DISTRICT HEALTH PLAN 2015/2016
UTHUKELA
KWAZULU-NATAL
UTHUKELA DISTRICT HEALTH PLAN 2015/16
1. ACKNOWLEDGEMENTS
The District Health Plan is a collective effort. This report could not have been prepared without the generous contributions of the Hospital Management, Program managers in the District Office and partner support from HST.
Information and Guidance from the Health Service Planning, Monitoring and Evaluation Component KZN Department of Health.
The Provincial Office is dependent on the reports from the Districts to compile the Provincial District Health Plan.
The demographic data was obtained from the District Profiles Document distributed at the Rationalisation Workshop.
The poverty and social deprivation data was obtained from the following sources;
District Health Barometer 2010/2011 Census 2011 document District Profiles Document distributed at the Rationalisation Workshop and DHER reports
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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 Uthukela 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 FIGURES...... 6 5. LIST OF GRAPHS ...... 6 6. LIST OF TABLES ...... 6 7. LIST OF ACRONYMS ...... 8 8. EXECUTIVE SUMMARY BY DISTRICT MANAGER ...... 11 PART A - STRATEGIC OVERVIEW ...... 24 1. SITUATIONAL ANALYSIS...... 24 6.1 MAJOR DEMOGRAPHIC CHARACTERISTICS ...... 31 6.3 EPIDEMIOLOGICAL (DISEASE) PROFILE OF THE DISTRICT ...... 35 7. DISTRICT SERVICE DELIVERY ENVIRONMENT ...... 44 7.1 DISTRICT HEALTH FACILITIES ...... 44 7.2 TRENDS IN KEY DISTRICT HEALTH SERVICE VOLUMES ...... 48 8. DISTRICT PROGRESS TOWARDS THE ACHIEVEMENT OF THE MDG’S . 53 9. PROVINCIAL AND DISTRICT CONTRIBUTION TOWARDS THE NATIONAL DEVELOPMENT PLAN 2030 ...... 55 10. SUMMARY OF MAJOR HEALTH SERVICE CHALLENGES AND PROGRESS MADE FOR THE PREVIOUS THREE FINANCIAL YEARS ...... 57 10.1 INTRA DISTRICT EQUITY IN THE PROVISION OF SERVICES ...... 59 11. ORGANISATIONAL ENVIRONMENT ...... 62 Human Resources ...... 62 12. DISTRICT HEALTH EXPENDITURE ...... 67 14. PART B - COMPONENT PLANS ...... 72 15. 13. SERVICE DELIVERY PLANS for district health services ...... 73 13.1 SUB-PROGRAMME: District Health Services ...... 73 13.2 Sub-Program: District Hospitals ...... 84 16. HIV & AIDS & TB CONTROL (HAST) ...... 93 14.1 PROGRAMME Overview ...... 93 14.2 HIV & AIDS, STI & TB CONTROL (HAST): Strategies/ Activities to be implemented 2015/16 ...... 101 17. MATERNAL, NEONATAL, CHILD AND WOMEN’S HEALTH AND NUTRITION ...... 106 15.1 PROGRAMME Overview ...... 106 15.2 STRATEGIES/ Activities to be implemented 2015/16 ...... 121 18. 16. DISEASE PREVENTION AND CONTROL (DPC) ...... 125 16.1 PROGRAMME Overview ...... 125 16.2 STRATEGIES/ Activities to be implemented 2015/16 ...... 132 19. 17. INFRASTRUCTURE, EQUIPMENT AND OTHER SUPPORT SERVICES 135
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18. SUPPORT SERVICES ...... 138 18.1 PHARMACEUTICAL SERVICES ...... 139 18.3 EQUIPMENT AND MAINTENANCE ...... 147 18.4 EMERGENCY MEDICAL SERVICES (EMS) ...... 148 20. 19. HUMAN RESOURCES ...... 155 21. 20. DISTRICT FINANCE PLAN ...... 161 23. PART C: LINKS TO OTHER PLANS ...... 163 24. 21. CONDITIONAL GRANTS (Where applicable) ...... 163 22. PUBLIC-PRIVATE PARTNERSHIPS (PPPs) and PUBLIC PRIVATE MIX (PPM) ...... 165 25. PART E: INDICATOR DEFINITIONS ...... 167 part f: annexures ...... 168 Annexure 1 rEGIONAL HOSPITAL ...... 168
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4. LIST OF FIGURES
Figure 1: UTHUKELA POPULATION PYRAMID 2014/15 ...... 31 Figure 2: Leading causes of years of life lost ...... 35
5. LIST OF GRAPHS
Graph: 1: (a): Population distribution per Municipality - raw figurers...... 32 Graph: 2: PHC Utilisation (Provincial Clinics) vs. Population to PHC facility (Provincial clinics) – 2013/14.. 49 Graph: 3: PHC Utilisation rate in relation to PN Workload Provincial Clinics ...... 49 Graph: 4: District Hospitals Cost per PDE vs. IPD and OPD ...... 52 Graph: 5: Equity of resources vs population and headcount – 2013/14 ...... 59 Graph: 6: District Hospital Expenditure in relation to Service Delivery – 2013/14 ...... 69
6. LIST OF TABLES
Table 1: Population comparison DHIS 2014 and Census 2011 per sub-district ...... 11 Table 2: Chemical poisoning cases April to September 2014 ...... 18 Table 3: Community Bursaries awarded...... 19 Table 4: District Population 2013/14 ...... 32 Table 5 (A1): Social Determinants of Health ...... 33 Table 6: Infant and child mortality ...... 36 Table 7: MCWH challenges ...... 37 Table 8: HIV and AIDS / TB ...... 39 Table 9: HIV AIDS challenges ...... 40 Table 10: (NDoH 1): PHC facilities (Provincial and LG combined) per Sub-District as at 31 March 2014 ... 44 Table 11: Provincial Clinic Facility to Population – 2013/14 ...... 45 Table 12: (NDoH 2): District Hospital Catchment Populations 2013/14 ...... 46 Table 13: OPD not referred 2013/14 ...... 47 Table 14:(NDoH 3): PHC Headcount Trend ...... 48 Table 15: Difference in Headcounts - Okhahlamba ...... 48 Table 16: (NDoH 4): District Hospital activities...... 50 Table 17: (NDoH 5): Review of Progress towards the Health-Related Millennium Development Goals (MDG’s) and required progress by 2015 ...... 53 Table 18: (NDoH): Alignment between NDP Goals 2030, Priority interventions proposed by NDP 2030 and Sub-outcomes of MTSF 2014-2019 ...... 55 Table 19: Summary of major challenges ...... 57 Table 20: (NDoH 6): PHC Expenditure ...... 59 Table 21: (NDoH 7 (a)): Number of patients to staff type (Sub-District) – PDoH PHC Clinics ...... 60 Table 22: (NDoH 7 (b)): Number of patients to staff type (Sub-District) – CHC ...... 60 Table 23: (NDoH 8): Population to Staff per sub-district – 2013/14 ...... 61 Table 24: Employees due for retirement ...... 63 Table 25: Staff type to Patient Ratio in Facilities [per 10 000] – Provincial Clinics ...... 64
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Table 26: Cost per Headcount in relation to Workload ...... 65 Table 27: District Hospital Staff to PDE Ratio ...... 66 Table 28: (NDoH 9): Summary of District Expenditure ...... 67 Table 29: (NDoH 10): Capita PHC expenditure per sub-district – 2013/14 ...... 68 Table 30: (NDoH 11): PHC Budget and Expenditure (%) excluding “Other Donor Funding” – 2013/14 ...... 68 Table 31: (NDoH 12): PHC Cost per Headcount– 2013/14 ...... 68 Table 32: District Hospital Expenditure ...... 69 Table 33: Non-Negotiable Expenditure per PDE ...... 70 Table 34: (NDoH 13): Situation Analysis: Indicators for District Health Services 2013/14 Financial Year ..... 76 Table 35: (NDoH 14): District Performance Indicators – District Health Services ...... 77 Table 36: (Table 15): District Specific Objectives Performance Indicators – District Health Services ...... 80 Table 37: District Health Services Strategies 2015/16 ...... 84 Table 38: (NDoH 16) Situational Analysis Indicators for District Hospitals – 2013/14 Financial Year...... 85 Table 39: (NDoH 17) Performance Indicators for District Hospitals...... 88 Table 40: (NDoH 18): Performance Indicators for District Hospitals ...... 91 Table 41: District Hospitals Strategies/Activities 2015 ...... 92 Table 42: (NDoH 19): Situational Analysis Indicators for HIV & AIDS, STI and TB Control – 2013/14 Financial Year...... 94 Table 43: (NDoH 20): Situational Analysis Indicators for HIV & AIDS, STI’s and TB Control - 2013/14 Financial Year...... 97 Table 44: (NDoH 21): District Strategic Objectives and Annual Targets for HIV & AIDS ...... 99 Table 45: HIV&AIDS, STI & TB Strategies / Activities 2015/16 ...... 101 Table 46: (NDoH 22): Situational Analysis Indicators for MCWH & N – 2013/14 Financial year ...... 109 Table 47: (NDoH 23): Performance Indicators for MCWH&N ...... 113 Table 48: (NDoH 24): District Objectives and Annual targets for MCWH&N ...... 117 Table 49: Nutrition Strategies and Activities 2015/16 ...... 121 Table 50: (NDoH 25): Situational Analysis for Disease Prevention and Control – 2013/14 Financial Year. 128 Table 51: (NDoH 26): Situational Analysis for Disease Prevention and Control - 2013/14 Financial Year129 Table 52: (NDoH 27): District Objectives and Annual Targets for Environmental Health Services ...... 131 Table 53: Rehabilitation services strategies ...... 132 Table 54: (NDoH 38): Performance Indicators for Health Facilities Management ...... 135 Table 55: Projects for Region 3 according to Infrastructure Head Office for the Region: ...... 137 Table 56: (NDoH 39): Pharmaceutical Services Performance Indicators ...... 139 Table 57: (NDoH 30): Pharmaceutical Services ...... 140 Table 58: Centralised Chronic Management of drugs (CCMD) ...... 142 Table 59: Posts for FPS ...... 146 Table 60: Forensic Pathology Services ...... 147 Table 61: District Equipment and Maintenance ...... 147 Table 62: (NDoH 31 (a)): Operational Ambulances per 10,000 Population Coverage (inclusive of LG) .. 148 Table 63: (NDoH 31 (b)): Ambulance Response Time Rural under 40 minutes (Inclusive of LG) ...... 149 Table 64: (NDoH 31(c)): Ambulance Response Times Urban under 15 minutes (Inclusive of LG) ...... 150 Table 65: (NDoH 31 (d)): EMS Inter-facility Transfer ...... 151 Table 66: EMS vehicles – mileage and repair costs ...... 152 Table 67: (NDoH 32): Performance for Human Resources ...... 155 Table 68: (NDoH 33): Plans for Health Science and Training ...... 158 Table 69: (NDoH 34): District Health MTEF Projections ...... 161 Table 70: (NDoH 36): Outputs of a result of Conditional Grants...... 163 Table 71: (NDoH 38): Outputs as a result of PPP and PPM ...... 165 Table 72: indicator definition ...... 167 Table 73: Customised performance Indicators – Regional Hospital ...... 169 Table 74: District Objectives and Annual Targets for regional Hospital ...... 172 Table 75: Regional Hospital ...... 173 Table 76: Regional Hospital challenges ...... 174
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7. 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 papillo 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
MMLLH Make me look like a Hospital
MMLLC Make me look like a clinic
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
PSS Patient Satisfaction Survey
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Abbreviations Description
R
RV Rota Virus Vaccine
S
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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8. EXECUTIVE SUMMARY BY DISTRICT MANAGER
EXECUTIVE SUMMARY BY DISTRICT MANAGER
UThukela District recommits itself to ensuring ‘A long and Healthy Life for all South Africans, in this case the people of UThukela District. Service delivery strategies will focus on the following key outputs of the NSDA:
• Increasing life expectancy
• Decreasing maternal and child mortality
• Combating HIV/AIDS and decreasing the burden of diseases from tuberculosis
• Strengthen health system effectiveness
• Reducing non-communicable diseases
Below is a summary of the five (5) components of the DHP, namely, service delivery, support services, infrastructure, human resources and finances.
Service Delivery
Table 1: Population comparison DHIS 2014 and Census 2011 per sub-district Data element Emnambithi Imbabazane Indaka Okhahlamba Umtshezi Total
DHIS population 2014 245 772 116274 105476 135676 85926 689124
Census Population 237 437 113 073 103 116 132 068 83 153 668 847 2011
Difference in population data (DHIS 8334 3201 2359 3608 2773 20275 versus Census)
The total district census population for Uthukela in 2014 is 689 124 with an uninsured population of 95%; therefore 658 111 population relies on health care services provided by the State. The district’s socio-demographics pose a challenge to service delivery and hence the district actively participates in Operation Sukuma Sakhe so to engage other key stakeholders to better the lives of all. However there has been some improvement as well as challenges experienced for the past year and the district will focus its energies in overcoming these.
Uthukela District is also affected by quadruple burden of disease, namely hypertension, diabetes, stroke, heart disease, severe malnutrition incidence < 5 year (8.5/1000), diarrheal diseases in children < 5 year (7.3/1000) and injuries from road accidents along the N3. HIV and TB remain a challenge in the district. Baby nevirapine uptake is 100% and managed to reduce Baby PCR test positive around 6 weeks from 4% to 1.6% (2013/14). There are challenges of clients refusing to test on HCT and claim to know their status HCT testing rate is sitting at 99% and the Male Medical Circumcision for (2013/14) is 5 265. There is no roving recruited in St Chads, the budget was allocated to Ladysmith Hospital for a roving team. Estcourt hospital MMC roving team was appointed and consisting of 5 staff members with a total of 2070 MMC cases.
However improved TB management strategies had visible impact. For example smear conversion rate at 2 months increased from 63.4% in 2nd quarter (2012/13) to 89.1% in Quarter 4 (2013/14)
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while the TB curate was 81.9% in Quarter 1 of 2013 and has improved to 87.8% in Quarter 4 of 2013/14. All fixed facilities are initiating patients on ART. Another achievement was TB new smear positive defaulter rate dropped from 4% in Q1 of 2013/14 quarter to 3% in Q4 of 2013/14). The district has started implementing the Gene-Expert roll out which has improved TB Diagnosis and the Turn Around time for Culture and DST. The sputum results available within 2 to 24 hours. The immunization coverage is at 76.4%, Facility maternal mortality is (123.0/100 000) for 2013/14.
There is 100% investigation of adverse events in District hospitals and all health institutions have Health Information team in place and meet every month. All 3 hospitals are maintaining baby friendly status. The wellness programme was launched by all facilities including the district office and expanding to the communities especially the senior citizens.
2011 mid-year population estimates will have an impact on population-based indicators (baseline and targets) in 2014/15.
PHC Services
The district has re-aligned itself to a ward based community care within Operation Sukuma Sakhe in order to shift focus from curative to preventive and promotive health care. The accessibility to Health services in Indaka is a problem due to the faction fights and security problems. Clinic operational managers from Okhahlamba have been allocated to the war rooms in the clinic area. Department of health from Okhahlamba is actively involved and represented in the local Sukuma Sake task team.
The district has 14 complete school health teams. There are now 4 incomplete teams. 2 professional nurses without enrolled nurses and 2 enrolled nurses without professional nurses, unfortunately due to geographical locations the 4 incomplete teams cannot form 2 complete teams. Recruitment of school health nurses has been devolved to the sub-district. Provincial office conducted an audit of what equipment is available for school health and what the needs were. The needs were sent to Province who was to avail equipment through National Office. The equipment used by the teams is from facilities they are attached to, therefore the shortage in equipment. Some of this equipment is very old and in-effective e.g. BP Machines that still has mercury vs digital currently in use. Ten vehicles have been purchased for school health services, in some institutions these vehicles become pool vehicles. In Okhahlamba, Dukuza and Busingatha clinic do not have school teams attached to them. Implementation of school health service is feasible but need a positive mind shift towards the value of school health and creating a demand towards preventive and promotive health which the school health service is mainly about. National imitative of shifting of the school health service to Department of Basic Education would be valuable in the long run. The District needs additional school health teams in order to reach the expected coverage.
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Eskom donated a Mobile Health Clinic to district to assists with the many challenge of the District.
The medical staffs appointed to work on the mobile are very passionate people and strongly believe in making a difference in their community.
Photo; of mobile bus donated by ESKOM
The Eskom Mobile Clinic has specifically been designed to reduce the barriers that children are often faced with during their educational careers. The mobile clinic encompasses:
• A dental booth equipped with all necessary material to screen, polish, oral health education, restoration of teeth, scaling and do fillings on teeth.
• A Primary Health Care (PHC) consultation room to carry out general health check-ups; nutritional assessments, hearing assessments, gross and fine motor assessments, as well as immunisations.
• A visual care booth to perform a thorough assessment of eye sight, provide the necessary treatment and even spectacles where necessary.
Learners with severe medical problems that cannot be treated within the mobile unit are referred by the medical staff to the nearest clinics and public hospitals.
The Eskom Ingula Mobile Clinic visited Zaaifontein Primary School in the opening week then it visited Umvulo Primary School. The mobile then moved onto Brakwaal Primary School, Masheshisa Primary school and finished off at Inyamazwe Full Service School which are all situated in Ladysmith. The mobile unit saw a total of 275 pupils during the month of August and September 2014.
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Photos of services rendered in the mobile bus.
5 outreach programmes were done in Okhahlamba in 2014 to hard to reach areas. Services rendered were as follows – cervical screening, HIV testing, TB screening, condom distribution, minor ailments treated, implanon, dietician services, therapy services. Monthly outreach is been done by therapists, audiologist in hard to reach areas. Under 5 years seen 49, 5yrs and above 405.
Adolescent and Youth Friendly services.
Total of nine clinics implementing AYFS in Uthukela District. Three initiated and supported by Pathfinder International of SA (PISA), Dukuza, Watersmeet and Injisuthi. Chiva SA has so far initiated six clinics as AYFS facilities namely, Driefontein, ST Chads CHC, Ezakheni 2, Steadville, Emmaus gate and A.E. Havilland.
During February the National DOH and Provincial DOH Youth Development coordinators visited the District to orientate Operational Managers on the expanding of AYFS Implementing sites. Subsequent to the visit, two facilities have received a facility staff orientation workshop and 30 Health care workers of different categories in Walton clinic and Sigweje clinic have been orientated in the AYFS implementation and are ready to implement.
The AYFS is implemented in line with the MTSF 2014-2019 and NDP 2030 outcome: To increase life expectancy amongst Adolescent and Youth (10-24) through the promotion of Healthy life styles
Prevention of diseases (Chronic and NCD)
Reduction in risks related to health factors
The target for the 2015/2016 financial year is 25 AYFS implementing clinics per District per year.
CCGs
The number of CCG’s is 707 in the District according the HIV/AIDS business plan. Okhahlamba have 14 wards and 157 CCG’s covering all the wards, coverage not as expected due to the vast and mountainous terrain. Not all the wards in Indaka have CCG coverage.
The district was able to recruit only four (4) District Clinical Specialists, namely, Advance Midwife, Obstetrics, Paediatrics and PHC.
PHC Supervision
Fluctuation of the PHC Supervisory rate can be attributed to the fact that during the last quarter of 2013/14 Estcourt area lost one PHC Supervisor and another one went on sick leave which took almost 3 months leaving one PHC Supervisor to cover both Imbabazane & Umtshezi sub-districts which had an impact on the whole district PHC supervision rate. Similar to Estcourt, Emnambithi
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sub-district was left with one PHC Supervisor out of two, after one of them got a post as a PHC Manager, the post is still not filled and it is not easy for one PHC Supervisor to cover all fixed clinics in one month as the PHC Supervision Policy stipulates. Another contributory factor was the lack of understanding of the importance of not only having tools when PHC Supervisors visit clinics, but also understand that after every supervisory visit quality Improvement plans should be formulated with the clinic staff on areas where performance was found to be of poor standard. To improve on the above, a workshop was conducted for PHC Supervisors and PHC OM’s on PHC Supervisory tools as appearing in the PHC Supervision Manual and on PHC Supervision Policy. Improvement is also expected as Estcourt hospital has appointed two PHC Supervisors. The last contributory factor is the lack of prioritizing PHC service delivery by some fleet managers where the PHC Supervisors at time are not provided with transport to visit facilities in spite of having put a written request timeously. The District fleet manager has committed to meet with all fleet managers and PHC Management in the district, date still to be set, to build an understanding of the importance of prioritizing vehicle allocations to staff and compliance with PHC Supervision policy which stipulates that provision of transport for PHC Supervision should be added as one of the KRA’s for Fleet Management. PHC Supervisory rate slightly improved from 46.2 (2012/13) to 48.1 (2013/14). The quality of these visits is still a challenge as it is indicated under the challenges in the programs tables with regarding to the implementation of guidelines and protocols. The rate for the first 6 months is 39.1%. At Indaka sub-district the supervisors was working as PN in the clinics with staff shortages. Campaigns also influenced this rate as these supervisors in team leaders for the campaign teams and worked as PN’s in Bergville clinic. PHC supervisors in Okhahlamba assists during leave periods for CNP’s in mobile units.
Ideal Clinic Concept
Through the DCST facilitation, information on the Ideal Clinic concept was disseminated to the facility management teams and implementation there of 10 pilot clinics chosen by the management with first assessments completed by the end of February 2014. Through the assistance of our partner HST the latest Ideal Clinic assessments yielded the following results: Umtshezi sub-district scored the best performing sub-district nationally at 84,60%. Under the 10 best performing facilities, Wembezi Clinic scored number two nationally at 89,12%, followed by Cornfields Clinic at number three nationally at 87,37%, AE Havilland at number five nationally scored 86,83% and Forderville Clinic at number nine scored 83,52%. Provincially Uthukela was rated number three at 62,85%. Locally the latest assessment for our 10 pilot clinics yielded the following scores:
1. AE Havilland 86, 83%
2. Watersmeet 82, 47%
3. Walton S. 74, 09%
4. Rockcliff 66, 84%
5. Dukuza 64, 10%
6. Gcinalishone 63, 78%
7. Amazizi 62, 50%
8. Ntabamhlope 57, 65%
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9. Sigweje 54, 59%
10. Injisuthi 48, 47%
WBOTs/ Family Health Teams
Two functional WBOTs operating from Wembezi Clinic were re- established in the second quarter of the current financial year; through the assistance of the district office where a double cab van was made available for the teams to share in wards 1, 2 &3 in Imbabazane sub-district, Estcourt. The 3rd team to operate from AE Havilland Clinic will hopefully be functional too if the request made to Toyota for sponsorship through head office MCWH unit; becomes successful.
Maternal, Neonatal and Child health
Baseline assessments results showed that in the district, maternal, perinatal and paediatric morbidity and mortality meetings were irregular where not supported by management and there were clear guidelines and action plans.
Currently all facilities are conducting regular morbidity and mortality meetings above through DCST intervention minutes kept as evidence.
Maternal deaths analysis is half yearly done and feedback given to facilities.
CARMMA (waiting mother’s area) sites were not available DCST targeted 6 sites at Ladysmith Hospital, St Chads CHC, Oliviershoek clinic, Ntabamhlope, A.E. Haviland, Estcourt hospital and Emmaus Hospital. The only challenge is optimal utilisation especially for A.E. Haviland since it has postponed 24 hour service. Oliviershoek not fully functional due to the requests from mother to have food available, negotiations with supporting NGO to assist with food packs.
Pictures of the waiting mother’s area at St. Chad CHC
ST CHADS CHC
Improvement of skills are done continuously onsite i.e. in 2012 there were high number of PPH related deaths DCST obstetrician intervened and started mentorship programme with district hospitals medical personnel.
Improvement of clinical skills and leadership roles of ADM’S then ADM mentorship programme has been started in partnership with RMCH.
Previously the district was scheduling ANC visits then several meetings were held with Operational Managers to stop scheduling which improved ANC before 20weeks from 35% in 2012 to 57% Q2/2014.
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ESMOE training done all facilities has at least two master trainers and drills are conducted monthly.
Partograph audits have been started to improve quality of intra-partum care.
Started EMS harmonization meetings though there is some challenges, still work in progress.
NEONATAL AND CHILD HEALTH
Only one facility was reporting on PPIP and CHILD PIP programmes, trainings were then conducted for all facilities currently all facilities including the CHC are reporting.
Key intervention plans were developed by all hospitals and a CHC on neonatal and child survival and implemented accordingly.
HBB champions have been trained for all hospitals and have started cascading the trainings in their local hospitals.
KMC project has been started from the community to clinics EMS and hospitals up to discharge.
KMC champions, EMS team, maternity and neonatal OM’S and ANM’S have been trained on KMC.
Morbidity and mortality audit meetings are done.
ETAT trainings were conducted for the hospitals and the CHC to ensure 24 hour access to effective triage and resuscitation.
KINC trainings and roll out for district hospitals is facilitated towards accreditation of the nursery departments.
There was no resuscitation equipment for the nursery departments currently there are CPAP machines. Facilities were using trays for resuscitation.
Involvement in supporting quarterly SAM audit and MDT’S (Multi-disciplinary teams).
Arranging the ADD registers availability for the facilities.
Mini ISIS project facilitation started from Indaka and was successfully implemented with minor challenges at Ekuvukeni clinic currently planning to roll out to other sub districts.
Siyanqoba strategies are facilitated together with MNCWH programmes team.
There are 7 EMS bases in prioritised clinics. Inter-transfer transport available in the District.
The District experience challenges in the poisoning cases that is not food related, the most cases are chemical related. Since Environmental Health Services falls under the District Municipality investigation reports are not completed. The main contributory factor was the unavailability of transport for EHPS to go out and do investigations which has been now resolved, as well as easy accessibility of the poisonous substances to communities such as the granules used to kill rats that is sold by street venders. Awareness campaigns and surveys together with environmental health will be conducted in the month of December to sensitize the community, identify the suppliers and to take samples for chemical analysis.
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Table 2: Chemical poisoning cases April to September 2014
i Substance Substance Thinners Unknown green Weed killer Jeye’s Fluid Rattex Doom Potassium Floor Polish Enalapril ingestion Brake Fluid Organic Phosphate Spirit ingestion Total
Number of 1 1 1 1 2 2 3 1 2 1 2 2 19 cases
In 2012/13 the District was declared as a Rabies epidemic area. Okhahlamba had 164 cases of animal rabies from April 2013-June 2013 and 227 cases in July-December 2013, and this was evident in the vaccines over expenditure in Emmaus Hospital. From April 2014 till September 2014 a total of 561 dog bite cases in the district with 509 cases classified as category 2 and 3 and these categories needs vaccination according to the protocol for dog bites.
At the moment there is no facility that is compliant with the vital and extremes measures of NCS. There was no Quality Assurance at the District Office for almost a year, which resulted in the no monitoring, supervision and mentoring by the District Office regarding NCS and Quality assurance since the appointment of the program manager support and mentoring of sub-districts is evident.
Support Services
All institutions have appointed and trained hospital boards. Clinic committees were appointed by the MEC in 2014 for only 30 clinics out of 37. In Umtshezi and Imbabazane the biggest challenge with appointing of clinic committees in the RDP clinics.
The RDP clinic committees and job creation are not compliant with regards to statutory requirements due to the following reasons;
• Not registered for Unemployment Insurance Fund
• Not registered at Professional Security Industries regulatory Authority
• Security staff is changed every 3 months in order to create jobs.
• Security cannot be held responsible for any thefts and losses at the clinics.
Infrastructure
The district continues to implement the Infrastructure and maintenance plan, however the district received 3 (three) municipal clinics, of which some are not suitable to be health care facilities. The district needs to reprioritize some PHC Services due to condition of buildings taken over from municipalities in the following clinics;
Connor Street (PN workload 42.3) and Forderville (PN workload 25) within a 5 kilometre radius from each other. Estcourt PHC Gateway (PN workload 33.2) also within 5 km radius.
Walton clinic (PN workload 24.7) with Ladysmith Gateway Clinic (PN workload 26.2) within a radius of 3km
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Both Connor street and Walton clinic infrastructure does not meet the criteria for Health Services and National Core Standards.
Infrastructure at clinics poses a challenge especially to accommodate increasing numbers of ARV patients and expanding programs.
Okhahlamba sub-district needs fix clinics in the following areas, Khetani and Isandlwana as these areas is only receiving services from a Mobile Unit once a month with a PN workload that ranges from 41.3 to 60.0. Land was already identified and procured by the community for the clinic. These priorities were included in the STP document since 2010. Khetani is served by Mobile 2 with a headcount of 22 447 for the first six months of 2014/15. Isandlwana is served by Mobile 1 (22 145 headcount) and Mobile 3 (19 169 headcount) for the first six months of 2014/15. These headcounts are much more than the fixed clinic’s headcount in the sub-district. These areas without a fix clinic impact negatively on the OPD not referred (7 532 cases) at Emmaus Hospital.
Human Resources
The district like others experiences challenges in recruiting scarce skills especially medical doctors, PHC specialties, pharmacists and the District Clinical Specialist teams. The vacancy rate is as follows for the district according to the funded posts. Medical officer’s vacancy rate is 16.49%, Pharmacists 23.9% Pharmacy assistants 23%, However the district in the last three years has managed to send 70 students to study Cuban Medical Training in Cuba. It is envisaged that these will come back and serve their own community, especially when the DOH is focusing on PHC re-engineering and the sub-district Model. The summary of community bursaries awarded for students studying Health Science Qualifications in the South African Universities is depicted below. The district has a total of 156 bursaries holders, it is important that institutions will consider this list when recruiting staff.
Table 3: Community Bursaries awarded. Field of Study Year of Years Allocation Funded Medicine 2006 4 Medicine 2006 7 Medicine 2007 5 Pharmacy 2007 3 Dentistry 2008 4 Medicine 2008 6 Medicine 2008 5 Medicine 2008 6 Medicine 2008 5 Medicine 2008 5 Nursing 2008 3 Medicine 2009 4 Medicine 2009 4 Medicine 2009 5
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Field of Study Year of Years Allocation Funded Medicine 2009 5 Medicine 2009 5 Medicine 2009 5 Medicine 2009 6 Optometry 2009 5 Physiotherapy 2009 5 Medicine 2010 4 Medicine 2010 3 Medicine 2010 4
Medicine 2010 2 Dentistry 2011 2 Medicine 2011 4 Medicine 2011 4 Medicine 2011 3
Medicine 2011 3 Medicine 2011 3 Medicine 2011 3 Medicine 2011 3 Medicine 2011 4 Optometry 2011 3 Pharmacy 2011 1 Physiotheraphy 2011 3 Radiography 2011 3 Radiography 2011 3 Radiography 2011 3 Speech and Language 2011 4 Pathology Bachelor in Clinical 2012 3 Medical Practice Bachelor in Clinical 2012 3 Medical Practice Bachelor in Clinical 2012 3 Medical Practice Dietetics 2012 3 Medicine 2012 3 Nursing 2012 3 Optometry 2012 3 Pharmacy 2012 3
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Field of Study Year of Years Allocation Funded Bachelor in Clinical 2013 1 Medical Practice Bachelor in Clinical 2013 1 Medical Practice Bachelor in Clinical 2013 2 Medical Practice Bachelor in Clinical 2013 1 Medical Practice Bachelor in Clinical 2013 1 Medical Practice Bachelor in Clinical 2013 2 Medical Practice Emergency Medical 2013 1 rescue Services Medicine 2013 1 Medicine 2013 2 Medicine 2013 1 Medicine 2013 2 Medicine 2013 2 Medicine 2013 2 Medicine 2013 2 Medicine 2013 2
Medicine 2013 2 Medicine 2013 2 Medicine 2013 1 Medicine 2013 2 Optometry 2013 2 Orthotics and 2013 1 Prosthetics Orthotics and 2013 2 Prosthetics Orthotics and 2013 2 Prosthetics Orthotics and 2013 2 Prosthetics Orthotics and 2013 2 Prosthetics Orthotics and 2013 2 Prosthetics Pharmacy 2013 1
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Field of Study Year of Years Allocation Funded Radiography 2013 1 Radiography 2013 2 Radiography 2013 1 Radiography 2013 1 Radiography 2013 1 Bachelor in Clinical 2014 1 Medical Practice Bachelor in Clinical 2014 1 Medical Practice Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Medicine 2014 1 Orthotics and 2014 1 Prosthetics Radiography 2014 1 Radiography 2014 1 Radiography 2014 1 Radiography 2014 1
In service staff Nurse Training:
16 Professional Nurses working at PHC level enrolled for one year Diploma in Clinical nursing Science Health assessment Treatment and Care Course with University of KwaZulu-Natal.
