Action Learning Pilot Programme

Action Learning Pilot Programme Project Khaedu Ulundi Health District - preliminary findings 28 October 2005 Ulundi health district v1

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 Ulundi health district v1

Executive summary and key message The district seems to be largely in control of its delivery with high relative standards. However there are opportunities to improve planning, coordination and communications to make best use of available (scarce) resources, particularly professional skills The District has inherited a legacy of misplaced assets that make optimising utilisation difficult. However, better planning and coordination with other parties, improved communication and small incremental investments could make a significant difference to service delivery Ulundi health district v1

Surprisingly, for such a rural area, many things seem to work well in the District • Patient referral system seems to be working quite efficiently at the hospital (helped by geographic position, remote from Ulundi) • Overall cleanliness of facilities is good given age of certain facilities at hospital • Drugs seemed available at both clinic and hospital level (although potential for more chronic dispensing at clinics) • Key statistics are being kept up to date • Staff seem friendly and well disposed towards patients despite severe shortages – staff will cover for each other, even on day off • Patient queues are relatively short and well organised Ulundi health district v1

Patient referral system to the hospital is working well…but greatly helped by the hospital being 10km from Ulundi Gateway clinic patients Jan-Oct 2005 Ulundi health district v1

Situation The district seems to be largely in control of its delivery with high relative standards, however there are opportunities to improve planning, coordination and communications to make best use of available (scarce) resources, particularly professional skills Situation • Professional resources in short supply, particularly at supervisor level • Some clinical nurses stretched and under leveraged, others under utilised • Legacy of misplaced physical assets results in patchy utilisation • Small incremental, but highly leveraged, investment opportunities seem to be ignored • Some basic requirements to do the job e.g. appropriate vehicles for PHC managers, are not available • Systems manager seems overloaded at the hospital • Outsourcing process appears poorly coordinated • Patients are happy with actual treatment but unhappy with waiting times • Staff are generally neutral Ulundi health district v1

Key resources are critically short… Ulundi health district v1

…particularly at supervisor levels Supervisor Posts Ulundi health district v1

The disparity in work load between peri-urban and rural clinics is significant… Average patients seen per nurse equivalent N.B. Gateway has clerical support Ulundi health district v1

…and nurses are under leveraged at some rural clinics “We spend too much time on administration” “Without the student nurses and general assistants we wouldn’t be able to do all the administration” Ulundi health district v1

Legacy of misplaced assets - beautiful but under utilised Wela clinic… Ulundi health district v1

…stuck miles from anywhere… Wela Clinic More logical placement by schools Ulundi health district v1

…versus at a community traffic point… Schools, shop, pay point, taxi terminus Ulundi health district v1

… as a result Wela is under utilised relative to physical capacity and original budget Staffing Budgets Ulundi health district v1

Small incremental, but highly leveraged investments, have been largely ignored E.g. a computer for records… PRELIMINARY Annual Costs Cost to Replace lost Files Ulundi health district v1

Rural roads can be very bad… Ulundi health district v1

..and punishing on ordinary cars… Ulundi health district v1

…but some basic tools to do the job are missing E.g. additional basic high ground clearance vehicles for PHC management “PHC supervisors receive no car subsidy, despite years of trying to get one” “…who wants to risk their own vehicle on these roads” “we are told only 3 litre Isuzu double cab 4X4s are available for contract which are out of our budget” Ulundi health district v1

Current single PHC dedicated vehicle to cover 11 clinics Ulundi health district v1

Registry Telecom Trans port Grounds Cleaning Porters Mortuary Finance and Systems manager mandate at the hospital seems very broad F&S Manager Security Cater -ing Laundry General Admin Info Services Expen diture& budget Accoun ting & revenue Procur Ment & stores Asset control Patient Admin 187 staff in total out of 445 Ulundi health district v1

Outsourcing process appears poorly coordinated “We outsourced catering and security but we still have the original staff on our books” “Outsourced contract is not available at the hospital and we cannot certify the payment or service level agreements” “The contract has been rolling on a month-to-month basis for more than 3-years” “The outsourced catering is of poor quality, we never eat there” Ulundi health district v1

Hospital patients are somewhat unhappy with wait times at the hospital, but are happy with the quality of service, cleanliness and skills of staff… Very good Good OK Poor V. poor Ulundi health district v1

Clinic patients are somewhat unhappy with wait times but are generally quite happy with the quality of service, cleanliness and skills of staff… Very good Good OK Poor V. poor Ulundi health district v1

Staff have issues with career progression, the PMDS and quality of facilities but are relatively happy Very good Good OK Poor V. poor Ulundi health district v1

Complications The district seems to be largely in control of its delivery with high relative standards, however there are opportunities to improve planning, coordination and communications to make best use of available (scarce) resources, particularly professional skills Situation Complications • Professional resources in short supply and generally at supervisor level • Clinical nurses stretched and under leveraged others underutilised • Legacy of misplaced physical assets results in patchy utilisation • Small incremental, but highly leveraged, investment opportunities seem to be ignored • Some basic requirements to do the job e.g. appropriate vehicles for PHC managers, are not available • Systems manager seems overburdened • Outsourcing process appears flawed • Patients are happy with actual treatment but unhappy with waiting times • Staff are generally neutral • Decision making appears heavily centralised • District role appears duplicative • Limited recognition of key governance structures • Patient transport is not tied into clinic or hospital needs creating artificial ‘peaks’ in demand • Hospital effectively competes with clinics for staff E.g. rural allowances apply to both • Laboratory vehicle and supervisors all make separate, lengthy and expensive trips to the clinics Ulundi health district v1

