GERT SIBANDE DISTRICT MUNICIPALITY

Table of Contents

1. Demographic Information ...... 3 2. Social Determinants of Health ...... 5 3. Service Delivery Platform ...... 9 3.1. Public Health Facility Types Sub-Districts ...... 9 3.2. Private Medical Practices and Hospitals ...... 10 3.3. Maps ...... 11 3.4. District Hospital Performance ...... 14 3.5. Trend of Public Health Expenditure ...... 16 3.6. Trend of Health Services Delivery ...... 17 3.1. Burden of Disease ...... 18 3.1.1. Poverty and Hunger ...... 18 3.1.2. Child Health ...... 19 3.1.3. Maternal and Woman’s Health ...... 20 3.1.4. HIV/TB ...... 21 4. Performance on Priority Indicators 2012/13 ...... 23 5. Glossary ...... 28 6. Indicator Definitions...... 29

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1. Demographic Information

Gert Sibande is one of the 3 districts of province of . The seat of Gert Sibande is Ermelo. The district code is DC30. The district is named after the ANC activist Gert Sibande.

Gert Sibande District has the following neighbours:

 Nkangala to the north (DC31)  Ehlanzeni to the north-east (DC32)  The kingdom of Swaziland to the east  Zululand to the south-east (DC26)  Amajuba to the south (DC25)  Thabo Mofutsanyane to the south-west (DC19)  Fezile Dabi to the south-westDC20)  Sedibeng to the west (DC42)

The district contains the local municipalities of Govan Mbeki , , Mkhondo, Msukaligwa, Lekwa ,Pixley Ka Seme and Dipaleseng .

The District has a total population of 1,043,193, with a population density of 32.7/Km2.

Demographic Data

Geographical area 31,841 Km2

Total population (Census 2011) 1,043,193

Population density (Census 2011) 32.7/Km2

Percentage of population with medical insurance (General Household Survey 2007) 14. %

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Age Group Female Male Number % Of total population Number % Of total population 0-4 Years 59,063.00 6% 59,731.00 6% 5-9 Years 53,751.00 5% 53,899.00 5% 10-14 Years 50,997.00 5% 51,984.00 5% 15-19 Years 54,201.00 5% 54,324.00 5% 20-24 Years 52,533.00 5% 55,195.00 5% 25-29 Years 48,103.00 5% 51,613.00 5% 30-34 Years 35,718.00 3% 38,747.00 4% 35-39 Years 32,140.00 3% 31,878.00 3% 40-44 Years 29,144.00 3% 26,867.00 3% 45-49 Years 28,031.00 3% 23,462.00 2% 50-54 Years 23,532.00 2% 20,863.00 2% 55-59 Years 18,729.00 2% 16,586.00 2% 60-64 Years 13,696.00 1% 11,331.00 1% 65-69 Years 9,613.00 1% 7,183.00 1% 70-74 Years 8,152.00 1% 4,870.00 0.5% 75-79 Years 5,002.00 0.5% 2,738.00 0.3% 80+ Years 6,383.00 1% 3,134.00 0.3% Total 528,788.00 51% 514,405.00 49%

The majority of household heads are males and black Africans and 1.6% of households have teenage household heads (less than 19 years).

Age Household Head

19 Years and 20-35 Years 36-65 Years 66-84 Years 85 Years and older younger 1.6% 31.7% 56.2% 9.6% 1%

Race Household Head Gender Household Head

Black Coloured Indian or Asian White Female Male

89.5% 0.7% 0.9% 8.5% 38.8% 61.2%

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The main language spoken in Gert Sibande is IsiZulu (60%), followed by Siswati (13%), and (9%).

2. Social Determinants of Health

According to the 2007 DHB, the deprivation index for the district is 2.5.

In terms of services to communities, 9% of households do not have access to piped water, 19.8% have no access to improved sanitation (bucket system, pit latrines without ventilation or no toilet) and 35.4% have no access to refuse removal by local authority or private company. In terms of housing, 10.8% of households live in informal dwellings or squatter settlements.

Household Access to Basic Services Census 2011 Percentage traditional and informal dwelling, shacks and squatter settlement 10.8%

Percentage households without access to improved sanitation 19.8%

Percentage households without Access to Piped Water 9.0%

Percentage households without access to electricity for lighting 16.6%

Percentage households without refuse removal by local authority/private company 35.4%

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According to Census 2011, 11.7% of household heads are unemployed and 19.2% of households live with an annual income below R4, 800 or less than R400 per month. In terms of the education level, 9.1% of the population have no schooling. The majority of the households have 5 or less people per household and only 2.8% of households have 10 or more people per household.

