of 1.9% and which is very high compared to previous years. Mortality reviews and training on Malaria management need to be strengthened. Mosvold hospital has been the only site for cataract surgery for the past 10 years. Hlabisa started doing the cataract surgery as from April 2014 with the support from the cataract surgeon from Mosvold hospital. In 2013/14 489 operations were done which gives a cataract surgery rate of 798/mill population which is below the provincial target of 1 430/mill pop. The district will revive Cataract Finders. There is an increase in new cases of hypertension and diabetes. The district needs to strengthen promotion of Healthy Life Style. 13 amputations performed as at the end of second quarter 2014/15 due to diabetes, which indicates poor management of diabetes and delay in seeking medical attention. Some hospitals have established outreach teams (Mpilonde Chronic Medication dispensation) to communities to dispense chronic medications. This initiative has reduced congestion in clinics and hospitals and it has reduced patient waiting times in facilities. 1/5 (Hlabisa) has no Mental Health seclusion ward. The hospital is in a process to identify a corner for seclusion. The district is experiencing a high defaulter rate of Mental Health Care Users. The programme will be linked to CCG programme. There have been no cases of cholera reported in the past ten years. The District continues to monitor for notifiable medical condition including meningococcal meningitis and hepatitis B. There were isolated food poisoning outbreaks. STRATEGIC CHALLENGES FOR THE SUB-PROGRAM - Shortage of Cataract Surgeons 108 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 - Increased number of amputations due to diabetic complications - Poor implementation of health lifestyle practises in the community 109 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 36 (NDoH 25): Situational Analysis for Disease Prevention and Control - 2013/14 Financial Year Indicator Type Hlabisa LM Jozini LM Mtubatuba LM The Big Five UMhlabuyalingana LM District Avg False Bay LM 1. Clients screened for hypertension Quarterly No Not Collected Not Collected Not Collected Not Collected Not Collected on DHIS Not Collected on DHIS on DHIS on DHIS on DHIS on DHIS 2. Clients screened for diabetes Quarterly Not Collected Not Collected Not Collected Not Collected Not Collected on DHIS Not Collected No on DHIS on DHIS on DHIS on DHIS on DHIS 3. Percentage of people screened for mental disorders Quarterly % Not Collected Not Collected Not Collected Not Collected Not Collected on DHIS Not Collected on DHIS on DHIS on DHIS on DHIS on DHIS PHC Client screened for mental disorders No PHC headcount total No 4. Percentage of people treated for mental disorders Quarterly % Not Collected Not Collected Not Collected Not Collected Not Collected on DHIS Not Collected on DHIS on DHIS on DHIS on DHIS on DHIS Client treated for mental disorders at PHC level No Clients screened for mental disorders at PHC level No 5. Cataract surgery rate No per million 0.0/mil 2568.7/mil 0.0/mil 0.0/mil 0.0/mil 798/mil uninsured population Cataract surgery total No 0 489 0 0 0 489 Population uninsured total No 70 209 182 556 172 382 34 761 153 220 613 129 6. Malaria case fatality rate % 14.3% 0% 0% 0% 1.1% 1.9% Malaria death reported No 2 0 0 0 1 4 Number of malaria cases (new) No 21 51 41 3 95 211 110 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 37 (NDoH 26): Performance Indicators for Environmental Health Services Estimated Provincial Audited/ Actual Performance Medium Term Targets Data Frequency Performance Targets Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Clients screened for DHIS / Tick Quarterly Not Not Not Not collected TBD TBD TBD Establish collected collected collected hypertension register No baseline 2. Clients screened for DHIS / Tick Quarterly Not Not Not Not collected TBD TBD TBD Establish collected collected collected diabetes register No baseline 3. Percentage