Presentation on the Key Challenges Experienced in the Provincial Health Sector

1. Presentation on the Key Challenges Experienced in the Provincial Health Sector Presented by Dr Benjamin M. Malakoane Member of Executive Council: Department of Health Free State Province 26 May 2015 at 10:00 am

2. TABLE OF CONTENTS • Integrated Management • Pharmaceutical Services • Emergency Medical Services • Infrastructure and Facilities • Information and Communication Technology • Primary Health Care Re-Engineering

3. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Key Challenges CoE / Goods & Services conflict • CoE has been increasing from 57% in 2009/10 to 64% in 2013/14, leading to crowding out of Goods & Services. • Due to fiscal discipline initiated during 2014/15, CoE decreased by 1%. This resulted in service delivery pressures emanating from lack of appointment of personnel. Economy, Efficiency & Effectiveness

4. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Integrated Program Management Budget Allocation Goods & Services from 2009/10 to 2017/18 • Whilst the budget has been nominally increasing, the inflation has impacted negatively on the purchasing power. • The increase in accruals is demonstrative of the inadequate budget allocation. • Accruals have a negative ripple effect on the Cash flow of the ensuing years. Economy, Efficiency & Effectiveness

5. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Integrated Program Management 2014/15 PRELIMINARY PERFOMANCE Economy, Efficiency & Effectiveness

6. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Integrated Program Management ACCRUALS FSDoH operated during 2014/15 at 70% Capacity of Goods and Services Economy, Efficiency & Effectiveness

7. The Health System Governance & Accountability [HSGA] Model Effects of the Challenges: Pharmaceutical Services Leadership, Governance, Finance, HR, Info. Management & Change Management I. UNAVAILABILITY OF MEDICINES • Inadequate funding for pharmaceuticals • Due to declining provincial allocation and increasing price of medication, including the increasing patient numbers, the allocation for medicine, despite being ring-fenced and increasing in nominal value, the allocation for medicine continue to be crowded-out by price increase s of medication and Compensation of Employees. On average pharmaceutical price inflation has been between 20 and 24% whilst the budget increase from 2011/12 through 2013/14 has been 8%, 24% and 14%. During the same period, goods and services budget has been increasing by 3%, 11% and 15% overall. • Delay in paying suppliers due to cash flow constraints leads to suspensions of accounts • Delay in arrangements of pharmaceutical contracts • Due to change in responsibility in the arrangement of pharmaceutical contracts from National Treasury to NDoH Pharmaceutical Services, a delay was experienced in arranging contract. Department was forced to buy out on quotations which affect the lead time. • The stock level at Medical Depot is far less than demand from facilities • Currently the stock holding level is approximately 60% due to cash flow constraints and low capital trading. Economy, Efficiency & Effectiveness

8. The Health System Governance & Accountability [HSGA] Model Pharmaceutical Services Leadership, Governance, Finance, HR, Info. Management & Change Management Pharmacists per district vs norm recommended by WHO Economy, Efficiency & Effectiveness

9. The Health System Governance & Accountability [HSGA] Model Pharmaceutical Services Leadership, Governance, Finance, HR, Info. Management & Change Management Departmental Distribution of Pharmacists: Economy, Efficiency & Effectiveness

10. The Health System Governance & Accountability [HSGA] Model EMS [Pre & Inter Hospital Transfers] Leadership, Governance, Finance, HR, Info. Management & Change Management • Ageing fleet: Fleet increase vs Replacement • Due to budgetary constraints, the rate of replacing emergency vehicles is low. Of the 186 ambulances at the disposal of the department, 123 are over 3 years of age • National norm requires 270 rostered ambulances (1 ambulance: 10 000 population). There is currently 136 rostered ambulances with a shortage of approximately 150 ambulances. • The above scenario leads to: • Fleet accumulate high mileage due to long distances travelled, on average ambulances travel more 100 000km per year • Patient Transport travel more than 170 000km per year • Only 76% of towns are having dedicated EMS services • More than 11 000 patients are being referred to specialist treatment in Mangaung from peripheral areas of the Province Economy, Efficiency & Effectiveness

11. The Health System Governance & Accountability [HSGA] Model EMS [Pre & Inter Hospital Transfers] Leadership, Governance, Finance, HR, Info. Management & Change Management • Ageing fleet: Fleet increase vs Replacement (Continued) • To procure approximately 150 more ambulances will require: • Capital Repayment (3 year lease basis) • Per 1 vehicle R17 000 pm • 150 x 12 months = R30.6 m • Km travelling (operational): • ave. 100 000 p.a. x 150 x R3.50 = R52.5 m • Total = R83.1 m Economy, Efficiency & Effectiveness