Indian Manipal Project: Phase I
Two students were selected for Manipal Project and already in India Munipal University. One student is enrolled on a 4 year BSC Pharmacy Programme and the other one on BSC Ultrasound Radiography Programme. Their training program commenced in August 2014.
Critical non-clinical and clinical posts were recruited and filled by AURUM in the District in the following categories;
• Data capturers
• Pharmacy assistants and data capturers
• Sub-District HAST Co-ordinators
• TB Assistants
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• HAST (Lay Counsellors)
• HAST Support Officers
• Site Mentors (sub-districts)
• Leadership course is offered by HST/SA SURE to managers in order to strengthen leadership practices. The purpose of this training is to capacitate managers to identify the root causes of problems/challenges and draw up QIP to address the gaps.
The contracts for the above mentioned categories expired September 2014, the contracts for data capturers and lay counsellors was extended to 31 March 2015, the other categories till the 31 December 2014.A motivation was submitted for unfreezing of these posts following the normal HR recruitment procedures.
All incorrect linkages were corrected during February month with the assistance of Head office HR, Finance and HR at District and sub-district level. At the current moment the district have 48 out of adjustments that needs urgent attention by HR managers.
Finances
The district operates with a budget of R1 281 695 000 (2014/15) the district endeavours to comply with the PFMA and the Treasury Regulations. St Chad’s finances and supply chain management need urgent priority as indicated in annexure B.
Additional staff for payroll administration required for each institution (supervisory level).
Recruitment of finance manager at Emmaus Hospital, recruitment of finance personnel at Estcourt Hospital and the recruitment of an AM: Management Accounting at Ladysmith Hospital.
Accurately reflect on the performance targets which the Uthukela District in Kwazulu-Natal will endeavour to achieve given the resources made available in the budget for 2015/16.
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PART A - STRATEGIC OVERVIEW
1. SITUATIONAL ANALYSIS
The format of the Planning document (including DHER), Uthukela note with interest the good alignment with the District Health Plan and we are able to extract valuable information to inform District Health Planning, evaluation and reporting. Over the years, the District made concerted effort to achieve: improved Access, Equity, Efficiency, and Sustainability in planning and delivery of health services. It is now evident that we are beginning to achieve some of our goals. A significant proportion of our stabilized patients on ARV are managed at PHC, increased from (2012/13) 20 734 t0 (2013/14) 31 929 including 1 137 children for the financial years. Okhahlamba (2 260) and Emnambithi (1 009) is the only sub-districts with down referred patients to mobile service. Utilization rate in rural municipalities too, shows an increase from 2.1 to 2.5. All indications are that our strategy to promote use of PHC Clinics as a gateway to other levels of care is working. However, we still have to meet the national target of 3.5 visits per person. The PHC Headcount for the District increased with 3.6% from 2012/13 (1 646 398) to 2013/143 (1 705 654).
The District challenge in this regard is to adequately resource Primary Health Care. Over the years we have had significant expansion of programmes at PHC with no corresponding increase in resources. The re-engineering of PHC has been approved and we must move to ensure optimum filling of posts with the required skills mix to deliver a comprehensive package of care. There are many challenges with the appointment of family health teams, and it did not contribute positively to the PHC strengthening and District Health Services. Government has made its intention clear as to the goal of improving life expectancy of our citizens and PHC especially remains the cornerstone for universal access to quality care and a gateway to other levels of care. The PHC Approach to health care requires revival as it tackles the main determinants of health. The District collaboration in the IDP’s and Social Sector programme must be strengthened. The socio–economic profile of our patients, with late health seeking behaviour and some preferring traditional medicine prior to accessing the formal health care, result in very ill patients coming to our facilities. There is also a trend in demand for “social admissions”, especially during the holiday period therefore the Department of Social Welfare should be involved at facility level with these cases. Furthermore, the inability of some patients to return back to their homes upon discharge also forces us to keep patients longer.
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Map 1: Uthukela
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Map 2: Emnambithi District Facilities
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Map 3: Imbabazane District Facilities
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Map 4: Indaka District Facilities
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Map 5: Okhahlamba District Facilities
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Map 6: Umtshezi District Facilities
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6.1 MAJOR DEMOGRAPHIC CHARACTERISTICS
Figure 1: UTHUKELA POPULATION PYRAMID 2014/15
Source: DHIS
This pyramid reflects that the priority for service delivery must be focused on the age group 0- 29 years which includes the following services; • School Health Services • ARV initiation of children (target 10%) increased with 0.39% from the 2012/13 to 2013/14 financial year 8.29% • Reproductive Health Services • Child Health Services From 0 - 9years the male population is slightly more than the female population. From 30 years to 74 years the difference between the female and male population is significant and ranges from 3 305 to 5 921. From 64 years and older the female is double or triple the number of males.
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It would be good if the research section within the strategic planning unit could conduct a research in the District to determine the causes of male population decreasing with such huge numbers from a certain age group
Table 4: District Population 2013/14
Sub-District Total Population Uninsured population % pop uninsured kz Emnambithi Local 231 031 Municipality 243 191 95.00 kz Imbabazane Local 109 510 Municipality 115 274 95.00 kz Indaka Local 99 496 Municipality 104 733 95.00 kz Okhahlamba Local 127 802 Municipality 134 528 95.00 kz Umtshezi Local 80 818 Municipality 85 072 95.00
DISTRICT TOTAL 682 798 648 657 95.00
Source: DHER 2013/14
Graph: 1: (a): Population distribution per Municipality - raw figurers
Emnambithi 134 528 243 191 Imbabazane 85 072 Indaka 104 733 115 274 Umtshezi
Okhahlamba
Graph 1(b): Population distribution per Municipality - percentage
Emnambithi 12, 12% 36, 36% Imbabazane 20, 20%
Indaka 15, 15% 17, 17% Okhahlamba
Umtshezi
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Source: DHIS The sub-district of Emnambithi has a lower population density (84/km²) than Indaka (107km²) despite having the major town of Ladysmith located in the sub-district. This is due to the fact that there is comparatively a sizable urban population at Ladysmith with a sparsely populated surrounding rural area. In Indaka sub-district, although a rural area, it is more evenly populated in the rural areas as there are no major towns in this sub-district in which to attract the population to a specific area. Umtshezi is sparsely populated (39/km²) except for the small town of Estcourt and Okhahlamba and is also sparsely populated (45/km²) with Bergville as its main town. Imbabazane is densely populated although in a rural environment comparatively with the only major industrial town being also Estcourt. It is also the smallest of the sub-districts at (828 km²) in Uthukela followed by Indaka at (991 km²). Service delivery is difficult in especially the Okhahlamba area with many remote areas due to the mountains and poor road infrastructure in some places. The District cross boundary patients from Lesotho, Mooiriver and Free State too, present us with challenges for timeous repatriation /discharge to their place of residence. We must strengthen our relationships with our Free State colleagues to improve referral to and from there.
6.2 SOCIAL DETERMINANTS OF HEALTH
Table 5 (A1): Social Determinants of Health
Data Sub-Districts Source Total number of of number Total households Unemployment rate populationPercentage of line poverty below living perof R283 month in Numberof households dwelling Informal in Numberof households dwelling formal Households of Percentage sanitation to access with Households with to access potable water Households of Percentage electricitywith to access rate Adult literacy Census 50 529 49% 71% 2585 320672 68% 58% 68% 65% 2001 EMNAMBITHI/ Community 50 259 36% 59% 1507 71 914 69% 72% 69% 71% LADYSMITH Survey 2007
Census Not 58 058 34% 61% 1305 46 710 82% 92% 82% 2011 available Census 24 372 84% 88% 209 9 577 62% 34% 47% 39% 2001 Community INDAKA 21 081 44% 77% 84 10 604 82% 75% 61% 53% Survey 2007
Census Not 20 035 57% 94% 77 12 213 81% 68% 58% 2011 available Census 13 094 50% 79% 270 7 838 77% 58% 64% 57% 2001 Community UMTSHEZI 15 232 29% 72% 503 8 332 78.4% 69% 70% 65% Survey 2007
Not 5425 36.9% 59% 388 13 272 78.3% 80% 73% Census available
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Data Sub-Districts r Source Total number of Total number households Unemployment rate Percentage of population line poverty below living per month of R283 in Number households of dwelling Informal in Number households of formal dwelling Percentage of Households with access to sanitation Households with access to potable wate Percentage of Households with access to electricity rate literacy Adult 2011 Census 26 678 60% 82% 753 10 974 76% 25% 40% 41% 2001 Community OKHAHLAMBA 28 508 29% 66% 399 11 660 85.5% 49% 62% 55% Survey 2007
Census Not 27 576 43.4% 79% 114 11 793 88% 68% 75% 2011 available Census 23 030 74% 86% 224 10 754 89% 17% 64% 47% 2001 Community IMBABAZANE 24 559 52% 70% 270 11 371 92% 47% 60% 59% Survey 2007
Census Not 22 365 48.6% 73% 109 13 080 94% 75% 69% 2011 available Census 95 132 59% 78% 4041 71 813 82% 41% 57% 49% 2001 Community District Total Survey 139 639 36% 65% 2793 71 914 88.7% 63% 64% 60% 2007
Census Not 147 286 39% 61.5% 1994 97 067 89% 79.8% 71% 2011 available
Looking at the population ages for KZN ranging from 30 years to 49 years the HIV prevalence is above the district average of 37.1%, ranges from 59% to 37.5%. The PMTCT program seems to have a positive impact on the HIV positivity rate in the age groups 10 -14 years. It dropped from 19.2% in 2010 to 0.0% in 2012. Although the HIV Prevalence in the age group 15 years to 19 years decreased from 20.5% in 2010 to 16.6% in 2012, the youth and adolescent services still needs to be promoted more. The District has 3 clinics supported by Pathfinder and 8 clinics by CHIVA on youth and adolescent services. Uthukela District prevalence decreased from 39% in 2011 to 37.1% in 2012. The District is still under the 10 highest prevalence Districts. The Antenatal survey also shows that the level of education impacts on the result, the none and primary education levels have the highest rates with 33.9%.
The spread of TB and other respiratory problems could be due to the lack of access to proper sanitation facilities, poor hygienic conditions, lack of access to safe portable and adequate water, food poisoning and chemical poisoning and poor ventilation to structures and overcrowding.
PHC re-engineering will address the service delivery in sparsely populated areas through more mobile teams and WBOT.
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The number of households in informal dwellings in Uthukela District decreased from 4041 in 2001 to 2793 in census 2011. This trend is following vision for the 2030 National Development Plan where people will have to live in more formal dwellings rather than informal dwellings. The high unemployment rate and percentage of population living in poverty in Emnambithi and Indaka is a root cause of faked epilepsy and waste of medication and laboratory tests to confirm levels of medication on patients who want disability grants. Robberies and other injuries are high due to poverty.
6.3 EPIDEMIOLOGICAL (DISEASE) PROFILE OF THE DISTRICT
Mortality Data: Include among others: 10 Major causes of death
Figure 2: Leading causes of years of life lost
Source: District Health Barometer 2012/13
The district’s 2009 burden of disease (BOD) profile is considered from an analysis of the causes of death. Uthukela’s 2009 quality of death certification was relatively poor with 25.4% of the certificates submitted not being useful for public health analysis. Although this is below the South African mean of 30.2%, it is a long way from the internationally recognisable standard of 10%. Of the unusable classifications, 6.2% of deaths were assigned to ‘ill-defined’ causes and 19.2% to ‘garbage codes’. An analysis of the Years of Life Lost (YLLs) after redistribution of the deaths by four broad cause groups reflects that the highest proportion of YLLs was due to HIV and TB (31.5%), followed by communicable diseases (together with maternal, perinatal and nutritional conditions) (33.3%). Non-communicable diseases (24.6%) ranked third whilst the lowest proportion (10.6%) of YLLs was due to injuries. The district is in the process of establishing a MDR unit at Estcourt Hospital to enhance the initiation of TB patients on treatment.
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Maternal Mortality Infant and child mortality The blue figures is excluding Ladysmith hospital as this is a Regional hospital, however if one looks at the mortality rates is for the district it needs to be included as Ladysmith also provides Level 1 services due to the fact that Emnambithi and Indaka sub-districts have no district hospital.
Table 6: Infant and child mortality
Indicator 2011/2012 2012/2013 2013/2014 2014/15 (first six months) (Excluding Ladysmith (Excluding (Excluding (Excluding Hosp.) Ladysmith Hosp.) Ladysmith Hosp.) Ladysmith Hosp.)
Facility Maternal Mortality 132.8 (N17/D12799 ) 266.5 (N28/D10508) 123.1(N15/D12 187) 200.6(N11/D5484) rate (204.8) N14/D6835 (140.0) N10/D7141 (73.3) N5/D6820 (117.6) N3/D2551
Number of Maternal deaths 17; 28; 15; 11
(14) (10) (5) 3
Delivery rate under 18 years 9.4(N1026/D10906) (9.1) 9.8(N1033/D10553); 9.2(N 1137/D 12 285) 10.1 (N554/D5505) N617/D6820 (9.1) N645/D7095 (9.2) N 628/D6 803 (10.3) N265/D2568
Facility Infant Morality under 9.6/1000(N272/D2848) 7.1/1000(N282/D3988) *11.5%(N216/1878) *7%(N102/D1439) 1 year (9.7)N125/12922 (9.2)N117/D12699 *(7.8%) N123/D1571 *6.9%(N41/D586)
Still birth rate in facility/1000 25.2(N141/D5596) 27.5(N298/10806) 23.7(N296/D12483) 31(N177/D5661)
(19.7)N52/D2636 (24)N124/D5155 (19.1)N133/D6935 (26.7)N70/D2621
Facility Child Mortality under 7.5 (N310/D4127) 6.1(N336/5542) 4.7(N261/D5499) 5.3(N126/D2357) 5 year (10.3) N165/D1606 (6.2)N156/2260 (5.6) N141/D2535 (5.2)N53/D1017
Neonatal mortality rate in 6.5 (N83/D12 799) 7.5(N79/10508) 7.2(N132/D18360) 8.6(N76/D5483) facility (11.5)N79/D6835 (14.1)N73/D5031 (5.7) N104/D18360 (10.2)N261/D2511
Children under 5 Severe 16.7(N24/D144) 13.5(N26/D192) 19.3(N32/D166) 9.1(N8/D88) Malnutrition Case Fatality (12.3)N8/D65 (7.5)N11/147 (15.9) N22/D138 (7.9)N5/D63 rate, all hospitals)
Child under 5 years 4.3(N31/D721) 4.1(N44/D1070) 3.3 (N42/D1262) 3.3(N14/D421) diarrhoea case fatality rate (4.3)N10/D225 (4.3)N17/D391 (2.7) N14/D515 (2.1)N4/194
Child under 5 years 5.1(N21/D408) 2.9(N16/D547) 2.8(N10/D353) 3.4(N11/326) pneumonia case fatality (3.6)N10/D279 (2.8)N9/D326 (2.6) N16/D620 (2.6)N5/D189 rate
*The calculation for this indicator from 2013/2014 was aligned to the APP 2015/16 to 2017/18. The denominator was changed from estimated live births to inpatient separations under 1 year.
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Table 7: MCWH challenges Indicator CHALLENGES IMPACT ON SERVICE STRATEGIES DELIVERY Couple year protection rate Low coverage of Health High number of Support district trainings Workers trained on sexual unplanned on sexual and and reproductive health pregnancies leading reproductive health policy into high child mortality policy rate and maternal Continuous support and mortality mentoring of health care workers
Strengthen one stop shop approach ANC Before 20 weeks Lack of knowledge by the Increased number of Strengthen stakeholders community on maternal deaths due involvement trough OSS importance of early to late diagnosis and antenatal booking delay in initiation of treatment Support trainings for CCGs on maternal health issues Antenatal clients initiated on Poor implementation of Increased rate of Strengthen support visit HAART guidelines by the Health mother to child and continuous Care Workers transmission of HIV mentoring of HCW on implementation of guidelines Increased number of maternal deaths due to HIV related conditions Maternal mortality rate Lack of skills in Increased number of Support training management of obstetric deaths due to programmes for emergencies avoidable conditions midwives
Ensure scheduled trainings for the facilities Neonatal morbidity & mortality Lack of skills in Increased neonatal Support training of management of labour death rate midwives in and delivery management of labour and delivery ,interpretation of partograph Stillbirth rate Poor implementation of Increased stillbirth rate guidelines by HCW during Antenatal care PCR positivity rate post cessation Noncompliance of Increased child Strengthen health of breastfeeding mothers on exclusive mortality rate education on exclusive breastfeeding breastfeeding
Poor implementation of Ensure Capacitation of guidelines by HWC HCW on guidelines 18 months uptake rate Poor maternal follow up Increased in child Strengthen mortality implementation of policies and guidelines Severe Acute Malnutrition case Poor Growth Monitoring A high number of Integrated fatality rate under 5 years and Promotion (GMP) at malnutrition cases Management of Acute a primary health care requires more money Malnutrition (IMAM) is level, this is illustrated by to be spent on the national strategy
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Indicator CHALLENGES IMPACT ON SERVICE STRATEGIES DELIVERY our low weighing curative nutrition in seeking to strengthen coverage under 1 year. the form of early identification of Early and age in therapeutic malnutrition and appropriate introduction supplements which intervention thereof. All of complementary foods are rather expensive. children under the age which reduces the This reduces available of five years will have chances of children funds that could be their nutritional status getting nutrients required utilized for preventive assessed and classified by the body for optimal / promotive health periodically which growth and service delivery. should help in scaling development. up malnutrition case Early cessation of finding. Nurses and Breastfeeding Nutrition Advisors have Partial compliance with been trained on IMAM. the WHO ten steps to in Nutrition Advisors are hospital management of currently involved in Severe Acute following SAM cases at Malnutrition. a household level discharged from the hospital to prevent them from being re admitted, they report on a monthly basis on each SAM case they have followed up. We are planning to embark on a “one cup of maas per day” campaign, this is aimed at encouraging every household with a child younger than 2 years to give a cup of “maas” daily. This will at least ensure that a child gets some protein, calcium and energy to contribute to growth and development. Maas has been chosen because it is the nutritious, available, accessible, acceptable and affordable food item that many household can afford.
Severe Acute Malnutrition Case Fatality Rate keeps on fluctuating each year and each quarter. If we look at the data trend tabulated above, it has decreased but it was sitting at 17.1% in the 4th quarter of financial year 2013 / 2014. It then declined significantly in the first quarter of the current financial year (2014 / 2015) as it was at 8.1%. The first 6 months rate is at 9.1%. Ladysmith Regional Hospital still has the highest fatality rate, it has recently been counted in the top 11 hospitals in the province with the highest number of malnutrition deaths. Emmaus is also in the same list. Late admission remains the major contributing factor, however the recent clinical chart audits revealed that case management at a ward level
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(including Outpatient Department) need a lot of attention. Estcourt Hospital has the least number in our District compared to the other 2 hospitals, however their audit results (internal) showed a different picture. It is however critical to note that the root causes of malnutrition are only health related, they include availability of basic needs such as water and sanitation, if these are not accessible, children are likely to have diarrhoeal diseases which ultimately lead to malnutrition. The fact that children continue to die from malnutrition despite all the health and nutrition programmes being implemented, indicate that the provision of basic services to the most affected communities need to be facilitated.
District HIV & Aids Profile District TB Profile
Table 8: HIV and AIDS / TB Indicator Actual Performance
2011/12 2012/13 2013/14 2014/15(first 6 months)
1. TB (new pulmonary) defaulter rate 6.5% 3.7% 3% 1%
All smear+ TB cases defaulted 71 47 30 7
New smear+ PTB cases 1092 1302 1 290 701 89 70.5 2. TB AFB sputum result turn-around time 61.3 62.3 under 48 hours rate
TB AFB sputum result received within 48 hrs. 33 791 39 176 46 092 14 924
TB AFB sputum samples sent 55 122 62 843 51 789 21 168
3. TB new client treatment success rate 78.9% 82.7% 83.7% 87.2
TB clients cured OR completed treatment 856 1057 1 080 611
TB (new pulmonary) clients initiated on 1084 1280 1 290 701 treatment
4. TB (new pulmonary) cure rate 71% 74.5% 81.3% 86.0%
TB (new pulmonary) clients cured 770 953 1049 603
TB (new pulmonary) cases put on treatment 1084 1280 1 290 701
5. TB MDR confirmed treatment initiation rate Not at District level Not at District Not at District Not at District done at referral level done at level done at level done at Hosp referral Hosp referral Hospital referral Hospital
TB MDR confirmed client initiated on treatment Not at District level Not at District Not at District Not at District done at referral level done at level done at level done at Hosp referral Hosp referral Hospital referral Hospital
TB MDR confirmed new client 84 80 104 83
6. HIV testing coverage (15-49 years) 45.8% 40.3% 33.1% 29.8 (annualised)
HIV test client 15-49 years 185 219 165 328 112 877 44 477
Population 15-49 years 404 178 409 493 353 012 148 880
7. Number of male medical circumcisions 8 256 8 760 7 118 5 369 performed (excl. Reg (excl. Reg Hosp) Hosp) 3 950
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4 625
8. Total clients remaining on ART (TROA) at end 36 337 40 7279 42 065 49 026 of the month)
Table 9: HIV AIDS challenges Indicator CHALLENGES IMPACT ON SERVICE STRATEGIES DELIVERY HCT Uptake . Lack of resources . Lower HCT . Train all nursing human and material for uptake. categories on HCT so as HCT. to assist with PICT. . Undiagnosed Training is ongoing. people infected with HIV . Borrow resources from increase Partners where possible.
workload at . Support institutions in . Dysfunctional nerve facilities due to reestablishment and Centre meetings in two OIs. functionality of Nerve Municipalities. . Poor Centers. coordination and monitoring of HAST Programs.
HTA Failure to recruit HTA teams. . 9 Identified HTAs . Advocate for support not serviced. by the Provincial office.
. Health services . Support Ladysmith access by key Hospital to service the populations HTA’s within its minimized. catchment area.
. Budget for HTAs not utilized.
CONDOM -Unsustainability supply of New incidence of INCREASE CONDOM PERFORMANCE condoms from Provincial HIV and STI infection DEMAND IN GREY AREAS Department. Scale up local -Condoms not being used condom advocacy continuously. -Female condoms not well Increase community marketed mobilization/ awareness -Inadequate resources for and the social condom distribution marketing of condoms -No support officer for condom programme INCREASE CONDOM
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Indicator CHALLENGES IMPACT ON SERVICE STRATEGIES DELIVERY -No transport/ driver for SUPPLY condom distribution in grey Manage condom areas procurement, storage -No peer educators for effectively condoms -Poor data reporting Map and identify SDSs
Improve the distribution and transport of condoms
ENSURE CONDOM QUALITY Assure condom quality before and after distribution
Quality assure the distribution Programme
IMPROVED DATA MANAGEMENT Improve training and support in monitoring and evaluation (M&E)Enhance reporting on activities and data management
Improve timely submission on data to the DHIS
MMC performed -Poor MMC uptake Low coverage of DEMAND CREATION especially on out of school MMC is one key Increase community youth(Health testing and driver of new HIV mobilization/ screening for HIV increase and STIs infections. awareness and the the number of sexual social marketing of active males not to go for circumcision) MMC Programme -In adequate mobilization Scale up local MMC of clients has been observed and create low programme advocacy intake to medical male circumcision. IMPROVE MMC UPTAKE -No dedicated transport Provision of adequate for client and staff resources for MMC -Community leaders are programs not advocating for MMC programme CCGs and
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Indicator CHALLENGES IMPACT ON SERVICE STRATEGIES DELIVERY School Health nurses not trained on MMC Mobilization -No collaboration of all stake holders to market, implement and own MMC programme -No complete MMC roving team ( failure to attract doctors) -No support officer for MMC programme -No adequate ,suitable resource to conduct 2 days MMC out of health facilities -Few health workers trained on MMC programme -Negative media publicity results in the reluctance of males to do circumcision. -Non- compliance of Health institution to provide minimum circumcisions per day. -Poor data reporting.
TB suspicion index TB index of suspicion not The indicator does low calculated according to not indicate a true Intensify TB case finding number of people screened picture of suspected Index for TB and target of 5 to 10% cases as it is not met. calculated against headcount above 5yrs. TB Death rate is high and this could be prevented if all people were screened and tested for TB therefore early initiation of treatment. Newly TB diagnosed Not all new cases are Some of the newly patient treatment started on treatment as diagnosed TB Improve New TB Treatment start Rate not 100% soon as the diagnosis is patients continue Initiation Rate confirmed. spreading TB Bacillus Gaps identified in even though they Recording and Reporting have already been diagnosed ( Due to Patients providing Health various reasons)
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Care Facilities with incorrect residential addresses TB Treatment Some smear positive Not all smear Completion Rate is patients ’Sputa not taken as positive TB patients Improve TB Treatment high stipulated by the guidelines are cured and Outcomes to monitor the response to evidence is needed treatment. for all cases diagnosed based on sputa to be cured from TB. TB treatment Though an improvement More new infections Defaulter Rate high has been noted on the diagnosed and indicator, there are still some MDR TB increase Improve TB Treatment patients interrupting due possibly due to Outcomes treatment and are patients interrupting spreading TB Bacteria and treatment. treatment interrupters are potential MDR TB cases. MDR TB Initiation MDR TB notification rate The spread of MDR rate not 100% increase noted. Newly TB to contacts of diagnosed patients are not index case. Improve the Management all initiated on treatment as of MDR and XDR TB soon as they are diagnosed Further progression of MDR TB burden in the district. HAST Programmes Due to workload increase, Poor performance in Strengthen TB/HIV coordination and there is poor coordination of some of the HAST Integration support at Sub- HAST Programmes at the Programmes district level not sub-district level which is an Indicators optimal. indication that someone should be coordinating in- order to achieve good outcomes. TB/HIV co-infected Not all TB Nurses are TB/HIV clients are Ensure that clinicians are patients receiving NIMART trained. getting TB and trained in TB/HIV Integrated CPT and ARTs. other opportunistic Management. Recording and infections and an Motivate for more Health Reporting gaps increase in death Care Workers to be trained rate. on NIMART in order to have Indicator collected Inaccurate and more capacity indicator from two sources unreliable data improvement submitted to the Together with M&E Unit resulting in next level. address the challenge of discrepancies collecting data from two sources and decide on one document.
TB Recording and TB data Submission Reports generated Improve TB Recording and Recording not deadlines not met by some are Inaccurate Reporting optimal health facilities and Unreliable reports g Incomplete data submitted
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7. DISTRICT SERVICE DELIVERY ENVIRONMENT
7.1 DISTRICT HEALTH FACILITIES
PRIMARY HEALTH CARE FACILITIES This table is to reflect PHC service delivery platform in the sub-district to inform access and equity. Both Provincial and LG facilities must be reflected.
Table 10: (NDoH 1): PHC facilities (Provincial and LG combined) per Sub-District as at 31 March 2014 Sub-Districts Health Posts Mobiles Satellites Clinics Community Day Community Standalone District Centre1 Health Centres MOU3 Hospitals (24 x 7)2
LG P LG P LG P LG P LG P LG P LG P Emnambithi 0 0 0 5 0 0 0 12 0 0 0 1 0 0 0 Imbabazane 0 0 0 2 0 0 0 5 0 0 0 0 0 0 0 Indaka 0 0 0 2 0 0 0 7 0 0 0 0 0 0 0 Okhahlamba 0 0 0 3 0 0 0 6 0 0 0 0 0 0 1 Umtshezi 0 0 0 2 0 0 0 6 0 0 0 0 0 0 1 District 14 36 1 2
Source: DHIS In Okhahlamba there is a need for 2 fixed clinics and a mobile team as mentioned earlier in the document. Indaka motivated for an extra mobile team. All sub-districts needs to motivate for family health teams.
1 There are no Community Day Centers in KwaZulu-Natal 2 All Community Health Centers (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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Table 11: Provincial Clinic Facility to Population – 2013/14 Sub-Districts/ District PHC facility per pop ratio - Health PHC facilities per pop - Mob PHC facilities per pop ratio - PHC facilities per pop ratio - CHC Post provincial Clinical provincial provincial
Emnambithi 0.0 0.2 0.49 0.0
Imbabazane 0.0 0.16 0.39 0.04
Indaka 0.0 0.17 0.76 0.0
Okhahlamba 0.0 0.2 0.34 0.0
Umtshezi 0.0 0.31 0.61 0.0
District 0.0 0.19 0.48 0.1 Source: DHER 2012/13 Customised District Report For mobile units not a big variance between sub-districts, Umtshezi the highest rate due to the fact that this sub-district have only 9% of the District population which shows that this sub-district has increased access to services.. The same scenario is applicable for the clinics with a rate of 0.61.Okhahlamba have the second highest percentage of the population (20.8%) but the lowest ratio of clinics 0.34%, which shows again the inequity of resource allocation within the District. Okhahlamba, Catkin valley has no mobile services clients have to travel to Emmaus hospital or to Winterton to attend the mobile clinic. Khetani area (Winterton) has a large population which has no access to a fixed clinic only a mobile clinic. The surrounding areas around in Okhahlamba are mountainous and clients have to walk long distance to reach mobile points. Frequency of mobile visits is a challenge due to the number of points currently visited by 3 mobile teams and the number of clients seen at these points including the highest number for down referred ART clients. (see page12) All fixed clinics are situated on one side of Okhahlamba leaving other areas with no clinic services, only mobile clinics serving the area. Indaka, there are three mobile teams, but only two of them are being utilised (mobile vehicle in for repairs and there are no support vehicles). In the process of recruiting resources for the 3rd mobile which will utilises the one mobile vehicle from the existing mobile team. Most of our areas are hard to reach areas. The distance between Sigweje, Rockcliff and Ekuvukeni is within a 5-7km radius, which leads to low utilisation rate at PHC services. The facility to population rate in Indaka for mobiles (2nd highest) and clinics (highest) in the district yet the low utilisation rate of 1.9 80% area is seen once a month by the mobile teams. (Unavailability of mobile vehicles) Unavailability of essential medication due to failure of PPSD to deliver on time in all sub-districts (PPSD has back orders and delivers one month late) Some of the areas are affected by the demarcation, (Douglas clinic at Elenge area and Gunjana clinic nearer to Mangweni), these clinics are situated on the border of Uthukela and Umzinyathi and the transport routes are easily accessible to Umzinyathi district, especially for the older citizens. Limehill mobile is also affected by these transport routes. The transport routes from Sahlumbe clinic are more accessible to Estcourt area.
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Table 12: (NDoH 2): District Hospital Catchment Populations 2013/14 Name of District Hospital 2012/13 2013/14 Estcourt Estcourt Estcourt Emmaus Emmaus
Catchment Population of District Hospital 146 724 192 494 75 093 (134 528) 223 846
% uninsured Population 84.5% 84.5% 84.5% 84.5%
Uninsured Catchment Population Of District Hospital 123 982 162 464 63 454 189 150 Source: DHER 2013/14 (GIS)
Note: District Hospital Catchment Populations are calculated according to the catchment population of referring clinics.