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The proportion of enumeration area types gives an indication of infrastructure development, rural/urban settings and population distribution in the district. 69.9% of enumeration areas are formal residential areas, 11.1% traditional residential areas, 11.8% farming areas or smallholdings and 5.1% informal residential areas.

The map below displays the geographical space that the different enumeration area types occupy in the district. Gert Sibande district has vast farming areas. Traditional residential areas occupy a large area of the district. There are big industrial areas around Secunda and relatively big vacant areas in Albert Luthuli sub-district.

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3. Service Delivery Platform

Community District Regional Satellite Specialised TB Grand Sub District Clinic Mobile Health Centre Hospital Hospital Clinic Hospital Total

Albert Luthuli 17 4 2 4 27 Dipaleseng 4 2 1 7

Govan Mbeki 9 3 2 5 19

Lekwa 6 1 1 3 1 12

Mkhondo 7 4 1 8 4 24

Msukaligwa 9 2 4 1 1 17 (Functioning as Clinics) Pixley Ka Seme 5 2 2 3 12

Total 57 18 8 28 1 4 2 118

Public Health Facility Types Sub-Districts

Health services are delivered by 8 district hospitals, 1 regional hospital, 18 community health centers, 57 clinics, 4 satellite clinics and 28 mobile clinics.

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3.1. Private Medical Practices

Sub-District Number Albert Luthuli Local Municipality 12 Dipaleseng Local Municipality 4 Govan Mbeki Local Municipality 67 15 Mkhondo Local Municipality 8 Msukaligwa Local Municipality 30 Pixley Ka Seme Local Municipality 12 Grand Total 148

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3.2. Maps

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Quintile 1 and Quintile 2 Schools in Relation to Public Health Facilities.

Badplaas

Carolina Albert Luthuli LMEersthoek

Lochiel

Chrissiesmeer Breyton

Leandra Lothair Kinross Govan Mbeki LMLeslie Ermelo Msukaligwa LM Secunda

Amsterdam Balfour

Greylingstad Panbult Lekwa LM Bettiesdam Holmerdene Dipaleseng LM

Standerton Meyerville Amersfoort Mkhondo LM Piet Retief

Wittenberg

District Berbice Pixley Ka Seme LM Sub-Districts Braunschweig Commondale Towns Clinics_Satellites CHC District Hospitals Q2Schools Q1Schools

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3.3. Hospital Performance

3.3.1. District Hospitals

District hospital performance on 4 key indicators is displayed in the table below. Usable bed utilisation measures the occupancy of district hospital beds, namely the proportion of usable beds occupied over the year, and therefore measures how efficiently a hospital is using its available capacity. BUR should be read in conjunction with the average length of stay (ALOS). If a low ALOS occurs in conjunction with a high bed utilisation rate (>90%), this suggests that the hospital has a high demand for beds. A very high bed utilisation rate (BUR) suggests that the quality of care provided to the patients may be compromised due to insufficient staff to provide optimal care to patients or patients might get discharged before optimal recovery due to the high demand for beds. A very low BUR may suggest that the hospital is under-utilised either because there is no need for the service in the area, or because patients choose not to use the hospital. The BUR rate in Gert Sibande district was low for Amajuba hospital throughout the reporting period.

The average length of stay (ALOS) indicator measures how long on average each patient spends in hospital. It measures aspects of the quality and efficiency of the hospital. If the ALOS is persistently high it suggests that patients spend too much time in hospital either because they are not timeously discharged or appropriately treated resulting in longer recovery times, or they are not discharged when they should be often due to shortage of doctors in a hospital. Admission, treatment and discharge procedures should therefore be reviewed. If the ALOS is persistently low (less than 1.5 days), it could mean that patients are discharged earlier than they should be, or referral rates to other hospitals are high. The ALOS in Gert Sibande district was within acceptable range from national and provincial averages in the 4 financial years under review.

The Caesarean section (C-section) rate is an important indicator of access to essential (and emergency) obstetric care and is one of the key maternal health indicators. It is also an important indicator that contributes to the quality of maternal and neonatal care. Elsie Ballot hospital does not seem to do any Caesarean sections. The caesarean section rate in the other hospitals was within acceptable range of the national and provincial average.

The perinatal mortality rate (PNMR) is the number of perinatal deaths per 1 000 births. Perinatal deaths are the sum of stillbirths plus early neonatal deaths (<7 days). The PNMR is the most sensitive indicator of obstetric care. The perinatal mortality rate was within acceptable range from provincial and national averages in 2012/13 for all hospitals.

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Indicators values in black font are within an acceptable range from national and provincial average. Indicator values highlighted in yellow are considerably below or above the national or provincial average and should raise concern.