of people DHIS Quarterly % Not Not Not Not collected TBD TBD TBD Establish collected collected collected screened for mental calculates baseline disorders PHC Client screened for mental DHIS / Tick No disorders register PHC headcount total DHIS / Tick No Register 4. Percentage of people DHIS Quarterly % Not Not Not Not collected TBD TBD TBD Establish collected collected collected treated for mental disorders Calculates baseline Client treated for mental DHIS / Tick No disorders at PHC level register Clients screened for mental DHIS / Tick No disorders at PHC level register 5. Cataract surgery rate DHIS Quarterly 679/1mill 735/1mill 798/1mill 1374/1mill 1410/mil 1400/mill 1434/mill 930/mil No per 1 mil uninsured population Cataract surgery total DHIS / No 426 414 489 850 880 900 950 8 895 Theatre register Population uninsured total DHIS / Stats No 627 336 563 211 613 129 618 650 624 310 643 039 662 330 9 566 487 SA 6. Malaria case fatality rate Malaria Annual 1% 1% 1.9% 1.6% 1.3% 1% 0.5% <0.5% Register % 111 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Estimated Provincial Audited/ Actual Performance Medium Term Targets Data Frequency Performance Targets Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Malaria death reported Malaria No 2 2 4 3 3 2 1 - register / Tick register PHC Number of malaria cases (new) Malaria No 187 172 211 207 203 199 195 - register / Tick register PHC Table 38 (NDoH 27): District Objectives and Annual Targets for Environmental Health Services Strategic Estimated Frequency Audited/ Actual Performance Medium Term Targets Objective Performance Indicator Data Source Performance Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. Malaria incidence per Malaria Annual 0.28/1K 0.25/1K 0.33/1K 0.31/1K 0.30/1K 0.29/1K 0.27/1K 1000 population at risk register Per 1000 population at risk Number of malaria Malaria No 187 172 211 200 195 194 186 cases (new) register/Tick register PHC Population DHIS/Stats SA Population 660 354 666 523 638 011 643 757 649 646 669 135 689 209 Umkhanyakude 2. Hypertension incidence DHIS Quarterly 25.9/1K 24.5/1K 22.2/1K 25.2/1K 20.7/1K 19.5/1K 18.5/1K (annualised) No per 100 112 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Strategic Estimated Frequency Audited/ Actual Performance Medium Term Targets Objective Performance Indicator Data Source Performance Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Hypertension client DHIS / PHC No 2 737 2 622 2 588 2 798 2548 2 497 2 447 treatment new tick registers Population 40 years DHIS / Stats No 105 077 106 077 118 315 120 836 124 463 128 197 132 043 and older SA 3. Diabetes incidence DHIS Quarterly 0.83/1K 0.63/1K 0.8/1K 0.85/1K 0.8/1K 0.76/1K 0.72/1K (annualised) No per 1000 Diabetes client DHIS / PHC No 545 423 527 546 519 509 499 treatment new tick registers Population DHIS / Stats No 660 354 666 523 638 011 643 757 649 646 669 135 689 209 Umkhanyakude SA 113 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 16.2 STRATEGIES/ ACTIVITIES TO BE IMPLEMENTED 2015/16 Strategies Activities 1. Improve case management of malaria - Conduct training twice a year on Malaria management - Conduct Annual mortality review for Malaria 2. Improve cataract surgery rate - Identify Cataract Case Finders - Request Regional Hospitals to provide Eye Surgeon through flying Doctors 3. Strengthen Healthy life style - Conduct awareness campaign - Encourage Work and Play Programs at all institutions 4. Strengthen surveillance system - Active and passive case finding - Conduct patient follow-ups - Submit notifiable medical condition forms 5. Improve diabetic and hypertension - Early screening and diagnosis - Follow the treatment guidelines 114 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 17. INFRASTRUCTURE, EQUIPMENT AND OTHER SUPPORT SERVICES Table 39 (NDoH 38): Performance Indicators for Health Facilities Management Indicator Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Expenditure on facility maintenance as % of total