Project Khaedu SMS Action Learning Programme Lower Umfolozi Health District - preliminary findings

1. Project Khaedu SMS Action Learning Programme Lower Umfolozi Health District - preliminary findings 4 November 2005 Empangeni health district v2

2. Agenda • Executive summary • Situation • Complications • Some suggestions Caveat: We have only been here 4 days and could easily have made a mistake or misinterpreted some data…we apologise in advance Empangeni health district v2

3. Executive summary and key message The clinics, in general, appear to be under-managed due to resource constraints and organisation structure deficiencies (out of the control of the clinics), which have not been reviewed for many years The clinics within the district have inherited an organisational structure as well as the assets from the former government that make optimising utilisation difficult. However, better planning and co-ordination with hospital management, improved communication and small incremental investments could make a significant difference to service delivery. Empangeni health district v2

4. Situation The clinics, in general, appear to be under-managed due to resource constraints and organisation structure deficiencies (out of the control of the clinics), which have not been reviewed for many years Situation • Apparent shortage of key professional staff, although old establishment is not indicative • No agreed organisation structure for the clinics • Facilities cramped in some clinics (e.g. Thokozani) • Unpleasant waiting conditions for patients • Not enough consulting rooms • Maintenance at Thokozani problematic • Employee morale appears patchy • Training and career progression available for professional staff, but little for e.g. GA’s • Lack of support from local police • No implementation of PMDS while District addresses backlogs • Inconsistency between Persal report and management information • Overall budget overspend as of 30/09/05 • Expenditure reflects overspending in overtime which has not been practically utilised • Prioritisation of crucial items lacking in budget allocation Empangeni health district v2

5. Despite difficult working conditions, staff dedication is commendable • Staff willing to assist in any emergency even if off-duty • Staff willing to risk their lives despite life-threatening conditions, e.g. Khandisa • Staff coming in early at work and immediately attending to patients who have themselves arrived early, e.g Dlangubo • Staff not discouraged by unavailability of working tools and still commit themselves to service delivery, e.g. General assistants • Staff willing to take over responsibilities that are not necessarily their responsibilities due to shortage of staff, e.g nurses doing administrative clerk work Empangeni health district v2

6. Thokozani Clinic is the largest in the district, assisting almost 14,000 patients per month Average number of patients per month 15,000 13,992 Patients under age of 5 10,000 Patients over age of 5 5,778 5,000 2,913 0 Thokozani Khandisa Dlangubo Empangeni health district v2

7. Monthly fluctuations in volume of patients are minimal Average number of patients per month (total for 3 clinics) 25,000 22,880 22,765 21,994 Patients under age of 5 20,000 15,000 Patients over age of 5 10,000 5,000 0 July August September Empangeni health district v2

8. The disparity in work load between peri-urban and rural clinics is significant… Empangeni district Ulundi district Urban Rural / semi-rural Empangeni health district v2

9. …leading to congestion and long wait times at high-volume clinics Thokozani Clinic Empangeni health district v2

10. Although the clinics are well-built… Empangeni health district v2

11. …facilities in some clinics are poorly maintained… Thokozani Clinic Empangeni health district v2

12. …while computer equipment is under-utilised New PC, but no training and no software…never used Empangeni health district v2

13. Key resources are critically short • Professional staff, despite constant recruitment attempt • Shortage of support staff including attrition posts, e.g. Admin clerk that passed away in Dlangubo • Lack of equipment, some remain un-replaced and not upgraded • Long outstanding requirement for major maintenance and renovation, e.g. Thokozani • Conversion of status of the clinic not commensurate with resource provision Empangeni health district v2

14. Vacancy rate appears low, but the establishment has not been reviewed for many years Source: Persal establishment report – may not be consistent with reality on the ground Empangeni health district v2

15. Patients are unhappy with time taken and availability of medicine, but happy with staff Very good Good OK Poor V. poor Empangeni health district v2