12. The Health System Governance & Accountability [HSGA] Model EMS [Pre & Inter Hospital Transfers] Leadership, Governance, Finance, HR, Info. Management & Change Management Population vs Resources required Economy, Efficiency & Effectiveness

13. The Health System Governance & Accountability [HSGA] Model EMS [Pre & Inter Hospital Transfers] Leadership, Governance, Finance, HR, Info. Management & Change Management Costing for Ambulances Human Resources Economy, Efficiency & Effectiveness

14. The Health System Governance & Accountability [HSGA] Model EMS [Pre & Inter Hospital Transfers] Leadership, Governance, Finance, HR, Info. Management & Change Management -Expenditure Comparison per Year Economy, Efficiency & Effectiveness

15. The Health System Governance & Accountability [HSGA] Model Infrastructure and Facilities Leadership, Governance, Finance, HR, Info. Management & Change Management Maintenance Backlog Economy, Efficiency & Effectiveness

16. The Health System Governance & Accountability [HSGA] Model Infrastructure and Facilities Leadership, Governance, Finance, HR, Info. Management & Change Management Hospital, CHC and Clinics Needed (Basis: Service Transformation Plan and 25 year Infrastructure Plan) Economy, Efficiency & Effectiveness

17. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Infrastructure and Facilities Tertiary & Central Hospitals PELONOMI : KEY CHALLENGES (Revitalization Organizational Development) New Adult ICU High Care Staffing Needs Economy, Efficiency & Effectiveness

18. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Infrastructure and Facilities PELONOMI : KEY CHALLENGES (Revitalization Organizational Development) Tertiary & Central Hospitals Economy, Efficiency & Effectiveness

19. The Health System Governance & Accountability [HSGA] Model Information and Communication Technology Leadership, Governance, Finance, HR, Info. Management & Change Management • Limited bandwidth speed in hospitals (currently running with 64k/128k) and no data connectivity at clinics to implement systems R 50m • ICT equipment is dilapidated (i.e. servers, switches) R20m • Need to implement integrated Patient Management Systems (i.e. Patient Records Systems, Computerised Maintenance Management System, PACS/RIS, Intergrated Revenue System) R125m • In ability to implement Business Continuity and Disaster Recovery (UPS to ensure continuity even during Eskom load shedding) R5m (Annually Cloud Hosted) • Need to recruit skilled ICT personnel and increase capacity to cope with the increasing expectation R2,430m (Critical Posts incl. Security and IT Governance) Economy, Efficiency & Effectiveness

20. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Primary Health Care Re-engineering Ward Based Outreach Teams • The FSHoD cannot reach the target of school health coverage due the shortages in School Health Teams. This also affects the implementation of HPV campaign. • Challenges faced are on expanding the existing Ward Based Outreach Teams from 46 to 85.. The team comprises of a professional nurse and six (6) Community Health Workers. • Cost for the professional nurses is R7.2mill p.a. • This is to address APP target, for full provincial coverage the actual need is 560 teams. • CHW receive stipend of R1 800 per month and have not been appointed due to professional nurses not being appointed • Challenges on expanding School Health Teams from 21 to 63. The cost for the expansion is R19 mill p.a. In the current year, only 9 additional teams will be added. Quintile 1 and 2 Schools 2014/15 Economy, Efficiency & Effectiveness

21. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Primary Health Care Re-engineering District Clinical Specialist Teams • The province is also having a challenge of recruiting District Clinical Specialist. Currently the teams are not complete. There is a shortage of 12 specialists. • To appoint specialist it will cost R20.76 mill p.a. Economy, Efficiency & Effectiveness

22. The Health System Governance & Accountability [HSGA] Model Leadership, Governance, Finance, HR, Info. Management & Change Management Burden of Disease • The burden of disease has increased largely due to HIV/AIDS and TB, with the result that morbidity and mortality in pregnant women and children have increased. The HIV prevalence among antenatal clients has increased from 30.6% in 2010 to 32.5% in 2012. Trauma due to accidents and violence continue to put more pressure on the services. • The demand for health services has increased at all levels of care putting a strain on the resources (Human and material) that are already limited. • 82.9% ( 2 286 392/2 757926) of the Free State population is uninsured and therefore access public health services. • Almost 60% of the provincial population (1,404, 549 people) is in the group 15 – 44 years, which is in the child bearing age. Economy, Efficiency & Effectiveness

23. THANK YOU