Emmaus hospital is serving the entire sub-district catchment population of 134 528, which include the mobiles and fix clinics and are more than twice the figures mentioned in the table for Hospital catchment population. The lower figures will impact on the resource allocation to Emmaus hospital in the new financial year. The difference for Estcourt is not as big as the one for Emmaus. Emmaus hospital is serving an immediate community around the hospital of 75 093 that has no other services other than mobile points on monthly and others on a bi- monthly basis. The other fixed clinics also refer clients to the Hospital. The distance from the hospital to the most remote clinic situated deep in the mountains is 90km one way (Busingatha clinic). The remaining population of 60 584 is being seen by the clinics which are all situated on one side of the sub-district. Bergville clinic situated in Bergville town need to be expanded to cater for 8 hour/7day a week service depending on building of new hospital in Bergville (2020). Ladysmith Hospital is a regional hospital, but provides also Level 1 services as there is no other hospital for the Indaka and Emnambithi catchment population. There is a CHC in Emnambithi but the medical officer’s coverage is very low which impact negatively on the regional service delivery at Ladysmith Hospital. It is actually very difficult to determine the percentage of Level 1 services as the patients utilise the same wards. The following challenges contribute to the situation at Ladysmith hospital; No accommodation for medical officers at St. Chads Although Ladysmith is a Regional hospital and not included in Program 2, the in effectiveness of the management to implement a referral policy impact negatively on the PHC Headcount in Emnambithi as illustrated in the table below. Regional hospital is not supposed to attend to patients without any referral letter as Ladysmith Gate clinic is within 500m from the OPD. If all institutions can implement the referral policy and utilises the Gate clinics more effectively and efficiently the District can use the R23 508 726 for OPD not referred cases at Hospital for PHC services. Hospitals
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always complaint that they under budgeted, yet accommodate PHC clients. If these clients were re directed to the gate clinics the sub-districts utilisation rate would increase to the expected target. OPD cases not referred (5 152 District Hospitals) seen at OPD, which is 3% of the total OPD Headcount, a Regional Hospital not supposed to see OPD not referred cases. These not referred cases have a R14 900 234 cost implication at the Hospital which could be used for Regional services. 175 700 more clients could be seen at a PHC level with a cost of R135 per Headcount. The hospitals commented that Dental headcount is part of OPD Headcount not referred. The Dental Headcount is subtracted from the OPD not referred, yet still a R23 508 726 cost implication for the District.
Table 13: OPD not referred 2013/14 Hospital OPD not referred Cost of seeing these clients at a Extra HC at PHC level if the referral Increase in utilisation rate if the not District and regional level. policy is implemented correctly referred clients is re directed to a Gate Clinic not attended to at OPD Ladysmith 9 438 R14 900 234 90 032 3.1 (Emnambithi) Emmaus 4 100 R6 825 676 58 140 3.4 (Okhahlamba) Estcourt (Umtshezi) 1 052 R1 782 816 10 487 2.4 Total 14 590 R23 508 726 175 700 3.0
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7.2 TRENDS IN KEY DISTRICT HEALTH SERVICE VOLUMES
7.2.1 PRIMARY HEALTH CARE SERVICE VOLUMES AND UTILISATION
Table 14:(NDoH 3): PHC Headcount Trend Sub-District 2012/13 2013/14 Variation
PHC PHC PHC Total PHC PHC Total PHC PHC PHC Total PHC Headcoun Total Utilisation Headcoun Headcoun Total Headcou Headcou Total t – Head Rate t – t Utilisa nt – nt Utilisatio Provincial count Provincial tion Provincial n Rate Rate
Emnambithi 611,684 611,684 2.0 659,494 659,494 2.7 7.8% 7.8% 35%
Imbabazane 274,250 274,250 1.8 283,128 283,128 2.5 3.2% 3.2% 38%
Indaka 229,610 229,610 2.3 248,812 248,812 2.4 8.3% 8.3% 4.34%
Okhahlamba 293,639 324,644 2.0 314,381 314,381 2.3 7.06% -3.16% 15%
Umtshezi 161,290 206,210 2.7 199,839 199,839 2.3 23.9% -3.08 -14.8%
District 1,561,119 1,646,398 2.1 1,705,564 1,705,564 2.6 9.2% 3.5% 23.8%
Source: DHIS Olivershoek to become a CHC in 2016/17. Additional rooms be added to current labour ward to comply with requirements for Olivershoek to become MOU in 2015/2016.The 3 clinics refer to Olivershoek clinic which is a 24-hour clinic seeing head count of 59 856 per annum. The nearest Hospital (Emmaus) is 50+ km from Oliviershoek.
Table 15: Difference in Headcounts - Okhahlamba 2014/2015 First six 2014/15 months Year Variation PHC services 2012/2013 2013/2014 projection raw Variation % Amazizi 34 951 30 895 13 089 26 178 -4 056 -11.6%
Bergville Clinic 31 005 36 781 18 587 37 174 5 776 18.6%
Bergville Mob 1 40 698 40 372 22 145 44 290 -326 -0.8%
Bergville Mob 2 41 857 43 178 22 447 44 894 1 321 3.2%
Bergville Mob 3 32 437 40 104 19 169 38 338 7 577 23.4%
Businghata 18 614 20 625 9 717 19 434 2 011 10.8%
Dukuza 36 940 34 389 21 482 42 964 -2 551 -6.9%
PHC gate Clinic 28 086 29 876 14 598 29 196 1 590 5.6%
Oliviershoek Clinic 59 856 38 251 18 904 37 808 -21 605 -36.1%
TOTAL 324 644 314 381 160 138 320 276 -10 263 -3.2%
Mobile 3 is serving the same area as Oliviershoek. The mobile had an increase of 7 667 headcount due to the fact that the ARV medication is down referred to the mobile units. With the implementation of the verification teams the data recording is much more accurate. The
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headcounts for Oliviershoek was duplicated in the 2012/13 financial year thus the big decrease in headcount. The District target was not met due to the fact that Okhahlamba and Umtshezi had a 3% drop in headcounts. All sub-districts utilisation rates increase except for Umtshezi; this is due to the fact that the catchment population’s figurers were updated with the 2011 census population data.
Graph: 2: PHC Utilisation (Provincial Clinics) vs. Population to PHC facility (Provincial clinics) – 2013/14
2.8 25000 Rate facilty
23055 22421 to
2.7 20266 20000 2.6 18454 14961 15000 Utilisation 2.5 14179
prrovincial
2.4
PHC 10000
to 2.3 5000 2.2 2.7 2.5 2.4 2.3 2.5 2.3 Provincial 2.1 0 Population
PHC Utilisation Rate Avg catchment Population per clinic
Source: DHIS 2013/14 dump file
The utilisation rate and workload in Graph 2 and Graph 3 is not the same as in the DHER document due to the fact that HISP at national level did not import the corrected DHIS file from the District. Province made a decision for the District to use the corrected file.
Graph: 3: PHC Utilisation rate in relation to PN Workload Provincial Clinics
2.8 50.0 44.1 2.7 40.3 40.0 2.6 33.8 2.5 29.4 29.2 31.4 30.0 2.4 Rate 20.0
Rate 2.3 10.0 2.2 2.7 2.5 2.4 2.3 2.3 2.5 2.1 0.0 Utilisation
Workload PHC
PHC Utilisation rate PN Workload
District Hospital activities – 2013/14
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Estcourt hospital managed to increase the bed utilisation rate from the previous financial year by 9.3%. The hospital analysed the utilisation rates per ward and decreased the beds in the lowest utilisation wards. The hospital is in the process to establish a MDR initiation unit for the entire district.
Table 16: (NDoH 4): District Hospital activities District Hospitals Year Emmaus Estcourt District Uthukela
1. Inpatient Days – total 2012/13 34,942 66,091 101,033
2013/14 35 527 70 030 105 557
Variation 1 035 3 939 4 524
2. Day patient - total 2012/13 126 106 232
2013/14 160 24 184
Variation 34 82 48
3. OPD Headcount not referred new 2012/13 8547 4138 12,685
2013/14 7 532 4 068 11 600
Variation -1 015 -70 - 1 085
4. OPD Headcount – total 2012/13 68,475 81,601 150,076
2013/14 65 977 74 526 140 503
Variation -2 498 -7 075 -9 573
5. Emergency headcount total 2012/13 4,702 12,336 17,038
2013/14 3 411 13 341 16 752
Variation -1 291 -1 005 -286
6. Total Ambulatory (OPD Headcount Total + 2012/13 73,177 93,937 167,114 Emergency Headcount total) 2013/14 69,388 87,867 157 255
Variation -3 789 -6 070 -9 859
7. Patient Day Equivalent 2012/13 59,153 97,143 156,297
2013/14 58 736 99 331 158 067
Variation 417 2 188 1 770
8. Delivery by caesarean section rate 2012/13 17.2% 26% 22.5%
2013/14 13.6% 27.7% 23.0%
Variation -3.6% 1.7% 0.5%
9. Usable Beds (DHIS) – Annual 2012/13 1872 4020 5892
2013/14 1872 3900 5772
Variation 0 -120 -120
10. Average length of stay – total 2012/13 4.7 5.3 5.1
2013/14 4.7 5.6 5.3
Variation 0 0.3 0.2
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District Hospitals Year Emmaus Estcourt District Uthukela
11. Inpatient bed Utilisation rate – total 2012/13 61.5% 54.1% 56.4%
2013/14 62.5% 63.8% 63.4%
Variation 1.0% 9.7% 7%
12. Emergency Headcounts total as % of 2012/13 6% 13% 10% Ambulatory 2013/14 4.9% 15% 10.6%
Variation -1.1% 2% 0.6%
13. Ratio of Ambulatory to Inpatient Days Total 2012/13 2.1 1.4 1.7
2013/14 1.9 1.25 1.5
Variation -0.2 0.15 -0.2
14. Useable beds / 1,000 population 2012/13 1.06 1.74 1.44
2013/14 1.14 1.49 1.36
Variation 0.08 -0.25 -0.8
15. Inpatient Separations - total 2012/13 7,435 12,578 20,013
2013/14 7 749 12 524 20 273
Variation 314 -54 260
16. Inpatient deaths - total 2012/13 529 797 1,326
2013/14 540 861 1 401
Variation 11 64 75
17. Cost per PDE 2012/13 R 1,535 R 1,558 R 1,595
2013/14 R1, 665 R1 ,695 R1 684
Variation R130 R136 R89
Source: DHIS Downloads 2012/13 & 2013/14 Professional Nurses receiving 8 % in hospitable allowance instead of 12% rural allowance due to the deep rural setting it is in. Uthukela District is not classified as deep rural district. It was explained that the District hospitals with the low BUR must consider re classification in order to increase the BUR instead of keeping the classification with a low BUR that might impact on resource allocation in the new financial year.
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Graph: 4: District Hospitals Cost per PDE vs. IPD and OPD
80% 71% 67% R 4 000 70% 60% R 3 500 60% R 3 000 50% 37% 40% 30% R 2 500 25% 30% R 2 000 20% 10% 2% 4% 4% R 1 500 0% R 1 000
Total IPD as % of PDE Total OPD as % of PDE Total Emergency as % of PDE Cost per PDE
Source: DHER 2013/14 Customised District Report
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8. DISTRICT PROGRESS TOWARDS THE ACHIEVEMENT OF THE MDG’S
Table 17: (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 District progress 2013/14 District targeted progress 2013/14 data 2014/15 ( first six months)
Goal 1: Halve, between 1990 Incidence of underweight 11.4/1000 and 2015, the children under 5 years of age 16.6/1000 DHIS 11.8/1000 Eradicate Extreme (N945/D81 753) Poverty And Hunger proportion of people who suffer from Severe malnutrition under 5 5.8/1000 hunger 6.5/1000 DHIS 6.5/1000 years incidence ) (N479/D81 753)
Goal 4: Reduce by two-thirds, Under-five mortality rate – use 4.7% Reduce Child between 1990 and proxy “Inpatient death under 5 (N261/D5499) 5.1 2015, the under-five years rate” 61/1000 DHIS Mortality (excl. Ladysmith 5.1 mortality rate 5.6%)(N141/D2535)
Infant mortality rate – use proxy 6.3% “Child under 1 year mortality in (N220/D3468) 11.2 facility rate” 42/1000 DHIS (excl. Ladysmith 4.4 8%)(N127/D1583)
Goal 4: Reduce by two-thirds, Measles 1st Dose under 1 year 76.7% 83.3 95.6 DHIS Reduce Child between 1990 and coverage (N13 667/D17 537) Mortality 2015, the under-five mortality rate Immunisation coverage under 1 76.4% 82.7 93.8 DHIS year (N13 627/D17 537)
Goal 5: Reduce by three- Maternal mortality ratio (only 123.1/100 000 Improve Maternal quarters, between facility mortality ratio) (N15/D12 187) 10 1990 and 2015, the 192.31/100 000 DHIS Health (excl. Ladysmith 3 maternal mortality 73.3/100
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MDG Target Indicator Provincial progress Source of District progress 2013/14 District targeted progress 2013/14 data 2014/15 ( first six months)
rate 000)(N5/6820)
Proportion of births attended by 64.4% (N12285/D19 skilled health personnel (Use 073) 69.4 delivery in facility as proxy 84.3% DHIS (excl. Ladysmith 38.0 indicator) 35.7%)(N6803/D19073)
Goal 6: Have halted by 2015, HIV prevalence among 15- National HIV 16.6% ANC results for 13/14 not and begin to reverse 19year-old pregnant women Syphilis available Combat HIV and 16.8% AIDS, malaria and the spread of HIV and Prevalence other diseases AIDS Survey of SA
HIV prevalence among 20- 24- National HIV 33.6% ANC results for 13/14 not year-old pregnant women Syphilis available 37.2% Prevalence Survey of SA
Contraceptive prevalence rate DHIS 53.2% 57.9% (use Couple year protection 37.5% rate as proxy)
Proportion of tuberculosis cases ETR.net 81.3% 84.5% detected and cured under 73.5% (N1049/D1290) directly observed treatment, short-course (DOTS)
The District experienced an increase in the severe malnutrition rate, in all sub-districts. All sub-districts have also many hard to reach areas. Indaka has also faction fights between the communities which impacts on mobile service delivery. Indaka had two outreach teams, but these teams are not functional anymore due to the resignation of staff. Okhahlamba did not have any outreach teams in the financial year. The outreach teams for Umtshezi and Imbazane is not functional due to challenges with transport, only 2 teams are functional the others working in the PHC clinics. The reproductive health implants was introduced to clients as from November 2013, the figure decreased drastically from April 2014 due to the stock out at PPSD. A total of 3070 implanon inserted during the first 6 months of 2014/15
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9. PROVINCIAL AND DISTRICT CONTRIBUTION TOWARDS THE NATIONAL DEVELOPMENT PLAN 2030
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 18: (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 expectancy at birth a. Address the social determinants that affect HIV & AIDS and Tuberculosis prevented and successfully increased to 70 years health and diseases Managed Tuberculosis (TB) prevention and cure progressively improved; d. Prevent and reduce the disease burden and promote health Maternal, infant and child mortality reduced
Prevalence of Non-Communicable Diseases reduced by 28% Maternal, infant and child mortality reduced
Injury, accidents and violence reduced by 50% from 2010 levels
Health systems reforms completed b. Strengthen the health system Improved health facility planning and infrastructure delivery
Health care costs reduced
c. Improve health information systems Efficient Health Management Information System for improved decision making
h. Improve quality by using evidence Improved quality of health care
Primary health care teams deployed to provide care to Re-engineering of Primary Health Care families and communities
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NDP Goals 2030 NDP Priorities 2030 Sub-Outcomes 2014-2019 (MTSF)
Universal health coverage achieved e. Financing universal healthcare coverage Universal Health coverage achieved through implementation of National Health Insurance
Posts filled with skilled, committed and competent individuals f. Improve human resources in the health sector Improved human resources for health
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
This section should outline (e.g. imbalance in service delivery platform, staff mix and provision of care, problems in referral chain, district hospital and PHC infra-structure revitalisation, quality of care improvements, public/private interactions).
Table 19: Summary of major challenges Challenges Root cause and Possible - Responsible Time frame Interventions Person
Inequity in PHC expenditure per capita un- Budget allocations by CFO and Budget 2015/16 insured, within the sub- Head Office office financial year districts
AE Havilland clinic is not Staff shortages Estcourt PHC 2015/16 fully functional (24HR) due Management financial year to staff shortages.
PHC expenditure using The National HER National HER 2015/16financial only sub-programme(2.2 document formulas team year and 2.3)( National) different from the Provincial calculations
No staffing norms in the Provincial HR 2015/16 department, which makes it difficult to compare staff Financial year levels within the sub- districts.
One medical doctor Recruitment to rural area National and 2015/16 placed in CHC at St. and available Provincial offices Chads accommodation makes it Financial year very difficult to attract officials.
One side of Okhahlamba Commissioning of clinics Infrastructure 2015/16 has no clinics, due to poor in the one area of Head Office terrain /hard to reach Okhahlamba as Financial year areas indicated in the STP which is served by mobile clinics
No adherence to referral Hospital management Hospital 31 March 2015 pattern must implement the management
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Challenges Root cause and Possible - Responsible Time frame Interventions Person
referral patterns.
Communities must be educated about referrals
Provincial HR not Mobile units not saw as HR section Head 31 March 2015 approving posts/structures cost drivers units. Office – for mobile clinics, now establishment. hospital staff is used and Each mobile to be seen the expenditure is skewed. as cost center, no idea of the cost-effectiveness and sufficiency of mobiles.
Staff establishment for
mobile services created PPSD Mobiles have no demander codes to order directly from PPSD. The Mobiles to receive shortage of drugs was also demander codes reported by the district team.
Transport for School Health Provincial office has only Provincial office 31 July 2015 teams and Family Health supported the District with – fleet teams 10 vehicles for outreach management. teams. Provincial office to assists the District in transport.
Equipment for School Order was placed with Provincial office Financial year Health teams Provincial Office, but yet 2015/16 not received. Currently using equipment that is available at clinics, yet not the ideal situation. Provincial; office to procure funds in the new financial year.
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10.1 INTRA DISTRICT EQUITY IN THE PROVISION OF SERVICES
Include information relevant to equity form the DHER Report. This should include plans and strategies for improvement.
Table 20: (NDoH 6): PHC Expenditure Sub-District PHC Expenditure / PHC Utilisation Rate PN to Patient % Share of District Uninsured Capita Provincial clinics Population
Emnambithi R472.39 2.7 2.1 34.82 Imbabazane R210.29 2.4 1.3 18.12 Indaka R252.57 2.4 1.7 16.90 Okhahlamba R360.96 2.3 3.1 20.88 Umtshezi R416.16 2.3 2.2 9.28 District R365.46 2.5 2.1 100%
Source: DHER 2013/14 Customised District Report, DHIS
Graph: 5: Equity of resources vs population and headcount – 2013/14 50.0% 40.0% 44.5% 46.0% 30.0% 20.0% 36% 37% 19.5% 16.7% 17% 16% 19.7% 10.0% 15% 14% 12% 14.2% 10.9% 9.7% 11% 0.0% 8.2% 10.6% 20% 22%
% Share of PN's % Share of Population % Share of Expenditure % Share of Headcount
Source: DHER 2013/14 Customised District Report
Equity is still not considered in Imbabazane and Indaka Imbabazane has 17% of the population, but only 9.7% of expenditure and 10.9% of the PN’s Indaka has 15% of the population, but only 10,6% of expenditure and 8.2% of the PN’s. Night duty PN’s do not see as many patients as during the day – 24 hour services. Indaka sub-district has hard to reach areas as a result they do not use facilities after hours, and prefer to wait for the morning because of transport issues and unavailability of proper roads. The issue of rural allowance is effecting the appointment of staff, as the District is not seen as deep rural, yet some of these areas are very remote and inaccessible for service delivery. Emnambithi on the other hand has 35% of the population, but 46% of the expenditure and 44.5% of the PN’s. With Umtshezi and Okhahlamba there is not much difference between the population and resource allocation.
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Table 21: (NDoH 7 (a)): Number of patients to staff type (Sub-District) – PDoH PHC Clinics Sub-District Specialist Administrator Administrator Clinical Staff Other Counsellor Data Capturer General Worker / Cleaner Medical Officer Nurse Assistant Pharmacist Assistant Basic Pharmacist Assistant Post Basic Pharmacist Professional Nurse Staff Nurse
Kz Okhahlamba 23 852 8 676 12 721 38 163 11 224 12 901 3 470 5 963 Local Municipality
Kz Emnambithi Local 22 919 15 279 26 964 50 932 12 733 32 742 4 538 7 162 Municipality
Kz Imbabazane Local 80 907 26 968 40 453 60 680 20 226 80c907 6 742 14 277 Municipality
Kz Indaka Local 36 347 16 775 24 231 36 46 13 630 21c808 8 077 6 815 Municipality
Kz Umtshezi Local 36 642 22 901 22 901 45 802 15 268 61 070 4 261 9 160 Municipality
Source: DHER 2013/14 Customised District Report, DHIS Difficulty in interpretation of this table due to the following reasons;
No norms for staff types at PHC services
Previous year different formula used, expressed as per 1000
The patient number to PN’s reflects again the inequity in Imbabazane (6 742) and Indaka (8 077), these figurers almost double for Umtshezi and Okhahlamba. Table 22: (NDoH 7 (b)): Number of patients to staff type (Sub-District) – CHC Sub-District Pharmacist Assistant Basic Pharmacist Assistant Post Basic Pharmacist Professional Nurse Staff Nurse Specialist Administrator Administrator Clinical Staff Other Counsellor Data Capturer General Worker / Cleaner Medical Officer Nurse Assistant
Kz Emnambithi Local 3 360.1 8 552.9 15 680 47 041 18 816 23 520.5 8 552.9 47 041.0 47 0410.0 47 041.0 2 045.3 4 480.1 Municipality
Source: DHER 2013/14 Customised District Report, DHIS
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The patients to staff type are the highest for data capturers yet the quality of data is of crucial importance service delivery planning and resource allocation. Taken into consideration that all clinic data is captured daily on the E-tool from the source documents and all ARV patients’ files is captured after each visit. All clinics should have 2 data capturers to cover the days when staff is sick or on leave.
Table 23: (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
Kz Okhahlamba Local Municipality 2069.7 1966.2
Kz Emnambithi Local Municipality 60797.8 57757.8 1654.4 1571.6
Kz Imbabazane Local Municipality 3202.1 3041.9
Kz Indaka Local Municipality 3879.0 3685.0
Kz Umtshezi Local Municipality 1546.8 1469.4
Source: DHER 2013/14 Customised District Report, DHIS
Note: The National Table A12 has been combined to incorporate both Medical Officers and Professional Nurses.
The table reflects the true reflection as Medical Officers is not placed at PHC facilities; they only work one/twice a week for 2-3 hours at a clinic level. The cost per capita for Emnambithi almost doubled from 2010/2011 (R292) to 2012/2013 R481) due to the resources especially Human Resources at St. Chads CHC.
In future the total population will be used due to the implementation of NHI and the table indicates the big differences between the ratio in uninsured and total population. The sub-districts with the lowest PN to Uninsured population have also the lowest Cost per Capita. This reflects that the OSD impacts on the cost of service delivery.
4 District hospital plus PHC
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11. ORGANISATIONAL ENVIRONMENT
Organisational Structure of the District Management Team
District Office 1 x District Manager (filled) 1 x Secretary (filled)
Sub Component: Integrated Sub Component: Transversal UTK Emergency Medical District Public Health Service Clinical & Facilities support Rescue System Development services 15 program managers
1 vacant MCWH
Sub Component: District Section: Corporate Service UTK Forensic Medical Health Service Delivery centre Pathology Service Planning Mon & Evaluation (District Engineer vacant)
Please note that the following specialists are part of DMT, although these posts are not on the approved structure for the District Office. PHC Specialist (Nursing) Gynecology Specialist (Medical) MCWH Specialist (Nursing) Pediatrics (Nursing)
Human Resources
Current deployment of human resources in relation to service delivery requirements; Accuracy of staff establishment at all levels of the system compared to service requirements (link with Persal report); It is quite noticeable that the District is doing its best to fill all the vacant funded posts. Persal report shows that posts appearing on Persal are 3 520. Posts that have been filled on Persal are 3 226 and 12 are partially filled which means that these might be sessional posts. In total active and filled posts are 3238. Vacant posts showing on Persal are 282. It must be noted that the abolished posts that do not appear on Persal are excluded. Staffing levels and staff mix: could current staff absorb additional visits; Staff recruitment and retention system and challenges Uthukela District is experiencing challenges regarding the retention of recruited staff. The discrepancy in rural allowance which is 22% and 18% depending on the area of operation for
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doctors seems to less attract doctors within Uthukela which only received 18% rural allowances. . Emphasis is always made to institutions to ensure that posts are filled on time especially the vacated posts since they are funded and the authority to unfreeze such posts is delegated to the Heads of the institutions. It is also stressed to Nurse Managers that the movement of nurses from one facility to the other should be communicated to both HR and Finance to avoid a scenario where one is working in another place and consuming the budget of another institution Absenteeism and staff turnover rates. The rate of absenteeism is very high attributed to high disease prevalence in Uthukela whereby the employees are also included in the statistics that is showing the diseases profile. Uthukela is a very cold district as a result the cold winter season also contributed to the high percentage of 78%. The root cause for the exit of staff is due to the rumors of the pension funds changes, although information session was held with the staff. The discrepancy in the rural allowance and lack of accommodation results to 54% staff turnover rate. A total of 49 employees is due for retirement is the MTEF period
Table 24: Employees due for retirement POST SALARY NOTCH RETIREMENT DATE
PNB2 Professional Nurse Grade 2 365 841.00 20140624 (Spec)
Emergency Care Officer 146 700.00 20151107
Nursing Assistant Gr3 135 723.00 20150727
Operator 92 976.00 20151028
Handyman 113 511.00 20150928
ASO:Counsel/ADV/HEA 162 963.00 20151130
Gen Orderly 81 312.00 20160215
Hosp Orderly 87 600.00 20150903
Gen Orderly 74 370.00 20160318
Chief HRO 212 106.00 20160331
Radiographer Gr2 261 024.00 20150516
Gen Orderly 76 617.00 20160309
Head Clinical Unt Med 1 203 807.00 20160102
Staff nurse Gr1 127 932.00 20160123
Prof. Nurse Gen. Gr1 191 784.00 20160321
Prof. Nurs. Gen. Gr3 256 584.00 20150702
Prof. Nurs. Gen. Gr1 Spec. 272 220.00 20151214
Clinic. Nurse Pract. Gr1 272 220.00 20150819
Clinc.Nurs. Pract. Gr2 315 579.00 20160202
Security Guard 73 269.00 20150814
Chief ASO 162 963.00 20160111
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POST SALARY NOTCH RETIREMENT DATE
Prof. Nurs. Gr2 Spec 388 128.00 20160413
Prof.Nurs.Gen Gr1 197 538.00 20170308
Oper.Nurs.Man. PHC 388 128.00 20161224
ASO 91 599.00 201`60422
Prof.Nurs.gen Gr1 175 509.00 20160515
Prof.Nurs.Gen Gr3 264 285.00 20170325
Gen Orderly 86 307.00 20160503
Gen Orderly 87 600.00 20161226
Hosp Orderly 87 600.00 20160810
Fin. Serv. Off. 162 963.00 20160409
Supply Chain Clerk 162 963.00 20160609
Gen Orderly 86 307.00 20160623
Linen Orderly 113 511.00 20170124
Gen Orderly 73 269.00 20161018
Man Pharmacy Serv Asst 625 260.00 20160526
Nurs. Assist. Gr3 139 797.00 20170106
Prof. Nurs.Spec. Gr1 297 462.00 20161220
Nurs Assist. Gr3 139 797.00 20160612
Staff Nurse Gr3 191 784.00 20160815
Clinical Nurs Pract Gr1 272 220.00 20160805
Clinical Nurs.Pract Gr1 280 386.00 20160815
Oper.Man Nurs PHC 399 762.00 20170312
Oper.Man Nurs PHC 411 759.00 20170226
Security Guard 80 112.00 20160427
Security Guard 80 112.00 20170325
Oper.Man.Nurs PHC 399 762.00 20160508
Nurs. Assistant Gr3 152 757.00 20160607
Table 25: Staff type to Patient Ratio in Facilities [per 10 000] – Provincial Clinics Sub-Districts MO to Patient PN to Patient EN to Patient ENA to Data General Provincial Provincial Provincial Patient Capturer to Worker to Clinics Clinics Clinics Provincial Patient Patient Clinics Provincial Provincial Clinics Clinics
Emnambithi 0.0 2.1 1.2 0.34 0.18 0.91
Imbabazane 0.0 1.3 0.62 0.13 0.18 0.53
Indaka 0.0 1.7 1.2 0.45 0.25 0.64
Okhahlamba 0.0 3.1 1.6 0.84 0.34 1.2
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Sub-Districts MO to Patient PN to Patient EN to Patient ENA to Data General Provincial Provincial Provincial Patient Capturer to Worker to Clinics Clinics Clinics Provincial Patient Patient Clinics Provincial Provincial Clinics Clinics
Umtshezi 0.0 2.2 1.0 0.15 0.29 0.88
District 0.0 1.73 0.94 0.33 0.17 0.59
Source: DHER 2013/14 Customised District Report
This table shows inequity in the District especially in the Staff to Patient Ratio for PN’s. It is evident that the ratio of 3.1 with the highest rate in Okhahlamba and Imbabazane the lowest with 1.3 ratios yet the more or less the same PN workload of 44.1 and 40.3 respectively. One would think that there should be a linkage between the Staff to patient ratio and the workload and utilisation rate, although this is not the situation when comparing the rates. A high staff to patient ratio of 3.1 should reflect a lower workload, but this is not the case in Okhahlamba.
The rate for the Staff to Patient ration of 1.1 is acceptable for a CHC as patients’ needs to be referred to the CHC from clinics. The most of the staff for the CHC previously worked in the District either at clinics or hospitals. The clinics staffs were drained to the CHC.
The table reflects the true reflection as Medical Officers is not placed at PHC facilities; they only work one/twice a week for 2-3 hours at a clinic level and is only willing to see 20-30 patients. The cost per capita for Emnambithi almost doubled from 2010/2011 (R292) to 2012/2013 R481) due to the resources allocated especially Human Resources at St. Chads CHC. Estcourt will ensure correct linking of staff at point of service delivery. Ladysmith shortage of staff- during night duty, according to the staff establishment 5 OM’s but now only 2 OM’s and a Manager on night duty if one person is sick or on leave not enough coverage, one Senior PN co-opted to assists with nigh duty. Estcourt 1 ANM, 1 OM on night duty, one OM boarded, all hospitals must ensure that night duty posts are filled according to the staff establishment for night duty
Additional mobile team to be established with additional vehicles to distribute the mobile points evenly and add additional points to cover areas that have no services or limited services.
The problem is at HR Head Office (establishment) whom does not want to create the posts that was approved by Budget Section, HR only consider the staff establishments according to the organograms for the category of clinics and does not take into consideration the demo-graphics and demands of the new programs introduced and additional service delivery required. All of the programs are PN driven yet number of PN on staff establishment remains the same, e.g. initiation of patient on ART (norms not adhered to – 500pt/PN).