district % 1.32% 1.19% 1.29% 1.7% 2.1% 2.6% 3% health expenditure Numerator R14 482 R14 460 R17 883 R24 922 181 R30 828 R40 570 R49 738 215 032 045 223 253 402 Denominator R1 097 927 R1 220 019 R1 383 028 R1 466 010 R1 468 010 R1 557 971 R1 657 946 372 345 895 629 629 266 742 2. Number of facilities that have undergone major and minor 1 2 2 1 1 2 3 refurbishment 3. Fixed PHC facilities with access to continuous supply of % 70% 67% 66% 66% 67% 67% 67% clean portable water Numerator 38 37 37 37 38 39 39 Denominator 54 55 56 56 57 58 58 4. Fixed PHC facilities with access to continuous supply of % 100% 100% 100% 100% 100% 100% 100% electricity Numerator 54 55 56 56 57 58 58 Denominator 54 55 56 56 57 58 58 5. Fixed PHC facilities with access to sanitation 100% 100% 100% 100% 100% 100% 100% Numerator 54 55 56 56 57 58 58 Denominator 54 55 56 56 57 58 58 6. Fixed PHC facilities with access to fixed telephone line % 100% 98% 98% 98% 100% 100% 100% Numerator 54 54 55 55 57 58 58 115 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicator Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Denominator 54 55 56 56 57 58 58 7. Percentage of PHC facilities with network access 0% 0% 1.8% 1.8% 35% 70% 100% (Provincial competency) Numerator 0 0 1 1 20 40 58 Denominator 54 55 56 56 57 58 58 8. Number of additional clinics and community health 0 0 1 1 2 0 0 centres constructed 116 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 18. SUPPORT SERVICES 18.1 PHARMACEUTICAL SERVICES The purpose of this program is to ensure availability of medicines and compliance to Pharmacy legislatives PHC Medicine Supply Management (MSM) remains a challenge in the District, because there are no dedicated Pharmacist Assistants PAs appointed at PHC. 5/62 PHC facilities (including mobile bases) have appointed Pas, and the Province is in the process of creating more posts for the remaining facilities as the proposed new PHC structure. This initiative is aiming at improving PHC MSM. The District has a high turnover of Pharmacy Managers at Manguzi, Mosvold and Mseleni. It is also difficult to attract and retain production level pharmacists in the District because of its deep rural nature. The district relies on Community Service Pharmacists for continuity of services. To address the attraction and retention of pharmacists, the District plans to implement the new Pharmacy structure in all hospitals within the District which will improve the Pharmacy Managers posts from being Assistant Managers to Deputy Manager: Pharmaceutical Services. The District office is planning to unfreeze and fill two pharmacists and two PAs posts to strengthen Pharmaceutical Services support to PHC facilities and to assist District hospitals when there is a shortage of hospitals pharmacists. Pharmaceutical and Therapeutics Committees (PTC) are being re-vitalised in the District. The District is in the process of formally selecting and appointing members of the District PTC. The Terms of Reference (TOR) have been approved with relevant attachments. TOR for formally establishing hospital PTC has been circulated to hospitals and it is anticipated that the hospitals PTC will be formally appointed by the end of 2014/15 financial year. Compliance with South African Pharmacy Council (SAPC) standards remains a challenge in the District as there were only two hospital who received an A grading (Bethesda and Hlabisa – until end of December 2015) and one hospital received B grading (Mseleni – until end of December 2014). It is anticipated that Mseleni hospital will not retain its B grading in 2015 as pharmacists are leaving the institution (four full time pharmacists). High turnover of Pharmacy Managers at Manguzi, Mosvold and Mseleni resulted in these hospitals not being graded. 