Average length of stay - Usable bed utilisation Caesarean section rate Perinatal mortality rate in facility Hospital total rate - total 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 Amajuba Memorial 4.1 4.7 4.5 43.6 54.7 57.4 24.0 17.9 18.8 39.4 23.7 31.8 Bethal 3.4 4.7 4.6 54.7 64.7 68.6 13.6 14.1 17.1 37.5 37.0 33.4 Carolina 5.3 3.5 3.7 61.0 56.7 69.0 18.1 15.2 23.2 36.6 33.6 39.2 Elsie Ballot 3.6 2.9 4.1 68.8 59.1 86.9 0.0 0.0 0.0 30.4 9.9 33.7 Embhuleni 4.6 4.2 3.7 70.8 75.6 79.6 14.0 18.7 16.8 45.3 28.5 39.2 Evander 4.0 4.3 4.6 72.4 67.8 74.0 27.6 27.6 22.8 24.6 40.6 41.1 Piet Retief 4.8 5.0 4.8 70.9 74.7 69.2 18.9 19.2 17.4 42.5 44.1 37.8 4.0 3.8 3.5 60.5 59.3 61.3 38.2 28.7 30.1 35.1 42.4 35.9 G Sibande 4.2 4.3 4.1 62.8 65.8 69.3 21.1 20.3 19.7 36.9 35.7 37.5 Mpumalanga 4.3 4.2 4.1 65.4 68.8 69.9 15.8 17.2 17.6 36.5 34.9 34.5 National Average 4.3 4.3 4.2 65.0 67.1 67.3 18.2 19.1 20.8 30.7 29.5 29.3

3.3.2. Regional Hospitals

All the indicator values for the Ermelo regional hospital were within acceptable range from the provincial and district averages.

Average length of stay - Usable bed utilisation Perinatal mortality rate Caesarean section rate Hospital total rate - total in facility 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 Ermelo 3.3 4.4 7.3 64.8 73.7 74.8 20.3 21.3 21.2 28.1 36.0 35.8 Mpumalanga 4.4 4.6 5.1 70.8 72.6 79.4 20.7 18.9 19.7 34.5 34.2 34.4 National Average 4.6 4.6 4.6 72.0 75.8 76.4 32.3 33.9 35.3 40.0 39.4 39.8

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3.4. Trend of Public Health Expenditure

PHC (non-hospital) expenditure per capita, uses a subset of total PHC expenditure; most importantly it excludes DHS expenditure on HIV, nutrition, coroner services and district hospitals. Per capita expenditure in Gert Sibande increased in line with the provincial average, but is still significantly below the national average.

The PHC expenditure per patient visit indicator measures the average cost of a patient visit to a primary care facility. In practice it is the average cost to the health service of a patient visit to a community health centre (CHC), clinic, satellite clinic or mobile clinic, excluding district hospitals. This indicator’s numerator is thus the total cost in a particular district of running all these facilities for a year. The denominator is the total PHC headcount for these facilities for the same year. It does not take into account the patient case mix found in practice. The cost per patient visit in Gert Sibande increased in line with the provincial and national average.

The District Health Services (DHS) expenditure per capita refers to the total expenditure on DHS, including the expenditure of local government (LG). The district’s DHS expenditure increased significantly above the national and provincial average in the reporting period.

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3.5. Trend of Health Services Delivery

The primary health care (PHC) utilisation rate indicators measures the average number of PHC visits per person per year to a public PHC facility. It is calculated by dividing the PHC total annual headcount by the total catchment population. The target for the South African public health sector is 3.5 PHC visits per person per year. The utilisation rate in Gert Sibande decreased slightly, but remained above the provincial and national average for the past 4 financial years.

The PHC under 5 utilisation rate has increased slightly over the past 4 financial years, but is still significantly below the provincial and national average.

Supervisory visits provide a system for identifying and addressing problems at facility level. The supervision rate is the number of fixed PHC facilities visited by a clinical supervisor at least once a month, as a proportion of the total number of fixed PHC facilities in the district. The target for monthly visits is 100%. The supervision visit rate in Gert Sibande increased slightly above the national provincial average.

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3.1. Burden of Disease

LEADING CAUSES OF YEARS OF LIFE LOST (YLL): Years of Life Lost (YLLs) are an estimate MORTALITY AND CAUSES OF DEATH REPORT 2010 of premature mortality based on the age at death and thus highlight the 16.0 1. Tuberculosis causes of death that should be targeted 14.7 2. HIV/AIDS 14.5 3. Lower respiratory tract… for prevention. The four leading single 11.5 4. Diarrhoeal disease causes of YLLs in South Africa were TB, 4.0 5. Road injuries pneumonia, diarrhoea and HIV related. 3.5 6. Hypertensive heart disease As these are all linked to HIV it suggests 3.4 7. Cerebrovascular disease that HIV-related mortality is by far the 2.9 8. Meningitis/Encephalitis leading cause of YLLs in the majority of 1.8 9. Preterm birth complications districts in South Africa. 1.8 10. Diabetes mellitus The three leading causes of death in 0 5 10 15 20 Gert Sibande district were TB, HIV/AIDS Percentage of total YYL and Lower respiratory infection. .