Table 26: Cost per Headcount in relation to Workload Sub-Districts and Total Staff Cost Total Staff Cost PN Workload Patient to PN District per PHC per PHC number Headcount Headcount (corrected expenditure – regional identifier)
Emnambithi R104.83 R120.80 29.4 4 539
Imbabazane R43.14 R50.14 40.3 6 742
Indaka R57.79 R66.20 29.2 8 077
Okhahlamba R64.52 R93.10 44.1 4 142
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Sub-Districts and Total Staff Cost Total Staff Cost PN Workload Patient to PN District per PHC per PHC number Headcount Headcount (corrected expenditure – regional identifier)
Umtshezi R97.79 R112.40 31.4 3 290
District R78.79 R95.10 33.8 5 400
Source: DHER 2013/14 Customised District Report, DHIS
The differences in staff costs are due to the correct linkage of staff, especially the mobile staffs previously mentioned. District Compensation of Employees per headcount not a true reflection due to the incorrect regional identifiers used by sub-districts which also contributes the variances between sub-districts. The biggest variances occurred in Indaka, Imbabazane and Umtshezi. The inequity in Imbabazane and Indaka is also visible in the COE cost per headcount.
Table 27: District Hospital Staff to PDE Ratio Total Medical Total Nursing Total Pharmacy Total Clinical Total Support District Hospital Staff to PDE Staff to PDE Staff to PDE Staff to PDE Staff to PDE ratio ratio ratio ratio ratio
Emmaus 0.19 2.8 0.1 0.24 1.1
Estcourt 0.21 2.8 0.13 0.16 1.3
District Total / Average 0.20 2.8 0.12 0.18 1.2 Source: DHER 2013/14 Customised District Report
Incorrect linking has been rectified were posts were available at the clinics the staff were correctly linked. The outstanding posts have been requested waiting to be put onto the establishment to all correct linking. The data is reflecting the last day of March for the posts filled, but there are many fluctuations during the financial year, especially with medical doctors and most of the doctors resign nearer to the end of a calendar year in order to start with a new job in the new calendar year.
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12. DISTRICT HEALTH EXPENDITURE
Table 28: (NDoH 9): Summary of District Expenditure
(Budget, Transfer to (Expenditure, (Expenditure, Transfer Data element (Budget, Province) (Budget, LG Own) (Expenditure, LG Own) LG) Province) to LG)
DF - 2.1: District Management 15 613 000.00 0.00 0.00 15 613 000.00 0.00 0.00
DF - 2.2: Clinics 194 625 000.00 0.00 0.00 194 846 013.00 0.00 0.00
DF - 2.3: Community Health 40 791 000.00 0.00 0.00 42 621 633.00 0.00 0.00 Centres
DF - 2.4: Community Services 0.00 0.00 0.00 0.00 0.00 0.00
DF - 2.5: Other Community Services 38 795 000.00 0.00 0.00 40 336 561.00 0.00 0.00
DF - 2.6: HIV/AIDS 165 892 000.00 0.00 0.00 166 051 442.00 0.00 0.00
DF - 2.7: Nutrition 2 205 000.00 0.00 0.00 2 205 757.00 0.00 0.00
DF - 2.9: District Hospitals 276 085 000.00 0.00 0.00 281 251 589.00 0.00 0.00
TOTAL DISTRICT 734 006 000.00 0.00 0.00 743 196 661.00 0.00 0.00
Source: DHER 13/14 District Customised Template Note: This table has been updated to align with the DHER 2012/13 template.
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Table 29: (NDoH 10): Capita PHC expenditure per sub-district – 2013/14 Total Expenditure Population District Service Delivery
PHC % Cost per Cot per Expen Expenditure Uninsured Uninsured PHC % Uninsured Sub-Districts diture / compared Capita Capita Expenditure population and District Capita to District 2012/13 2013/14 / Uninsured compared (Total Capita to District Popula tion)
Emnambithi R448.8 R472.4 95.00 R448.78 R109 138 233.6 46.0 R 506 Imbabazane R199.8 R210.3 95.00 R199.78 R25 130 609.44 10.6 R 189 Indaka R239.9 R252.6 95.00 R239.95 R33 633 339.33 14.2 R 189 Okhahlamba R342.9 R361.0 95.00 R342.90 R46 131 517.53 19.5 R 378 Umtshezi R395.4 R416.0 95.00 R395.35 R23 029 898.93 9.7 R 752 District R347.8 R3465.46 95.00 R448 R347.79 R23 7063 598.8 100.0 Source: DHER 2013/14 Customised District Report, DHER 2011/12 and 2012/13 In future the total population will be used due to the implementation of NHI and the table indicates the big differences between the ratio in uninsured and total population. The sub- districts with the lowest PN to Uninsured population have also the lowest Cost per Capita. This reflects that the OSD impacts on the cost of service delivery. The low cost for Medicines per headcount is due to the journals not done for medication delivered to mobiles and new clinics (Sigweje) that do not have demander codes. Demander codes were requested but PPSD is not issuing new demander codes due to staff shortages at PPSD.
Table 30: (NDoH 11): PHC Budget and Expenditure (%) excluding “Other Donor Funding” – 2013/14
Budget Amount Budget Expenditure Amount Expenditure
District Management (2.1) R 15 613 000.00 2.12% R15 613 666.00 2.10%
PHC (2.2 – 2.7) R 444 308 000.00 60.5% R 445 401 406.00 59.9%
District Hospitals (2.9) R 276 085 000.00 37.6% R281 251 589.00 38.3%
Source: DHER 2013/14 Customised District Report
Note: The National Table for District Finance Proportional Expenditure [%] is included in Table A15 above.
Table 31: (NDoH 12): PHC Cost per Headcount– 2013/14
LG PHC Facilities Provincial PHC Facilities Total Staff Cost per PHC Headcount
District N/A R137 R95.10 Note: The National Table for District Finance Proportional Expenditure [%] is included in Table A15 above.
The amount of R95.10 per headcount is 69% of the expenditure per headcount, which is within the norm.
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Table 32: District Hospital Expenditure District Hospital Expenditure per PDE ALOS BUR Proportion (%) of expenditure spent on staff (CoE)
Emmaus R 1665 4.7 62.5 76.7%
Estcourt R 1695 5.6 63.8 73.9%
District R1684 5.3 63.4 74.9% Source: DHER 2013/14 Customised District Report
The percentage expenditure of more than 70% on CoE in hospitals indicates that hospitals are overstaffed. Staff linkages was corrected in the financial year, one would expect to see a decreased percentage in the next financial year. The percentage value decreased from 83.3% in 2012/13 to 74.9% in 2013/14 as a result of the correct linkages of staff to the place of service delivery.
Graph: 6: District Hospital Expenditure in relation to Service Delivery – 2013/14 R 2 000 R 1 665 R 1 695 R 1 684 R 1 500 R 1 000 R1 277 R1 254 R1 262 R 500 R ‐
Cost / PDE CoE / PDE
Source: DHER 2013/134Customised District Report
The cost per PDE decreased from R1899 (201/13) to R1 684 (2013/14), this can be due to the journals that was done for PHC services for medicines. The finance office in the District Office really made an effort to correct the payments for PHC services.
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Table 33: Non-Negotiable Expenditure per PDE Non-Negotiable Emmaus Estcourt District
Infrastructure Rands per PDE R0.94 R2.70 Maintenance % over / under spent 44.7% -17.8% 1.2%
Rands per PDE R47.0 R46.7 Food Services per PDE % over / under spent 7.8% -0.1% 2.9%
Medicine Expenditure Rands per PDE R54.6 R63.5 per PDE % over / under spent 33.6% -165.5% -32.0%
Medical Sundries Rands per PDE R57.70 R62.50 (Supplies) Expenditure % over / under spent 12.0% 2.3% 3.2% per PDE
Essential Equipment per Rands per PDE R2.40 R11.50 PDE % over / under spent 1.2% 20.3% 18.6%
Laundry Expenditure Per Rands per PDE 0.0 R4.3 PDE % over / under spent 0.0 0.0 0.0%
Vaccination Expenditure Rands per PDE R28.90 R3.50 per PDE % over / under spent -250.8% 0.2% -145.4%
Blood Support Rands per PDE R20.6 R22.30 Expenditure per PDE % over / under spent 13.5% 7.6% 9.8%
Infection Control Rands per PDE R29.30 R47.70 Expenditure per PDE % over / under spent 44.4% -12.4% -1.3%
Medical Waste Rands per PDE R12.40 R9.60 Expenditure per PDE % over / under spent 12.0% -2.3% 8.2%
Rands per PDE R31.50 R34.70 Security Services per PDE % over / under spent 6.4% 4.1% 4.9%
Source: DHER 2013/14 Customised District Report
-Under expenditure is due to delays in stock being delivered from PPSD and stock not being available. -Expenditure for vaccines is high due to number of dog bite cases who requires rabies vaccine and immunoglobulin as per category 3 protocol .Number of dog bites x 554 all cases must get 3 vaccine injections (at a cost of R160.80 per vial x106 cases (R50 905.44) and category 3 cases must get immunoglobulin according to weight at a cost of R620.85 per vial (average of 3 vials per patient) R1862.55 x322 patients total cost R755022.38. Okhahlamba is an endemic area for rabies. Total budget spent on rabies vaccine R805927.82 The budget allocated for vaccines is insufficient to cover cost of rabies vaccine and immunization as per protocols total budget for 2013/2014 was R400 000 . Emmaus • Medical Supplies – 2012/13 the Institution was implementing National core Standard requirements, and the trend data was utilised to budget for 2013/14 therefore the under expenditure. • Medicines – Over budgeted
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• Blood Supply and Services – No invoices processed due to the storm. • Infrastructure Maintenance – delay in service of Mayor Equipment. • Medical Waste – Institutions was not paying for General waste until the later part of the financial year, only then this item line was utilised. • Security – Accrual which were not paid during February/March, roll over expenditure to this financial year. • Food Services – invoices were late delivered by supplier. • Infection Control – toiletries was contributed to under spending and the over allocated budget.
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14. PART B - COMPONENT PLANS
The main body of the DHP is composed of five inter-related components, namely: Service delivery; Service Delivery Support services; Infrastructure; Human Resources; and Finances.
The service delivery component is the core business of District Health Services. It covers the delivery of the full District Health Package of services, the management and supervision of these services, how well the service performs in terms of health outcomes and quality assurance. The other four (4) components in the DHP: support services, human resources, finances and infrastructure – are the resources required to support the core business of District Health service delivery. The five (5) components are inter-related in that an objective in one component will often have implications for other components. For example, if under Service Delivery, you want to improve supervision by employing an additional supervisor, you would need to plan for this in the HR component and plan for the extra expense in the Finance component.
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15. 13. SERVICE DELIVERY PLANS FOR DISTRICT HEALTH SERVICES
13.1 SUB-PROGRAMME: District Health Services
13.1.1 PHC SUB-PROGRAMME OVERVIEW
All PHC services have been provincialised. Infrastructure challenges as mentioned on page 10 remains a challenge for the District. Three of the clinics namely Limit Hill, Connor Street and Walton clinic is still operating in Local Government buildings which were originally constructed as offices and not clinics. Department of Health cannot spend any money on infrastructure issues as the buildings do not belong to the department. Although generic structures have been developed for PHC facilities it does not make provision for clinic-specific needs and demands. Structures will therefore be reviewed to make provision for improved supervision of inter alia Ward-Based and School Health Teams, as well as adequate staff/skills mix to accommodate the increased case load as a result of the decanting of ARV patients and improved community-based PHC.
Recruitment and retention of Specialists for the District Clinical Specialists Teams remain a challenge for the district.
Strengthening of the Mental Health Strategy 2014-2019 will continue. At PHC level focus will be on integration at PHC level (community-based and fixed facilities) to increase access and improve management of mental health care users.
Fully functional WBOT is still a challenge for the District, due to transport. Some of the team members did not have licenses.
The compliance of PHC facilities to vital and extreme measures of NCS will be continuously monitored and action plans developed to improve the current status. The sub-districts and districts established Fit teams.
The assessment for Ideal clinic concept will continue. The supporting NGO assessed all 37 PHC facilities during September and October month to determine the baseline. Follow-up visits will be done during November month at all PHC facilities. The District identified 10 facilities as pilot sites within the district.
Each mobile team has one Mobile vehicle which sometimes presents a challenge because if it has been sent for repairs or a service that particular team has to utilize a sedan or a van which in turn compromises services because it means some services cannot be rendered on that particular day or on those particular days. There are areas which the mobile teams have not been able to service like Mkangala and St Chads, some areas are serviced but the communities have requested that the frequency be increased, e.g. Jononoskop is visited twice a month and they have requested to be visited once a week, the Ward Councillor from Roosboom has requested that the area be visited every day from Monday to Friday because of the disease burden of the area. All these requests cannot be attended to because the teams are fully committed from Monday to Friday for four weeks, so an extra team comprising of 1 OM, 2 CNP’s, 2 EN’s, 1 ENA is needed urgently together with a mobile vehicle and equipment. Each Mobile Team has one Mobile and one support vehicles.
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Each mobile team has one Mobile vehicle which sometimes presents a challenge because if it has been sent for repairs or a service that particular team has to utilize a sedan or a van which in turn compromises services because it means some services cannot be rendered on that particular day or on those particular days. There are areas which the mobile teams have not been able to service like Mkangala and St Chads, some areas are serviced but the communities have requested that the frequency be increased, e.g. Jononoskop is visited twice a month and they have requested to be visited once a week, the Ward Councillor from Roosboom has requested that the area be visited every day from Monday to Friday because of the disease burden of the area. All these requests cannot be attended to because the teams are fully committed from Monday to Friday for four weeks, so an extra team comprising of 1 OM, 2 CNP’s, 2 EN’s, 1 ENA is needed urgently together with a mobile vehicle and equipment. Each Mobile Team has one Mobile and one support vehicles.
These following mobiles are old leading to constant breakdowns:
• KZN 26799- 134540 Kilometres- will need replacing in 2015/2016
• KZN 26800- 153278 Kilometres- needs replacing now
• KZN 26822- 137167 Kilometres-not suitable for utilization, vehicle shakes if speed exceeds 60km, has been repeatedly sent for repairs, with no improvement
• KZN 27580 –110195 Kilometres-will need replacing in 2015/2016
• KZN 26805-needs replacing broke down, sent for repairs, quotation was too high and it was declared as not economical to repair.
The infrastructure sometimes has a negative impact on PHC Services, some of these clinics were built a long time ago when there were not so many programs as currently.
Walton is an ex Municipal clinic, it is attached to Municipal offices, the walls are cracking but only minimal repair can be done by the Hospital Maintenance due to ownership,.
Limit Hill Clinic is also an ex Municipal Clinic it utilizes a building that was a library which is also old and falling apart ,even in this clinic only minimal repairs can be done because of ownership.
Acacia vale and Tholusizo are now too small for the areas they serve. All these challenges have affected even their assessments for National Core Standards and Infection Control:
Scores obtained during the assessments by the Office of the Health Standards in February 2014.
• Acacia vale- 41% on Extremes
• Tholusizo- 44% on Extremes
• Stead Ville- 48%on Extremes
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• Limit Hill- 39% on Extremes
• Walton -45% on Extremes
QUALITY SUB-PROGRAMME OVERVIEW
Quality aims at achieving the best possible care with the available resources.
The focus is on the client i.e. services should be designed to meet needs of the patient.
It requires the team effort to have better understanding and insight to problems and possible solutions.
Data help us to identify gaps thus helping us to plan for improvement.
NCS are NDOH initiative to improve quality of care
The aim was to develop a common definition of quality of care for all facilities.
Strategic challenges;
Poor implementation of ICDM and ICSM (Ideal clinic)
Non-functional WBOT
Lack of provisioning of PHC services in remote/hard to reach areas.
Non Sustainability of NCS
Recruiting from the Enrolled nurse pool a major problem as these staff does not have drivers licences making it difficult to utilize them for the outreach TB programs where the need is the greatest. Inadequate mobile vehicles for outreach teams. Non- compliance with extreme and vital measures
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Table 34: (NDoH 13): Situation Analysis: Indicators for District Health Services 2013/14 Financial Year Type Emnambithi Imbabazane Indaka Okhahlamba Umtshezi District Indicators 2013/14 2013/14 2013/14 2013/14 2013/14 Average 2013/14 1. Percentage of fixed PHC facilities compliant Quarterly % 0% 0% 0% 0% 0% 0% with all extreme measures of the National Core Standards
Fixed PHC facilities compliant with all the extreme No 0 0 0 0 0 0 measures of the National Core Standards for health facilities Fixed PHC clinics plus fixed CHCs / CDCs No 12 5 8 6 6 37 2. Patient experience of care survey rate (PHC Quarterly % 0% 0% 0% 0% 0% 0% Facilities) Fixed PHC facilities that have conducted Patient No 0 0 0 0 0 0 Satisfaction Surveys Fixed PHC clinics plus fixed CHCs / CDCs No 12 5 7 5 6 37 3. Patient experience of care rate Annual % Not Not reported Not Not reported Not Not reported reported reported reported Patient satisfied with health services No Patients participating in PSS No 4. OHH registration visit coverage Annual % Not Not collected Not Not collected Not Not collected collected collected collected OHH registration visit No OHH in Population No 5. Number of District Clinical Specialist Teams Quarterly No 0 0 0 0 0 0 (DCST’s) 6. PHC utilisation rate Annual 2.7 2.5 2.4 2.3 2.3 2.5 % PHC headcount total No 659494 283128 248 812 314 381 199 839 1,705,654
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Type Emnambithi Imbabazane Indaka Okhahlamba Umtshezi District Indicators 2013/14 2013/14 2013/14 2013/14 2013/14 Average 2013/14 Population Total No 243,190 115,275 104,734 134,528 85,072 682,799 7. Complaints Resolution Rate Quarterly % 78.1 92.9 40.0 16.1 91.1 44.9
Complaints resolved No 25 13 2 24 51 115 Complaints received No 32 14 5 149 56 256 8. Complaint resolution within 25 working days % 94.1 38.5 150.0 91.7 92.2 89.2 rate Quarterly Complaint resolved within 25 working days No. 24 5 3 7 7 139 Complaint resolved No. 25 13 2 8 10 155
Table 35: (NDoH 14): District Performance Indicators – District Health Services Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Freque Performanc Target Indicator ncy e Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
1. Proportion of fixed PHC QA % Not Not 0 25 30 50 75 Not in facilities compliant with all assessme Quarter reported reported APP the extreme measures of nt ly records the National Core Standards
Fixed PHC facilities compliant QA No - - 0 10 12 19 28 with all the extreme measures assessme of the National Core Standards nt for health facilities records
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Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Freque Performanc Target Indicator ncy e Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
Fixed PHC clinics plus fixed DHIS No - - 37 37 37 37 37 CHCs / CDCs calculat es 2. Patient experience of care QA % Not Not Not 100% 100% 100% 100% 100% survey rate (PHC Facilities) calculat Quarter reported reported reported es ly Fixed PHC facilities that have OSS No - - - 37 37 37 37 650 conducted Patient Satisfaction records Surveys Fixed PHC clinics plus fixed DHIS No - - 37 37 37 37 650 CHCs / CDCs calculat es 3. PHC Patient experience of DHIS % Not Not Not 80% 90% 95% 95% 75% care rate at PHC facilities calculat Annual reported reported reported es Patient satisfied with health PSS No - - - 4 736 6 660 7 030 7 030 - services results Patients participating in PSS PSS No - - - 5 920 7 400 7 400 7 400 - records 4. OHH registration visit DHIS % Not Not Not 56% 65% 70% 75% Dependa coverage calculat Annual collected collected collected nt on es baseline OHH registration visit DHIS/Tick No Not Not Not 3450 4407 5221 6152 Dependa register collected collected collected nt on WBOT baseline OHH in Population District No Not Not Not 6164 6780 7458 8203 Dependa Records collected collected collected nt on baseline0
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Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Freque Performanc Target Indicator ncy e Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
5. Number of District Clinical Persal/ Quarter 0 0 0 19 1 ( nursing 1 ( nursing 1 ( 11 teams Specialist Teams (DCST’s) District ly No (incomplete posts posts nursing all nursing Records – 4 filled) filled) posts posts members) filled) filled 6. PHC utilisation rate DHIS Annual 2.1 2.3 2.5 2.7 2.9 3.1 3.3 3.1 calculat % es PHC headcount total DHIS/PH No 1.347.493 10.476.892 1,705,654 1 860 629 2 017 446 2 177 424 2 339 934 34 052 C tick 067 register Population Total DHIS/Stat No 670.916 676.724 682.799 689 124 695 671 702 395 709 071 10 688 s SA 165 7. Complaints Resolution Rate DHIS Quarter 47.0 51.4 44.9 30.1 63.4 70 75 Not in calculat ly % APP es Complaints resolved DHIS / No 94 119 115 136 222 245 262 Complai nt 232 239 452 350 350 350 records Complaints received DHIS / No 256 Complai nt records 8. Complaint resolution DHIS Quarter 100% 105% 89.8 88.2 90 90 90 75% within 25 working days calculat ly % rate es
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Audited/ Actual Performance Estimated Medium Term Targets Provincial Data Freque Performanc Target Indicator ncy e Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
Complaint resolved within 25 DHIS / No. 94 126 101 120 200 221 236 - working days Complai nt
records Complaint resolved DHIS / No. 94 119 256 136 222 245 262 - Complai nts record
Indicator 3 [Outreach households]: The province is not yet reporting on the indicator and information system not yet activated.
Indicator 8 [DCST]: Due to numerous challenges with recruitment and retention of team members, it was proposed that teams will be appointed per Region to ensure improved support and governance. This is therefore not in line with the national target of full teams per district by 2019.
Indicator 10 [School ISHP Coverage]: The number of schools will be reviewed annually depended on Educations data based.
Indicators 11, 12 &13 [Screening of Grade 1, 4 & 8 learners]: There is no data to inform projections.
This will be reviewed once the baseline has been established.
Indicator 4 [Supervision]: Projections (denominator) based on commissioning of new clinics and therefore dependent on project completion.
Table 36: (Table 15): District Specific Objectives Performance Indicators – District Health Services Estim Provincial ated Target Audited/ Actual Performance Perfor Medium Term Targets Performance Frequency Strategic Objective Data Source manc Indicators Type e
2011/12 2012/13 2013/14 2014 2015/16 2016/17 2017/18 2015/16 /15
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Estim Provincial ated Target Audited/ Actual Performance Perfor Medium Term Targets Performance Frequency Strategic Objective Data Source manc Indicators Type e
2011/12 2012/13 2013/14 2014 2015/16 2016/17 2017/18 2015/16 /15
1. Increased PHC 1.1 PHC utilisation DHIS Quarterly 4.0 4.2 3.9 3.7 3.9 4.0 4.1 5.1 efficiencies rate under 5 calculates % and increase years (annualised) the number of visits by person PHC DHIS/PHC tick No 315 207 320 733 321 529 308 228 324 744 327 992 331 272 5 772 132 to PHC headcount register services. under 5 Population DHIS/Stats SA No 78 209 76 729 83 277 83 092 82 310 81 326 80 816 1 154 059 under 5 years
1.2 PHC Total DHIS/Tick No 315 207 320 733 321 529 308 228 324 744 327 992 331 272 5 772 132 Headcount under register SHS 5 years
2. Increased PHC 2.1 Expenditure DHIS/BAS Quarterly R104 R135.70 R139 R147 R196 R210 R250 R284 expenditure. per PHC R headcount
Total BAS (R’000) R’000 291 941 858 217 527 085 237467645 264 545 790 396 818 685 457 259 040 584 983 500 9 668 107 expenditure PHC
PHC DHIS No 1 476 892 1 646 398 1,705,654 1792 308 2 017 446 2 177 424 2 339 934 34 052 067 headcount calculates total
3. Increased 3.1 Number of District Quarterly 2 5 12 18 20 24 24 171 cum number of School Health Records/ No school health Teams Persal (cumulative) teams according to the ISHP norms
4. Increased 4.1 Number of Health Quarterly 21 23 24 29 34 39 45 Not in APP number of accredited Health Promotion No Health Promoting Schools database (cumulative) Promoting Schools
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Estim Provincial ated Target Audited/ Actual Performance Perfor Medium Term Targets Performance Frequency Strategic Objective Data Source manc Indicators Type e
2011/12 2012/13 2013/14 2014 2015/16 2016/17 2017/18 2015/16 /15
5. Improved 5.1 Dental DHIS Quarterly 108.7 158.2 152.5 796.2 500.0 450.0 400.0 19.1 dental health extraction to calculates Ratio by reducing restoration ratio the dental Tooth DHIS/Tick No 9 129 10 126 15 250 19 108 - - - - extraction to extraction register restoration Tooth DHIS/Tick No 84 64 1 24 - - - - rate. restoration register
6. All PHC 6.1 Percentage QA Annual % % % 50 70 75 100 100 facilities of PHC facilities assessment % conditionally conditionally records compliant to the compliant to National Core NCS. Standards
Clinics QA No 0 0 0 19 25 28 37 654 conditionally assessment compliant records (50%-75%)to National Core Standards
CHC’s and DHIS No 37 37 37 37 37 37 37 654 clinics total calculates
7. Increase PHC 7.1 District PHC BAS / Stats SA R R448 R655 R687 R785 R800 R900 R950 R1 011 efficiency and expenditure per increase the uninsured person cost per Total expenditure BAS R’000 291 941 858 389 029 830 446 061 405 514 346 272 528 709 600 600 547 500 639 936 150 9 668 107 uninsured on PHC services person at PHC Number of DHIS / Stats SA No 664 770 593 734 648 657 654 666 660 887 667 275 673 617 9 555 556 uninsured people in the Province (Stats SA)
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Estim Provincial ated Target Audited/ Actual Performance Perfor Medium Term Targets Performance Frequency Strategic Objective Data Source manc Indicators Type e
2011/12 2012/13 2013/14 2014 2015/16 2016/17 2017/18 2015/16 /15
8. Improved PHC 8.1 PHC DHIS % 31.1 44.6 48.1 39.1 60 65 70 68 supervision supervisor visit rate rate (fixed clinic/ CHC/ CDC)
PHC supervisor Supervisor No 156 230 248 101 266 304 328 5 328 visit (fixed clinic/ checklists CHC/ CDC)
Fixed clinics plus DHIS No 444 444 444 444 444 468 468 654 fixed CHCs/CDCs Calculates
9. Increased 9.1 Number of District No 0 0 18 (not fully 2 Fully 15 cum – 25 cum – 37 cum – 82 number of functional Ward Management functional) functional fully fully fully cum(fully WBOT Based Outreach / functional functional functional staffed 25) Teams (Family Appointment Health Teams) letters (cumulative)
10. Increased 10.1 School ISHP DHIS % 23 18 39 48 55 65 70 75 school health coverage coverage. (annualised) Schools with any DHIS / Tick No 107 84 178 221 253 299 322 4 904 learner screened register SHS
Schools – total DHIS / DoE No 464 461 461 461 461 461 461 6 539 database
11. Increased 11.1 Number of No 0 0 0 10 20 37 37 Not in APP number of Primary Health PHC clinics Care Clinics that qualify as Ideal compliant to Clinics Ideal clinic initiative.
12. All clinics with 12.1 Number of No 30 30 30 30 32 34 36 Not in APP functional Primary Health clinic Care Clinics with functional Clinic committees Committees
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13.1.2 District Health Services: Strategies /Activities to be implemented 2015/16 Table 37: District Health Services Strategies 2015/16 Strategies Activities
1. Sustained MMLLH /MMLLC /PSS Ensure that the assessments for MMLLH/MMLLC/PSS are done quarterly. Use results to improve service delivery. 2. Increased number of facilities compliant Use the results from the supporting partner to improve on the current status of with Ideal Clinic initiative clinics.
3. Ensure the reinforcement of NCS To monitor the implementation of the QIP’s after any assessment. Monitor the close-off of the QIP’s.
4. Sufficient staff at Okhahlamba Motivation for additional staff already submitted to Head Office.
5. Replacement of boarded mobile 14 mobile vehicles included in the transport plan vehicles
6. Increased PHC Supervisory Rate. Motivate for another post at Emnambithi sub-district – norm is 1 supervisor for 5 PHC facilities Liaise with transport manager to co-ordinate transport needs 7. Inform staff about the retirement Together with HR work on a retention strategy processes after 2016.
8. HR to speed up recruitment processes Discuss with HR on how to speed up the process. regarding verification procedures.
13.2 Sub-Program: District Hospitals
13.2.1 Sub-Programme Overview District hospital services provide level 1 care services under sub-program 2.8 ARV, MMC services, Rehabilitation, Dietetics, Audiology, Dietetics TB (dedicated ward & Clinic) and Speech service at hospital level as well as
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outreach services .
Strategic Challenges; Lack of adequate transport for MMC Increased numbers of clients awaiting cataract surgery – service only available at Regional Hospital Lack of access to fixed PHC services at the one side of the sub-district near Winterton, which impact on the not referred cases on OPD. Lack of sufficient accommodation for health care workers. Lack of seclusion rooms for mental health users. Difficulty in recruiting and retaining staff to the deep rural areas due to lack of accommodation and 8% rural allowance when some urban areas are getting 12%. Training is being done for staff to upgrade them to speciality but they do not stay for long after serving their post qualification obligation Transferring of patients to Regional hospital is a major problem in a) getting doctors to accept the patients 2) specialists are not always available for the specific speciality which means a lot of time is wasted sending clients to Ladysmith hospital only to have the patient returned to the District hospital and then to be transferred to Pietermaritzburg or Durban hospitals. MMC has no dedicated transport which makes it difficult to fetch the clients for the camps this results in patients being cancelled for the operation. No landing strip near the hospital for AEROMED in Okhahlamba sub district, so this service is not fully utilized. Recruiting for the Enrolled nurse pool a major problem as these staff does not have driver’s licences making it difficult to utilize them for the outreach TB programs where the need is the greatest, to trace defaulters and assist with injections for MDR cases. Usage of traditional medication remains a major problem as babies and maternity cases come to the hospital with severe herbal intoxication. The ratio of data captures to patients is very high at the mobile clinics that have the highest work load and only 1 data capture from AURUM. Increased number of patients with MDR in the sub-district and the long waiting time for the clients to be initiated on MDR treatment at the tertiary hospital.