16. What are patients saying? “I am happy about the service at Khandisa. Even though all the services are not available every day, they tell me about that. They give counseling for any health-related issues that I am facing” “Although the clinic hours are convenient, it would be better if the clinic was open 24-hours”(Dlangubo) “Sometimes medicine is not available and we have to come back again and pay double transport” “When we come to the clinic, we take a bus but if we finish late, we have to take a taxi home which is more expensive” “We are sometimes left in the consulting room for up to 30 mins waiting while the sister is busy with something else” “Nurses take very long breaks” “I was seriously ill…could hardly walk…but nobody attended to me. I eventually left without being attended to. Cards were not available Empangeni health district v2

17. Staff are most unhappy with quality of facilities Very good Good OK Poor V. poor Empangeni health district v2

18. What are staff saying? “The patients do not have to wait long here – as they come in, we see to them” (Khandisa) “We do not have equipment for cleaning or laundry. We use our own hands to mop and there is no bucket system. Management has been contacted about this, but nothing has been done” “We wish we had a washing machine” “We don’t have enough space here (Thokozani) and when it rains there is not proper shelter and we have to move patients inside, causing severe congestion. We have been promised renovations, but nothing has happened” “We have a computer but have never been trained how to use it” “There is no clerk here and we have to rotate staff around to compensate” “In the PHC meeting, only the PHC manager, but never the Finance manager” “I have been here 19 years and I have never had any training” Empangeni health district v2

19. Dlangubo Clinic has the largest variance of actual spend versus budget… -5% variance -3% variance -17% variance 103 41 132 Thokozani Khandisa Dlangubo Empangeni health district v2

20. Negative variances are made up as follows: Empangeni health district v2

21. Complications The clinics, in general, appear to be under-managed due to resource constraints and organisation structure deficiencies (out of the control of the clinics), which have not been reviewed for many years Situation Complications • Shortage of key professional staff • No agreed organisation structure for the clinics • Facilities cramped in some clinics (e.g. Thokozani) • Unpleasant waiting conditions for patients • Not enough consulting rooms • Maintenance at Thokozani problematic • Employee morale appears patchy • Training and career progression available for professional staff, but little for e.g. GA’s • Lack of support from local police • No implementation of PMDS while District addresses backlogs • Inconsistency between Persal report and management function • Overall budget overspend as of 30/09/05 • Expenditure reflects overspend in overtime which has not been practically utilised • Prioritisation of crucial items lacking in budget allocation • Lack of coordination of activities between the hospital and the clinics e.g. recruiting of staff nurses • Clinics perceive that they have little input into decision making • Remuneration (in some cases) does not appear to match level of responsibility • High span of control for sister-in-charge • Vacant posts take long to get filled, even for non-professional staff e.g. clerks • Further delays exacerbated by faulty equipment e.g. Thokozani • No simultaneous treatment of mother and child • No clearly-displayed direction chart showing process for the patients • Centralisation of finance and human resource functions Empangeni health district v2

22. At certain clinics, process for patients is long, with extended wait times 30mins 5hrs 10mins Patient enters clinic Registration in manual book, card issued Waiting in queue Consulting with Professional nurse 1hr 1hr 1hr Measure BP, Urine testing, Weighing Join queue for TB consulting Get medication and leave Back to queue for consulting room Get medication and leave 5,40hrs max 1hr Get medication and leave 6,40hrs max 7,40hrs max Empangeni health district v2

23. However a better process, that is shorter and more efficient, was found in some clinics 30mins 2hrs 10mins Patient enters clinic Registration,measure BP, weighs, check temp Waiting in queue Consulting with Professional nurse 1hr 1hr 1hr Immunisation, wound dressing, injection Join queue for TB consulting Get medication and leave Get medication and leave Get medication and leave 2,40hrs max 3,40hrs max 3,40hrs max Empangeni health district v2