3.1.1. Poverty and Hunger

A child that does not gain weight (failure to Weighing Rate under 5 years 2003-2012 thrive) is one of the first signs that there 91.6 90.5 93.2 91.1 100.0 85.2 might be serious underling disease such as 82.8 80.4 79.9 84.4 82.8

80.0 anaemia, malnutrition, TB or HIV. All 60.0 children should therefore be weighed at every visit to a facility and the weight should 40.0

Percentage be recorded on the Road to Health card. 20.0 The weighing rate in Gert Sibande has 0.0 increased above the national and provincial 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 average. G Sibande DM Mpumalanga ZA Linear (G Sibande DM)

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Malnutrition is mostly linked to poverty. Severe Severe malnutrition incidence under 5 years malnutrition serves as a vital domestic 2003-2012 indicator in tracking efforts directed towards 14.0 eradicating extreme poverty and hunger in 12.0 9.8 South Africa as part of Millennium 10.0 8.7 7.7 Development Goal (MDG) 1.1. Malnutrition 8.0 5.4 5.6 6.0 4.7 5.3 and disease form a horrendous cycle – one 3.6

4.0 2.7 3.0 feeds off the other. Malnourished children Per 1000 pop 2.0 have more frequent and severe infections, 0.0 particularly diarrhoeal and respiratory 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 diseases. More frequent and severe infections G Sibande DM Mpumalanga lead to increasing malnutrition. ZA Linear (G Sibande DM) The severe malnutrition rate in Gert Sibande district decreased below the national and provincial average.

3.1.2. Child Health

Diarrhoea and Pneumonia are leading causes Diarrhoea incidence under 5 years 2003-2012 of death among children in SA. 150.0 The impact of Rota Virus vaccination is evident in the significant decrease in 100.0 75.3 75.8 72.4 76.7 73.0 diarrhoea incidence rate in Gert Sibande 61.2 56.8 district in line with the provincial average and 50.0 41.0 25.1 24.0 Per 1000 pop significantly below the national average. 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 G Sibande DM Mpumalanga ZA Linear (G Sibande DM)

Pneumonia incidence under 5 years 2003-2012 120.0 The impact of Pneumococcal vacination is

100.0 evident in the significant decrease in the 80.0 pneumonia incidence rate in Gert Sibande, in 56.3 60.0 49.5 44.0 line with the provincial average and 38.4 33.7 37.2 40.0 31.4 27.1 significantly below the national average. 21.9 19.3 Per 1000 pop 20.0 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Sibande DM Mpumalanga ZA Linear (G Sibande DM) 19

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Immunisation coverage can serve as an Measles under 1 year coverage rate 2003-2012 indicator of a health system’s capacity to 120.0 deliver essential services to the most 100.0 87.8 78.2 78.5 78.7 82.7 vulnerable members of a population. The 71.4 74.2 68.9 80.0 61.4 66.9 Measles coverage figures are also used to 60.0 report on Target 4A of MDG4 which is to 40.0 Percentage reduce the under-five mortality rate. 20.0 0.0 The measles 1st dose coverage in Gert 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Sibande has increased over the years in line with the provincial average, but is still below G Sibande DM Mpumalanga the national average. ZA Linear (G Sibande DM)

3.1.3. Maternal and Woman’s Health

Antenatal Coverage monitors to what Antenatal coverage rate 2003-2012 extent antenatal services are reaching 120.0 98.4 100.5 102.4 pregnant women. It measures the 92.9 95.5 96.3 91.6 93.1 97.0

100.0 84.7 percentage of pregnant women that

80.0 attend an antenatal clinic in a health care 60.0 facility at least once during her pregnancy

40.0 and is proxy indicator for MDG 5b for Percentage 20.0 measuring access to reproductive health 0.0 services. The Antenatal coverage in Gert 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Sibande district has increased in line with G Sibande DM Mpumalanga the national and provincial average in 2012. ZA Linear (G Sibande DM)

Early booking rate is very important Antenatal visits before 20 weeks rate 2003-2012 especially for PMTCT. The antenatal visits 50.0 before 20 weeks rate increased steadily 40.0 36.6 36.9 but remained below the national and 32.5 32.5 27.9 28.5 29.2 29.1 provincial average since 2010. 30.0 27.6 26.8

