BRIEFING TO SELECT COMMITTEE ON
APPROPRIATIONS
Expenditure on National Health Insurance Grant
and NHI Pilot sites 2014 /2015
9 JUNE 2015
1
Outline
• Focus areas for the National Health
Insurance Conditional Grant (NHI-CG) in
2014/15
• GP Contracting
• Expenditure on Schedule 5 and Schedule 6 CG
2014/15 FY
• Expenditure and activities (Donor funding and Global
Fund)
• 2014 / 2015 NHI Rapid Appraisal
2
NHI Pilot Districts
10 NHI PILOT DISTRICTS
Vhembe
City of Tshwane
Dr Kenneth Kaunda
Gert Sibande
Thabo Mofutsanyane
Umzinyathi
Umgungundlovu
Pixley ka Seme
O.R.Tambo
Eden
Districts
NHI Pilot Districts
GP Contracting
• The following two slides show the number of
GPs by NHI Pilot District as well as NHI pilot
district doctor coverage.
• Three options were being tested:
– Direct contracting through NDOH
– Service Provider
– Western Cape option
Total Number of Contracted GPs
(working as at 31 March 2015)
No
Province
District
No of signed
contracts
No of GPs
working
1
Western Cape
Eden
17
15
2
Mpumalanga
Gert Sibande
36
35
3
North West
Dr Kenneth Kaunda
23
23
4
Eastern Cape
OR Tambo
1
1
5
Northern Cape
Pixley ka Seme
11
10
6
Free State
Thabo Mofutsanyana
24
24
7
KwaZulu-Natal
uMgungundlovu
41
32
8
KwaZulu-Natal
uMzinyathi
14
12
9
Limpopo
Vhembe
26
24
10
Gauteng
Tshwane
94
80
TOTALS
287
256
GP PHC facility coverage - March 2015
versus March 2014
No of Clinics
Pixley Ka Seme
Vhembe
Gert Sibande
Kenneth Kaunda
OR Tambo
Umzinyathi
Umgungundlovu
Tshwane
Thabo
Mofutsanyana
Eden
38
Clinics with
% coverage
doctor service 2014
2014
26
68.42%
Clinics with
% coverage
doctor service 2015
2015
31
81.58%
115
68
59.13%
71
61.74%
42
31
73.81%
39
92.86%
42
32
76.19%
35
83.33%
143
0
0.00%
0
0.00%
34
14
41.18%
17
50.00%
59
40
67.80%
47
79.66%
89
38
42.70%
51
57.30%
67
28
41.79%
34
50.75%
58
47
81.03%
57
98.28%
Composition PHC Facility Doctor
Coverage - March 2015
Districts
Type of Contract/ Employment
National
Contracted
GPs
Pixley Ka Seme
Vhembe
Gert Sibande
Kenneth Kaunda
OR Tambo
Umzinyathi
Umgungundlovu
Tshwane
Thabo Mofutsanyana
Eden
Doctors on
Full time
employment
Doctors
doing
Outreach
from
Hospitals
Provincially NGO
contracted doctors
doctors
Total
22.73%
27.27%
4.55%
45.45%
0.00%
100.00%
28.57%
1.79%
32.14%
37.50%
0.00%
100.00%
55.81%
9.30%
6.98%
4.65%
23.26%
100.00%
30.00%
42.50%
7.50%
11.43%
0.00%
100.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
75.00%
25.00%
0.00%
0.00%
0.00%
100.00%
46.51%
23.26%
11.63%
18.60%
0.00%
100.00%
84.29%
15.71%
0.00%
0.00%
0.00%
100.00%
79.07%
20.93%
0.00%
0.00%
18.60%
100.00%
32.08%
47.17%
3.77%
9.43%
7.55%
100.00%
GP/Doctor Contracting
• The introduction of an independent service provider to recruit and
place GPs in facilities has increased the number of GPs contracted.