117 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Tracer medicines stock out rate was 6% (2nd Quarter 2014/15) compared to 10% (annual 2013/14) for Institutions. Although this is slightly above the target (5%), stock out of medicines remains unacceptable and would result in poor patient outcomes. Provincial Pharmaceutical Supply Depot (PPSD) order schedules were issued on a month to month basis and were unpredictable form the beginning of the year, as result there was a lag time of about two weeks between anticipated dates resulting in some facilities ordering in six weeks instead of four weeks intervals. CHALLENGES - High turnover of Pharmacists - Unavailability of PHC Pharmacist Assistant posts - Poor monitoring of (MSM) in hospitals and PHC facilities - Noncompliance with Standard Treatment Guidelines (STGs) and Essential Medicines Lists (EML) in hospitals and PHC facilities 118 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 40 (NDoH 39): Pharmaceutical Services Performance Indicators Indicators Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Percentage of institutions % 80% 60% 80% 80% 100% 100% 100% (District Hospitals and CHC’s) with functional of Pharmaceutical and Therapeutics Committees (PTC’s) Number of CHC’s and District 4 3 4 4 6 6 6 Hospitals with functional Pharmaceutical and Therapeutic Committees Number of District Hospitals and 5 5 5 5 6 6 6 CHC’s 2. Any ARV Drug Stock Out Rate % Indicator Indicator not Indicator not Indicator not Indicator not Indicator not Indicator not not clearly clearly clearly clearly clearly clearly defined clearly defined defined defined defined defined defined Number of ARV drug’s out of stock Number of ARV’s drugs 3. Any TB Stock Out Rate % Indicator Indicator not Indicator not Indicator not Indicator not Indicator not Indicator not clearly clearly clearly defined clearly defined not clearly clearly clearly defined defined defined defined defined 119 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Indicators Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Number of TB drugs out of stock Number of TB drugs 4. Percentage of Hospitals with % 100% 100% 100% 100% 100% 100% 100% Pharmacists Number of District Hospitals with 5 5 5 5 5 5 5 Pharmacists Number of District Hospitals 5 5 5 5 5 5 5 5. Percentage of CHC’s with % N/A N/A N/A N/A 100% 100% 100% Pharmacists Number of CHC’s with 1 1 1 pharmacists Number of CHC’s 1 1 1 120 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 41 (NDoH 30): Pharmaceutical Services Estimated Strategic Audited/ Actual Performance Medium Term Targets Performance Indicator Data source Type Performance Objective 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. 1. Percentage of Pharmacy Annual 40% 40% 60% 40% 83% 100% 100% Pharmacies that records % obtained A and B grading on inspection Pharmacies with A or B Pharmacy No 2 2 3 2 5 6 6 Grading records Number of pharmacies Pharmacy No 5 5 5 5 6 6 6 records 2. Tracer medicine stock- Pharmacy Quarterly N/A N/A N/A N/A N/A N/A N/A out rate (PPSD) records % Number of tracer medicine Pharmacy No out of stock records Total number of tracer Pharmacy No medicine expected to be in records stock 3. Tracer medicine stock- Pharmacy Quarterly 2% (incl. PHC) 6% 6% 6% 5% 5% 5% out rate (Institutions) records % Number of tracer medicines Pharmacy No 92 196 200 200 200 200 200 stock out in bulk store records Number of tracer medicines Pharmacy No 6 009 3 300 3 300 3 240 3 888 3 888 3 888 expected to be stocked in records the bulk store 2. 4. Number of mortuaries Management Annual 0 0 0 0 0 1 1 rationalised No 121 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Strategies Activities 1. Strengthen Pharmaceuticals services - Implement new District hospital Pharmacy structure HR - Expand the District Office Pharmaceutical Services to strengthen PHC support - Create PAs posts at PHC facilities to improve PHC MSM 2. Strengthening of District and Hospital - Revitalize and establish PTC committees Pharmaceutical and Therapeutics - Conduct audits on Standard Treatment Guidelines implementation and training Committees to ensure adequate - Conduct National Core Standards (NCS) audits training on EML/STGs 3. Strengthen