20.0 Percentage 10.0 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Sibande DM Mpumalanga ZA Linear (G Sibande DM)

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The delivery rate in facility indicator Delivery in facility rate 2003-2012 measures the proportion of all deliveries 120.0 that take place in public health facilities 100.0 under the supervision of trained personnel. 81.4 75.4 78.2 80.1 80.1 80.0 67.6 70.7 The indicator serves as a proxy measure of 58.1 60.0 51.3 access to public sector facilities and the measure of utilisation of these facilities by 40.0 32.9 Percentage pregnant women and is used to track 20.0 improvements in maternal health as part 0.0 of Millennium Development Goal 5. 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 The delivery in facility rate increased G Sibande DM Mpumalanga significantly but remained below the ZA Linear (G Sibande DM) national and provincial average.

Couple year protection rate 2003-2012 The couple year protection rate is a composite indicator of the different 40.0 36.9 contraceptive methods. It reflects the 35.0 33.2 27.9 availability, accessibility and acceptability

30.0 25.6 25.1 of reproductive health services and serves 25.0 20.7 as proxy indicator for MDG 5b. 20.0 15.9 14.9 13.2

15.0 12.8 The couple year protection rate increased Percentage 10.0 but remained below the provincial and 5.0 national average. 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

G Sibande DM Mpumalanga ZA Linear (G Sibande DM)

3.1.4. HIV/TB

The TB programme aims to reduce the pool of infected people in South Africa. The strategy employed to do this, attempts to prevent transmission of TB and to cure those who have already contracted the disease.

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The TB Cure rate in Gert Sibande increased TB Cure Rate 2003-2010 (DHB 2011/12) steadily over the years but remains below 80.0 the national and provincial average. 61.4 64.0 56.1 57.6 60.0 53.0 42.5 45.2 40.0 29.1

Percentage 20.0

0.0 2003 2004 2005 2006 2007 2008 2009 2010

G Sibande: DC30 MP ZA Linear (G Sibande: DC30)

HIV Prevalence Antenatal Survey 2006-2011 The HIV prevalence in the Gert Sibande (Antenatal Survey 2011) increased significantly above the national 50 and provincial average in 2011. 40

30

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Percentage 10

0 2006 2007 2008 2009 2010 2011 Gert Sibande Mpumalanga ZA Linear (Gert Sibande)

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4. Performance on Priority Indicators 2012/13

The charts below are constructed using statistical process control (SPC) principles and use control limits to indicate variation from the national average (as well as national target where available). The purpose of this type of display is to give feedback on the performance of the district compared to the performance range of all 52 districts for the period under review (2011/12) for selected priority indicators. The display shows one standard deviation (68%), two standard deviation (95%) and three standard deviation (99.8%) control limits. Values within the 1SD below or above national average are said to display 'normal cause variation' in that variation from the mean can be considered to be random. Values outside these limits (in the darker green or orange sections) are said to display 'special cause variation' at a two standard deviation level, and a cause other than random chance should be considered. Values outside these sections (in the dark green or red sections) also display 'special cause variation' but at against a more stringent test. Variation at the two standard deviation level can be considered to raise an alert, and variation at the three standard deviation level to raise an alarm.

* Values that fall in the positive standard deviations are good for certain indicators e.g. Immunisation coverage where higher is better, but the opposite is true for indicators that measures disease burdens or e.g. PCR test positive at 6 weeks rate where lower (negative standard deviations) is better. For other indicators like ALOS both too high and too low is bad and the "good range" will fall in both 1SD and -1SD. Performance should therefore be interpreted in conjunction with the colours codes above. 23

INDICATOR PERFORMANCE COMMENT

DISTRICT HEALTH SERVICES

1 SD below the national average and Utilisation rate PHC 2.2 1.7 2.5 3.5 significantly below the ANHP target of 2.8.

Utilisation rate under 5 1 SD below the national average and 4.0 3.4 4.6 6.7 years - PHC significantly below the national target of 5.

Fixed PHC facilities with a 1 SD above the national average but below 81.4 0.5 75.9 100 monthly supervisory visits rate national target of 90%

MATERNAL, NEONATAL, CHILD AND WOMEN’S HEALTH AND NUTRITION

Antenatal visits before 20 1 SD below the national average and 38.3 31.5 44 73.6 weeks significantly below national target of 60%

Baby PCR test positive 1 SD above the national average and above 0 2.5 7.8 around 6 weeks rate national target of 2.5% 2.8

Cervical cancer screening 45.8 23.5 55.4 140.2 1 SD below the national average and coverage significantly below national target of 62%

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INDICATOR PERFORMANCE COMMENT

1 SD below the national average and below Couple year protection rate 33.1 23.7 37.8 73.3 the national target.

Delivery in facility under 18 1 SD above the national average and above 10.2 4 7.7 13.4 yers the national target of 9%.