Table 38: (NDoH 16) Situational Analysis Indicators for District Hospitals – 2013/14 Financial Year. Indicators Type Emmaus Estcourt District Average
1. National Core Standards self-assessment rate Quarterly 100% 100% 100% %
National Core Standards self-assessment No 1 1 2
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Indicators Type Emmaus Estcourt District Average
District Hospitals total No 1 1 2
2. Quality Improvement plan after self-assessment rate Quarterly 100% 100% 100% %
Quality Improvement plan after self-assessment No 1 1 2
District Hospitals total No 1 1 2
3. Percentage of District Hospitals compliant to all extreme Quarterly 0 0 0 and vital measures of the National Core Standards %
District Hospitals fully compliant (75%-100%) to all extreme and No 0 0 0 vital measures of National Core Standards
District Hospitals total No 1 1 2
4. Patient experience of care survey rate 100 100 100
Number of district hospitals that have conducted patient No 1 1 2 satisfaction surveys
District Hospitals total No 1 1 2
5. Patient experience of care rate Annual 63% 82% 76.3 %
Number satisfied customers No 52 129 181
Number users participated in survey No 80 157 237
6. Average length of stay Quarterly 4.7 5.6 5.1 Days
In-patient days No 35 527 70 030 105 557
Day patients No 35 607 70 042 105 649
Inpatient separations No 7 589 12 500 20 089
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Indicators Type Emmaus Estcourt District Average
7. Inpatient bed utilisation rate Quarterly 62.5% 59.0% 60.8% %
In-patient days No 35 527 70 030 105 557
Day patients No 35 607 70 042 105 649
Inpatient bed days available No 1 872 3 900 5 772
8. Number of district mental health teams established No 0 0 0
9. Expenditure per PDE Quarterly R1665 R1695 R1684 R
Expenditure total R’000 R97 783 635 R168 335 413 R266 119 048
Patient day equivalent No 58736 99331 158067
10. Complaint resolution rate Quarterly 12.1 95.3 32.6 %
Complaint resolved No 16 41 57 Complaint received No 132 43 175 11. Complaint resolution within 25 working days rate Quarterly 93.8 97.6 96.5 %
Complaint resolved within 25 days No 15 40 55
Complaint resolved No 16 41 57
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Table 39: (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 2 2 2 2 2 2 2 37 assessment assessment records
District Hospitals total DHIS No 2 2 2 2 2 2 2 37 calculates
2 Quality Improvement plan QA/DHIS Quarterly 100 100 100 100 100 100 100 100 after self-assessment rate calculates %
Quality Improvement plan after QA No 2 2 2 2 2 2 2 37 self-assessment assessment records
District Hospitals total QA No 2 2 2 2 2 2 2 37 assessment records
3 Percentage of District QA/DHIS Quarterly Not reported Not 0 50% 100 100 100 100 Hospitals compliant to all calculates % reported extreme and vital measures of the National Core Standards
District Hospitals fully compliant QA No - - 0 1 2 2 2 37 (75%-100%) to all extreme and assessment vital measures of National Core records Standards
District Hospitals total DHIS No - - 2 2 2 2 2 37 calculates
4 Patient experience of care QA / DHIS Quarterly Not Not 100 100 100 100 100 100 survey rate calculates % reported reported
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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 2 2 2 2 2 37 have conducted patient assessment satisfaction surveys records
District Hospitals total DHIS No 2 2 2 2 2 37 calculates
5 Patient experience of care DHIS Annual Not Not 76.3 80 80 85 85 85 rate calculates % reported reported
Number satisfied customers PSS No 61 64 64 68 68 2 380
Number users participated in PSS No 80 80 80 80 80 2 800 survey
6 Average length of stay DHIS Quarterly 5.5 5.1 5.3 5.3 5.3 5.3 5.3 5.5 calculates Days
In-patient days Midnight No 105 647 101 033 105 557 104 664 108 734 112 028 115 443 2 043 291 census
Day patients Midnight No 295 232 184 338 194 205 217 8 325 census
Inpatient separations DHIS No 18 949 20 013 20 089 19 654 20 665 21 261 21 876 374 817 calculates
7 Inpatient bed utilisation rate DHIS Quarterly 64.1 56.4 60.2 62.2 61.9 63.8 65.8 65.1 calculates %
In-patient days Midnight No 105 647 101 033 105 557 104 664 108 734 112 028 115 443 2 043 291 census
Day patients Midnight No 295 232 184 338 194 205 217 8 325 census
Inpatient bed days available Manageme No 5 429 5 892 5 772 5 772 5 772 5 772 5 772 3 173 310 nt
8 Number of mental health DHIS No 0 0 0 1 1 1 1 teams established calculates
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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 R1402 R1 595 R1684 R2 064 R 2100 R2 200 R2 300 R2 301 R
Expenditure total BAS R’000 219 024 646 296 808 003 266 119 048 324 486 256 341 046 300 367 120 600 394 406 300 6 204 036
Patient day equivalent DHIS No 156 223 156 297 158 067 157 208 162 403 166 873 171 481 2 695 554 calculates
10 Complaint resolution rate DHIS Quarterly 42.6 63.9 32.6 16.3 55 65 80 Not in APP %
Complaint resolved PSS No 49 76 57 44 127 150 184
Complaint received PSS No 115 119 175 270 230 230 230
11 Complaint resolution within DHIS Quarterly 100 100 96.5 86.4 88 88 88 75 25 working days rate %
Complaint resolved within 25 PSS No 49 76 55 38 112 120 147 2 130 days
Complaint resolved PSS No 49 76 57 44 127 150 184 2 841
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Table 40: (NDoH 18): Performance Indicators for District Hospitals Estimated Provincial Strategic Audited/ Actual Performance Medium Term Targets Frequency Performance Target 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 27.6 24 22.5 20.9 20.3 19.5 19 18.5 section rate calculates % Improve the hospital Delivery by caesarean section Delivery No 1 166 1 121 1 162 1 044 1 091 1 148 1 201 25 709 efficiency by register implementing Delivery in facility total Delivery No 4 869 4 992 5 556 5 144 5 594 6 044 6 494 92 940 the long term register plan for hospital 2. OPD headcount- total DHIS/OPD Quarterly 2 452 809 134 374 150 076 140 503 140 170 144 462 148 658 153 106 revitalisation tick register No 2014-2019 3. OPD headcount not DHIS/OPD Quarterly 12 685 13 757 11 600 14 358 13 600 13 100 12 800 577 426 referred new tick register No
Sustained 4. Number of District Quarterly 37 functional Hospitals with functional No 2 2 2 2 2 2 2 hospital boards boards.
Both District 5. Proportion of District QA / DHIS Quarterly Not Not 0 0 100 100 100 100 Hospitals Hospitals conditionally calculates % reported reported conditionally compliant to National compliant Core Standards with NCS. District Hospitals conditionally QA No 0 0 2 2 2 37 compliant assessment records
District Hospitals Total DHIS No 2 2 2 2 2 37 calculates
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13.2.2 District Hospitals: Strategies /Activities to be implemented 2015/16 Table 41: District Hospitals Strategies/Activities 2015 Strategies Activities
1. Monitoring of compliance to NCS to be done on an ongoing Visits to operational areas to conduct follow-up audits basis District QA and IPC teams to visit the hospital for NCS audit
2. Ensure proper resource allocation which is in line with NCS Develop NCS aligned resource allocation through procurement procedures
3. Develop NCS audit teams through promoting integration of services Integrate IPC, QA and Waste management functions
4. Reduced number of non-referred OPD cases. 2 fixed PHC clinics prioritised for the sub-district – included in STP document
5. Adequate Accommodation Implementation of the accommodation policy
6. Increase cataract surgery Estcourt Hospital to provide cataract surgery.
7. Adequate transport for MMC 1 x 35 seated bus and 1x 24 seated bus included in the fleet management plan submitted to Head Office for the 2 Hospitals
8. Seclusion facilities compliant with specifications Engage infrastructure for plans and building of seclusion rooms – make use of ablution block.
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16. HIV & AIDS & TB CONTROL (HAST)
14.1 PROGRAMME Overview Purpose of HAST Programme The HAST Programme is for the development of effective responses to HIV AND AIDS within the District. Communities should be able to access quality services from all HAST Components. The HAST Programme supports the implementation of the National operational plan for comprehensive HIV and AIDS care. The strategic goals and objectives for each HAST Programme are informed by the National Operational Plan for HIV AND AIDS Care and Treatment, the National HIVAND AIDS Strategic Plan for 2012-2016, the National 20 Point Plan and the priorities set by quarterly National Programme meetings. The HAST Programme is enabled to implement the operational plan through the Conditional Grant. The performance for each HAST Programme is monitored through the progress of performance indicators. The planning and implementation of HAST Programmes is done within the framework of the Primary Health Care approach.
HCT AND HTA Inadequate number of HAST Counsellors in facilities as this category is being phased out, the Counsellors leaving the service are not replaced thus facilities are unable to reach HCT targets. Equipment for use during outreach events inadequate, the borrowed gazebos from Partners are not always available. All four Sub district have identified hot spots in the form of taxi ranks, farms, FETs in 3 Sub districts. Only 3 are functioning as HTAs i.e. Tugela Tollgate Truckers Wellness, Ladysmith Correctional Services and Bergville Correctional Services. The rendering of HTA Health services have recently commenced at FETs. Umtshezi, Emnambithi and Indaka Municipalities reported to have started using the staff from Mobiles. Not all of the FET staff seems to be on board resulting in lack of continuous support during the visits by the DOH staff. Unavailability of HTA teams and dedicated transport pose challenges to sustained frequent visits thus some the FETs do not meet the HTA criteria as yet. Appropriate tools for HTA reporting not fully rolled out, first training was conducted on 8 September 2014. Motivate for 3 HTA teams for Estcourt, Indaka and Okhahlamba sub-district. Support prioritization of HTA functioning, training of HCW on key populations, risk reduction of STI and HIV transmission amongst key populations and appropriate reporting. Ensure availability of dedicated transport for HTA staff.
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TB Control: The purpose of the sub-program is to reduce the; TB incidence Rate Increase TB cure Rate Reduce TB loss To Follow up Rate. Scale up the interventions to improve Susceptible TB and MDR/XDR TB Treatment Outcomes.
Challenges TB screening is not done as an integrated service therefore the district did not achieve target for TB suspicion Index. There is no fully functional MDR TB Decentralised site, the site is only functional 2 days a week- awaiting staff appointments. Shortage of human and material resources, e.g. injection teams and tracer vehicles. The unavailability of lab assistant and lab information system resulted in the Gene Xpert rollout not functional at Indaka sub-district. High staff turnover resulted in poor adherence to guidelines which impact negatively on the TB treatment outcomes. Vertical management of TB data management is impacting on the TB performance.
Table 42: (NDoH 19): Situational Analysis Indicators for HIV & AIDS, STI and TB Control – 2013/14 Financial Year. Indicator Type Emnambit Imbabazane Indaka Okhahlamb Umtshezi District hi a Average
1. Total clients remaining on ART month Quarterly 18390 4 514 3 672 7 996 7 493 42 065 No
2. Clients tested for HIV (incl ANC) Quarterly 62,684 25,426 27,630 30,133 20,980 166,853 No
3. TB symptom 5 years and older screened rate Quarterly 0 0 0 0 0 0 %
Client 5 years and older screened for TB symptoms No. Not Not Not Not Not Not collected collected collected collected collected collected
PHC headcount 5 years and older No.
4. Male condom distribution Rate Quarterly 35.0 36.9 117.6 83.5 78.1 60.6 Rate per male
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Indicator Type Emnambit Imbabazane Indaka Okhahlamb Umtshezi District hi a Average
Male condoms distributed No 2,626,772 1,200,363 2,897,279 3,051,035 1,980,079 11,755,528 Population 15 years and older male Populati on 74,637 32,399 24,560 36,389 25,239 193,224 5. Female condom distribution Rate Quarterly 0.4 0.6 0.7 0.4 1.1 0.6 Rate per female
Female condoms distributed No 36,902 25,098 25,289 18,221 33,554 139,064 Population 15 years and older female Populati on 247,553 90,867 41,216 36,563 47,199 31,708 6. Medical male circumcision performed – Total Quarterly 3 566 317 291 1 035 1 909 7 118 No
7. TB client treatment success rate Quarterly 83.4% 82.1% 84.8% 85.7% Included in 84% % Imbabazane sub-district ETR.net set up
TB client successfully completed treatment No 307 303 302 168 1 080
TB client start on treatment No 368 370 356 196 1 290
8. TB client lost to follow up rate Quarterly 2.4% 3.5% 2.8% 3.6% Included in 3.1% % Imbabazane sub-district ETR.net set up
TB client lost to follow up No 9 13 10 7 39
TB client start on treatment No 368 370 356 196 1 290
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Indicator Type Emnambit Imbabazane Indaka Okhahlamb Umtshezi District hi a Average
9. TB client death Rate Annual 6.3% 5.9% 6.5% 5.1% 6% %
TB client died during treatment No 23 22 23 10 Included in 78 Imbabazane sub-district ETR.net set up
TB client start on treatment No 368 370 356 196 1 290
10. TB MDR confirmed treatment start rate Annual Data not at District, only At MDR site, no MDR site in District %
TB MDR confirmed client start on treatment No
TB MDR confirmed client No
11. TB MDR treatment success rate Annual Data not at District, only At MDR site, no MDR site in District %
TB MDR client successfully treated No.
TB MDR confirmed client start on treatment No. The calculation of TB data per sub-district is a huge challenge, due to the fact that it must be calculated manual as ETR.net can only generate district and facility reports. The system is not set-up to filter per sub-district.
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Table 43: (NDoH 20): Situational Analysis Indicators for HIV & AIDS, STI’s and TB Control - 2013/14 Financial Year 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 ART DHIS Quarterly 36 337 40 727 42 065 49 026 53 862 70 192 93 361 1 368 247 month calculates No
2. Clients tested for HIV (incl. DHIS Quarterly 222 748 206 039 166 853 150 072 182 966 201 051 221 403 3 469 831 ANC) calculates No
3. TB symptom 5 yrs and older DHIS Quarterly Not Not Not Not Depends on Depends on Depends on - screened rate % collected collected collected collected baseline baseline baseline
Client 5 years and older screened TB Register No. - for TB symptoms
PHC headcount 5 years and older DHIS No. - calculates
4. Male condom distribution Rate DHIS Quarterly 10.4 69.2 60.8 81.6 86.6 106.3 150.7 62 calculates Rate per male
Male condoms distributed DHIS/Stock No 2 274 014 15 362 931 11 755 528 16 028 516 17 629 167 21 944 826 31 556 529 212 000 000 cards
Population 15 years and older male DHIS/Stats Populati 217 519 220 855 193 224 199 829 203 101 206 354 209 382 3 428 447 SA on
5. Female condom distribution DHIS Quarterly 0.1 1.0 0.9 0.7 0.7 0.8 0.9 - Rate calculates Rate per female
Female condoms distributed DHIS/Stock No 33 828 221 718 139 064 177 612 184 426 258 707 382 308 - cards
Population 15 years and older DHIS/Stats Populati 239 585 243 570 247 553 251 575 255 539 259 467 263 374 - female SA on
6. Medical male circumcision DHIS / MMC Quarterly 8 586 8 760 7 118 10 738 11 800 12 950 14 100 176 000 performed – Total register No (excl (Excl (excl.Ladysm (excl.Ladysm Ladysmith Ladysmith ith 4 625) ith 7 900) 4 763) 5200)
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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
7. TB client treatment success ETR.Net % 78.9% 78.3% 84% 87.2% 89% 91% 91% 85 rate calculates
TB client successfully TB Register No 856 1293 1 080 1 222 1 406 1 538 1 647 33 611 completed treatment
TB client start on treatment TB Register No 1084 1650 1290 1 402 1 580 1 690 1 810 39 542
8. TB client lost to follow-up rate ETR.Net Quarterly 6.5% 4.1% 3.1% 1% 1% 1% 1% Not in APP calculates %
TB client lost to follow up TB Register No 71 68 39 14 16 17 18
TB client start on treatment TB Register No 1092 1650 1 290 1402 1 580 1 690 1 810
9. TB client death Rate ETR.Net Annual 3.04 5.6 6% 7% 6% 5% 4% 3% calculates %
TB client died during TB Register No 33 92 78 98 95 85 72 1 050 treatment
TB client start on treatment TB register No 1084 1650 1 290 1 402 1 580 1 690 1 810 30 000
10. TB MDR confirmed treatment ETR.Net Annual Not at Not at Not at district Depends on 66 start rate calculates % district level district level level done at functional done at done at referral Hosp MDR Unit at
referral Hosp referral Hosp Estcourt
TB MDR confirmed client start on TB Register No 2 000 treatment
TB MDR confirmed client TB Register No 84 80 104 166 3 000
11. TB MDR treatment success EDR Annual Not at Not at Not at district Depends on 80% rate calculates % district level district level level done at functional done at done at referral Hosp MDR Unit at
referral Hosp referral Hosp Estcourt
2 400
TB MDR client successfully EDR Register No treated
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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 3 000 on treatment
Table 44: (NDoH 21): District Strategic Objectives and Annual Targets for HIV & AIDS
Estimated Provincial Audited/ Actual Performance Medium Term Targets Strategic Data Frequency Performance Performance Indicator Target Objective Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
1. Number of patients that EDR.Net Annual Not at Depends on started regimen iv treatment calculates No District functional (MDR-TB) level MDR Unit at Estcourt
2. MDR-TB Six month interim EDR.Net Annual Not at Depends on 80% outcome calculates % District functional level MDR Unit at Estcourt
Number of clients with a EDR No 2 400 negative culture at 6 months Register who started treatment for 9 months
Total patients who started EDR No 3 000 treatment in the same period Register
3. Number of patients that ETR.Net Annual Not at Depends on 425 started XDR-TB treatment calculates No District functional level MDR Unit at Estcourt
4. XDR-TB Six month interim EDR.Net Annual Not at 65% outcome calculates % District level
Number of clients with a EDR No 130 negative culture at 6 months Register who started treatment for 9 months
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Estimated Provincial Audited/ Actual Performance Medium Term Targets Strategic Data Frequency Performance Performance Indicator Target Objective Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
Total patients who started EDR No 200 treatment in the same period Register
Reduced 5. TB incidence (per 100 000 ETR.Net Annual Incomplete 192/100 663/100 441/100 000 430/100 400/100 380/100 000 600/100 TB population) No per info 000 000 000 000 000 incidence. 100,000
New TB infections ETR.Net No 1 302 4531 3044 3237 2810 2695 64 839
Total population in KZN DHIS/Stats SA Population - 676 723 682 798 689 124 695 671 702 395 709 071 10 806 538
Reduce 6. HIV incidence (annual) ASSA2008 Annual 1.03 1.03 1.04 the HIV % 1.01 1.01 1.01 1.02 incidence
Scale up 7. STI treated new episode DHIS Quarterly 43.2 43.5 46.8 47.3 47.0 46.7 46.4 14.9/1000 prevention incidence (annualised) calculates No per services in 1000 all sub- districts. STI treated new episode DHIS/Tick No 21 533 21 953 20 727 21 214 21 414 21 614 21 814 73 795 register PHC/ casualty
Population 15 years and older DHIS/Stats Population 450 404 457 186 440 777 448 122 455 368 462 568 469 728 7 739 574 SA
Reduced 8. TB (new pulmonary) defaulter ETR.Net % 6.5% 4.1% 3.1% 1% 1% 1% 1% Not in APP TB rate calculates defaulter rate. TB(new pulmonary)treatment TB No 71 68 39 14 16 17 18 defaulter Register
TB(new pulmonary)client TB No 1092 1650 1 290 1402 1 580 1 690 1 810 initiated on treatment Register
Improved 9. TB AFB sputum result turn- ETR.Net % 61.3 62.3 89 70.5 78.8 82.5 87.5 TB turn - around time under 48 hours calculates around rate time
TB AFB sputum result received TB No 33 791 39 176 46 092 29 848 31 619 32 795 33 743 within 48 hours Register
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Estimated Provincial Audited/ Actual Performance Medium Term Targets Strategic Data Frequency Performance Performance Indicator Target Objective Source Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
TB AFB sputum sample sent TB No 55 122 62 843 51 789 42 336 40 215 39 752 38 564 Register
Increased 10. TB (new pulmonary) cure rate ETR.Net % 78.9 78.3 84% 87.2% 89% 91% 91% 85% TB cure calculates rate
TB (new pulmonary) client TB No 856 1293 1 080 1 222 1 406 1 538 1 647 33 611 cured Register
TB (new pulmonary) client TB No 1 084 1 650 1290 1 402 1 580 1 690 1 810 39 542 initiated on treatment Register The calculation of TB data per sub-district is a huge challenge, due to the fact that it must be calculated manual as ETR.net can only generate district and facility reports. The system is not set-up to filter per sub-district.
14.2 HIV & AIDS, STI & TB CONTROL (HAST): Strategies/ Activities to be implemented 2015/16
List in a point form key strategies/activities that would be implemented by the district to reach the 2014/15 targets set for the Sub-program HIV & AIDS, STI & TB CONTROL (HAST)
Table 45: HIV&AIDS, STI & TB Strategies / Activities 2015/16 Strategies Activities
1. Strengthen implementation of PICT in Train PNs, ENs and ENAS on PICT. Facilities. Monitor and support PICT implementation.
2. Increase HCT uptake Re-establish and strengthen functioning of Nerve Centres at all levels. Involve OSS stakeholders in planning and implementation of HCT activities. Expand HCT to HTAs on regular basis.
3. Improve reporting on HCT data. Conduct facility visits for data review. Attend data review meetings.
4. Ensure sustained availability of Motivate for transport.
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Strategies Activities transport for HTA staff.
5. Decrease HIV incidence (zero new To coordinate stakeholders in the community to market and implement the programme e.g. NGO e.g. SACTWU infections and manage HIV Traditional coordinator, Faith based organizations, Government department, Tertiary Institution, Private Sector ,FET prevalence ) by up scaling mmc Colleges, Department of Correctional Services uptake Support in creating public awareness, Community Mobilization and Stakeholder engagement Facilitates advertisement of MMC Camps Dates on local newspaper 1 per quarter for each sub-district Support in distribution of MMC IEC material Support Community Dialogues Supporting Campaigns targeting learners in School 6. Improve MMC uptake at facility Support Establishment of complete Roving teams per Sub- District level Facilitate in recruitment of data capturers or support officer Coordinate and support sub-district teams to perform 100 MMC weekly Support and coordinate resources to conduct two MMC camps per district per month Coordinate resources to conduct monthly MMC in all Correctional Services Facilitate procurement of transport dedicated to MMC programme Coordinate capacity building on MMC and Continuous update for healthcare workers.
7. Monitoring and evaluation Collection and collation of monthly reports
8. Decrease HIV incidence (zero new Working with OSS and NGO Partners to promote the culture of self –respect and sensitivity towards contracting and infections) and manage HIV spreading HIV and STI prevalence To advocate for distribution both male, female condoms and condo cans according to the list provided by sub-district stake holders in all public and private health care facilities by identifying new site. Develop a slot on HIV / STI and condom awareness during HIV/STI health days in local newspaper i.e. Ladysmith Gazette and the Herald and to dispel myths misconceptions about both male and female condoms Promote consistent and correct use of condoms through mass media and other community flora. Increase knowledge on correct use and disposal of condoms among end -users. Set up programs to decrease stigma and negative perceptions around public condoms and their use Share information through the mass media, including leaflets, IEC, Local gatherings; about the processes to quality assure condoms distributed in the public domain.
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Strategies Activities Identify target consumers. Design and implement intervention to address misuse, abuse of condoms. Expand the distribution network to achieve targets
9. Increase community mobilization/ Support facilities in conducting mass campaigns, door to door campaigns and condom distribution hotspot areas i.e. awareness and the social marketing Prison, taxi ranks, hostels and squatter camps ( BLITZ) of condoms Utilize special events to build up community support for condom use Support in conducting condom mass education and community dialogue in communities around facilities Commemorate world AIDS days and coordinate and support build up events two weeks before the event. Identify and designate community members as peer educators and promoter of condom use. Provision of training on condoms usage, storage etc. to health sector staff and non-health sector staff. in order to promote availability and accessibility of HIV preventive measures 10. Scale up local condom advocacy Working with OSS and NGO Partners to promote the culture of self –respect and sensitivity towards contracting and spreading HIV and STI
To advocate for distribution both male, female condoms and condo cans according to the list provided by sub-district stake holders in all public and private health care facilities by identifying new site.
Develop a slot on HIV / STI and condom awareness during HIV/STI health days in local newspaper i.e. Ladysmith Gazette and the Herald and to dispel myths misconceptions about both male and female condoms Promote consistent and correct use of condoms through mass media and other community flora.
Increase knowledge on correct use and disposal of condoms among end -users.
Set up programmes to decrease stigma and negative perceptions around public condoms and their use
Share information through the mass media, including leaflets, IEC, Local gatherings; about the processes to quality assure condoms distributed in the public domain.
Design and implement intervention to address misuse, abuse of condoms. Expand the distribution network to achieve targets
Identify target consumers by conducting Mapping of formal and non-formal sites e.g. HTAs, hard to reach areas, taverns Hotel, motels, Taxi ranks, FETs etc.
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Strategies Activities Facilitate in Installation of condom dispensing device in ablution facilities
Monitor and coordinate distribution of condoms by condom distributors in grey areas.
Conduct facility support visits using the supervision tool and compile a written report on strengths and weaknesses thereafter develop plans of action together with health facility teams.
11. Increase awareness and the social Support facilities in conducting mass campaigns, door to door campaigns and condom distribution hotspot areas i.e. marketing of condoms Prison, taxi ranks, hostels and squatter camps ( BLITZ)
Utilize special events to build up community support for condom use
Support in conducting condom mass education and community dialogue in communities around facilities
Commemorate world AIDS days and coordinate and support build up events two weeks before the event.
Identify and designate community members as peer educators and promoter of condom use.
Provision of training on condoms usage, storage etc. to health sector staff and non-health sector staff. in order to promote availability and accessibility of HIV preventive measures
Monitor and support the provision of integrated HAST integration and condom distribution in all facilities.
Engage with relevant community leaders by attending meetings e.g. Traditional leaders, Political leaders, Religious in addressing social and cultural norms
Ensure availability of condoms at all times.
Engaged mobile health and outreach services and NGOs in distribution of condoms in grey areas
Motivate for a post of condom support officer 12. Improved Data Management Ensure appropriate training and refresher training on condom logistics, reporting and data management for all relevant officials.
Facilitate in recruitment data capturers or support officer
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Strategies Activities Ensure that all relevant officials are trained in the Logistic Management Information System (LMIS) and DHIS. Ensure high-quality reporting from all district points ,including PDSs and SDSs Ensure compliance with DORA reporting from all quarters. Ensure availability of appropriate data collection and reporting tools Support facilities in implementing the New TB Screening Policy. 13. Intensify Activities to improve the TB Support and facilitate HAST Outreach Programmes and door to door campaigns at community level. Suspicion Index Liase with M&E to review and modify the formula for the calculating the TB Suspicion rate indicator. Joint venture of operation MBO with Operation Sukuma Sakhe Support Maternity Sections in screening all Pregnant Moms for TB. Support institutions in screening all children for TB. Facilitate the establishment of the district fully functional MDR TB Decentralised Unit. 14. Establishment of a fully functional Support the MDR TB institution in the appointment of Staff. district MDR TB Decentralised Site Liaise with Provincial Office for the support with EDR Computer and Kudu Wave Machine. Organise and coordinate for the training of staff on the Management of MDR TB Conduct Facility support visit to monitor the Programme.
15. Improve TB Treatment Outcomes Support and Motivate facility staff to collect smears at due times and according to TB guidelines. To conduct facility support visits and conduct remedial training according to identified gaps. Support and strengthen adherence counselling by facilities to all patients on TB treatment. Support and Motivate facility staff in the full utilisation of TB Treatment calendars and TB Diary. Phone other districts and follow up to claim TB Treatment outcomes on TB transferred patients.
16. Develop a fully functional GXP Liaise with NHLS to install the Lab Information System to the GXP machine at St Chads CHC and also to provide a Lab Assistant testing Site at St Chads CHC for the to process the specimens. Indaka Sub-District. Once the site is functional, monitor and evaluate the functioning of the site and conduct collaborative meetings with NHLS to identify gaps and address them appropriately.
17.Improve TB Data Management Motivate for active involvement and management of district/sub-district M&E Unit in TB data management. Conduct TB data Management workshops for Data Capturers and TB Nurses. Conduct Facility Support Visits and do remedial training on data gaps identified. Conduct TB record Reviews and Audits, identify strengths and gaps thereafter develop a quality improvement plans with relevant facilities. Monitor the submission of TB Data from facility to sub-districts and from sub-district to district level, identify bottlenecks and address them accordingly. As a motivation, provide award certificates to the best performing facility per quarter per sub-district.
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17. MATERNAL, NEONATAL, CHILD AND WOMEN’S HEALTH AND NUTRITION
15.1 PROGRAMME Overview
Purpose of Nutrition Programme Nutrition is a vital component of the long and healthy life for all people living in South Africa. Optimal Nutritional status of an individual leads to optimal health and very little chance of diseases and illnesses. South African citizens and particularly personnel residing in Uthukela Magisterial District need to be intensively educated on Nutrition so that they are able to make better eating and food choices necessary to prevent any nutrition related disorders. Nutrition Programme also exist to make a meaningful contribution towards MDG 4 in reducing child mortality. This is through protecting, promoting and supporting Breastfeeding as a key child survival strategy, this is coupled with promoting appropriate and timeous introduction of complementary foods. Another strategy is to ensure that children under the age of 5 years receive Vitamin A supplementation and de worming on a six months interval to reduce the chances of them getting malnutrition which is currently one of the major contributing factors to child mortality.
Strategic Challenges: • Poor assessment of pregnant women for possible under nutrition, and poor supplementation of those that require it. • Poor utilization of the whole therapeutic supplementation programme as it is still being viewed as a household food security programme. • Under budgeting for the therapeutic supplementation programme. • Late identification of children under the age of 5 years for under nutrition, hence they present late to the hospital and often die. (this is confirmed by the high casa fatality rate due to severe acute malnutrition, and low weighing coverage for children under 1 year ) • Poor interpretation of growth curves, and intervention thereof for children under the age of 5 years. • Poor implementation of nutritional guidelines, at times no length measurements taken in children under the age of 5 years which makes it difficult to identify possible stunting and wasting early. • Low exclusive Breastfeeding rates, hence majority of non-breastfed babies are at risk of dying from under nutrition, it must however be mentioned that the DHIS data indicates high figures which are in contrary to the practice, this is because mothers often give tell health workers that they are Breastfeeding exclusively when they are mix feeding in practice, this is often observed during household visits and community outreach programmes.
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• Poor availability of IEC material in local languages and visual aids to aid the community understand the intended nutrition message.
MNCHW/PMTCT programme aim is to accelerate implementation of strategies to reduce maternal and child morbidity and mortality through quality maternal and child health care
The targets and indicators are in line with the MDG4: reduction of child mortality and MDG 5 - improved maternal health
Child and maternal mortality remain unacceptable high; child mortality rate at 76, 4 %, maternal mortality at 123, 1/100 000 1n 2013/14
The main focus of the programme is to address the following strategies:
Universal access to sexual and reproductive health
Promotion of family planning to every women who comes into contact with health worker, and capacitation of HCW on new SRH policy
Making emergency contraceptive, Pre- exposure and post- exposure prophylaxis available in all facilities
Reduction of under 5 years mortality rate
Elimination of mother to child transmission of HIV infection
Implementation of policies and guidelines
Management of under-five using IMCI classification
Reduction of maternal mortality
Intensifying management of HIV positive pregnant clients and improved management of infections
Improved management of labour and delivery
Combat TB and HIV
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STRATERGIC CHALLENGES
• Low coverage of staff trained on sexual and reproductive health due to high staff turnover.
• Inadequate knowledge by staff on New PMTCT guidelines, due to late availability of new guidelines and high staff turnover.
• Low uptake of antenatal booking before 20 weeks.
• High still births rate
• High number of maternal and child mortality due preventable conditions
• Poor management of under 5 children due to challenges in the implementation of community IMICI
• Low uptake rate for retest at 32 weeks for pregnant women
Overview Integrated School Health Service
Integrated School Health Service is part of the comprehensive primary health package which operates within the Department of Basic Education (CSTL) Framework, implemented in partnership between Departments of Health, Department of Basic Education, Department of Social Development and all other relevant stakeholders Integrated school Health Policy outlines how the services will be strengthened and expanded Emphasis is put on reaching full learner coverage starting with the previously disadvantaged schools 15 School health team Versus 24 school health teams needed in order to reach the coverage. 3 Teams Emnambithi (1 half team/E/N only) 2 Teams Imbabazane (1 half team1 E/n only) 4 Teams Indaka 4 Teams Okhahlamba (1P/n without E/N) 2 Teams Umtshezi
461 Schools in District, number of schools per sub-district as follows; 101 Emnambithi 67 Imbabazane 118 Indaka 110 Okhahlamba 65 Umtshezi Schools were clustered together, in order to improve on coverage, yet only 32 schools covered per team per year. The norm is 11 schools per team per year, therefore no follow-ups done only first assessments.
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Adolescent and Youth Friendly Service
AYFS aims to improve health status of young people through the prevention of illnesses and promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equity. Efficiency, quality and sustainability of adolescents and Youth Friendly Services in all settings.
Strategic challenges
Dedicated Space for the delivery of AYFS.