stock management in all - Monitoring of MSM in hospitals and PHC facilities facilities - Conduct stock taking 122 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 18.2 EQUIPMENT AND MAINTENANCE Acquisition plan attached as annexure B Table 42: District Equipment and Maintenance Indicators Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2015/16 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. Percentage of Annual 88% 99% 100% 109% 100% 100% 100% maintenance budget % spent Expenditure on No 14 482 215 14 4600 032 17 883 045 18 306 921 20 137 613 22,151,374 24,366,512 maintenance (preventive and scheduled) Maintenance budget No 16 365 312 14 548 000 17 883 000 16 833 000 20 140 000 22 168 000 24 405 000 2. Proportion of Annual Monitored by Monitored Monitored Monitored Monitored by Monitored by Monitored by by by by Provincial Provincial Provincial Programme 8 ( Provincial % Provincial Provincial Provincial infrastructure infrastructure infrastructure infrastructure budget) infrastructure infrastructur infrastructur infrastructur Office Office Office spent on all Office e Office e Office e Office maintenance (preventative and scheduled) Expenditure on No maintenance (preventive and scheduled) Infrastructure budget No 3. Number of health Annual 1 2 2 1 1 2 3 facilities that have No. undergone major and minor refurbishments 123 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 18.3 EMERGENCY MEDICAL SERVICES (EMS) SUB PROGRAMME OVERVIEW The District has a challenge of having insufficient vehicles, inadequate staff and skills to meet the service demand. Currently (end of Q2 2014/15) there are 12 ambulances (1:53 167 population), whereas the National Standard and Norms is 1:10 000. The response times are still a big challenge due to poor road infrastructure, poor road signage and geographic nature of area. The ambulances take hours to get on scene especially on gravel roads and the sense of direction from callers sometimes it possess a challenge, whereby landmarks are not fixed and visible. The district has insufficient staff both in the Administration and Operations side, this compromises service delivery especially when it comes to daily operations. The district has limited skilled individuals on the operation (Roads) there are less Advance Life Support (ALS) and Intermediate Life Support (ILS) to meet our daily demands. The terrain for UMkhanyakude District is very bad, which contributes to poor response times. The patient pick up points are very far from the bases, which can cause a response time of 4 hours from Base to scene. The absence of Regional and Tertiary hospitals in the District causes EMS to have a high rate of Inter-facility Transfers. 124 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 43 (NDoH 31 (a)): Operational Ambulances per 10,000 Population Coverage (inclusive of LG) District Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Hlabisa Local Municipality Ratio 1,93158 0.274 (2/7.31) 0.547 (4/7.31) 0.547 (4/7.31) 1 (7/7.31) 1 (7/7.31) 1 (7/7.31) Jozini Local Municipality Ratio 1,24241 0.368 (7/19) 0.474 (9/19) 0.474 (9/19) 1 (19/19) 1 (19/19) 1 (19/19) Mtubatuba Local Municipality Ratio 1,21244 0.167 (3/18) 0.167 (3/18) 0.167 (3/18) 1 (18/18) 1 (18/18) 1 (18/18) Big 5 False Bay Local Municipality Ratio 1,14878 0.5 (2/4) 0.5 (2/4) 0.5 (2/4) 1 (4/4) 1 (4/4) 1 (4/4) UMhlabuyalingana Local Ratio 0.563 (9/16) 0.563 (9/16) 1,11175 0.438 (7/16) 1 (16/16) 1 (16/16) 1 (16/16) Municipality UMKHANYAKUDE Ratio 1,34038 0.328 (21/64) 0.422 (27/64) 0.422 (27/64) 1 (64/64) 1 (64/64) 1 (64/64) Table 44 (NDoH 31 (b)): Ambulance Response Time Rural under 40 minutes (Inclusive of LG) Audited/ Actual performance Estimate MTEF Projection Provincial Target 2015/16 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Hlabisa Local Municipality 26% 21% (645/3050) 9% (451/4986) 23% (942/4127) 60% (2750/4551) 75% (3421/4551) 75% (3421/4551) (3314/12746) Jozini Local Municipality 15% 25% (1052/4289) 20% (1315/6431) 