• The contract only came into effect in November 2014,
• Prior to the introduction of the independent service provider, just
over 150 doctors were recruited during the 21 months of the project.
• Since November 2014, a further 150 doctors have been recruited
increasing the number of doctors to 256.
• The service provider has a further 300 doctors in the recruitment
pipeline however this is contingent on funding
• During 2015/16 the intention is to supply a minimum of 180,000
hours to clinics in 9 pilot districts.
District by District Placement
Placement limited to 156 FTE
(Due to the budget cut for FY 15/16 only 156 Full Time Equivalent (FTE)
doctors could be contracted)
•
•
Original target was to recruit 450 FTE’s
• i.e. 50 doctors/district for the 9 participating NHI districts.
(Eden district elected not to participate)
Western Cape approach
• The Western Cape DOH is excluded as they are implementing a
different framework.
• The WCDOH is using a principle of deploying existing medical
officers employed by the WCDOH to clinics in the Eden district, and
using the grant funding, they are employing doctors on sessional
basis in hospitals to cover the gap left by the medical officers
deployed to clinics.
• According to the WCDOH, this has proved to be highly effective
strategy as attracting private GPs to hospitals is easier than to
clinics.
• The team is assessing the impact of this model against the NDOH
and the service provider model.
11
NHI-CG Schedule 6 Focus Area
GP Contracting
• GPs were slow in signing up for the GP contracting
initiative because of concerns that the state of our health
facilities will hamper their quality of work
• Their concerns about the state of our PHC facilities are
being addressed through the Ideal Clinic programme and
while the working environment in many of our clinics is still
being attended to, the GPs who have signed on have
reported that they have been pleasantly surprised by the
good working conditions in some of clinics. As result many
have since increased the working hours they spend working
in public health facilities
• Contracting numbers improved with the appointment of an
external service provider
NHI-CG Schedule 6 Focus Area
•
•
•
•
GP Contracting
This feedback is gathered through interactions with the GPs
during orientation sessions and during support visits to the
health facilities where they are providing services
This positive trend has also been demonstrated by the
constantly increasing number of GPs who have signed on
At the end of March 2014 we had 119 GPs working to
complement permanent staff in public health facilities.
This number increased to 256 at the end of March 2015
The number of GPs on contract now will expend 100% of
the budget for 2015/16
National Health Insurance Grant
2014/15 (Schedule 5)
BUDGET
Province
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
TOTAL
Original
National Provincial
Budget Adjustments Roll-overs
R'000
R'000
R'000
1 049
7 000
7 000
3 281
7 000
5 848
14 000
700
7 000
770
7 000
7 000
7 000
6 956
7 000
70 000
6 956
11 648
EXPENDITURE
Adjusted
Budget
Expenditure
R'000
R'000
1 819
8 049
6 959
7 000
10 281
5 660
19 848
18 126
7 700
7 178
7 770
3 286
7 000
3 975
7 000
5 890
10 712
13 956
88 604
63 605
Budget
Available
R'000
6 230
41
4 621
1 722
522
4 484
3 025
1 110
3 244
24 999
% Spent
of
Budget
%
22.6%
99.4%
55.1%
91.3%
93.2%
42.3%
56.8%
84.1%
76.8%
71.8%
National Health Insurance Grant
2014/15 (Schedule 6)
Grant Name
NHI-Indirect Grant
Adjusted
Expenditure Budget
Budget
2014/15
Available
2014/15
%
Spent
of
Budget
R'000
R'000
R'000
%
388 044
82 261
305 783
21%
Project Deliverables
in NHI Pilot Districts
using donor funds
during 2014-15
NHI Green Paper Phase 1: Focus Areas
•
•
•
•
•
•
•
•
NHI White Paper and Legislative Process
Management reforms and designation of Hospitals
Establishment Office of Health Standard Compliance
Public Health facility audit, Quality Improvement and
Certification
Building capacity to manage NHI Through the
strengthening of District Management
Costing Model
Establishment of NHI Fund
Accreditation and contracting of private providers by
NHI Fund
NHI Green Paper Phase 1: Focus Areas
•
•
•
•
•
•
•
•
Hospital Reimbursement reform
Appointment of District Clinical Specialists Support
Municipal Ward-based Primary Health Care Outreach Teams
School -Based PHC services
Public Hospital Infrastructure and Equipment
Human resources for health
Information management and systems support
NHI Conditional Grant to support piloting of initial work in 10
Districts
• Population Registration
• ICT
• Accreditation and contracting of private providers by NHI Fund
18
Hospital Reimbursement reform
Hospital Reimbursement reform
• Fist phase for developing and testing of a Diagnosis
Related Grouper (DRG) as an alternative
reimbursement tool for hospitals was completed
• This involved developing a base DRG tool for the 10
central hospitals across the country.