Maternal mortality ratio in 1 SD above the national average and above 187.6 0 132 292 facility the national target of 148.

Facility mortality under 5 4.4 0.8 4.5 9.9 1SD below the national average. years rate

Immunisation coverage 1 SD below the national average and below 81.7 69.6 94 118 under 1 year the national target of 90%.

Measles 1st dose under 1 SD below the national average and below 88.4 75 99.7 125.1 1 year coverage the national target of 93%.

1 SD below the national average but in line PCV 3rd dose coverage 91.6 72.1 98.4 124 the national target of 91%.

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INDICATOR PERFORMANCE COMMENT

1 SD below the national average but above RV 2nd dose coverage 99.0 65.3 100.3 128.9 the national target of 91%.

Vitamin A coverage 12-59 2 SD below the national average and 28.7 21.9 42.8 60.9 months significantly below the national target of 50%

Diarrhoea with dehydration 9.5 4.7 12 32.9 1 SD below the national average. incidence under 5 years

2 SD below the national average (lowest Pneumonia incidence 21.0 21 66.8 177.9 incidence in country) and significantly below under 5 years national target of 68.

1 SD below the national average (good), and Severe malnutrition 3.1 0.9 4.4 18.1 significantly below the national benchmark under 5 years incidence target of 10.

HIV AND TB

HIV testing rate 1 SD below the national average and below 90.1 79.4 94 100 (excluding antenatal) the national benchmark target of 100%.

Male condom distribution 19.0 5.4 22.1 69.3 1 SD below the national average. rate

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INDICATOR PERFORMANCE COMMENT

HOSPITAL

Average length of stay - 1SD below the national average (good) but 4.1 1.1 4.2 6.8 total slightly above the national target of 3.8.

Caesarean section rate 19.7 0 20.8 40.1 1 SD below the national average.

1 SD above the national average (good) but Usable bed utilisation rate 43.6 67.3 94.3 below the national target of 73%. 69.3

1 SD above the national average but below Cateract surgery rate 832.2 0 553 2832 the national target of 1500.

1 SD below the national average and Complains resolution rate 56.2 0 68.6 100 significantly below the national target

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5. Glossary

Deprivation indices and socio-economic data

The deprivation index is a measure of relative deprivation across districts within South Africa. Just as any index, the deprivation index is a composite measure derived from a set of variables. Variables included in the analysis are considered to be indicators of material and social deprivation. The deprivation indices for this report were generated using StatsSA’s GHS and 2007 Community Survey (CS) data and have been calculated in such a way that the indices are directly comparable to the deprivation indices generated from the 2005 GHS data. This therefore provides three years of deprivation trend data. To simplify interpretation, the deprivation index was normalised such that the district that is least deprived has a deprivation index of 1. Districts with higher values are relatively more deprived than districts with lower values. The score itself does not have any intrinsic meaning, but the relative scores show which districts are more deprived than others and can be used to rank districts. Each district was thus ranked according to levels of deprivation and categorised into socioeconomic quintiles (SEQ). Districts that fall into quintile 1 (worst off) are the most deprived districts. Those that fall into quintile 5 are the least deprived (best off).

Since there is no official consensus on a single measure of poverty or deprivation, an additional indicator is included with the deprivation index. This is the percentage of households with access to piped water. This indicator is provided from both the GHS and the CS data up to 2007. Unfortunately no new district level data for the deprivation index or access to piped water has been collected since 2007, thus the socio-economic quintiles from 2007 have been used for each of the years thereafter to enable on-going analysis of equity according to socio-economic status.

Variables included in the calculating the deprivation index were:

 The proportion of the district’s population that are children below the age of five  The proportion of the district’s population that are black Africans  The proportion of household heads in the district that are females  The proportion of household heads in the district that has no formal education  The proportion of working-age population within the district that is unemployed (  The proportion of the district’s population that lives in a traditional dwelling, informal shack or tent  The proportion of the district’s population that has no piped water in their house or on site  The proportion of the district’s population that has a pit or bucket toilet or no form of toilet  The proportion of the district’s population that does not have access to electricity, gas or solar power for lighting, heating or cooking.

District boundaries and maps

Geographic information from the Municipal Demarcation Board is used to define district and provincial boundaries and is the same as is followed by the DHIS.

For some DHB indicators such as the deprivation index, old demarcation boundary data was used.

Averages

It is important to note that all averages (provincial, national, metro and ISRDP) are weighted averages, based on the total numerator and denominator for all the sub-areas included, and are thus not averages of the district indicator values.