Dedicated staff to drive the program.
High number of young people involved in risky sex.
High number of HIV infected youth
High number of youth on ART
High number of youth committing suicide.
Youth involved in substance abuse
Table 46: (NDoH 22): Situational Analysis Indicators for MCWH & N – 2013/14 Financial year Indicator Type Emnambithi Imbabazane Indaka Okhahlamb Umtshezi District a Average 1. Antenatal 1st visit before 20 weeks rate Quarterly % 56.0 44.6 48.8 56.3 60.1 54.1
st Antenatal 1 visit before 20 weeks No 2 877 1 014 880 1 911 1 369 8 051
st Antenatal 1 visit total No 5 139 2 273 1 805 3 395 2 277 14 889 2. Proportion of mothers visited within 6 days of Quarterly % 51.6 189.3 1,407.6 75.8 35.2 67.2 delivering their babies
Mother postnatal visit within 6 days after delivery No 3 127 1 113 1 112 1 778 1 131 8 261
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Indicator Type Emnambithi Imbabazane Indaka Okhahlamb Umtshezi District a Average
Delivery in facility total No 6 028 588 79 2 346 3 210 12.285
3. Antenatal client initiated on ART rate Annual 99.4 99.4 101.4 99.2 96.8 99.1
%
ANC client started on ART ART Register 1 695 468 426 760 609 3 958
ANC client eligible for ART initiation ART Register 1 706 471 420 766 629 3 992
4. Infant 1st PCR test positive around 6 weeks rate Quarterly % 1.6 1.1 1.9 2.0 0.9 1.6
Infant 1st PCR test positive around 6 weeks No 28 9 10 22 5 74
Infant 1st PCR test around 6 weeks No 1 756 808 515 1 120 540 4 739
5. Immunisation coverage under 1 year (annualised) Quarterly % 77.4 82.5 67.0 78.0 76.5 76.4
Immunised fully under 1 year new No 4 494 2 549 2 134 2 910 1 540 13 627
Population under 1 year No 5 843 3 109 3 206 3 757 2 026 17 941
6. Measles 2nd dose coverage Quarterly % 74.7 66.3 60.8 74.0 72.6 70.4
Measles 2nd dose No 4 133 1 962 1 878 2 646 1 396 12 015
Population 1 year No 5 843 3 109 3 206 3 757 2 026 17 941
7. DTaP-IPV-HepB-Hib 3 - Measles 1st dose drop-out Quarterly 8.3 -6.6 5.2 -0.2 3.4 2.0 rate %
DTaP-IPV-HepB-Hib 3 to Measles1st dose drop-out No 408 -159 120 -7 55 417 DTaP-IPV-HepB-Hib 3rd dose No 4 787 2 417 2 292 2 958 1 630 14 084
8. Child under 5 years diarrhoea case fatality rate Quarterly % No District No District No District 5.1 0.4 2.7 Hospital Hospital Hospital
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Indicator Type Emnambithi Imbabazane Indaka Okhahlamb Umtshezi District a Average
Child under 5 years with diarrhoea death No 13 1 14
Child under 5 years with diarrhoea admitted No 255 260 515
9. Child under 5 years pneumonia case fatality rate Quarterly % No District No District No District 4.0 2.2 2.8 Hospital Hospital Hospital Child under 5 years pneumonia death No 5 5 10
Child under 5 years pneumonia admitted No 125 228 353
10. Child under 5 years severe acute malnutrition case Quarterly % No District No District No District 18.2 13.1 15.9 fatality rate Hospital Hospital Hospital
Child under 5 years severe acute malnutrition death No 14 8 22
Child under 5 years severe acute malnutrition admitted No
11. School Grade R screening coverage Quarterly % Not done Not done Not done Not done Not done Not done
School Grade R learners screened No.
School Grade R learners - total No.
12. School Grade 1 screening coverage Quarterly % 26.6 69.3 21.2 57.0 72.0 45.1
School Grade 1 learners screened No. 767 1148 413 1458 805 4591
School Grade 1 learners - total No. 6 417 3 283 4 030 4 360 2 618 20 708
13. School Grade 8 screening coverage Quarterly % 9.8 6.4 15.4 24.6 25.9 15.9
School Grade 8 learners screened No. 246 108 345 411 197 1307
School Grade 8 learners - total No. 4 623 2 551 3 358 3 733 2 109 16 374
14. Couple year protection rate Quarterly % 44.2 36.8 69.5 64.1 65.6 53.2
Contraceptive years dispensed No 30,903 11,475 18,762 22,975 16,320 100,434
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Indicator Type Emnambithi Imbabazane Indaka Okhahlamb Umtshezi District a Average
Population 15-49 years female No 63,990 28,735 24,845 33,023 22,620 173 213 15. Cervical cancer screening coverage (amongst Quarterly % 73.8 52.3 57.3 59.0 71.9 64.9 women)
Cervical cancer screening in women 30 years and No older 3 894 1 188 1 129 1 555 1 327 9 093
Population 30 years and older female/10 No 5 246 2 259 1 960 2 621 1 834 13 920
16. Human Papilloma Virus Vaccine 1st Dose Annual Not reported Not reported Not reported Not reported Not reported Not reported coverage %
Numerator No
Denominator No
17. Vitamin A dose12 – 59 months coverage Quarterly % 40.4 29.7 28.2 35.2 28.7 33.9
Vitamin A dose 12 - 59 months No 17 011 6 724 6 750 9 640 4 237 44 362
Population 12-59 months (multiplied by 2) No 42 054 22 590 23 896 27 372 14 766 130 678
18. Maternal mortality in facility ratio Annual No 0.0 0.0 0.0 85.5 93.7 73.3 per 100K
Maternal death in facility No 0 0 0 2 3 5
Live birth in facility No 538 623 77 2,338 3,199 6 820
19. Early neonatal death in facility rate Annual No district No district No district 18 18 18 hosp hosp hosp Per 1 000
Death in facility 0-7 days No 38 52 90
Live birth in facility No 2065 2950 5015
Note: School Health data only captured from October 2013 on DHIS for financial year 2013/14
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Table 47: (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 36.6 39.5 54.1 55.4 63.5 76.2 82.1 60 weeks rate %
Antenatal 1st visit before 20 weeks DHIS / Tick No 5 260 5 535 8 051 7 984 9 242 11 243 12 278 140 402 register PHC
Antenatal 1st visit total DHIS No 14 390 14 008 14 889 14 352 14 555 14 755 14 955 234 003 calculates
2. Proportion of mothers visited DHIS Quarterly 60.5 63.8 67.2 73.4 75 78 80 75.5 within 6 days of delivering their % babies
Mother postnatal visit within 6 days DHIS / Tick No 7 776 8 071 8 261 9 638 9 939 10 125 11 056 156 202 after delivery Register PHC
Delivery in facility total DHIS / No 12 857 12 656 12 285 12 978 13 252 13 501 13 821 206 969 Delivery register
3. Antenatal client initiated on DHIS Annual 100 71.0 99.1 95.0 98 100 100 - ART rate calculates %
ANC client started on ART ART Register No 1 102 843 3 958 3 404 3 736 4 015 4 315 -
ANC client eligible for ART initiation ART Register No 1 092 1 188 3 992 3 586 3 813 4 015 4 315 -
4. Infant 1st PCR test positive DHIS Quarterly 2.9 2.2 1.6 1.0 0.5 0.4 0.4 <1 around 6 weeks rate %
Infant 1st PCR test positive around 6 DHIS / Tick No 151 113 74 50 26 21 22 972 weeks register PHC
Infant 1st PCR test around 6 weeks DHS / Tick No 5 142 5 494 4 739 4 904 5 104 5 314 5 504 97 220 Register PHC
5. Immunisation coverage under DHIS Quarterly 86.1 97.8 76.4 82.7 90 92 92 96.3 1 year %
Immunised fully under 1 year new DHIS / Tick No 15 179 14 446 13 627 14 460 15 035 14 701 14 337 207 619 register PHC
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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 17 537 17 901 17 939 17 479 16 705 15 979 15 584 215 481 SA
6. Measles 2nd dose coverage DHIS Quarterly 80.7 85.5 70.4 81.5 87 90 90 - %
Measles 2nd dose DHIS / Tick No 13 558 12 626 12 015 13 812 14 430 14 582 14 396 - register PHC
Population 1 year DHIS / Stats No 17 038 17 638 17 441 17 099 16 586 16 202 15 995 - SA
7. DTaP-IPV-HepB-Hib 3 - Measles DHIS Quarterly -5.6 0.8 2.9 4.7 4 3.5 3.5 - 1st Dose drop-out rate %
DTaP-IPV-HepB-Hib 3 to Measles1st DHIS / Tick No -842 123 417 724 588 489 475 - dose drop-out register PHC
DTaP-IPV-HepB-Hib 3rd dose DHIS / Tick No 15 082 14 587 14 084 15 280 14 705 13 979 13 584 - register PHC
8. Child under 5 years diarrhoea DHIS Quarterly 3.9 4.3 2.7 2.1 2.1 2.1 2.1 2.6 case fatality rate %
Child under 5 years with diarrhoea DHIS / Tick No 10 17 14 8 6 5 5 296 death register
Child under 5 years with diarrhoea Admission No 225 391 151 388 276 252 237 11 103 admitted Records
9. Child under 5 years pneumonia DHIS Quarterly 3.6 2.8 2.8 2.6 2.4 2.1 2.1 2.1 case fatality rate %
Child under 5 years pneumonia DHIS / Tick No 10 9 10 10 9 8 204 death register
Child under 5 years pneumonia Admission No 279 326 353 378 383 398 403 9 898 admitted records
10. Child under 5 years severe DHIS Quarterly 12.3 7.5 15.9 7.9 7.4 7.4 7.4 7.4 acute malnutrition case % fatality rate
Child under 5 years severe acute DHIS / Tick No 8 11 22 10 9 8 7 279 malnutrition death register
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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 65 147 138 126 120 110 100 3 766 malnutrition admitted records
11. School Grade R screening DHIS Quarterly Not done Not done Not done Not done - coverage %
School Grade R learners DHIS / Tick No. - screened register SHS
School Grade R learners - total DHIS / DoE No. - database
12. School Grade 1 screening DHIS Quarterly Not Not 14.81 53.5 55 65 70 - coverage % reported reported
School Grade 1 learners DHIS / Tick No. 4 591 11 044 - screened register SHS
School Grade 1 learners - total DHIS / DoE No. 20 708 20 628 - database
13. School Grade 8 screening DHIS Quarterly Not Not 5.64 53.3 55 65 70 - coverage % reported reported
School Grade 8 learners DHIS / Tick No. 1307 8852 - screened register SHS
School Grade 8 learners - total DHIS / DoE No. 32 748 16 590 - database
14. Couple year protection rate DHIS Quarterly 23.5 64.4 53.2 57.4 63 65 70 55 %
Contraceptive years dispensed DHIS No 43 185 118 492 100 435 109 574 121 884 127 510 139 262 1 631 308 calculates
Population 15-49 years female DHIS/Stats SA No 182 946 185 548 188 143 190 811 193 467 196 169 198 946 2 966 034
15. Cervical cancer screening DHIS Quarterly 50.7 65.2 64.9 52.8 65 70 80 81 coverage (amongst women) %
Cervical cancer screening in DHS / Tick No 6 782 8 011 9 093 8 042 9 500 10 460 12 224 193 688 women 30 years and older register PHC / Hospital register
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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 13 375 12 231 13 505 13 919 14 616 14 943 15 281 239 122 female/10 SA
16. Human Papilloma Virus DHIS Annual Not Not Not 86.8 90 90 90 - vaccine 1st Dose coverage % reported reported reported
DHIS / Tick No 5375 - HPV vaccine grade 4 girls register SHS
Grade 4 girls multiplied by 2 DHIS / DoE No 6191 - enrolment
17. Vitamin A dose12 – 59 months DHIS Quarterly Not 33.7 33.9 39.8 50 60 65 65 coverage % reported
Vitamin A dose 12 - 59 months DHIS / Tick No 41 549 44 362 52 272 65 608 78 412 84 807 209 695 register PHC
Population 12-59 months (multiplied DHIS / Stats No 123 858 130 809 131 228 131 216 130 686 130 472 216 898 by 2) SA
18. Maternal mortality in facility DHIS Annual 204.8 140 73.3 83.2 53.3 25.9 25.3 119/100k ratio No per 100K
Maternal death in facility DHIS / No 14 10 5 6 4 2 2 245 Midnight census
Live birth in facility DHIS / No 6 835 7 141 6 820 7 214 7 493 7 695 7 893 205 712 Delivery register
19. Early neonatal death in facility DHIS Annual % 1.2 1.1 1.5 0.72 0.6 0.5 0.5 - rate
Death in facility 0-7 days No 78 77 104 52 44 42 43 -
Live birth in facility No 6 835 7 141 6 820 7 214 7 493 7 695 7 893 -
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Table 48: (NDoH 24): District Objectives and Annual targets for MCWH&N Audited/actual Performance Estimated Provincial Strategic Medium Term Targets Performance Frequency Performance Target Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
1. Reduced 2.1 Infant ASSA2008 Annual 43/1000 42/1000 42/1000 41/1000 40/1000 40/1000 39/1000 39/1000 infant mortality rate Rate per mortality rate 1000 to 29 per 1000 live births by March 2020
2. Reduce the 4.1 Under 5 ASSA2008 Annual 63/1000 61/1000 60/1000 59/1000 58/1000 57/1000 56/1000 57/1000 under 5 mortality rate Rate per mortality rate 1000 to 40 per 1000 live births by March 2020
3. Reduce 6.1 Child under DHIS Annual 7.9 7.7 7.3 4.1 3.9 3.7 3.5 12.9 under-5 5 years calculates No per diarrhea with diarrhoea with 1000 dehydration dehydration incidence incidence to (annualised) less than 9.5 per 1000 by Child under 5 PHC Tick No 722 588 604 344 304 300 282 14 887 March, years diarrhea Register with dehydration new
Population DHIS/Stats SA No 81 750 82 748 83 279 83 095 82 310 81 326 80 816 1 154 059 under 5 years
4. Reduce 7.1 Child under DHIS Annual 76.4/1000 118.7/1000 69/1000 41.1/1000 39/1000 37/1000 35/1000 88.9/1000 under-5 5 years calculates No per pneumonia pneumonia 1000 incidence incidence to (annualised)
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Audited/actual Performance Estimated Provincial Strategic Medium Term Targets Performance Frequency Performance Target Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
less than 29 Child under 5 PHC Tick No 7 343 5 110 5 743 3 414 3 210 3 009 2 828 99 138 per 1000 by years with Register March 2020. pneumonia new
Population DHIS/Stats SA No 81 750 82 748 83 279 83 095 82 310 81 326 80 816 1 154 000 under 5 years
5. Reduce 8.1 Child under DHIS Annual 4.3/1000 5.4/1000 5.8/1000 6.5/1000 6.1/1000 5.8/1000 5.5/1000 4.6/1000 severe acute 5 years severe calculates No per malnutrition acute 1000 malnutrition incidence incidence under 5 (annualised) years to less than 4.6 per Child under 5 DHIS/Tick No 353 402 479 538 502 471 444 5 127 1000 by years with register PHC severe acute March 2020. malnutrition new
Population DHIS/Stats SA No 81 750 82 748 83 279 83 095 82 310 81 326 80 816 1 154 059 under 5 years
6. Reduce the 3.1 Child under DHIS Annual 7.7/1000 6.9/1000 *7.8% *6.8% *6.0% *5.2% *4.5% 4.8 child under 1 1 year mortality Per 1 K year in facility rate (annualized) mortality in facility rate Inpatient death DHIS No 143 129 *123 *80 *71 *69 *65 2 400 to less than under 1 year calculates 4% Inpatient DHS No 18 436 18 479 *1571 *1172 *1150 *1326 *1444 190 000 seperations calculates under 1 year
7. Reduce the 5.1 Inpatient DHIS Annual % 10.3 6.1 5.1 5.2 5.0 4.9 4.7 4.3 inpatient death death under 5 under 5 - rate to years rate less than 4% by Inpatient death DHIS No 165 156 129 106 99 92 83 3 225 March 2020 under 5 years calculates
Inpatient DHS No 1 606 2 516 2 525 2 034 1 988 1 884 1 780 75 000 separations calculates under 5 years
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Audited/actual Performance Estimated Provincial Strategic Medium Term Targets Performance Frequency Performance Target Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
12.3 RV 2nd DHIS Quarterly 85.3 96.6 77.7 87.0 90 90 90 dose coverage % (annualised)
RV 2nd dose DHIS / Tick No 15 033 14 264 13 853 15 210 15 035 14 831 14 026 Register PHC
Population DHIS / Stats No 17 537 17 901 17 939 17 479 16 705 15 979 15 584 under 1 year SA
7. Reduced 13.1 Infant DHIS Quarterly 99.5 99.9 98.2 97.8 100 100 100 100 mother to given NVP % child within 72 hours after birth transmission. uptake rate 5
Infant given DHIS / Tick No 1980 2 417 1 922 2 234 2 415 2 587 2 510 69 048 NVP within 72 register OPD/ hours after birth PHC, delivery register
Live birth to HIV DHIS / No 1989 2 419 1 957 2 282 2 415 2 587 2 510 69 048 positive woman delivery register
8. Reduce the 14.1 Delivery in DHIS Annual 9.0 9.1 9.2 8.7 8.2 7.9 7.7 8.5 delivery rate facility under 18 % under 18 years rate years. Delivery in DHIS / No 617 6 45 628 616 595 580 575 17 689 facility to Delivery woman under register 18 years
Delivery in DHIS / No 6 820 7 095 6 803 7 116 7 215 7 325 7 456 209 969 facility total Delivery register
5 Baby Nevirapine uptake rate
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Audited/actual Performance Estimated Provincial Strategic Medium Term Targets Performance Frequency Performance Target Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16
9. Promote 15.1 Infants DHIS Quarterly 32.6 64.0 67.6 70.8 75 75 75 -- exclusive exclusively % breastfeedin breastfed at Hepatitis B 3rd g to all dose mothers. Infant Tick register No 4 045 9 806 9 505 10 818 11 029 10 484 10 188 - exclusively PHC breastfed at HepB3rd dose
HepB 3rd Dose Tick register No 15 082 14 587 14 084 15 280 14 705 13 979 13 584 - PHC
10. Increase 16.1 Number of DHIS Monthly No facility 3 3 9 15 24 30 number of health facilities implementin care facilities implementing g AYFS implementing AYFS AYFS to 35 by
2020
11. Increase 17.1 Number of Attendance Monthly 50Data 100 number of health health care registers 50 50 100 100 care providers providers not trained on AYFS trained in AYFS to coll
150 by 2020 ecte d
12. Increase 18.1 Number of Daily clinic Data not 1013 2143 3500 4900 6100 8200 TBD number of youth young people register collected accessing health accessing Monthly services services to 9000 by 2020
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Audited/actual Performance Estimated Provincial Strategic Medium Term Targets Performance Frequency Performance Target Objective Data Source Indicators Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 19.1 Number of Staff data Monthly No peer 1 10 10 20 30 40 13. Increase peer educators base of educators number peer implementing NGO-Love educators trained life on AYFS to 45 by 2020
*The calculation for this indicator from 2013/2014 was aligned to the APP 2015/16 to 2017/18. The denominator was changed from estimated live births to inpatient separations under 1 year.
15.2 STRATEGIES/ Activities to be implemented 2015/16
Table 49: Nutrition Strategies and Activities 2015/16 Strategies Activities
1. Strengthen stakeholders involvement through OSS Intensify health education on importance of early booking through CCGS and staff Ensure that community dialogues on importance of attending antenatal clinics early are conducted Ensure that stakeholders are involved through Operation Sukuma Sakhe Support training of CCGS on maternal issues Support implementation of Mom Connect Support /Involve PHC WBOTS
2. Strengthen implementation of guidelines Monitor Initiation of all eligible pregnant women on HAART irrespective of CD4 cell count Ensure Giving of Nevirapine to all exposed babies Monitor Scaling up of exclusive breastfeeding
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Strategies Activities Ensure Appointment of Mother to Mother s to assist in implementation of PMTCT strategies. Emphasize Testing of all pregnant women for HIV at booking Dissemination of guidelines and policies Ensure adherence counselling is done to improve adherence of clients
3. Enhance training on maternal health Conduct fire drills and ESMOE trainings Improve competencies of midwives in correct use of partogram Support trainings on management of neonatal conditions e.g. HBB Ensure availability of norms and standards
4. Promote on-going scale up of training in comprehensive method mix Ensure that Mentorship and supervision of trained HCW. Ensure that counseling of choice on Family Planning. Involve community to assist in distribution of condoms. Monitor Dissemination of printed IEC material.
5. Breastfeeding promotion and complementary feeding Training of Healthcare workers on Infant Feeding and appropriate, timeous complementary feeding. Breastfeeding promotion campaigns at sub district level. Support Facility and Community Based infant feeding counselling and education to mothers and caregivers. Facilitate the implementation of a “one cup of “maas” per day” campaign aimed at advocating for each household with a child under the age of 2 years to get a cup of “maas” on a daily basis on top of the normal household diet, this is part of the vigorous fight against malnutrition in children under the age of 2 years. Request for the printing of relevant information, education and communication material for distribution to the clinics, crèches, and other community service points such as home affairs offices and pension pay points.
6. Maternal Nutrition Training of Healthcare workers on Maternal Nutrition as an important aspect of preventing malnutrition in early childhood. Provide necessary technical support on Nutritional assessment of pregnant and lactating women and up scaling the supplementation for those who are found to be underweight.
7. Growth Monitoring and Promotion Training of Health workers on Growth Monitoring and Promotion with a special emphasis on Length / Height Measurement as it is still poorly done, making it less possible to identify stunting and wasting.
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Strategies Activities Conduct period data reviews with the data collectors and generators, to strengthen reporting of weighed babies. Babies are weighed but they are often not reported
8. Vitamin A Supplementation Provide technical support to the Health care workers including community care givers necessary to increase Vitamin A coverage as it indicates the success of the programme, the higher the coverage the less chances of children under the age of 5 years getting malnutrition.
9. Therapeutic Supplementation and Management of Severe Acute Facilitate procurement of the necessary therapeutic supplements for all Primary Health Malnutrition Care Facilities and monitor the adherence to the issuing guide. Conduct periodic audit to the hospitals to determine the level of compliance with the WHO ten steps to management of Malnutrition, provide feedback and necessary technical support.
10.Prevention of Overweight and Obesity Train Health workers on a provincial guideline on prevention of overweight and obesity. Organize the Nutrition Indaba for health workers and other stakeholders i.e. local mayors and counsellors to present the malnutrition situation in the District and highlight the areas of concern that require their immediate attention. Advocate for and seek financial support for the erection of billboards with a healthy eating message in all 5 Local Municipalities.
11. Sustained ISHP District Exco and Sub-District committees Establish committees at sub-district level.
12. Established and sustained a District Health Promotion Forum Provincial Health Promotion Manager promised to assist in formulation of the forum
13. Monitoring progress towards accreditation of Adolescent Friendly Visit facilities to establish the status and challenges. Clinics /Health Promoting Clinics
14. Strengthen the incorporation of Nutrition data into routine health Review nutrition indicators in the District Health Information System information system and ensure that the information is used for Capacitate health managers on the use of nutrition data for decision making purpose. decision making at all levels. Monitor trends in key nutrition indicators and share information with key stakeholders. *15. Management systems for effective provision of adolescent and Conduct AYFS workshops for the District management Youth Health Programmes Ensure that all implementing clinics have the service plan based on the needs of young people Training of data captures to manage the flow data of AYFS service utilisation rate Ensure collection of information according to age and gender e.g. (M/F ;10-14,15-19,20-24) *16. Provision of safe and supportive environment Ensure clinic staff is adequately trained on infection control measures Ensure environment for young people is safe and clean. Ensure staff is trained on client privacy particularly young people *17. Adequate drug supplies and equipment The clinic should have enough drugs to meet the young people’s needs
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Strategies Activities Necessary drugs and contraceptives to be available for the youth Drug supplies for the treatment of STIs to be available. Drug supplies to treat opportunistic infections to be available *18. Train and develop staff on youth issues. Orientation workshops to take place on site. All staff categories to be trained in order to carry out AYFS. Values clarification to be trained so as to address staff attitudes towards young people *19. Proper referral system for young people. Systems and procedures and records to indicate effective follow up care Effective referrals and counter referrals important for young people continuum of care. Referral facilities to be informed about all AYFS implementing clinics * The following strategies were discussed at a meeting by the National and Provincial AYFS program managers and the District were requested to include these strategies in the DHP.
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18. 16. DISEASE PREVENTION AND CONTROL (DPC)
16.1 PROGRAMME Overview
SUB-PROGRAMME OVERVIEW REHAB:
• To provide a comprehensive, integrated, sustainable, preventative, promotive and rehabilitative based service at hospital level, clinic level, CHC level, community level, home based rehabilitation care, and supportive school based services, with reference to occupational therapy, physiotherapy, speech therapy and audiology. Services are available to all persons, and especially rendered to disability persons and patients with chronic conditions which may lead to disability.
STRATEGIC OBJECTIVES:
• Improve access to rehabilitation services by increasing the number of service delivery points, visits to PHC clinics, home visits and community- based programmes.
• Strengthen rehabilitation services in institutions by improving staffing levels and increasing service delivery by increasing number of services available.
• Strengthen outreach services: to take services closer to our clients by increasing outreach visits, adding more service delivery points, and strengthen role in Operation Sukuma Sakhe.
• Provision of health and rehabilitation services at all levels of care to people with disabilities including those with functional impairments to maximize their potential and independence.
• Clear backlogs and reduce waiting times for assistive devices namely walking Aids, Wheelchairs and Hearing Aids by establishment of assistive device committees. Support measures to re-collect assistive devices no longer in use to be re-issued to other patients.
• Continue to implement wheelchair repair and maintenance services (SLA with DPSA –KZN).
• Improve Community Based Rehabilitation services in the District by supporting the CBR workers we have in Uthukela District. Leasing with institutions and NGOS to mobilize people with disabilities and form support groups.
• Strengthen existing rehabilitation centres and forums. Collaboration with NGOs, who participate and act as the pilot community rehabilitation centres. Current locations of these centres are in:-
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o Winterton,
o Rookdale,
o Wembezi,
o Ntabamhlope &
o Ncibidwane.
STRATEGIC CHALLENGES
• Infrastructure at hospital level, clinic level and community level is not ideal with inadequate numbers of consulting rooms and insufficient space to accommodate rehabilitation services.
• Clinics are not designed to accommodate rehabilitation services, with regards to space and therapeutic equipment and resources are scarce. It will be in the interest of clients if therapists are consulted in the designing of new facilities, to ensure that appropriate infrastructure is put in place; that will assist to improve service delivery. Currently, therapists are required to share 1 room during PHC outreach visits thus comprising patient confidentiality
• Limited number of therapists at hospital level, CHC level and community level.
• Not enough functional rehabilitation centres and services rendered to patients once discharged.
• Not enough communication between CCGS, CBR facilitators and therapists when identifying and providing rehabilitation to patients.
SUB-PROGRAMME OVERVIEW INFECTION PREVENTION & CONTROL
PURPOSE OF INFECTION PREVENTION AND CONTROL
IPC aims at preventing and controlling the infections in all health care facilities and community and to respond rapidly and effectively to possible outbreaks and highly contagious diseases.
Ensuring appropriate infection control management at all times by empowering, mentoring and infection control practitioners at hospital and community health centres.
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Conducting IPC audits with District IPC Team using the IPC tools.
STRATEGIC OBJECTIVES
Strengthening the implementation of the IPC practices by ongoing training of clinical and non-clinical staff on IPC guidelines and IPC policies.
Ensure that all the facilities conduct the self- assessments and monitor and support the quarterly.
Monitoring of compliance on IPC practices by visiting the facilities to do follow up on audits done and monitor the Quality Improvement Plans.
Ensure the reinforcement of IPC practices by conducting ongoing in-service training and workshops.
STRATEGIC CHALLENGES
Lack of appropriate hand washing facilities that are compliant with NCS in most facilities.
Cleanliness is still not on acceptable standard due to the fact that the private contractors always shot of cleaning material and equipment, and not having enough staff for cleaning .
SUB-PROGRAMME OVERVIEW CHRONIC DISEASES & EYE PROGRAMME
• To improve health status by decreasing complications of chronic diseases and improve access to health-care services and other inequalities through inclusive, integrated, comprehensive and sustainable partnerships between individuals, communities, government, NGOs and private sector. To protect and promote health and prevent, reduce and control risks associated with ill health.
STRATEGIC OBJECTIVES CHRONIC DISEASES & EYE PROGRAMME
• Coordinate community rallies and events that convey health messages and practices which support health messages programme.
• Monitor indicators which measure health practices in institutions.
• Analyse emerging health practices and trends and introduce remedial.
• Promotion of Healthy lifestyle in senior citizens.
• Prevention of complications of eye problems by early detection and management.
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STRATEGIC CHALLENGES CHRONIC DISEASES & EYE PROGRAMME
• Low cataract surgery rate no theatre space at regional hospital and one part time registered opthalmologist.
• No outreach teams in the district to trace defaulters of chronic medication due to transport challenges.
• Shortage of Ophthalmologists at Ladysmith Regional Hospital supporting sub-districts makes it difficult to cover the whole district in managing patients with cataract.
Table 50: (NDoH 25): Situational Analysis for Disease Prevention and Control – 2013/14 Financial Year. Indicator Type Emnambithi Imbabazane Indaka Okhahlamba Umtshezi District Avg
1. Clients screened for hypertension Quarterly No Not collected Not collected Not collected Not collected Not collected Not collected
2. Clients screened for diabetes Quarterly Not collected Not collected Not collected Not collected Not collected Not collected No
3. Percentage of people screened for mental Quarterly % disorders
PHC Client screened for mental disorders No Not collected Not collected Not collected Not collected Not collected Not collected
PHC headcount total No 659,494 283,128 248,812 314,381 199,839 1,705,564
4. Percentage of people treated for mental disorders Quarterly %
Client treated for mental disorders at PHC level No
Clients screened for mental disorders at PHC level No Not collected Not collected Not collected Not collected Not collected Not collected
5. Cataract surgery rate No per million 217.7/1mil 0 0 0 0 217.7/1mil uninsured population
Cataract surgery total No 149 0 0 0 0 149
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Indicator Type Emnambithi Imbabazane Indaka Okhahlamba Umtshezi District Avg
Population uninsured total No 231 031 109 510 99 496 127 802 80 818 648 657
6. Malaria case fatality rate % 0 0 0 0 0 0
Malaria death reported No 0 0 0 0 0 0
Number of malaria cases (new) No 0 0 0 3 0 3 Note; the cataract surgery rate is for Ladysmith hospital as this is the only hospital who provided the services.