• As at March 2015, the Department had managed to
extract clinical and financial data from central
hospitals.
• The data has been categorised into 25 Major Diseases
as part of the preliminary technical work to develop
and apply a disease algorithm.
• Technical work on case mix and actuarial analyses has
been undertaken on the data that has been aggregated
and a triangulation process has been undertaken with
regards to data from other third party sources.
Hospital Reimbursement reform
• A group of 10 professional nurses with extensive clinical
(diagnostic and procedural) coding experience were
employed to collect the data.
• The coding team was deployed to 8 of the 10 central
hospitals in South Africa.
– The team was supported onsite by a team supervisor,
project management assistant and project management
team.
• The clinical data collection tool was developed, tested and
approved for use.
• From 17 June 2014 until 6 March 2015, a total of more than
24 000 files were coded (final total in verification process).
This exceeded the target of 22 500 files expected.
• All data is maintained in the secured database
Appointment of District Clinical
Specialists Support
National DCST Recruitment Status
Province
Ad
Midwife
Anaesthetist
Family
Physician
Obstetrician
Paediatric
Nurse
Paediatrician PHC Nurse
Total
EC
8
5
1
6
3
7
30
Free State
5
5
2
5
1
5
23
Gauteng
5
5
4
5
4
5
29
KZN
11
7
4
11
3
11
47
Limpopo
5
5
2
5
2
5
24
MP
2
2
3
2
3
13
NW
4
3
3
3
3
4
20
NC
5
1
5
1
2
1
5
20
WC
1
3
2
3
1
3
1
14
Total
46
6
37
23
41
22
446
220
1
1
Source: National DCST Database: 31 March 2015
Municipal Ward-based Primary Health Care
Outreach Teams
WBPHOT in NHI Pilot Districts
Number of WBOT
registered January
2015
WBOT Required
based on 1:1500
households
Number of WBOT
registered March
2014
Amajuba DM
74
10
10
Dr K Kaunda DM
139
49
93
G Sibande DM
182
9
64
Oliver Tambo DM
199
223
223
Pixley ka Seme DM
33
41
44
T Mofutsanyane DM
145
29
68
Tshwane MM
608
19
155
uMgungundlovu DM
182
17
19
Umzinyathi DM
76
20
22
Vhembe DM
229
17
54
Eden
109
-
-
Grand Total
1976
434
752
NHI Pilot District
25
CHWs trained in Cellphone Technology to
Improve Reporting
Teams
trained
No of CHWs
uMgungundlovu
4
63
Thabo Mofutsanyana
30
178
Dr Kenneth Kaunda
18
158
Gert Sibande
Cacadu
Total
12
16
80
99
81
579
DISTRICT
WBOT being trained on the mHealth:
•
Those teams reporting to DHIS have
received basic orientation to use of cell
phones
• Scheduled training on the full mHealth
manual
27
School -Based PHC services
School Health Services
• To improve access to school health services
additional School Health Mobile Vehicles were
purchased and distributed in the NHI Pilot
Districts
– 27 Mobile PHC Trucks
– 17 Oral Health Mobiles
– 3 Eye Care Mobiles
Appointment of school-based teams led
by a nurse
PROVINCE
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Total
NO. OF TEAMS
65
20
62
147
47
32
3
25
43
444
PHC Facility Renovations
PHC Facility - Renovations
PHC Facility - Renovations
Photo’s of Dr Consulting Rooms
Boiketlo Clinic (FS)
34
Photo’s of Dr Consulting Rooms
Delekile Khoza clinic (NW)
35
Human resources for health
Information management and systems
support
Patient Administration
Rationalisation of Registers
Assesment of PHC Patient Information systems
PHC Facilities Patient
Administration
Rationalisation of Registers
Background
• The Health Systems Trust (HST) has been commissioned to coordinate and
manage the national roll-out of the rationalised set of registers in all PHC
facilities and provide technical support to provinces during this process.