Financial year and calendar year

Some indicators are displayed for (April – March), which is the financial year of the Department of Health. Indicators for financial years are annotated as 2012/13. Other sources such as the TB data from ETR.net, antenatal HIV survey, water quality and cause of death data cover a calendar year (January – December). Data from StatsSA surveys are for the period of the census or survey.

Finance indicators

All expenditure trends over time used from the DHB have been adjusted for inflation, and figures are quoted in real 2011/12 prices, unless indicated otherwise.

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6. Indicator Definitions

Indicator name Indicator definition Numerator description Denominator description Source

Deprivation Index The deprivation index is a Health Economics Unit, composite index of deprivation UCT - based on data using StatsSA Census and from StatsSA Census household survey, recalculated to 2001, GHS and Deprivation a district level. Community Survey Percentage traditional and Number of households that are Total number of informal Total number of Census 2011 informal dwelling, shacks informal dwellings, shacks or dwellings, shacks or households and squatter settlement squatter settlements as squatter settlements percentage of total households Percentage households Number of households that do Total number of Total number of Census 2011 without access to improved not have access to improved households without households sanitation sanitation (bucket, pit latrine or access to improved no toilet facilities) as percentage sanitation. of total households Percentage households Number of households that do Number of households Total number of Census 2011 without Access to Piped not have access to piped water without access to piped households Water within 200m from dwelling as water percentage of total households

Basic services Basic Percentage households Number of households that do Number of households Total number of Census 2011 without access to not have access to electricity for without access to households electricity for lighting lighting (as proxy of availability of electricity for lighting electricity in community) as percentage of total households Percentage households Number of households that do Number of households Total number of Census 2011 without refuse removal by not have access to refuse removal without refuse removal households local authority/private by local authority/private by local company company authority/private company

Cost per Patient Day in Average cost per patient per day Total expenditure on Patient day equivalent - DHB 2011/12 district hospitals seen in a hospital (Expressed as health district hospitals Total Rand per patient day equivalent). Percentage of District Finance 29

Indicator name Indicator definition Numerator description Denominator description Source Percentage of District Percentage of total district health Provincial expenditure Total provincial DHB 2011/12 Health Expenditure on services spent on district on District Management expenditure on District District Management management Health Services Non-hospital PHC Total amount spent on non- Provincial expenditure Uninsured population DHB 2011/12 expenditure per capita hospital PHC health services per on the following sub- (total population less person without medical scheme programmes of DHS medical scheme coverage coverage. PHC (non-hospital) (district management, x population) expenditure per capita, uses a clinics, CHCs, community subset of total PHC expenditure; based services and other most importantly it excludes DHS community services) expenditure on HIV, nutrition, plus nett local coroner services and district government expenditure hospitals on PHC Non-hospital PHC Total amount spent on non- Provincial expenditure Total PHC headcount DHB 2011/12 expenditure per patient hospital PHC health services per on the following sub- visit primary health care visit. The PHC programmes of DHS expenditure per patient visit (district management, indicator measures the average clinics, CHCs, community cost of a patient visit to a primary based services and other care facility. In practice it is the community services) average cost to the health service plus nett local of a patient visit to a community government expenditure health centre (CHC), clinic, on PHC satellite clinic or mobile clinic, excluding district hospitals but including the cost of managing the district. This indicator’s numerator is thus the total cost in a particular district of running all these facilities for a year. The denominator is the total PHC headcount for these facilities for the same year. It does not take into account the patient case mix found in practice.

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Indicator name Indicator definition Numerator description Denominator description Source

Medical scheme coverage Percentage of population who Modelled from StatsSA

have medical scheme insurance GHS Insurance ALOS: Average length of The average number of patient Inpatient days + 1/2 Day Separations - Discharges DHIS NDoH5 (data for stay (district hospitals) days that an admitted patient patients + Deaths + Transfers out District Hospitals only) spends in hospital before + Day patients separation. If the ALOS is persistently high it suggests that patients spend too much time in hospital either because they are not timeously discharged or appropriately treated resulting in longer recovery times, or they are not discharged when they should be. Admission, treatment and discharge procedures should therefore be reviewed. If the ALOS is persistently low (less than