18% (1342/7289) 54% (4351/8000) 63% (5012/8000) 63% (5012/8000) (4392/29280) Mtubatuba Local Municipality 29% 12% (537/4330) 20% (1130/5771) 19% (1224/6521) 48% (3455/7230) 65%(4723/7230) 65%(4723/7230) (3899/13445) Big 5 False Bay Local Municipality 31% 17% (361/2075) 12% (311/2649) 17 % (676/3942) 42% (1730/4150) 68%(2834/4150) 68%(2834/4150) (4572/14748) UMhlabuyalingana Local 28% 25% (915/3636) 16% (801/5093) 19% (1046/5621) 47% (3116/6511) 77% (4987/6511) 77% (4987/6511) Municipality (3062/10936) UMKHANYAKUDE 26% 20% 16% 19% 51% 69% 69% 33% (19239/73996) (3510/17380) (4008/24930) (5230/27500) (15402/30402) (20986/30402) (20986/30402) (71 802/217 229) 125 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Table 45 (NDoH 31(c)): Ambulance Response Times Urban under 15 minutes (Inclusive of LG) Ambulance Response Time: Urban Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 N/A % N/A % N/A % N/A % N/A % N/A % District Average % Table 46 (NDoH 31 (d)): EMS Inter-facility Transfer Rate District Type Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Hlabisa Local Municipality % 10%(838/8758) 14%(1345/9562) 17%(1508/9134) 14%(171012426) 16%(2000/12500) 16%(2000/12500) 16%(2000/12500) Jozini Local Municipality % 10%(768/7851) 11%(912/8230) 14%(1214/8671) 15%(1324/9145) 18%(1700/9300) 18%(1700/9300) 18%(1700/9300) Mtubatuba Local Municipality % 2%(102/5624) 2%(167/7490) 2%(92/7812) 1%(67/8423) 4%(310/8500) 4%(310/8500) 4%(310/8500) Big 5 False Bay Local Municipality % 2%(98/4621) 2%(135/5432) 1%(53/6512) 1%(45/6812 2%(170/7000) 2%(170/7000) 2%(170/7000) UMhlabuyalingana Local % 12%(708/5822) 13%(854/6756) 14%(983/7193) 18%(1341/7354) 21%(1590/7700) 21%(1590/7700) 21%(1590/7700) Municipality UMKHANYAKUDE % 8%(2514/32676) 9%(3413/37470) 10%(3850/39322) 10%(4487/44160) 13%(5770/45000) 13%(5770/45000) 13%(5770/45000) 37% (230 000/620 000) 126 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 19. HUMAN RESOURCES Table 47 (NDoH 32): Performance for Human Resources TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Health district Personnel category1 Hlabisa PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 32 47 22 27 30 30 33 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 9 14 14 17 17 19 19 Professional nurses 143 136 154 160 160 165 167 Pharmacists 4 5 4 5 6 6 7 Radiographers 3 3 3 4 4 4 5 Jozini PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 65 90 99 110 115 120 122 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 18 23 25 27 29 29 31 Professional nurses 121 130 151 163 170 180 190 Pharmacists 5 4 5 6 7 7 8 Radiographers 5 5 4 5 5 6 7 127 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 CHC facilities Medical officers 0 0 0 0 8 8 8 Professional nurses 0 0 0 0 38 41 45 Pharmacists 0 0 0 0 3 3 3 Radiographers 0 0 0 0 1 2 2 The Big 5 False Bay PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 7 13 19 31 36 40 45 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 0 0 0 0 0 0 0 Professional nurses 0 0 0 0 0 0 0 Pharmacists 0 0 0 0 0 0 0 Radiographers 0 0 0 0 0 0 0 Mtubatuba PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 65 46 76 90 95 100 105 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 0 0 0 0 0 0 0 Professional nurses 0 0 0 0 0 0 0 Pharmacists 0 0 0 0 0 0 0 128 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Radiographers 0 0 0 0 0 0 0 UMhlabuyalingana PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 80 105 100 113 115 120 125 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 19 27 29 30 32 32 32 Professional nurses 191 193 179 190 195 200 205 Pharmacists 5 7 6 6 7 7 8 Radiographers 5 5 6 6 6 6 7 District PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 249 301 316 371 391 410 430 Pharmacists 0 0 0 0 0 0 0 CHC Medical officers 0 0 0 0 8 8 8 Professional nurses 0 0 0 0 38 41 45 Pharmacists 0 0 0 0 3 3 3 Radiographers 0 0 0 0 1 2 2 District hospitals 129 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Medical officers 46 64 68 74 78 80 82 Professional