24. Some Suggestions The clinics, in general, appear to be under-managed due to resource constraints and organisation structure deficiencies (out of the control of the clinics), which have not been reviewed for many years Situation Complications Suggestions • Complete organisational structural review of clinics • Including level & remuneration of sister-in charge • Some functions & delegations for recruitment and selection be decentralized to districts • Procurement procedure to be reviewed and to incorporate room for input and structured feedback • Look at best practice in record management and maximise utilisation of available computers • Misallocations on the financial transactions must be journalised before issuing of expenditure reports • Implementation of an efficient Performance Management and Development System • Shortage of key professional staff • No agreed organisation structure for the clinics • Facilities cramped in some clinics (e.g. Thokozani) • Unpleasant waiting conditions for patients • Not enough consulting rooms • Maintenance at Thokozani problematic • Employee morale appears patchy • Training and career progression available for professional staff, but little for e.g. GA’s • Lack of support from local police • No implementation of PMDS while District addresses backlogs • Inconsistency between Persal report and management function • Overall budget overspend as of 30/09/05 • Expenditure reflects overspend in overtime which has not been practically utilised • Prioritisation of crucial items lacking in budget allocation • Lack of coordination of activities between the hospital and the clinics e.g. recruiting of staff nurses • Clinics perceive that they have little input into decision making • Remuneration (in some cases) does not appear to match level of responsibility • High span of control for sister-in-charge • Vacant posts take long to get filled, even for non-professional staff e.g. clerks • Further delays exacerbated by faulty equipment e.g. Thokozani • No simultaneous treatment of mother and child • No clearly-displayed direction chart showing process for the patients • Centralisation of finance and human resource functions Empangeni health district v2

25. Other suggestions (finance) • Monthly cash flow report • Misallocations needs to be corrected within a particular month • Spend within the budget e.g. overtime • Consider allocating a resource (with financial knowledge) to assist with understanding of finances at a clinic level • Consider revising budgeting process • Clinics to be given opportunity to input before finalisation of budget • Review previous spending trends to improve budget • Expenditure report must also show the projected figures • Urgently review the maintenance issue at Thokozani Clinic and review the process for pro-active maintenance for clinics in general Empangeni health district v2

26. The supervisors could potentially add more value • Currently role includes: • ‘Inspecting’ clinics monthly • Counter-signing supply forms and pass to PMSC • Co-chair monthly meetings • Getting quotations on receipt of motivation forms from clinics for procurement of equipment • Role could be redefined to create a more fulfilling, value-adding management echelon • More focus on active management versus mere “coordination” • Play bigger role in issues of financial management (but need training) • More interaction with staff and more hands-on at the clinic coal face • Take more responsibility in Human resource functions regarding clinics, including decision-making Empangeni health district v2

27. The organisation structure could be reviewed (potential provincial issue) • Sister-in-charge has very broad span of control and responsibility, but is not compensated for this in terms of salary or level • Leads to poor morale of professionals in this position due to high work loads Consider raising the level of this position Empangeni health district v2

28. A more efficient people-friendly process should be considered 30mins 30mins 1hr Patient enters clinic Queue and registration by Admin clerk Measuring of BP, weighing, temp check Consulting queue and actual consultation 1hr 30mins 30mins Immunisation, wound dressing, injection TB consulting Get medication and leave • Note • Clerk will relieve nurses to concentrate on their work • Issuing colour cards based on patient requirements • Process of immunisation, wound dressing, injection can be faster with Staff nurse concentrating on that • Each step in process should have a designated official • Emergency cases to be promptly responded to Get medication and leave Get medication and leave 2,hrs max 2,30hrs max 2,30hrs max Empangeni health district v2

29. There appears to be enough space to expand, to alleviate capacity constraints at some clinics… Khandisa Clinic Empangeni health district v2

30. Many thanks for hosting usSiyabonga Kakhulu Empangeni health district v2