BRIEFING TO THE AD HOC COMMITTEE ON CO-ORDINATED OVERSIGHT ON SERVICE DELIVERY

1. BRIEFING TO THE AD HOC COMMITTEE ON CO-ORDINATED OVERSIGHT ON SERVICE DELIVERY 02-04 FEBRUARY 2010

2. HEALTH SECTOR 10 POINT PLAN 2009-2014 (i) Provision of Strategic leadership and creation of a social compact for better health outcomes; (ii) Implementation of a National Health Insurance Plan; (iii) Improving Quality of Services; (iv) Overhauling the health care system and improve its management; (v) Improving Human Resources Management; (vi) Revitalization of physical infrastructure; (vii) Accelerated implementation of HIV and AIDS Plan and reduction of mortality due to TB and associated diseases; (viii) Mass mobilisation for better health for the population; (ix) Review of the Drug Policy; (x) Strengthening Research and Development.

3. RANGE OF PRIMARY HEALTH CARE SERVICES

4. Introduction • The National Department of Health has adopted the District Health System as a vehicle for the delivery of Primary Health Services • National Policy on DHS was developed in 1995 • Chapter 5 of the National Health Act is devoted to the establishment of the DHS • There are 52 Health Districts whose boundaries are coterminous with District Municipalities • Delivery of PHC is through the provinces.

5. Introduction NHA calls for the establishment of the District Health council which shall be led by the District Municipality This act also calls for the alignment of the District Health Plan and IDP The National Department of Health developed a comprehensive and integrated package for the delivery of Primary Health Care since 2001. In order to ensure that there are quality health services at the point of delivery, the NDoH has also developed norms and standards for PHC.

6. Norms and Standards • The provision of PHC in the Republic is aligned to the prescribed norms and standards. • With the production of an essential package for comprehensive and integrated PHC, norms and standards have continued to guide the implementation of the PHC package of service. • South Africa has provided comprehensive and integrated PHC services for 10 years.

7. Model of Service Delivery • The Department of Health across spheres of government remains committed to the provision of primary health care services (PHC) through a functional District Health System (DHS). • Services are delivered through PHC facilities • Community Health Centres • Fixed clinics, • mobile clinics • Health Posts • There are services that are delivered through community health workers • All these form the platform for the delivery of PHC within the DHS.

8. Range of Services The following range of service being delivered through fixed PHC facilities and mobile clinics. These services range from promotive, preventive, curative and rehabilitative health services. They cater for children, women, youth and elderly, mental health, etc. These services are as follow among others: • Health Education and Patient Education • Family Planning • Immunisation • Ante-Natal Care • Rehabilitation etc

9. Range of Services • Post Natal Care • Maternity and Labour • Cervical Cancer Screening • Services Sexual Assault including Prophylaxis • HIV and AIDS services including Prevention from Mother to Child Transmission (PMTCT), Voluntary Counseling and Confidential Testing • Chronic Care and Care for the Elderly (Geriatrics) including Palliative Care at community level • Mental Health and Substance Abuse • Management of trauma and common ailments

10. Method of delivering these services • The services are delivered through: • Provincial PHC facilities (full package delivered for free) • Municipalities (limited package delivered for free) • There is a limited involvement of private sector in the delivery of PHC delivered at a fee)

11. Hours of delivery of PHC Services • These services are delivered through: • 8 hours 5 days a week (common in small communities and all municipal clinics) • 12 hours 7 days a week • 12 hours 5 days a week • 24 hours 7 days a week • One day per (for mobile clinics and health posts)

12. Future Plan • Since 2000 there have been changes and demands on the health system. • The NDoH has planned to audit all PHC facilities and package of essential services during this current financial year and up till 2012. • The audit will focus on both infrastructure, package and the staffing needed to deliver the package of PHC services • The outcome of this exercise will inform the future delivery model of PHC in the country.

13. Deliverables for PHC and DHS

14. Deliverables for PHC and DHS

15. Deliverables for PHC and DHS

16. Highlights of integrated service delivery • ISRDP : • The strategic objective of the ISRDS is “to ensure that by the year 2010 the rural areas would attain the internal capacity for integrated and sustainable development”.

17. List of Rural Nodes: The following have been identified as ruralnodes

18. Information Sources • ISRDP used data drawn from: • Stats SA General Household Surveys and Community Survey 2007, • Antenatal and Syphilis Surveys, • 2001 Census data and Midyear Population Estimates and BAS and PERSAL systems for financial data. • The DHIS ZA_NDOH5_06_09 data file. • Data disaggregated to facility level in one combined National data file was used for the health status and Health outcomes indicators. • Data for 2009 is only up to July 2009.