nurses 455 459 484 513 525 545 562 Pharmacists 14 16 15 17 20 20 23 Radiographers 13 13 13 15 15 16 19 Table 48 (NDoH 33): Plans for Health Science and Training CONTINUOUS PROFESSIONAL CAPACITY BUILDING / TRAINING 6 INDICATORS Estimated Medium term targets performance 2014/15 2015/16 2016/17 2017/18 Clinical Training for Medical and Allied Professionals Number of trained employees 20 25 25 30 Mid-Level Worker Training Number of trained employees 40 60 50 50 HIV/AIDS Management Number of trained employees 60 60 60 60 Nursing Education and Training Number of trained employees 120 120 140 140 Management and Leadership Number of trained employees 200 100 150 150 Finance Management Number of trained employees 40 30 30 30 Artisan Training Number of trained employees 40 40 25 25 Human Relations Training Number of trained employees 300 250 250 250 Compulsory Induction Programme Number of trained employees 250 200 100 100 6 This would include formal and informal (short courses, refreshers, etc.) courses. 130 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 CONTINUOUS PROFESSIONAL CAPACITY BUILDING / TRAINING 6 INDICATORS Estimated Medium term targets performance 2014/15 2015/16 2016/17 2017/18 Internship for Unemployed Graduates Number of trained employees 11 11 11 11 Adult Education and Training Number of trained employees 60 50 50 50 Strategic Management Number of trained employees 10 10 10 10 Health and Safety Related Training Number of trained employees 40 50 50 60 Generic Skills Training Number of trained employees 20 20 20 20 Employee Assistance Programme Training Number of trained employees 4 5 4 4 Supervisory Skills Training Number of trained employees 80 80 50 50 20. DISTRICT FINANCE PLAN Table 49 (NDoH 34): District Health MTEF Projections Sub-programme Audited outcome Main Adjusted Revised Medium term expenditure estimates appropriation appropriation estimate R’ thousand 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 District R8 148 487 R11 777 427 R10 799 016 12 077 000 - R11 825 665 12 653 462 13 539 204 14 486 943 Management Clinics R201 289 144 R212 533 461 R247 334 420 281 418 000 - 277 342 093 300 756 040 321 808 963 344 335 590 Community Health 0 0 0 0 - 0 44 815 000 47 952 000 51309 000 Centres Community R4 026 000 0 0 0 - - - - - Services Other Community R49 563 803 R60 235 212 R77 083 822 87 468 000 - 88 656 011 94 861 932 101 502 267 108 607 426 Coroner Services R8 669 009 R8 317 815 8 884 511 9 376 000 - 9 195 439 9 839 119 10 527 858 11 264 808 131 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 HIV and AIDS R108 569 728 R147 645 551 R186 746 261 193 425 000 - 257 985 513 274 974 499 294 222 714 314 818 304 Nutrition R3 428 103 R3 321 474 R3 327 630 3 213 000 - 2 970 044 3 177 947 3 400 404 3 638 432 District Hospitals R500 869 279 R581 413 915 R647 730 390 691 354 000 - 703 819 607 753 086 980 805 803 069 862 209 283 Environmental R56 982 768 R57969 536 R63 348 901 64 968 000 - 59 453 402 63 615 140 68 068 200 72 832 974 Health Services TOTAL R941 546 321 R1 082 214 391 R1 245 254 951 1 343 299 000 - 1 397 451 108 1 499 272 686 1 604 221 774 1 716 517 298 Table 50 (NDoH 35): District Health MTEF Projections per Economic Classification R’ Thousands Adjusted Revised Medium-term estimate Audited Outcomes Main appropriation appropriation estimate 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Current payments R1 080 020 R1 202 156 R1 229 247 093 R1 466 558 000 - 1 534 429 726 1 689 939 807 1 860 023 593 2 015 954 000 473 245 Compensation of R811 601 015 R898 522 385 R 933 530 703 R1 114 323 000 - 1099 494 391 1 211 858 999 1 334 877 129 1 469 413 employees 528 Goods and services R268 418 985 R303 634 088 R295 716 390 R352 235 000 - 434 935 335 478 080 808 525 146 465 576 545 717 Transfers and subsidies to R4 146 922 R3 404 006 R6 544 568 R2 796 000 - 9 373 158 10 094 279 10 801 329 11 556 522 Payments for capital assets R13 483 710 R14 458 866 R9 589 043 R2 646 000 - 9 055 344 10 039 218 1 116 