– Reducing the 56 Registers used in PHC facilities to 6 Registers
• The set of rationalised registers that was implemented is as follows:
– PHC comprehensive daily tick register + reception daily headcount register
– TIER.net: ART for all HIV positive patients (including TB, Pregnant women,
HIV+e babies)
– TB registers (case identification and treatment registers)
– Theatre register ( for facilities performing MMC and TOPs)
– Delivery register
– Midnight census for PHC facilities providing inpatient services
Registers: Delivery status
Provinces
Total number of surplus Grand Total
registers to districts
Eastern Cape
Total number of
registers delivered to
facilities
8302
11480
19782
Free State
2442
7560
10002
Limpopo
4862
5100
9962
North West
3561
6840
10401
Northern Cape
2069
1440
3509
KZN and GP
(see next slide)
0
0
0
Total
21 236
32 420
53 656
New set of Registers
Findings: positive perceptions
• Waiting time reduced.
• Reporting on fewer elements and workload is less
• Uniformity of data collection tools leading to less
administration and more better recording
• More time spent with patients
• Removal of duplications
• Easy to collet correct data elements as layout on
one page
• Better reporting
Health Patient Registration
Primary Health Care Patient Information System
• In preparation of the development of an automated patient
based information system the HNSF work was extended to
include the assessment of patient-centric primary healthcare
(PHC) systems currently in use in the country, inlcuding systems
used in the private sector and aimed at primary healthcare.
Open Expression of Interest yielded 37 responses;
• 23 systems were shortlisted based on eligibility criteria;
• 1 Vendor retracted their submission;
• Rigorous evaluation process including:
– Definition of PHC system requirements;
– Collection of detailed information from system vendors;
– Representations from each system vendor;
– Site visits where each of the systems were deployed;
Primary Health Care Patient Information
System
• This assessment culminated in
recommendations on the most appropriate
PHC Patient based information system to be
deployed in PHC facilities
• The outcome of this assessment is Automated
PHC Patient Information systems implemented in the NHI pilot districts
( 700 facilities) and be linked to the second
phase of the scale up (1400 facilities)
•
Secure central database on a web based platform available to public health
facilities to capture and verify beneficiary identification via bar coded identity
documents and biometric methods. It also records patient visits to facilities.
•
Patient registry – a critical component to implement electronic health records
nationally.
•
Planning tool because beneficiaries are linked to facilities based on the their
demographic details.
•
•
Currently implemented at PHC facilities in NHI Pilot Districts.
Auto-generates a unique Health Patient Registration Number (HPRN) and
assigns to registered and successfully verified beneficiary.
– HPRN is an internal system number that could be able to uniquely identify
health beneficiaries for all other patients (including Foreign nationals).
– South African National ID Number remains the primary identification for
South African citizens.