Table 51: (NDoH 26): Situational Analysis for Disease Prevention and Control - 2013/14 Financial Year Estimated Provincial Data Frequenc Audited/ Actual Performance Medium Term Targets Performance Targets Source y 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 hypertension register No collected collected collected
2. Clients screened for DHIS / Tick Quarterly Not Not Not Not collected diabetes register No collected collected collected 3. Percentage of people DHIS Quarterly screened for mental calculates % disorders PHC Client screened for mental DHIS / No Not Not Not Not collected disorders Tick collected collected collected register PHC headcount total DHIS / Tick No 1 439 154 1 646 398 1 705 564 Register 4. Percentage of people DHIS Quarterly Not Not Not Not collected treated for mental disorders Calculate % collected collected collected s Client treated for mental DHIS / Tick No disorders at PHC level register Clients screened for mental DHIS / Tick No disorders at PHC level register
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Estimated Provincial Data Frequenc Audited/ Actual Performance Medium Term Targets Performance Targets Source y Type 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 5. Cataract surgery rate DHIS Quarterly 182/1Mil 176/1mil 217/1mil 328.0(accor 466 553 626 916.9 No per 1 ding to DHIS mil –used total uninsured population populatio and not n uninsured) Cataract surgery total DHIS / No 108 105 149 226 292 350 400 2 612 Theatre register Population uninsured total DHIS / No 664 770 662 488 667 511 620 211 626 104 632 156 638 124 2 848 703 Stats SA 6. Malaria case fatality rate Malaria Annual 0 0 0 0 130 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 52: (NDoH 27): District Objectives and Annual Targets for Environmental Health Services Provincial Strategic Estimated Data Frequency Audited/ Actual Performance Medium Term Targets Objective Performance Indicator Performance target Source Type Statement 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Eradicate 1. Malaria incidence Malaria Annual 0 0 0 0 0 0 0 malaria per 1000 register Per 1000 population at risk population at risk Number of malaria Malaria No 1 1 1 0 0 0 0 cases (new) register/Tick register PHC Population Uthukela DHIS/Stats Population 757 699 702 643 705 019 689 124 0 0 0 SA Decreased DHIS Quarterly 11.6 14.6 15.3 16.1 15.1 14.3 13.2 21.6 hypertension No/1000 incidence by DHIS/ PHC promoting health life Tick register No styles 1 614 2 070 2 202 2 356 2 258 2 182 2 055 57 908 DHIS/Stats No SA 137 981 140 656 143 547 146 535 149 565 152 602 155 754 2 680 949 Maintain a low diabetes mellitus Quarterly incidence by DHIS No/1000 0.65 0.85 0.8 0.7 1.0 1.0 1.o promoting health life styles 1.9 DHIS/ PHC 456 598 566 448 695 702 709 Tick register No 757 699 702 643 682 799 689 124 695 671 702 395 709 071 20 532 DHIS/Stats No SA 10 806 538 131 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 16.2 STRATEGIES/ Activities to be implemented 2015/16 Table 53: Rehabilitation services strategies Strategies Activities 1. Motivate for establishment of Support institutions by motivating for retention of community service officers to establish permanent rehabilitation services. permanent rehabilitation Meetings with Medical Managers and Human Resource Managers in institutions to advocate for permanent rehabilitation services at all institutions at services. Uthukela District. Submission of written motivations to Medical managers, Human Resources Managers and Finance Managers. 2. Support of Institutions and PHC Support institutions to motivate for adequate space for rehabilitation services in hospital level and clinic level. facilities towards achieving Support institutions to motivate for inclusion of rehabilitation services in hospital maintenance plans to help with all infrastructure adequate space for assessment problems. and treatment Support visits to be made to PHC facilities and recommendations to be made regarding allocation of space to work and maintenance of privacy by others means e.g. screens. Solution may require movement of rehab to another building with more space, does not necessarily need a budget. But for those that require budget part of the activities listed is assessment of the space currently utilized and advocating for inclusion in the plan. We hoping from these efforts, rehab may be included at a later stage in institutions where it is not there currently. 3. Support and co-ordination of Ensure Supervision of CBR workers placed in Indaka, Umtshezi and Imbabazane, ensuring they submit required reports. community –based Formulation of Operational plans for the CBR workers. rehabilitation programs in the Introduction of CBR workers to all health facilities, local organization of people with disabilities, Therapists outreach teams, sub-districts with CBR workers Community forums and Imbizo’s . placements (Indaka, Imbabazane and Umtshezi). Develop and provide CBR workers with resource list within their catchment area. Strengthening of outreach Development referral guidelines that are specific to their area. services and formulation of Provide logistic support for CBR workers. support groups in the other sub- Organize monitoring and evaluation meetings with CBR workers. districts without CBR placements i.e. Okhahlamba and Ensure outreach services and home visits are done by rehabilitation therapists and assistant/ technicians. Emnambithi 4. Monitor budget of Assistive Institutions to nominate names of members to serve in District Assistive Device Committee (Therapists, Finance Managers, SCM 132 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 devices for Uthukela District managers, local organizations of people with disabilities, ophthalmic nurse). through the establishment of a Committee meeting to happen bi-monthly after appointment of members by District Manager. District Assistive Device Establishment of District Assistive Device Committee that will procure all assistive devices for the District and control allocation of committee. funds for assistive devices in the District. Chairperson will be the District Disability and Rehabilitation Co-ordinator (In line with new provincial policy on assistive devices). Institutions to hand in procurement plans for procuring of all institutional assistive device Establishment of institutional assistive device committees. Provincial Orthotics and Prosthesis Meeting to be attended bi- annual to address problems with long waiting times. Institutions to be supported in formulation of contingency plans where there are no stocks. 5. Support Wheelchair repair sites Facilitate communication and collaboration between wheelchair repair sites, the provincial Department of health (Disability and based at Ladysmith Provincial Rehabilitation) and KZN DPSA provincial office. Hospital and Estcourt Provincial Co-ordinate meetings with wheelchair repairers, wheelchair supervisors/ therapists in hospitals for planning of maximized hospital. wheelchair repair services. Support and motivate all attempts to procure spares, equipment and provide technical support to the wheelchair repair project. 6. Facilitate improvement to Conduct Assessments for accessibility annually in all health institutions with therapists, systems manager, maintenance manager, access of people with quality manager. disabilities to health institutions. The group (accessibility committee) that conducted assessment to ensure recommendations are put in maintenance plan. To have Quarterly meetings towards improvement on recommendations made towards achieving 100% accessibility in their institution. 7. Liaise with DOE for Meeting with DOE representatives in DOE District office to create guidelines for referral for rehabilitation services. establishment of school-based Facilitation of therapist outreach programs to schools for screening, management and education of educators. services. Facilitation of rehabilitation therapists to attend school health promotion events to present rehabilitation services to the educators, community and perform screening. 8. Strengthening the Training the clinical and non-clinical staff on IPC guidelines and policy. implementation of IPC practices To conduct IPC workshops. for clinical and non-clinical staff 9. Monitoring of compliance on Visiting the facilities to do follow up on audits done and monitor the QIP’s. IPC practices Annual Baseline IPC Audits done Annual hand hygiene campaign conducted 10. Adherence to specifications 1. To order the correct specifications for hand washing facilities. required by NCS. 2. To also involve Maintenance department in the installation of hand washing facilities. 133 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 3.To consult with IPC Coordinators regarding quality of cleaning material and equipment 11. Adherence to Service Level To go through the contract document together to ensure that contractors are aware of cleaning materials and equipment Agreement by private cleaning expected from them. contractors. To schedule and conduct trainings of their cleaning staff on IPC practices. To have cleaning schedules available to all managers. 12. Ensure that all the facilities To monitor and support the assessment quarterly conduct self-assessment 13. Motivate for Estcourt Hospital to Letter to be written to the District Manager be a second site saver for the Facilitate Estcourt Hospital to purchase a second ophthalmic machine. district. Coordinate Estcourt Hospital to decrease the backlog for cataract surgery. 14. Facilitate sub- districts to Facilitate sub-districts to identify problems , referral patterns and render quality care at all levels to reduce cost at regional formulate outreach teams. hospital. Support sub-districts to manage chronic patients using EDL (essential drug list). 15. Motivate for full-time ophthalmologists at Ladysmith Meeting with Medical Manager at Ladysmith Regional Hospital. Regional Hospital to support sub district. Attend Regional meetings to motivate for permanent ophthalmologists at Ladysmith Regional Hospital. 134 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 19. 17. INFRASTRUCTURE, EQUIPMENT AND OTHER SUPPORT SERVICES Table 54: (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 % 1.8 1.5 1.3 1.1 1.2 1.2 1.1 district health expenditure Numerator R10 655 700 R11 759 000 R12 464 000 12 212 000 R11 716 460 R11 644 053 R 9 197 192 Denominator R538 750 793 R789 304 000 R734 006 000 R939 847 010 R986 839 361 R1 036 181 R 1 077 628 329 582 2. Number of facilities that have undergone major and 5 2 1 1 1 2 2 minor refurbishment 3. Fixed PHC facilities with access to continuous supply of % 97 97 97 97 97 97 98 clean portable water Numerator 37 37 37 35 35 35 33 Denominator 37 37 37 37 37 37 37 4. Fixed PHC facilities with access to continuous supply of % 100 100 100 100 100 100 100 electricity Numerator 37 37 37 37 37 37 37 Denominator 37 37 37 37 37 37 37 5. Fixed PHC facilities with access to sanitation 100 100 100 100 100 100 100 Numerator 37 37 37 37 37 37 37 Denominator 37 37 37 37 37 37 37 6. Fixed PHC facilities with access to fixed telephone line % 89 92 97 97 100 100 100 Numerator 37 37 37 33 34 36 36 Denominator 37 37 37 37 37 37 37 135 | Page UTHUKELA 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 7. Percentage of PHC facilities with network access 0 0 0 100 100 100 100 Numerator 0 0 0 37 37 37 37 Denominator 37 37 37 37 37 37 37 8. Number of additional clinics and community health 2 0 37 0 1 2 0 centers constructed . Challenges with water supply; Since 2011/12, the following clinics experienced problems with water. Gcinalishone Clinic the borehole runs dry every year during the winter months, dependent on the municipality to deliver water by tanker. Extra costs for the sub-district regarding water delivery. Sigweje Clinic problems experienced since the commissioning of the clinic as no underground water is available. Challenges with telephone communication; Since 2011/2012 the following clinics experienced problem with communication Kleinfontein no telephone infrastructure at clinic Kwa-Mteyi, Gcinalishone and Busingatha clinics the telephone lines were stolen by the community. Telkom installed a satellite phone at Busingatha clinic. During 2014/2015 – telephone lines stolen for Cornfields clinic. Estcourt hospital provided order to Telkom to install satellite telephone communication. 2015/20156 Construction of new OPD/x-ray/maternity and related facilities at Emmaus hospital to be completed in the current financial year. The handover of the building is scheduled for the end of May 2105. Proposed new facilities in the MTEF period; LADYSMITH FORENSIC MORTUARY Land has been donated by the Emnambithi/Ladysmith Municipality for the building of a Forensic Mortuary. However, there is a clause in the Donation Agreement which states that if the Donee fails to establish the Forensic Mortuary within a period of three years, the property will revert to the Donor at the cost of the Donee. Donation letters attached as an Annexure 1 to the document 136 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 LIMITHILL CLINIC Land has been donated by the Emnambithi/Ladysmith Municipality for the building of a new clinic in Limit hill. However, there is a clause in the Donation Agreement which states that if the Donee fails to establish the Forensic Mortuary within a period of three years, the property will revert to the Donor at the cost of the Donee. Donation letters attached as an Annexure 2 to the document. ISANDLWANA & KETHANI CLINICS – Land has been received by the Department for the construction of these clinics, but due to financial constraints, these clinics have not been built as yet. These clinics are on the STP since 2010 as priorities for the District. Table 55: Projects for Region 3 according to Infrastructure Head Office for the Region: NUMBER PROJECT NAME PROJECT DESCRIPTION 1. Newcastle hospital Replace water reticulation 2. Ladysmith Construction of new m3 forensic mortuary 3. Cosh and greytown Replacement of o.t. chillers at Cosh and Greytown hospitals and replacement of cssd hospitals chillers at cosh. 4. Limithill clinic - ladysmith Construction of new clinic at Limithill 5. Madadeni hospital Construction of psychiatrict unit for region 3 at Madadeni hospital 6. Roosboom clinic - Construction of new clinic ladysmith 7. Cosh Replace paediatric ward with male and female t.b. wards 8. Madadeni hospital Upgrade of pharmacy aircon. System 9. Ladysmith hospital Conversion of ward e3 into proper male and female psychiatric facilities 10. Regional laundry dundee Upgrade and refurbishment to laundry. (laundry services region 3) 11. Estcourt hospital Addition to existing hast buliding 12. Dundee Construction of large emrs base 13. Madadeni hospital Renovation to main kitchen 14. St chads Construction of new laundry facility 15. Cosh Construction of staff accommodation 137 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 NUMBER PROJECT NAME PROJECT DESCRIPTION 16. Niemeyer hospital Construction of new ablution facilities and renovation to nurses home 17. Greytown hospital Construction of staff accommodation 18. Madadeni hospital Renovation to laundry 19. Dundee hospital Construction of staff accommodation 20. Niemeyer hospital Re-design an upgrade ccmt waiting area. 21. All clinics Installation of generator sets 22. Burford - ladysmith Construction of new clinic 23. Cjm Construction of staff accommodation 24. Osisweni - Newcastle Upgrade of clinic to mou 25. Estcourt hospital Construction of new opd /casualty /pharmacy 26. Niemeyer hospital Upgrade of gateway clinic 27. Umzinyathi district Construction of septic tanks 28. Madadeni hospital Construction of mdr unit 29. Ntabasibahle qhudeni Construction of new clinic 30. Isandlwana - Emmaus Construction of new medium clinic with double accommodation 31. Kethani - Emmaus Construction of new medium clinic with double accommodation 18. SUPPORT SERVICES This section of the DHP addresses the support services, which enable health workers to operate and provide the actual health services, namely: Pharmaceutical services; Equipment and Maintenance; and Transport and EMRS. Data and Information Management 138 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 18.1 PHARMACEUTICAL SERVICES Table 56: (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 % Not recorded 66% 66% 100% 100% 100% 100% 100% (District Hospitals and CHC’s) with functional of Pharmaceutical and Therapeutics Committees (PTC’s) Number of CHC’s and District 2 2 2 3 3 3 3 3 Hospitals with functional Pharmaceutical and Therapeutic Committees Number of District Hospitals and 2 3 3 3 3 3 3 3 CHC’s 2. Any ARV Drug Stock Out Rate % Not recorded 1% 0% 1% 0.75% 0.3% 0.2% 0.2% Number of ARV drug’s out of stock 1 0 1 0.28 0.021 0.014 0.014 Number of ARV’s drugs 12 12 12 7 7 7 7 7 3. Any TB Stock Out Rate % Not recorded 2% 1% 1% 0.75% 0.5% 0.5% 0% Number of TB drugs out of stock 2 1 1 0.0375 0.025 0.025 0.025 Number of TB drugs 7 7 5 5 5 5 5 5 4. Percentage of Hospitals with % 100% 100% 100% 100% 100% 100% 100% 100% Pharmacists Number of District Hospitals with 2 2 2 2 2 2 2 2 139 | Page UTHUKELA 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 Pharmacists Number of District Hospitals 2 2 2 2 2 2 2 2 5. Percentage of CHC’s with % N/A 0% 100% 100% 100% 100% 100% 100% Pharmacists Number of CHC’s with pharmacists 0 0 1 1 1 1 1 1 Number of CHC’s 0 1 1 1 1 1 1 1 Table 57: (NDoH 30): Pharmaceutical Services Estimated Audited/ Actual Performance Medium Term Targets Strategic Objective Performance Indicator Data source Type Performance 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 1. Percentage of Pharmacy Annual 50% 66% 66% 100% 100% 100% 100% Pharmacies that records % obtained A and B grading on inspection Pharmacies with A or B Pharmacy No 1 2 2 3 3 3 3 Grading records Number of pharmacies Pharmacy No 2 3 3 3 3 3 3 records 2. Tracer medicine Pharmacy Quarterly No Data stock-out rate records % (PPSD) Number of tracer Pharmacy No medicine out of stock records Total number of tracer Pharmacy No medicine expected to records be in stock 3. Tracer medicine Pharmacy Quarterly Not recorded 2% 1% 2% 1.5% 1% 0.75% stock-out rate records % (Institutions) 140 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Estimated Audited/ Actual Performance Medium Term Targets Strategic Objective Performance Indicator Data source Type Performance 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Number of tracer Pharmacy No 1.1 1 1 0.735 0.5 0.365 medicines stock out in records bulk store Number of tracer Pharmacy No 55 55 49 49 49 49 49 medicines expected records to be stocked in the bulk store 4. Number of Manageme Annual Not Reported Not Reported Not mortuaries nt No Reported rationalised 1. Drug stock out rates improved from 2012/13 year due to improved stock monitoring using early warning monitoring tools and the stock Visibility solutions programme 2. ART drug availability was at 0% due to improved stock supplies that were delivered by suppliers soon before end of tender period and the initiation of FDC 3. The Paediatric TB initiation drug combination was discontinued resulting in shortages with the supply of section 21 single drug Pyrazanamide which was not registered for use by the MCC 4. A few Single drugs ARV’s have taken off from the indicator drug list as well as Streptomycin due to discontinuation of the drugs 5. One pharmacist and 6 pharmacist assistants were recruited through AURUM, to support PHC facilities, resulting in improved procurement of drugs and National core Standards at PHC level. 6. A Community Drug Dispensing site was set up with Pharmaceutical support at Isibane NGO supporting patients in excess of 800 patients. 7. Drug Utilisation reviews conducted identified challenges with adherence by clinicians at PHC to therapeutic monitoring of patients on ART and patient follow up of those failing treatment. Challenges 1. Except for Emmaus hospital which has lost PTC members, all facilities have functional PTC’s 2. Implementation of Community Chronic Drug dispensing at all sites was a challenge due to staff shortages at Ladysmith hospital and Estcourt hospital. 3. Monitoring and Evaluation systems for Pharmaceutical service not catered for by District M& E to monitor data required for quarterly reports making it a challenge to collect data timeously. 4. Drug storage areas at PHC still remain a challenge with increased numbers of patients seen, and space needed for chronic dispensing. Strategies and Activities for 2015/16 141 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 1. Strengthen Electronic drug procurement systems at PHC using tools developed with MSH, and implementation of Rx solution at hospitals and PHC stores. ( Rx not installed at the district yet, only the MSM tool is being that was developed by the district with assistance by MSH- specifically for PHC) 2. Strengthen functionality of PTC to address implementation of new Standard treatment guidelines for hospitals and PHC. 3. Strengthen support of down referral systems to Community Based facilities, and supporting dispensing after hours and during week-ends. 4. Improved Clinical Pharmacy Programme at hospitals including antimicrobial surveillance. 5. Motivation for recruitment of pharmacist assistants at PHC. There are only 6 pharmacist assistants seconded by AURUM, the district needs at least 16 Pharmacist assistant in addition. With high patient’s loads at both hospital pharmacies and clinics, quality of service at these facilities is compromised making it difficult to achieve key National Core Standards e.g. improved waiting time, improved drug availability and patient safety. The biggest challenge is faced at PHC facilities where there is no continuous support by pharmacy personnel as they are hospital based. Implementation of a down referral systems that includes Chronic Drug supply system to community based sites will ensure that the waiting times at facilities are reduced, further making more time available for ensuring that quality standards in pharmaceutical service delivery are maintained. This will also ensure improved access of drugs for the patients, as the distribution sites will be closer to patients’ homes, and thus improve adherence to treatment and health outcomes. A Plan for the Implementation of Chronic Drug Supply is herewith attached as an addendum. The district is planning to strengthen drug procurement systems at PHC to ensure that there is continuous availability of drugs and that the facilities are stocking the correct drugs according to new oncoming Standard Treatment guidelines. This will be strengthened through increased human resource capacity to support PHC, as well as ensuring that Standard Operating procedures for drug supply management are adhering to. 6 Pharmacist assistants have been recruited through secondment from the AURUM Institute to support PHC, with plans to subsequently absorb this cadre of personnel as permanent employees. Creation of pharmacist assistant posts for each facility has been made priority in the District Health Plan to ensure continuous pharmaceutical support for primary health care facilities. With reduced patient load in hospitals there will be more time for extension of services rendered to include for inpatients pharmaceutical services and implementation of a full Ward pharmacy practice in the hospitals. This will be in line with the DoH strategy of ensuring that pharmacists are getting more involved in Clinical Pharmacy in line with the undergraduate training that they have received. This will improve standards of Pharmaceutical care so that pharmacists are not just dispensers of medication but give expert drug advice. Table 58: Centralised Chronic Management of drugs (CCMD) 142 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Sub-Districts No of Current no of Expansion plans for March 2015 Targets for community- prescriptions 2015/16 Based down dispensed Additional Planned target. No No of CCMD sites No of referral sites CCMD sites for of prescriptions by prescriptions expansion March 2015 dispensed March 2014 Emnambithi 2 old age homes 300 3 900 6 2400 Okhahlamba 1 800 2 1400 4 1500 Umtshezi 0 0 2 600 4 1500 Indaka 0 0 2 600 6 1800 District Totals 3 1100 9 3500 20 7200 A District ICDM team was established involving the supporting NGO in order to fast track the implementation of the ICDM initiative. 18.2 FORENSIC PATHOLOGY SERVICES Uthukela District has three (3) facilities namely, Ladysmith, Estcourt and Bergville. These facilities budgets are managed at the District Office. District Priorities: Revitalisation of infra-structure at Ladysmith FPS Improved human resources for quality service delivery BERGVILLE MORTUARY Bergville mortuary only comprises of an office in a park home with no facility for storage of bodies and the conducting of post mortem examinations. The workload for Bergville is done by Bergville and Ladysmith personnel and that stretches the fact further that the facility (Ladysmith) is under staffed. Every time when there post mortems to be done for bodies picked up at Bergville, staff/ members are compelled to travel to Ladysmith to conduct post mortems. This also increases in terms of travelling cost as well as life span of the vehicles. 143 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Another point is that the overtime worked covering Bergville is being paid to Ladysmith staff as the services are being rendered for Bergville is taking place at Ladysmith. This results in further over expenditure of the overtime line in Ladysmith. In the Provincial plan it is indicated that Bergville mortuary will close down as the infrastructure is not suitable for mortuary services. Approval was received from the HOD and MEC of Health to close Bergville FPS. ESTCOURT MORTUARY Estcourt mortuary’s main challenge is that four of its staff members do not have driver’s licenses. However Head Office Forensic came up with an intervention plan for 2015/2016 financial year to assist all employees without driver’s licences. Driver’s licenses were not a requirement in the previous job descriptions, with the new job description a requirement. The shift system normally comprises of four staff members (drivers). Currently the facility has three staff (drivers) which makes it impossible to work the shift system and therefore overtime has to be worked and that results in huge amount of overtime worked and claimed by each staff member. In most of the cases the Manager has to attend to other call outs especially if there are drivers who are sick or on leave. The need of a fourth driver becomes necessary to render services as per the shift system. Once the transfer of two members from Mooi River to Estcourt FPS gets approved it will improve the service delivery and reduce the amount of overtime. LADYSMITH MORTUARY It has been noted from previous financial years that Ladysmith Mortuary has been overspending on the compensation of employee’s budget. The main reason for this is because the facility is under staffed currently. Recently one of the staff members has been placed on light duties due to medical condition (Referred by EAP by Practitioner) thus reducing the manpower. The medical officers’ that service the entire district are based in Ladysmith. Over expenditure is also linked to these medical officers’. Currently Ladysmith have no full time medical officers employed as one resigned however three others who are on contract. The lack of medical officers creates a problem for the entire district as we are required to make use of medical officers contracted from other districts. The cost implications include, transportation costs, overtime for the staff, and paying post mortem claims for these doctors. Medical officers also get paid for commuted overtime which covers the performance of emergency post mortems after normal working hours. This commuted overtime contributes to a major portion of the overtime and budget allocation is minimal on this item line. The current Facility which was the SAPS mortuary was condemned by the Inspectors from Department Of Labour, as not suitable and healthy to utilise it as a mortuary. Land was donated to the district for building a new facility, yet no funds by infrastructure to build. Attached is the donation letter by the Municipality. The body cabinets always need repairs at Ladysmith mortuary, the need to replace all four is becoming necessary as the cabinets were installed over twenty years ago. Funding for the replacement becomes a concern as well 144 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 FINANCIAL INFORMATION * Budget and Expenditure: For the First Quarter of 2014/2015 the overall spending was supposed to be at 25%, however there are areas where this overall expenditure was exceeded. - Estcourt FPS was allocated R 3 876 000 for the 2014/2015 financial year. - Compensation of Employees we were allocated R2 600 000 and for the first quarter we have spent 25% which is in line with what was expected. Goods and Services we were allocated R1 056 000 and 29% was spent which was above the set target thus exceeding by 4%. Machinery & Equipment was allocated a budget of R80 000 which has been committed in purchasing oscillating head saws and rib shears for the facility. Maintenance was allocated a budget of R140 000. * Reasons for over or under-expenditure There were no under expenditures, however the high cost drivers which were identified amongst others were: Accruals from last financial year – invoices that had to be paid for outstanding orders e.g. gloves, disposable sundries in this financial that contributed to the overspending. The accruals were caused by the situations which were beyond our control. Payment of contracted doctors, limited budget allocation although the need is seen as a non-negotiable as none of the mortuaries have dedicated medical officers appointed. The delays in delivery of gloves were the main reason amongst others. Employment of permanent doctor will also assist in terms of reducing overtime however the COE and Goods and Services budgets would have to be reviewed closely as these medical officers don’t come cheap. Payment of resettlement costs, S&T for training purposes and commuted overtime. Corrective measures Closer monitoring and evaluation of Forensic Pathology Services within the District and ensure accurate capturing of statistics to secure adequate funding. 145 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 59: Posts for FPS Sub-district Post Number Cost Forensic Pathology Officer – Grade 1 2 R239 964.00 Forensic Pathology Officer – Grade 2 2 R387 235.98 Emnambithi Support Service – Level 7 1 R251 310.06 Umtshezi Forensic Pathology Officer – Grade 2 2 R387 235.98 Support Service – Level 7 1 R251 310.06 TOTAL COSTS 8 R1517056.08 COST CONTAINMENT PLAN Ensure that vacant posts are filled whether by means of advertising or getting transfers from other facilities and these posts be filled by candidates with driver’s licenses. Encourage and assist every possible way that employees with no driver’s licenses to acquire them. If we get permanent doctor who can be able to conducts post mortems in the morning than late afternoons. Since Mooi River is closing down two staff members are in the process to be transferred to Estcourt Mortuary with their posts. If this process is finalized it will ensure that the workload is kept at a minimal thus saving the facility in terms of overtime. However there are two critical posts which were not filled at Estcourt Mortuary since 2008 (Forensic Pathology Grade II – Component no. 025796), if the process of unfreezing the posts can take place it will ensure that this Facility adapt to the shift system which does not allow overtime to be accumulated Four (04) week cycle duty roster where employee is rostered 160 hours). In order for this system to be implemented at least 14 Forensic Pathology Officers are required however at Estcourt we only have 10 and out of that ten four are without drivers licences. 146 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 60: Forensic Pathology Services Facility Indicator 2011/12 2012/13 2013/14 2014/45 Estcourt Number of bodies picked up 218 230 285 94 Number of post mortems conducted 214 222 278 94 Number of natural cases 20 31 35 15 Bergville Number of bodies picked up 169 155 132 50 Number of post mortems conducted 152 140 135 51 Number of natural cases 21 18 19 7 Ladysmith Number of bodies picked up 397 344 391 198 Number of post mortems conducted 388 331 394 200 Number of natural cases 54 32 14 16 18.3 EQUIPMENT AND MAINTENANCE See as attachments: Annexur Table 61: District Equipment and Maintenance 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 maintenance budget spent Annual 84 % 94 % 96 % 96 % 100 % 100 % 100 % % Expenditure on maintenance (preventive and No 11 716 460 11 644 053 9 197 192 10 655 700 11 759 000 12 464 000 13 212 000 scheduled) Maintenance budget No 13 985 000 12 329 000 9 563 000 11 093 000 11 759 000 12 464 000 13 212 000 147 | Page UTHUKELA 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 2. Proportion of Programme 8 ( infrastructure Annual budget) spent on all maintenance % (preventative and scheduled) Expenditure on maintenance (preventive and No 11 716 460 11 644 053 9 197 192 10 655 700 11 759 000 12 464 000 13 212 000 scheduled) Infrastructure budget No 3. Number of health facilities that have Annual 5 2 1 1 1 2 2 undergone major and minor refurbishments No. According to the acting District engineer, since 2011 the district only received budget for day to day maintenance and not budget for infrastructure projects. The infra-structure budget for projects is centralised at head office. The District experience challenges in the budget allocation for maintenance as the maintenance budget is not linked to the BAS allocations. 