Super Appr- oves DITC* PITC SITA Procure Ment agent Centralised decision making creates long lead times for basic procurement E.g. PC Computer User Mot- ivates Service Provi- dor DELIVERY! 3-6 Months “District is just a conveyor belt” * DITC only meets every quarter Ulundi health district v1

Key governance structures seem to be ignored E.g. Wela clinic committee • Committee formed to encourage local input into decision making and sense of ownership • At sites visited seemed to be functioning well, highlighting many key issues E.g. staffing, electricity supply, ambulance service • BUT, when they raise these issues in repeated letters, they are ignored: • 23rd Oct 2002 - request to train local youth as support staff – no response (many other letters ignored) • 29th March 2003 – request to meet with hospital management to discuss key issues – no response • 21st March 2005 – follow up letter – no response • 27th June – report on break ins – no response Sowing the seeds of discontent? – a number of resignations have already taken place in disgust!! Ulundi health district v1

Patient transport is not linked to location of facilities creating artificial ‘peaks’ in demand “I have to leave very early (4am) to get the taxi to the hospital” “We have to walk for hours to get to Wela” “In an emergency we can be forced to pay R500 to get to the hospital” Patient arrival times – Gateway clinic Transport driven peak Time of day Ulundi health district v1

Some Suggestions The district seems to be largely in control of its delivery with high relative standards, however there are opportunities to improve planning, coordination and communications to make best use of available (scarce) resources, particularly professional skills Situation Complications Suggestion • Professional resources in short supply and generally at supervisor level • Clinical nurses stretched and under leveraged others underutilized • Legacy of misplaced physical assets results in patchy utilisation • Small incremental, but highly leveraged, investment opportunities seem to be ignored • Some basic requirements to do the job e.g. appropriate vehicles for PHC managers, are not available • Hospital organogram is confusing, roles are not clear and at clinic outdated • Outsourcing process appears flawed • Patients are happy with actual treatment but unhappy with waiting times • Staff are generally neutral • Decision making appears heavily centralised • Limited recognition of key governance structures • District role appears duplicative • Patient transport is not tied into clinic or hospital needs creating artificial ‘peaks’ in demand • Hospital effectively competes with clinics for staff E.g. rural allowances apply to both • Laboratory, drug delivery and supervisors all make separate, lengthy and expensive trips to the clinics • Decentralise planning, delegations and improve communications E.g staffing • Work with the taxi industry to provide more frequent services to the clinics/hospital • Schedule repeat patients with improved taxi/bus service to spread load • Acquire vehicle to actively balance staffing against demand in Ulundi area • Consider integrating clinic sample collection and supervision into one role to provide a vehicle to PHC management and increase clinic supervision • Look at best practice in record management and buy a computer • Hire clerical support into clinics to leverage nurses • Upgrade or backup electricity supply into clinics • Improve utilisation of ‘surplus’ general staff in basic maintenance and cleanliness Ulundi health district v1

Some suggestions • Decentralise planning, delegations and improve communications E.g. staffing • Work with the taxi industry to provide more frequent services to the clinics/hospital • Schedule repeat patients with improved taxi/bus service to spread load • Acquire vehicle to actively balance staffing against demand in Ulundi area • Consider integrating clinic sample collection and supervision into one role to provide a vehicle to PHC management and increase clinic supervision • Look at best practice in record management and buy a computer • Hire clerical support into clinics to leverage nurses • Upgrade or backup electricity supply into clinics • Improve utilisation of ‘surplus’ general staff in basic maintenance and cleanliness • Improve inter-government coordination Ulundi health district v1

Taxi industry has under utilised assets for most of the day – 12.30 Ulundi Ulundi health district v1

Annual cost of subsidising* an extra taxi service is low relative to overall budgets of R102 million * Fuel and maintenance only – patients pay fixed rate to cover drivers costs Ulundi health district v1

Primary Clinic #1 Laboratory Trip Combined Trip Integrating laboratory sample collection and supervision visits could provide access and better control Current Potential Supervisors in one old vehicle Ulundi health district v1

Costs of additional clerical support for clinics is low relative to total budget N.B. or use the surplus general administration staff Ulundi health district v1

Records management is sub-optimal versus best practice [Pic from Samual] Ulundi health district v1

At Addington medical records has developed a number of best practices • All O/patients have to have an appointment before they are seen at Outpatients • All files logged out on the computer as soon as they are drawn • All appointment patient files drawn 2 days prior to appointment • Moved to respective clinics 1 day prior to appointment • Colour coding system to prevent mis-filing • Repeat prescriptions separated out and filed in separate area for rapid retrieval Ulundi health district v1

All files are logged out out on the computer as soon as they are drawn Ulundi health district v1

All appointment patient files drawn 2 days prior to appointment Photo taken on 18/5/05: Files ready to go to Medical Outpatients clinic Ulundi health district v1

All files are colour coded… …to enable quick identification of misplaced files Mis-placed files Ulundi health district v1

Repeat prescriptions are separated out and filed in separate area for rapid retrieval Ulundi health district v1

Other suggestions • Contract hire a suitable vehicle for PHC support and to balance staff versus patient load on a daily basis in Ulundi area • Decentralise planning, delegations and improve communications from District and Region E.g status of recruitment efforts, outsourced contracts management • Resolve issues in outsource contracts regarding responsibility for staff and SLAs • Split the role of Finance and Systems manager into ‘Finance’ and ‘Operational Management’ • Upgrade or backup electricity supply into clinics – improve Eskom liaison and/or put back the generators • Improve utilisation of ‘surplus’ general staff in basic maintenance, cleanliness and administrative support at both hospital and clinics Ulundi health district v1

Many thanks for hosting us Ulundi health district v1

Backup Ulundi health district v1

…which has impacted service delivery Ulundi health district v1

Ulundi health district v1

Action Learning Pilot Programme