KZN Beta Implementation September 2014
Focus on Patient Registration
Reception Desk Support
Integrated Team Approach
RIPDA
HPRS Certification of Competency
Daily Data Capture Onsite Training
Number of Patients Registered in 50
Beta Sites in the NHI Pilot Districts
• As at 31 May 2015
Province
OR Tambo District
Tabo Mofutsenyane
Tshwane
Umzinyati and
Umgundlovu
Vhembe
Gert Sibande
Pixley ka Seme
Dr K Kaunda
Grand Total
Captured Imported
at Beta
from
Sites
registers
27 355
47 348
29 002
6 856
4 191
18 182
Total
34 211
51 539
47 184
125 754
44 335
1 014
4 008
37 590
28 067 153 821
7 731 52 066
12 085 13 099
1 805
5 813
2 133 39 723
316 406
81 050 397 456
Verification Type
Asylum seeker - Section 22 permit
Drivers licence card
Legal refugee - Section 24 permit
Passport
Refugee ID book
RSA ID book
RSA smart card
Grand Total
Total verified
Patients
199
602
27
1 672
87
206 255
1 311
210 153
Nancefield
Morara
Masisi
Health Patient Registration
•The Patients Unique Identified are
being used to register the Patient at
the Health Facility and to do
verification at follow-up visits
•The system allow for tracking
patients between different facilities
•The Map Demonstrates the testing
of this by the implementation team
using the Green ID book of one of
the Team members
Tebang
Marakang
Harrismith
Hob House
-First Registration at Masisi
-And the person could be picked up
at Morara and Nancefield clinics in
Vhembe
-And Tebang, Marakang, Harrismith
and Hobhouse in Thabo
Mofutsenyane
Health Provider Registry
• Software development completed
• Infrastructure hardware established
• Next step is to develop an implementation
plan in consultation with health professional
organisations
Accreditation and contracting of
private providers
GP PHC facility coverage - March 2015
versus March 2014
No of Clinics
Clinics with
% coverage
doctor service 2014
2014
Clinics with
% coverage
doctor service 2015
2015
Pixley Ka Seme
38
26
68.42%
31
81.58%
Vhembe
115
68
59.13%
71
61.74%
Gert Sibande
42
31
73.81%
39
92.86%
Kenneth Kaunda
42
32
76.19%
35
83.33%
143
0
0.00%
0
0.00%
34
14
41.18%
17
50.00%
59
40
67.80%
47
79.66%
89
38
42.70%
51
57.30%
67
28
41.79%
34
50.75%
58
47
81.03%
57
98.28%
OR Tambo
Umzinyathi
Umgungundlovu
Tshwane
Thabo Mofutsanyana
Eden
Central Chronic Medicines Dispensing and
Distribution Program
Central Chronic Medicines Dispensing and
Distribution Program
•
•
•
•
•
CCMDD aims to decongest public healthcare facilities and improve access to
chronic medicines in South Africa.
The program contracts the dispensing and distribution of repeat prescriptions for
stable chronic patients to private sector service providers.
The program of two program components, Central Chronic Medicines Dispensing
and Distribution (CCMDD) and Pick-up Points (PuPs).
The first relates to individual patients’ medicines being centrally dispensed and
distributed to the point of service delivery.
The second relates to the provision of pre-dispensed medicines at private sector
pharmacies, or ‘Pick-Up-Points’ (PUP), that is conveniently located for patients.
 CCMDD is currently being rolled out in 10 districts, as well as in 2 hospitals that
are not in the NHI districts.
 Combined both models have in excess of 380,000 patients; with current
enrolments in the private distribution model half at around 190,000.