18.4 EMERGENCY MEDICAL SERVICES (EMS) Table 62: (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 Emnambithi No 0.08/10 000 0.20/10 000 0.24/10 000 0.28/10 000 0.28/10 000 0.36/10 000 0.44/10 000 2/243 148 5/244 664 6/246 020 7/247 211 7/249 078 9/250 574 11/252 077 Imbabazane No 0.24/10 000 0.24/10 000 0.24/10 000 0.31/10 000 0.31/10 000 0.47/10 000 0.62/10 000 3/126 911 3/127 293 3/127 576 4/127 769 4/127 895 6/128 662 8/129 434 Indaka No 0.17/10 000 0.34/10 000 0.34/10 000 0.42/10 000 0.42/10 000 0.59/10 000 0.75/10 000 2/188 618 4/118 761 4/18 808 5/118 774 5/118 433 7/119 144 9/119859 Okhahlamba No 0.21/10 000 0.27/10 000 0.34/10 000 0.41/10 000 0.41/10 000 0.54/10 000 0.67/10 000 3/146 281 4/146 724 5/147 057 6/147 298 6/147 477 8/147 919 10/148 362 Umtshezi No 0.46/10 000 0.46/10 000 0.76/10 000 0.91/10 000 0.90/10 000 1.05/10 000 1.35/10 000 148 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 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 3/64 799 3/65 558 5/65 558 6/65 871 6/66 356 7/66 456 9/66 7882 District total No 0.19/10 000 0.27/10 000 0.33/10 000 0.40/10 000 0.39/10 000 0.52/10 000 0.66/10 000 0.32 13/699 757 19/702 643 23/705 019 28/706 923 28/709 239 37/712 755 47/716 520 431/11 121 009 Table 63: (NDoH 31 (b)): Ambulance Response Time Rural under 40 minutes (Inclusive of LG) Sub-district Audited/ Actual performance Estimate MTEF Projection Provincial Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Emnambithi 25% 26% 35% 37% 46% 57% 71% 383/3415 939/3616 1409/3978 2006/5416 2508/5443 3135/5470 3919/5498 Imbabazane 34% 32% 43% 39% 48% 60% 74% 555/1634 499/1571 749/1728 868/2246 1085/2253 1356/2265 1695/2276 Indaka 19% 19% 26% 28% 35% 44% 54% 529/2830 594/3066 891/3373 1676/5949 2095/5979 2619/6009 3274/6039 Okhahlamba 24% 23% 31% 32% 40% 50% 60% 1119/4705 1116/4851 1674/5336 1774/5502 2218/5529 2773/5558 3328/5585 Umtshezi 37% 18% 25% 44% 55% 68% 85% 53/145 21/117 32/129 403/914 504/918 630/922 788/927 District Average 28% 24% 32% 34% 42% 52% 64% 55% 1639/12729 3169/13221 4755/14511 6727/20027 8410/20122 10513/20224 13004/20325 131582/263164 149 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 64: (NDoH 31(c)): Ambulance Response Times Urban under 15 minutes (Inclusive of LG) Ambulance Response Time: Audited/ Actual performance Estimate MTEF Projection Provincial Urban Target 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 Emnambithi 6% 7% 9% 10% 15% 21% 29% 46/7633 551/7494 827/8744 469/4761 704/4784 986/4808 1380/4832 Imbabazane 1% 1% 2% 11% 15% 23% 35% 1/86 1/115 3/127 8/72 11/73 17/74 26/74 Indaka 5% 5% 7% 5% 9% 15% 23% 3/750 40/794 60/873 16/313 29/314 46/316 74/318 Okhahlamba 2% 4% 6% 11% 16% 23% 35% 7/301 10/235 15/259 48/457 72/459 108/462 162/464 Umtshezi 9% 9% 12% 14% 20% 28% 39% 95/6342 620//6888 930/7577 768/5469 1100/5523 1540/5551 2156/5579 District Average 5% 5% 7% 12% 17% 24% 34% 22 % 152/15112 1222/15526 1835/17580 1309/11072 1916/11153 2697/11031 3798/11267 45534/206973 150 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 65: (NDoH 31 (d)): EMS Inter-facility Transfer 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 Emnambithi No 3674 5469 3316 3813 4576 5720 5915 Imbabazane No 1572 2743 3318 3982 4778 5973 7125 Indaka No 1073 1552 3859 4631 5557 6946 8310 Okhahlamba No 1791 2390 2943 3532 4238 5298 6198 Umtshezi No 4290 5003 4785 5742 6890 8612 9823 District No 12400 1757 18221 21700 26039 32549 37371 230 000 Challenges: Poor response times Population vs. service provision - Not meeting national norms-1:10 000 (ESV) Increased case load – one of major factors for poor response Aging fleet / Poor road infrastructure – poor terrain, vehicles with high mileage, long distances between bases Shortage of vehicles – vehicles expansion needed, vehicle replacement and down time for repairs Shortage of staff – vacant posts to be filled Reporting of EMS services, some tasks is delegated to the District Office and some to Head Office. The table on the next page indicates the kilometres per EMS vehicle and the costs for repairs for the first six months 2014/15. The high kilometres per vehicle is impacting negatively on the expenditure for repairs and is also a risk factor for staff and patients. During the past 2 years no replacement for EMS vehicles occurred. 151 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 66: EMS vehicles – mileage and repair costs Vehicle Fleet No. Make Model Mileage Maintenance and repair Costs – Registration first six months 2014/15 1KZN 21036 A 40 C Volkswagen Crafter 2008 360,550 KZN 24315 A 18 C Mercedes Sprinter 308 2009 353,058 KZN 24396 A 16 C Volkswagen Crafter 2009 297,975 R5 870.02 KZN24590 A 36 C Mercedes Sprinter 309 2011 274,831 R15 455.76 KZN 24578 A 32 C Mercedes Sprinter 309 2011 264,998 KZN 24561 A 29 C Mercedes Sprinter 309 2011 261,036 R5 990.84 KZN 24692 A 104 C Volkswagen Crafter 2011 253,215 R2 995.00 KZN 24329 A 4 C Mercedes Sprinter 308 2009 252,446 R5 560.01 KZN 24809 A 42 C Mercedes Sprinter 309 2012 251,510 R13 180.68 KZN 24582 A 34 C Mercedes Sprinter 309 2011 250,855 KZN 24545 A 15 C Mercedes Sprinter 309 2011 249,784 R138 764.87 KZN 24395 A 14 C Volkswagen Crafter 2009 245,982 KZN 24044 A 19 C VW Lt 35 2007 234,619 KZN 24811 A 46 C Mercedes Sprinter 309 2012 232,868 R13 370.32 KZN 24598 A41 C Mercedes Sprinter 309 2011 230,036 R28 147.11 KZN 24414 A 25 C Mercedes New shape - 2009 Model 2009 226,377 R24 586.99 KZN 24687 A 99 C Volkswagen Crafter 2011 217,282 R24 096.75 KZN 24576 A 31 C Mercedes Sprinter 309 2011 216,766 R14 117.93 KZN 24691 A 103 C Volkswagen Crafter 2011 215,891 KZN 24810 A 45 C Mercedes Benz 309 2012 205,995 R8 511.24 KZN 24693 A 105 C Volkswagen Crafter 2011 199,418 KZN 24696 A 106 C Volkswagen Crafter 2011 190,854 R2 995.00 KZN 24550 A 26 C Mercedes Sprinter 309 2011 184,769 R54 114.12 KZN 24688 A 100 C Volkswagen Crafter 2011 180,259 R7 062.92 KZN 24690 A 102 C Volkswagen Crafter 2011 176,438 152 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 KZN 24812 A 48 C Mercedes Sprinter 309 2012 176,324 KZN 24307 A 17 C Mercedes Sprinter 308 2009 166,806 KZN 24594 A 37 C Mercedes Sprinter 309 - MICU 2011 159,217 R23 749.12 KZN 24504 A 108 C Toyota Land cruiser 4500 2011 156,584 R13 249.78 KZN 24505 A 109 C Toyota Land cruiser 4500 2011 150,586 R11 209.96 KZN24721 A 1 C Volkswagen Crafter (MICU) 2012 140,093 R4 255.62 KZN 24556 A 28 C Mercedes Sprinter 309 2011 136,554 R22 427.69 KZN 24778 A 65 C Volkswagen Transporter 5 - Interfaculty 2012 105,689 R1 347.47 KZN 24722 A 8 C Volkswagen Crafter (MICU) 2011 93,551 R16 737.02 KZN 24689 A 101 C Volkswagen Crafter 2011 83,901 R4 473.60 KZN 24767 A 64 C Volkswagen Transporter 5 - Interfaculty 2012 69,462 TOTAAL R457 796.22 18.5 INFORMATION AND DATA MANGEMENT SERVICES: The District implement ted the DHIMS policy in all sub-districts and the SOP for PHC service and Hospital services was discussed during the alignment sessions for the new version of DHIS. A three day data quality workshop was conducted with all stakeholders involved in data collection where the following data quality tools were explained and distributed. Manual validation tool Data Quality Improvement plans for each level (district, sub-district and facility). Manual data validation guideline Monthly sign off forms PHC supervisor/program manager data verification form Sub-district verification/audit teams are in place and validate the data during the first week of the month. A member of the M & E Unit in the District Office joins the different teams during the verification process. A quarterly data verification session to clean the data before the quarterly report is completed. All fix clinics capture daily data on the E-Tool and export the data to the FIO monthly. The clinics are using CD’s or memory stick to save the export files and send then with transport to the FIO’s. The absence of network access in the facilities is impacting negatively on the following; Submission of data to the next level Anti-Virus protection 153 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Data quality feedback reports in order to correct data 11 fixed clinics do not have permanent data capturers and is dependent on the data captures seconded by AURUM. 3 TIER - only 2 facilities is not yet signed off, measures has been put in place to ensure that these facilities is signed off by the end of the 2014/15 financial year. The mobile PHC services is attending to a big number of down referred ARV clients, therefore the need arises for data captures at mobile services to capture also daily on 3 TIER. 154 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 20. 19. HUMAN RESOURCES Table 67: (NDoH 32): Performance for Human Resources Sub-district 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 Emnambithi PHC facilities Medical officers 0 0 0 4 6 8 10 Professional nurses 56 53 57 St Chads -37 St. Chads 44 St. Chads 46 St. Chads 48 LS = 82 LS = 89 LS = 92 LS = 95 Total 119 Total 133 Total 138 Total 143 Pharmacists 0 0 0 2 4 6 8 Regional hospitals Medical officers 47 61 57 65 + specialist 20 70 + specialist 75+ specialist 26 53 24 Professional nurses 249 274 282 239 250 265 270 Pharmacists 7 11 11 9 14 17 19 Radiographers 8 13 15 15 17 19 21 Imbabazane PHC facilities Medical officers 0 0 0 0 0 1 1 Professional nurses 34 32(+ 5 47 47 61 82 82 managers) Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers N/A N/A N/A N/A N/A N/A N/A Professional nurses N/A N/A N/A N/A N/A N/A N/A Pharmacists N/A N/A N/A N/A N/A N/A N/A 155 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Sub-district TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Radiographers N/A N/A N/A N/A N/A N/A N/A Indaka PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 30 28 32 30 50 56 59 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers N/A N/A N/A N/A N/A N/A N/A Professional nurses N/A N/A N/A N/A N/A N/A N/A Pharmacists N/A N/A N/A N/A N/A N/A N/A Radiographers N/A N/A N/A N/A N/A N/A N/A Okhahlamba PHC facilities Medical officers 0 0 0 0 1 1 1 Professional nurses 41 47 54 48 66 70 84 Pharmacists 0 0 0 0 0 0 0 District hospitals Medical officers 9 11 13 7 15 17 20 Professional nurses 50 56 73 62 85 110 117 Pharmacists 2 7 7 3 5 6 7 Radiographers 2 3 3 3 6 6 6 Umtshezi PHC facilities Medical officers 0 0 0 0 0 0 0 Professional nurses 31 32 40 42 52 52 52 Pharmacists 0 0 0 0 156 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Sub-district TOTAL POSTS FILLED Audited/ Actual performance Estimate MTEF Projection 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 District hospitals Medical officers 16 21 21 15 23 23 23 Professional nurses 104 152 152 125 141 145 150 Pharmacists 5 5 5 3 6 6 6 Radiographers 3 6 6 8 9 9 9 District PHC facilities Medical officers 3 3 3 4 6 8 10 Professional nurses 211 238 306 286 362 398 420 Pharmacists 0 1 1 2 District hospitals Medical officers 71 46 93 22 38 40 43 Professional nurses 396 411+ (67 497 187 226 255 267 managers) Pharmacists 13 22 23 6 11 12 13 Radiographers 17 21 11 11 15 15 15 Note: The District total does not include the totals for the regional hospital 157 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 68: (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 Sexual and Reproductive Health training of all Health Care Workers on the 97/367 -27% of 40% 60% 75% 90% new SRH policy and guidelines (pg.21) PN’s trained 44/283 – 12% of 30% 50% 75% 90% E/N’s trained Numerator PN’s trained Total number of PN’s Training of CCGs on Maternal & Child Health (pg.21) Above 80% 85% 90% 95% 100% trained Training of all Midwifes on ESMOE (pg.21 & 105) 0% Trained 30% 40% 50% 60% Training of all Health care workers on PMTCT Guidelines (pg.22) 122/367 -33% PNs 50% 80% 90% 100% Training of all Health care workers on Growth Monitoring and Integrated 108/367 – 29% PNs 50% 80% 90% 100% Management of Severe Malnutrition (IMAM) (pg.22) Training of Health care workers on Emergency Triage Assessment Treatment in 0% Trained 30% 50% 60% 80% SA (ETAT) Training of Health care workers on EPI & RTHB 196/387 – 54% PNs 60% 70% 80% 100% trained 80% 90% 100% 100% 211/283 – 76% ENs trained IMCI training of all PNs 186/367 – 5% PNs 60% 70% 80% 100% trained 6 This would include formal and informal (short courses, refreshers, etc.) courses. 158 | Page UTHUKELA 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 PICT training of all Nursing Categories (pg.26) 202/367 –55% PNs 70% 80% 90% 100% Trained 30% 50% 80% 100% E/N- 0% E/N/A- 0% 30% 50% 80% 100% Training on TB Guidelines and updating those previously trained on New TB 63/367 – 18% PNs 40% 60% 70% 80% guidelines (pg.28) trained 70% 80% 90% 100% 188/283 – 66% E\Ns trained Supporting of training of School Health Nurses on Male Medical Circumcision 0% trained 20% 30% 50% 60% Support training on Nurse Initiated & management of ART (NIMART) (pg.29) 182/367 – 51% PNs 55% 70% 80% 90% trained Support training on Infant & young child feeding 9(IYCF) for all health care 79/707 – 11% of 30% 40% 50% 60% workers (pg.105) clinical staff trained Support training in Ideal clinic 0% clinical staff 30% 40% 50% 60% trained Support training in mental health 86/367 – 24% PNs 40% 50% 60% 70% trained Training of all health care workers on management of sexual assault and rape 0% 30% 40% 40% 50% survivors Training of all health care personnel on new developments As per invite As per invite As per invite As per invite As per invite Support data management training of all health care workers and data As per invite As per invite As per invite As per invite As per invite captures 159 | Page UTHUKELA 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 Support M & E training of all health care workers and data captures As per invite As per invite As per invite As per invite As per invite Capacitation of trainers and other health professional to attend outside As per invite As per invite As per invite As per invite As per invite courses 33/367Pns = Training in cervical screening 20% 40% 60% 80% 8%Trained 45/367= 12% Support Training of health care workers in Eye problem 20% 30% 40% 50% trained Training of clinical staff in rabies 27% Trained 30% 40% 50% 60% Training of clinical staff in AYFS 20% Trained 30% 40% 50% 60% Support training of PNs on MMC adverse events 0% Trained 30% 40% 60% 80% CCGs training on CBR 0% Trained 50% 60% 80% 100% Support training of clinical staff adherence 0% Trained 30% 60% 90% 100% Support training of clinical staff on Key population and HTAs 0% Trained 30% 60% 90% 100% Training of PNs in STI 50% Trained 50% 70% 80% 90% Support training in HIV/AIDS counseling in clinical staff and traditional healers % clinical staff 59/140= 35% 45% 55% 70% 80% traditional healers Trained Support training of clinical staff in ICDM and PC101 %0 Trained 30% 50% 60% 80% Support training of NCDs 0% Trained 20% 30% 40% 50% Support training of clinical staff in milestone development 0% Trained 30% 40% 60% 80% Although the training plan is in place, yet influenced by National and Provincial trainings probable due to new inventions. 160 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 21. 20. DISTRICT FINANCE PLAN Table 69: (NDoH 34): District Health MTEF Projections Sub- Audited outcome Main Adjusted Revised Medium term expenditure estimates programme appropriation appropriation estimate R’ thousand 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 District 12 042 689 17 792 013.25 15 613 666 17 624 000 17 624 000 17 624 000 18 505 200 19 430 460 20 207 679 Management Clinics 160 349 179 186 017 028.61 194 846 013 316 927 410 317 171 148 317 171 148 332 773 781 349 412 470 363 388 968 Community Health 5 789 592 31 510 056.80 42 621 633 63 312 000 63 465 000 63 465 000 66 477 600 69 801 480 72 593 539 Centres Community 1 174 498 0 0 0 0 0 0 0 0 Services Other 34 089 000 34 306 000 34 306 000 Community (inclusive of (inclusive of (inclusive of 26 786 232 33 975 782.80 40 336 561 35 793 450 37 583 123 39 086 447 HIV/Aids HIV/AIDS R19 696 HIV/AIDS R19 19 696 000) 000) 696 000) Coroner 7 905 485 8 868 058.54 8 811 244 10 723 000 10 723 000 10 723 000 11 259 150 11 822 108 12 294 992 Services HIV and AIDS 95 269 500 135 581 666.50 166 051 442 178 940 000 179 135 000 179 135 000 18 788 000 19 728 1350 205 172 604 Nutrition 3 058, 38 1 945 295.86 2 205 757 2 552 000 2 552 000 2 552 000 2 679 600 28 13 580 29 261 230 District 220 835 924 252 233 391.69 281 251 589 315 282 600 315 282 600 331 463 580 348 036 759 361 958 229 Hospitals 315 679 600 Environmental Health 5 539 056 5 670 046.00 0 9 9 0 0 0 0 Services TOTAL 751 737 905 939 847 010 940 259 018 940 259 018 986 839 361 1 036 181 1 077 628 582 538 750 793 673 593 340.05 329 161 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 R’ Thousands Audited Outcomes Main Adjusted Medium-term estimate appropria appropri Revised tion ation estimate 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Current payments Compensation of 630, 159, 841 730,510,000 805,007,000 805,007,000 805,007,000 909, 039, 000 906,823,000 906,823,000 954,490,950 1,002,215,498 1,042,304,117 employees Goods and services 246 834,612 312,304,000 353,871,000 353,871,000 353,871,000 366, 263 ,0000 360,958,000 360,958,000 384,576,150 403,804,958 419,957,156 Transfers and subsidies to 11,091,289 3,108,000 2,357,000 2,357,000 2,357,000 2 ,503, 000 2,503,1000 2,503,1000 2,628,150 2,759,558 2,869,940 Payments for capital assets 14,774,714 8,337,000 6,730,000 6,730,000 6,730,000 3 ,890, 000 3,890,000 3,890,000 4,084,500 4,288,725 4,460,274 Total economic 1,281,695 000 1,274,174,000 1,274,174,000 1,345,779,750 1,413,068,738 1,469,591,487 902,860,456 1,054259,000 1,167,965,000 1,167,965,000 1,167,965,000 classification 162 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 23. PART C: LINKS TO OTHER PLANS 24. 21. CONDITIONAL GRANTS (WHERE APPLICABLE) Table 70: (NDoH 36): Outputs of a result of Conditional Grants Name of conditional Purpose of the grant Performance indicators Indicator targets grant (extracted from the Business Case prepared for each Conditional Grant for 2015/16 COMPREHENSIVE 1. Provision of comprehensive care, HIV prevention, . Number of functional HTA site with skilled human resource. 3 CNP and 3 ENs treatment and support for people infected and HIV AIDS assigned to HTA affected by HIV and AIDS at the HTA sites. . To have functional HTA teams at the three sub-districts. Institutions to priorities CONDITIONAL teams. ( 1 for functionality of these teams as budgets are generally allocated. Orientation GRANT (Applicable and training for the HTA teams to ensure smooth running of the programme. Estcourt,1 for to all Districts) Indaka and 1 for Okhahlamba. . Number of HTA teams with dedicated transport. 3 Mobile Clinics . Funding is allocated at the District Office for the purchasing of a dedicated for HTA teams HTA vehicle \(R700 000\0, however the purchasing of the vehicle was to take place at a Provincial level. The procurement of quality gazebos for outreach programmes, and or health days for teams to make use of. 2. HIV/AIDS STI – Condom distribution To secure the services of service providers for the distribution of condoms in grey areas and to increase the target of condom distribution within Uthukela District. To try and secure the appointment of a support officer for the issuing /distribution and monitoring of condom distribution with contracted service providers and to ensure the sustainability of the distribution of condoms even if there is no contracted service provider. Identification of additional grey areas for condom distribution per sub-district. Capacitate HCW on STI Prevention and management. X 50 condo cans medium and 50 Procure condo cans and wooden pallets for storage areas. –Procure female and jumbo size. male dildos. Procure educational material. 3. HIV/AIDS - MMC The District to ensure that MMC roving teams are appointed. MMC Roving 163 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Name of conditional Purpose of the grant Performance indicators Indicator targets grant (extracted from the Business Case prepared for each Conditional Grant for 2015/16 To renew contracts of MMC Traditional Co-ordinators (each sub-district - 5) on a Team consists yearly basis . of\; 1 x Doctor, 2 To procure MMC food packs for the camps. x PNs and 2 x EN’s. Continuous procurement of medical/surgical equipment for the performance of male medical circumcisions and to ensure targets set attainable. Uthukela need to have four fully To procure 200 sponge mattresses for the camps. fledged MMC Training for the MMC Traditional Co-ordinators and health workers. roving teams, i.e. To procure a dedicated vehicle for the MMC roving teams (4 x 4 Double Cab). at Ladysmith, Gazebos x16 (4 per team) 16 foldable tables and 32 foldable chairs. train |Estcourt, community leaders, CCGs and School Health teams and THPs. Emmaus and St. Chads CHC. 4. HIV/AIDS Home Based Care – CCG’s To increase the number of CCGs in Uthukela District., from 707 in the 2014-2015 Uthukela business plan to 730 CCGs in the new financial year 2015-2016 so as to currently have accommodate the uncovered areas e.g. Indaka and Imbabazane sub-districts. 708 CCGs To link the CCGs to the mother institutions / clinics for improved supervision and to contracted allocate the budget accordingly. however the business plan for Procure home based care kits and replenishment of the kits for the CCGs. 2014-2015 allows for 707. 5. HIV/AIDS ARV Therapy NIMART Training to be conducted in Uthukela District. 80% of Printing of guidelines. Professional nurses trained on To have dedicated tracer teams for ARV clients and to secure transport for such NIMART teams. Trainings to empower clinicians on adherence. 6. HIV/Aids Programme Management To fill the post of Admin Support for the HAST Unit in the District Office. 1 Admin and M&E Finance needed for the HIV/Aids conditional grant in Uthukela District. support officer appointed HAST Co-ordinators required per sub-district. Printing of IEC material. 164 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Name of conditional Purpose of the grant Performance indicators Indicator targets grant (extracted from the Business Case prepared for each Conditional Grant for 2015/16 7. HIV/AIDS HCT PICT training for all nursing categories to strengthen HCT uptake in facilities,. 90% of Nursing Procurement of test kits. Procure HCT barometers. categories trained on PICT 8. Skills development and management on HAST Number of human resources trained. Programmes. Number of support visits conducted. 22. PUBLIC-PRIVATE PARTNERSHIPS (PPPS) AND PUBLIC PRIVATE MIX (PPM) Table 71: (NDoH 38): Outputs as a result of PPP and PPM 165 | Page UTHUKELA 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 1. Not applicable to district 2. Partner’s forum revived and quarterly meetings have been set. Memorandums of agreement will be sought from all and reporting will improve by the development of partner data collection tools to all partners working in Uthukela. 166 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 25. PART E: INDICATOR DEFINITIONS Table 72: indicator definition 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. 167 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 PART F: ANNEXURES ANNEXURE 1 REGIONAL HOSPITAL SUB-PROGRAMME 4.1: REGIONAL HOSPITALS 5.1 OVERVIEW Ladysmith Provincial Hospital is a gazetted as a Regional Hospital though still renders some level l services due to lack of a district hospital in Emnambithi and Indaka Sub- district. Though there is a CHC (Community Health Centre) which is not fully optimized due to lack of (scarce skill) critical staffing namely doctors, nurses and rehabilitation health professionals, also accommodation playing a pivotal role in recruitment of this scarce skills and its non-availability creates a challenge Ladysmith Provincial Hospital does not form part of programme 2, though rendering some level I service mentioned above yes this impact negatively on PHC headcount due to non-adherence of referral policy given the fact that Gateway Clinic is within 500m walking distance to Casualty/MOPD and Walton Clinic 3km. A conscious decision has to be taken to make Gateway clinic 24hrs clinic in order to thrash the issue of referral pathway policy and also identify 2-3 clinics to render 24 hour services to address the issue of accessibility, referral policy and PHC headcounts and PN/ patient ratio, this reduces spending in LPH on level 1 clients, thus Ladysmith Provincial hospital will focus on rebuilding its status as a regional hospital. HIGH COST DRIVERS FOR LADYSMITH PROVINCIAL HOSPITAL Medicine Implants Groceries (PCK) Surgical/ medical supplies Medical and allied: Equipment R5000 Main reason for overspending under these items is because of 2013/14 accruals Way forward will be to identify items where there is under spending to offset current overspending (virement of funds) 2014 Available budget: R414 076 990.00 Commitment: R408 437.76 Expenditure to date: R218 908 127.75 Available budget: R194 760 424.49 % to date: 52.87% Availability of drugs: no challenges of note 168 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Budget: under budgeting for vaccines as half yearly expenditure trends indicate over expenditure R17 million business plan for 2014/2015 was submitted Only 3.5 million was approved There was a further cut on maintenance budget All planned projects have been stopped Only services and day to day operations are continuing Last financial year projects Cupboards – stopped – poor quality material Sluices – stopped – company turned down the offer – underquoted Clarifiers/Water heater renovations – continuing Table 73: Customised performance Indicators – Regional Hospital Indicator Data Source Type Audit actual performance Estimated Medium Term Targets Provincial Performanc Target e 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 1. Average length of DHIS Days 5.0 4.1 5.2 5.5 5.5 5.7 6.0 5.3 stay – total Inpatient days-total DHIS/ No 108 583 115 732 115 6561 118 638 120 277 125 088 130 092 1 854 385 Midnight Census Day Patients DHIS/ No 7 087 5 750 8 578 9 340 9 436 10 379 11 417 46 863 Midnight Census Inpatient Separations DHIS No 29 720 28 997 23 094 22 576 23 094 23 094 23 094 358 174 calculates 2. Inpatient bed DHIS Rate % 69.4 72.5 72.4 74.4 75.3 78.3 81.4 78.6 utilisation rate – total Inpatient days-total DHIS/ No 108 583 115 732 115 6561 118 638 9 436 10 379 11 417 1 854 385 Midnight Census 169 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Day Patients DHIS/ No 7 087 5 750 8 578 9 340 23 094 23 094 23 094 46 863 Midnight Census Number of usable beds DHIS/ FIO No 5 376 5 376 5 448 5 448 5 448 5 448 5 448 2 388 726 3. Expenditure per BAS/DHIS R R1348 R1765 R 1869 R2 380 R2 350 R2 340 R2 340 R2 342 patient day 7 equivalent (PDE) Total expenditure BAS R 308 986 266 352 203 185 395 395 631 434 274 922 447 343 650 400 895 820 360 806 940 7 582 087 Regional Hospital Patient day equivalents DHIS No 229 266 278 417 211 510 182466 190 359 171 323 154 191 3 236 980 calculates 4. Complaint DHIS % 71.3 % 63.2% 93% 100% 100% 100% 100% 75 % resolution within 25 working days rate Total number of Complaints No 48 31 40 28 - - - -- complaints resolved register within 25 days in reporting period Total number of Complaints No 70 49 43 28 - - - - complaints received register during the same reporting period 5. Number of mental DHIS No 0 0 0 1 1 1 1 health teams calculates established 6. Patient experience DHIS % 90% 90% 85% 82.5 85 85 85 85 5 of care rate calculates (Annual) Total number of users PSS results No 72 72 68 198 204 204 204 - that were satisfied with 7 For planning purposes, budget for NPI’s, Fleet, NHLS, registrars, radiological services, HTS, JME and Flying Doctors has been included in the budget projections 170 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 the services they received The total number of PSS results No 80 80 80 240 240 240 240 - users that participated in Client Satisfaction Survey 7. % of Regional QA database % Not reported 100 100 100 100 100 100 100 % Hospitals that have conducted gap assessments for compliance against the National Core Standards Regional Hospitals QA No - 1 1 1 1 1 1 13 conducted gap assessment assessment for records compliance Regional Hospitals total DHIS No - 1 1 1 1 1 1 13 calculates 8. Proportion of QA database % Not reported Not reported 0 0 100 100 100 35% Regional Hospitals assessed as compliant with the Extreme Measures of National Core Standards Regional Hospitals fully QA No - - 0 0 1 1 1 5 compliant (75%-100%) to assessment all extreme measures of records National Core Standards Regional Hospitals total DHIS No - - 1 1 1 1 1 13 calculates 171 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 74: District Objectives and Annual Targets for regional Hospital Strategic Indicator Data Type Audited /Actual Performance Estimated Medium Term Targets Provincial Objectiv Source Performan Target e ce Stateme 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2015/16 nts 1. Delivery by caesarean section DHIS % 21.2% 26.9% 29.1 32.0 30.6 32.1 33.7 39% rate calculates Number of caesarean sections DHIS/Deliver No 1283 1494 1 596 1 924 1 805 1 966 2 141 30 681 performed y Register Total number of deliveries in the DHIS/Deliver No 6037 5651 5482 5862 5 900 6 124 6 354 78 621 facility y Register 2. OPD headcount - total DHIS/OPD No 324 431 454 161 245 587 154 084 171 911 150 338 120 338 3 241 743 tick register 3. OPD headcount new cases not DHIS/OPD No 5 102 16 035 17 046 13 978 11 825 10 236 8 541 393 135 referred tick register Maintenance required: Renovate wooden shelves/cupboards in wards, casualty and OPD Replace sluice basins and drain pipes Repair septic tanks in the clinics Repair roof and ceilings in the clinics Replace uninterrupted power supply (UPS) in ICU Upgrades ward E3 to proper Psychiatric Ward Repair wood work in the walkways and neaten computer wires Renew crèche fence Repair swimming pool Privacy dry wall partitions installation 172 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Table 75: Regional Hospital Priority Areas for the MTSF 2014- 2019 Challenge Management of challenge • Patients bypass clinics& take chronic medication from • Employed PHC supervisors to ensure availability of the hospital and low clinic utilization staff and medication in the clinics • High prevalence of injuries& MVAs • Employed PHC manager • Large cataract surgery backlog • Planning to employ a specialist in Emergency medicine and a clinical manager • Employed a full time ophthalmologist • Overcrowding in OPD and long waiting times • Down refer patients to clinics and introduce an • Lack of accommodation for doctors leading to inability appointment system for improved referral system to retain staff • Applied for more accommodation and relaxation • Poor staff attitude and inappropriate uniform of housing rules for remote hospitals • Insufficient expenditure per patient day equivalent • Purchase white coats for doctors and proper work (R1073.60 vs R2314 target) Down refer patients to clinics ID and introduce an appointment system for improved referral system Improved quality of health care • Inadequate accommodation for staff. • Unavailability of white coats for doctors. • High prevalence of HIEs and malnutrition • Employed a sessional internal medicine specialist to • High malnutrition rate manager the medical wards • Congested medical ward due to AIDS • Employed a full- time ophthalmologist to clear the • Congested HIV clinic cataract backlog • Patient resistance to clinic down referral for chronic • Implement a tracing system to follow up on disease discharged malnutrition patients. • High backlog of cataract surgery • Down referral of stable HIV clients to PHC. • HCT backlog • Implementation of ICDM. • Implement PICT to address HCT. • Casualty stretchers non-repairable and no mobile X-ray • Procurement plan sent to DDG via HTS and ultrasound for trauma • Office allocated to HTS for a hospital based • No local HTS technician and long waiting time for technician equipment repair HIV & AIDS and Tuberculosis • CDC and TB clinic far apart from each other resulting in • Look at a system to implement an integrated service prevented and successfully patients spending a long time at the Hospital. delivery for ART patients. managed 173 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 Priority Areas for the MTSF 2014- 2019 Challenge Management of challenge • High maternal mortality rate • Purchased CTGs and employ more senior MOs. • High child mortality rate • ESMOE training and outreach to district hospitals and • High incidence of hypoxic ischemic encephalopathy clinics Maternal, infant and child mortality • Reduce malnutrition by interventions from dietetics reduced unit • Initiated a formal inquiry to be led by the Chief specialist from Greys • Strengthen outreach to referring district hospitals Improved human resources for • Casualty is run by one medical officer and has no • Unfreezing and creation of post sent to Dr health Accidents& emergency specialist Mansvelder • No nurse with A&E specialty. Shortage of doctors leading • Africa Heath Placement and Aurum given a list of HR to poor supervision of interns in O&G and surgery requirements for recruitment • Pharmacy without a manager and high overtime in • Head hunting in Namibia and DRC pharmacy due to lack of staff • No HOD`s in surgery, orthopedics, ophthalmology and A&E Improved health management and • ATLS not done by casualty MOs • Forms distributed to nurses and MOs for ATLS leadership Table 76: Regional Hospital challenges Output Challenge Management of challenge Improved health facility planning and • No gynecology ward • Dry wall partitioning infrastructure delivery • Lack of space for filling leading to lost files and long • Present improvement plan to infrastructure at waiting times head office • OPD and the old building of the hospital need revamping • No accommodation for doctors • Mothers lodge not yet functional • Congested boarder mothers prefab • Labour ward too far from theatre •Lack of office space 174 | Page UTHUKELA DISTRICT HEALTH PLAN 2015/16 • OPD overcrowding due to clinic bypassing • Outreach to communities in halls, etc. Re-engineering of Primary Health Care • WBOT appointed and fully functional. Health care costs reduced • No supervisory level staff at Finance section as from 1 • Filling of post is critical November 2013 • Financial management training to be • Lack of knowledge with current staff in finance office prioritized due to high staff turnover. • District finance manager to support/ • Huge backlog of commitments and payments not intervene captured on BAS, reflecting negatively on the expenditure report and estimated for MTEF due to staff turnover and no supervisory staff. Annexure 1 Regional Hospital Annexure 2 NGO \ Partner plan Annexure 3 See attachment – donation land FPS and Limit Hill Annexure 4 See attachment – Transport request Annexure 5 Draft STP 2015-2025 and 10 year Maintenance plan Annexure 6 HR Plan 2012-2015 – the new plan for HR only due by June 2015.02.26 The Work Skills Plan not yet available for new financial year. 175 | Page