19. Factors that characterised these nodes • Proportion of the area’s population that are children below the age of 5; • From a female headed household; • Household heads who have no schooling; • Adults between 25 and 59 classified as unemployed; • Living in a traditional dwelling, informal shack or tent; • No piped water in their house or on site; • Pit or bucket toilet or no form of toilet; and • No access to electricity or solar power for lighting, heating or cooking. • All these will lead poor health outcomes

20. Impact of factors on service delivery Inability to recruit and retain health professionals Poor access to facilities due to poor road infrastructure Diseases of poverty such as HIV and AIDS and TB as well as STI are prevalent Poor health literacy Poor nutritional status thus high vulnerability Poor absorptive capacity for resources allocated Poor spending of resources

21. Achievements (PHC in general) • In order to improve and standardize Health service delivery the department embarked upon the following: • Provincialisation of all PHC services from 2005 to 2015 (no municipality will deliver personal primary health care services except for metros) • Department will revitalize PHC services in order to improve access and coverage, as well as incorporation of other priority programmes • Conducting PHC facility and service package audit starting 2009/2010 to 2011/2012 • Collaboration with local and district municipality in the management of health care and health care risk waste

22. Achievements (PHC in general) • In order to improve and standardize Health service delivery the department embarked upon the following: • Development of handbook for the District Managers • Establishment of governance structures in the health facilities (where municipal councilors play a central role) • Development of the District Health plan and its integration with IDP’s of the local and district municipalities) • Development of the health facility manual and subsequent creation of posts for the health facility supervisors

23. Achievements (PHC in general) • Participation in the ISRDP working together with erstwhile DPLG and other stakeholders. • Collaboration with local and district municipalities in identifying and mitigating the social determinants of health such as water, sanitation and poverty etc • Collaboration with municipalities in the prevention and mitigation against outbreaks of communicable diseases as it was seen in Delmas and Musina • Identification of the priority districts that need special attention (with the view of improving services delivery on key priority programmes) • Finalisation of rural health strategy with a view of focusing on the rural and farming areas.

24. Achievements (PHC in general) • Primary Health Care budget has been increasing over the years and it moved from R 290 in 2008/09 to R 300 IN 2009/10 and is at R350 for 2010/2011 • PHC has been provincialised to be managed at the provincial level (municipalities will not render Personal PHC) • There has been devolution of Municipal Health Services. • The department has been budgeting for the municipal health services without that budget being allocated to the department. • Over the years the department has been responsible for water quality monitoring despite Municipalities being water services authorities

25. Achievements (PHC in general) • Service coverage was increased through the help of community health workers • Job creation through payment of stipends to the community health workers • Use of donor funding to expand service delivery

26. New initiatives that will improve service delivery • 18 Districts project: • Overhauling PHC to alleviate pressure from the hospital OPD • New plan for the implementation of the District Health System • Delegations for District Management Teams

27. 18 Priority Districts • How were they selected: • Through looking at deprivation index coupled with under performance on MDG linked programmes • Purpose: • To accelerate performance of these districts focusing on priority programmes • To galvanize support from all stake holders including development partners to support these districts • To have them identified and prioritized in the planning by the provinces • To improve performance towards meeting MDG’s

28. 18 Districts

29. Overhauling PHC • Purpose: • To improve performance of PHC facilities so that they can relieve the pressure from the hospital OPD • To create conditions that will encourage people to use PHC services • To ensure that PHC facility support referral system by being the first port of call for patients.

30. National plan to implement DHS • To consolidate the health service development • To strengthen health system • To ensure uniformity in the implementation of DHS policy and chapter 5 of the National Health act • To ensure a solid foundation on which to deliver PHC services

31. Delegations to District Managers • Purpose: • To give managers more responsibility and accountability in the acquisition, custody, control, management, and disposal of resources and commodities • Delegations Domains • Finance • Human Resources including employment relations • Supply Chain Management

32. Referral Policy • Purpose: • To ensure seamless delivery of health services for patients • To recognize the strata or tiers of service delivery and their connectivity • To avoid loss of patients through the systems • To enhance quality of care • To improve management of patients throughout the system

33. Challenges in the current system of Service Delivery • Impact of poverty and demand on health services • Inadequate human resource for health • Poor integrated planning framework – across sectors • Poor intersectoral collaboration • Inadequate management and operational capacity • Poor basic management support systems • Lack of accountability, which are further complicated by inadequate delegations • Inadequate promotion of quality of care - quality standards being developed • Increased verticalisation and moving away from service integration

34. Recommendations • Integrated planning and accountability must be mandatory for all departments • Responsibility and power must be decentralized to the lowers level of service delivery • Prioritization of social determinants of health by all other sector departments such as Roads and Transport, Human Settlement • Cluster arrangement of departments must be enforced up to the provincial level • Capacity must be developed at service delivery level as opposed to the central offices