Project Specific Expenditure 2014-15
Project Specific Expenditure 2014-15
Project
School Health Service Mobiles
Expenditure
Source
27 025 925. 30 EU
District Clinical Specialist teams
1 059 021.67 EU
PHC Ward Base Outreach Teams
3 940 454.29 EU
Ideal Clinic – Operation Pakhiso
10 631 079 EU
Health Information support including expansion of the
NHIRD
6 818 192.61 EU
Assessment of PHC Information Systems
6 472 000.00 EU
Patient Administration –Rationalisation of Registers
48 270 000.00 EU
Health Patient Registration
11 148 283.44 EU
NHI Project Management
Support for Human Resource, Financial and Health
Information Management
Broadband Connectivity for 50 PHC Facilities
Central Chronic Medicines Dispensing and Distribution
Program
1652907.58 EU
104 724 238.28 EU
6 490 000.00 Global Fund
Global Fund
NHI Pilot Sites Appraisal
Eden
Pixley ka Seme
OR Tambo Gert Sibande
Tshwane
Amajuba
uMgungundlovu uMzinyathyi
Vhembe
Dr K Kaunda Thabo Mofutsanyana
2013 2014 2015 2013 2014 2015 2013 2014 2015 2013
2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015
GOVERNANCE
NHI management structure in place
Full time NHI Project Manager in post *
District NHI task force team in post
Coordination mechanisms in place
District Health Management Teams
DHMT organogram number of posts
Organogram posts filled (%)
Quarterly review meetings taking place
Annual district health expenditure review
District health plan
NHI Conditional Grant Business plan
Clinic committees established
Clinic committees functioning
Hospital Reform
District hospitals re-designated
Full-time CEOs in post
F/T CEOs orientated at Leadership management
Academy (GT not attended)
Hospital boards established
Patient satisfaction survey past 12 months
NHI CONDITIONAL GRANTS
Actual plus committed expenditure (Q1-Q4 plus
committed) (amber 2014 Tshwane))
HR FOR HEALTH
WISN norms and standards
Training received
Pilot in Selected NHI facilities Completed
HR implementation plans
District HR implementation plan in place
Skills development / CPD
Skills development for nurses in place
62
Eden
Pixley ka Seme OR Tambo
Gert Sibande
Tshwane
Amajuba
uMgungundlovu uMzinyathyi
Vhembe
Dr K Kaunda Thabo Mofutsanyana
2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015
PHC RE-ENGINEERING
District Clinical Specialist Teams
DCST members in post (3/7)
DCST attended orientation training
DCST has action plan
ESMoE implementation
Ward-based PHC Outreach Teams
Teams in place
WBPHCOTs teams in place (more than 20%)
School Health Services
Schools health teams in place
All targeted schools reached (target 60%)
Mobile school health units operating
HPV Roll-out plan in place
GPs on a National Contract
GPs working in PHC Facilities on NDoH Contract
GP Performance Monitoring in place
GP System for CPD in place
Expenditure against budget
REFERRAL SYSTEMS
Referral system protocols developed
Referral system protocols in place
Planned patient transport system in place
Emergency transport system in place
63
Eden
Pixley ka Seme
OR Tambo
Gert Sibande
Tshwane
Amajuba
uMgungundlovu
uMzinyathyi
Vhembe
Dr K Kaunda Thabo Mofutsanyana
2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015
QUALITY IMPROVEMENT
FIT teams in place
FIT team plan available
Quality Assurance coordinator in post
Quality Assurance team in place
Quality improvement plan developed
Quality improvement plan monitored
Ideal Clinics
District Team for Ideal Clinic Project roll out in
place
Implementation plan for Ideal Clinic Project roll
out in place
PHC facilities to be staffed by GPs
PHC clinics assessed as ready for GPs (CHAI)
EQUIPMENT
Equipment meets EEL standards
PHC facilities equipment meets NDoH Standards
Number of Facilities fully equipped as per EEL
Capital acquisition plan in place
INFRASTUCTURE
Refurbishment (past 12 months)
Facility maintenance plans in place
Hospitals
Minor refurbishment
Major refurbishment
Complete overhaul
Primary Health Care Facilities
Minor refurbishment
Major refurbishment
Complete overhaul
HEALTH INFORMATION MANAGEMENT
DHS data reaches province within 15 days
Districts have received training on NHIRD
Districts with access to the NHIRD
Districts accessing NHIRD
64