1.5 days), it could mean that

patients are discharged earlier than they should be, or referral rates to other hospitals are high. BUR: Usable bed utilisation The number of patient days Total patient days - Total usable bed days DHIS NDoH5 (data for rate (district hospitals) during the reporting period, (Inpatient days + 1/2 Day District Hospitals only) expressed as a percentage of the patients) x 100 sum of the daily number of useable beds. (Comment: The calculation here is an approximation - it assumes (1) a day patient occupies a bed for half a day, (2) there are always 30 days in a month. A very high bed utilisation rate (BUR) suggests

ilisation that the hospital is very busy and

Ut that the quality of care provided

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Indicator name Indicator definition Numerator description Denominator description Source to the patients may be compromised due to insufficient staff to provide optimal care to patients. A very low BUR may suggest that the hospital is under- utilised either because there is no need for the service in the area, or because patients choose not to use the hospital. PHC utilisation rate The rate at which PHC services PHC total headcount Total population DHIS NDoH5 are utilised by the catchment population, represented as the average number of visits per person per year in the catchment population. The denominator is usually Census-derived population estimates. It is calculated by dividing the PHC total annual headcount by the total catchment population. The target for the South African public health sector is 3.5 PHC visits per person per year. PHC under 5 year The rate at which PHC services PHC headcount under 5 Total population below 5 DHIS NDoH5 utilisation rate are utilised by children under 5 years years years in the catchment population, represented as the average number of PHC visits per child under 5 per year in the target population. The denominator is usually Census- derived population estimates.

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Indicator name Indicator definition Numerator description Denominator description Source

Fixed PHC facilities with a Proportion of fixed PHC facilities Number of fixed PHC Number of fixed PHC

monthly supervisory visit visited by a dedicated clinic facilities visited at least facilities rate supervisor, who performs a visit once according to the clinic Supervision manual. The target for monthly

Management visits is 100%. Measles 1st dose coverage The percentage of children who Measles 1st dose under Target population under DHIS NDoH5 received their 1st measles dose 1 year 1 year (normally at 9 months) - annualised. Diarrhoea incidence under The number of children with Diarrhoea cases under 5 Population under 5 years DHIS NDoH5 5 years diarrhoea per 1 000 children in years -new the catchment population. Severe malnutrition under The number of children who Severe malnutrition Target population under DHIS NDoH5 5 years incidence weigh below 60% Expected under 5 years - new 5 years Weight for Age (new cases that month) per 1 000 children in the

target Pneumonia under 5 years Children under 5 years diagnosed Pneumonia under 5 Target population under DHIS NDoH5 incidence with pneumonia, per 1,000 years - new ambulatory 5 years children in the catchment

Child Health Child population Perinatal mortality rate in The perinatal mortality rate Stillbirths and Inpatient Total births in facility DHIS NDoH5 facility (PNMR) is the number of early neonatal deaths in perinatal deaths per 1 000 births. facility Perinatal deaths are the sum of stillbirths plus early neonatal deaths (<7 days). The perinatal

period starts as the beginning of

foetal viability (28 weeks gestation or 1 000g) and ends at

Maternal Health Maternal the end of the 7th day after delivery Delivery rate in facility The percentage of deliveries Deliveries in facility All expected deliveries in DHIS NDoH5 taking place in health facilities target population under supervision of trained

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Indicator name Indicator definition Numerator description Denominator description Source personnel. The number of children under one year, factorised by 1.07 due to infant mortality, is used as an estimated proxy denominator for expected deliveries per month. Antenatal coverage The proportion of pregnant Antenatal 1st visit Children under one year DHIS NDoH5 women coming for at least one factorised by 1.15 antenatal visit. The census number of children under one year factorised by 1.15 is used as a proxy denominator - the extra 0.15 (15%) is a rough estimate to cater for late miscarriages (~10 to 28 weeks), still births (after 28 weeks gestation), and infant mortality. Couple year protection rate The couple year protection rate is Contraceptive years Female target population DHIS NDoH5 a composite indicator of the equivalent (between 15 and 44 different contraceptive methods. years). The numerator is contraceptive years equivalent and the denominator is the female target population (between 15 and 44 years). It is measured as a percentage and reflects the availability, accessibility and acceptability of reproductive health services and serves as proxy indicator for MDG 5b. TB cure rate (new smear The proportion of new smear The number of initially Total number of new PTB NDoH TB Directorate positive PTB clients) positive PTB patients who smear positive patients smear positive cases completed treatment and were who converted to started on treatment proven to be cured (which means negative smears at two during the specified time. that they had two negative or three months after smears on separate occasions at starting treatment least 30 days apart). 34

Indicator name Indicator definition Numerator description Denominator description Source Percentage of deaths due The proportion of deaths due to Number of deaths due to Total number of deaths StatsSA Causes of Death to communicable diseases, communicable diseases communicable diseases

maternal, HIV/TB, non- /maternal, HIV/TB, non- /maternal, HIV/TB, non-

communicable diseases communicable diseases and communicable diseases

BOD and injuries injuries. and injuries.

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For more information on the content contact

Milani Wolmarans : Director Planning – 012 395 9149

Bennett Asia : Director District Health Services - 012 395 8760

Supported and funded by:

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