963 12 296 151 Total economic R1 097 927 R1 220 019 R1 245 380 704 R1 472 000 000 - 1 552 858 228 1 710 073 304 1 881 941 885 2 069 811 classification 372 345 917 132 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 PART C: LINKS TO OTHER PLANS 21. CONDITIONAL GRANTS (WHERE APPLICABLE) Table 51 (NDoH 36): Outputs of a result of Conditional Grants Name of conditional Purpose of the grant Performance indicators Indicator targets for grant (extracted from the Business Case prepared for each Conditional Grant 2015/16 COMPREHENSIVE To enable the health sector to Total Number of fixed public health facilities offering ART 62 HIV AIDS develop an effective response to Services (including two Gateways) CONDITIONAL HIV and AIDS including universal Number of new patients that started on ART 15 000 GRANT access to HIV Counselling and (Applicable to Testing all Districts) To support the implements of the Total number of patients on ART remaining in care. 84 769 National operational plan for comprehensive HIV and AIDS Number of beneficiaries served by CCGs categories 89 662 treatment and care To subsidise in-part funding for the antiretroviral treatment plan Number of active CCGs receiving stipends 823 Number of male and female condoms distributed 5 100 000 Number of High Transmission Areas (HTA) intervention sites 2 133 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Name of conditional Purpose of the grant Performance indicators Indicator targets for grant (extracted from the Business Case prepared for each Conditional Grant 2015/16 Number of Antenatal Care (ANC) clients initiated on lifelong ART Number of babies Polymerase Chain Reaction (PCR) tested at 1. 3420 6 weeks Number of HIV positive clients screened for TB 1682 Number of HIV positive patients that started on IPT 12430 Number of active lay counsellors on stipends 4990 Number of clients pre-test counselled on HIV testing (including 162160 Antenatal) Number of HIV tests done 162160 Number of health facilities offering MMC services 12 Number of Medical Male Circumcisions performed 17 848 Sexual assault cases offered ARV prophylaxis <320 134 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Name of conditional Purpose of the grant Performance indicators Indicator targets for grant (extracted from the Business Case prepared for each Conditional Grant 2015/16 Doctors and professional nurses training on HIV/AIDS, STIs, TB 40 and chronic diseases 22. PUBLIC-PRIVATE PARTNERSHIPS (PPPS) AND PUBLIC PRIVATE MIX (PPM) Table 52 (NDoH 38): Outputs as a result of PPP and PPM Name of PPP or PPM Purpose Outputs Current Annual Budget (R’Thousand) Date of Termination Measures to ensure smooth transfer of responsibilities 1. MAtCH Health systems DoH outputs Not known 2017 Capacity building strengthening done to DoH staff 2. SACTWU MMC DoH outputs Not known Capacity building done to DoH staff 3. FSH 360 Integration of DoH outputs Not known Capacity building MCWNH, Nutrition done to DoH staff and PMTCT 4. Star for Life Youth and DoH outputs Not known Capacity building Adolescent life skills done to DoH staff & HCT 5. Mpilonhle School Health DoH outputs Not known Capacity building Services done to DoH staff 135 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 Name of PPP or PPM Purpose Outputs Current Annual Budget (R’Thousand) Date of Termination Measures to ensure smooth transfer of responsibilities 6. UNPFA Sexual DoH outputs Not known Capacity building Reproductive done to DoH staff Health ,Safeguarding young People 7. UMTHOMBO Health Professional DoH outputs Not known 2019 YOUTH Bursary Scheme DEVELOMENT 136 | Page [UMKHANYAKUDE] DISTRICT HEALTH PLAN 2015/16 PART E: INDICATOR DEFINITIONS Indicator Short Definition Purpose of Primary APP Method of Calculation Calculati Type of Reporting Data Desired Indicator Indicator Source Source on Type Indicator Cycle Limitations Performance Responsibility Use this template if district has added any indicators throughout the document. 137 | Page