briefing to select committee on appropriations expenditure on national health insurance grant and...
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BRIEFING TO SELECT COMMITTEE ON APPROPRIATIONS
Expenditure on National Health Insurance Grant
and NHI Pilot sites 2014 /2015
9 JUNE 20159 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
Pixley ka Seme
Eden
Vhembe
Gert Sibande
O.R.Tambo
Thabo Mofutsanyane
Umzinyathi
Dr Kenneth Kaunda
Umgungundlovu
City of Tshwane
Districts
NHI Pilot Districts
10 NHI PILOT DISTRICTS
Pixley ka Seme
Eden
Vhembe
Gert Sibande
O.R.Tambo
Thabo Mofutsanyane
Umzinyathi
Dr Kenneth Kaunda
Umgungundlovu
City of Tshwane
Districts
NHI Pilot Districts
10 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
Clinics with doctor service 2014
% coverage 2014
Clinics with doctor service 2015
% coverage 2015
Pixley Ka Seme38 26 68.42% 31 81.58%
Vhembe115 68 59.13% 71 61.74%
Gert Sibande42 31 73.81% 39 92.86%
Kenneth Kaunda42 32 76.19% 35 83.33%
OR Tambo143 0 0.00% 0 0.00%
Umzinyathi34 14 41.18% 17 50.00%
Umgungundlovu59 40 67.80% 47 79.66%
Tshwane89 38 42.70% 51 57.30%
Thabo Mofutsanyana
67 28 41.79% 34 50.75%
Eden58 47 81.03% 57 98.28%
Composition PHC Facility Doctor Coverage - March 2015
Districts Type of Contract/ Employment
National Contracted GPs
Doctors on Full time employment
Doctors doing Outreach from Hospitals
Provincially contracted doctors
NGO doctors
Total
Pixley Ka Seme 22.73% 27.27% 4.55% 45.45% 0.00% 100.00%
Vhembe 28.57% 1.79% 32.14% 37.50% 0.00% 100.00%
Gert Sibande 55.81% 9.30% 6.98% 4.65% 23.26% 100.00%
Kenneth Kaunda 30.00% 42.50% 7.50% 11.43% 0.00% 100.00%
OR Tambo 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
Umzinyathi 75.00% 25.00% 0.00% 0.00% 0.00% 100.00%
Umgungundlovu 46.51% 23.26% 11.63% 18.60% 0.00% 100.00%
Tshwane 84.29% 15.71% 0.00% 0.00% 0.00% 100.00%
Thabo Mofutsanyana 79.07% 20.93% 0.00% 0.00% 18.60% 100.00%
Eden 32.08% 47.17% 3.77% 9.43% 7.55% 100.00%
• 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.
GP/Doctor Contracting
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.
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NHI-CG Schedule 6 Focus AreaGP 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 AreaGP 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)
Province
Original Budget
National Adjustments
Provincial Roll-overs
Adjusted Budget Expenditure
Budget Available
% Spent of
Budget
R'000 R'000 R'000 R'000 R'000 R'000 %
Eastern Cape 7 000 - 1 049 8 049 1 819 6 230 22.6%
Free State 7 000 - 7 000 6 959 41 99.4%
Gauteng 7 000 - 3 281 10 281 5 660 4 621 55.1%
Kwazulu-Natal 14 000 - 5 848 19 848 18 126 1 722 91.3%
Limpopo 7 000 - 700 7 700 7 178 522 93.2%
Mpumalanga 7 000 - 770 7 770 3 286 4 484 42.3%
Northern Cape 7 000 - - 7 000 3 975 3 025 56.8%
North West 7 000 - - 7 000 5 890 1 110 84.1%
Western Cape 7 000 6 956 - 13 956 10 712 3 244 76.8%
TOTAL 70 000 6 956 11 648 88 604 63 605 24 999 71.8%
BUDGET EXPENDITURE
National Health Insurance Grant 2014/15 (Schedule 6)
Grant Name Adjusted
Budget2014/15
Expenditure 2014/15
Budget Available
% Spent
of Budget
R'000 R'000 R'000 %
NHI-Indirect Grant 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
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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.
• 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
Hospital Reimbursement reform
Appointment of District Clinical Specialists Support
National DCST Recruitment Status
Source: National DCST Database: 31 March 2015
ProvinceAd 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 1 5 4 5 4 5 29
KZN 11 7 4 11 3 11 47
Limpopo 5 5 2 5 2 5 24
MP 2 1 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
Municipal Ward-based Primary Health Care Outreach Teams
WBPHOT in NHI Pilot Districts
25
NHI Pilot District
WBOT Required based on 1:1500
households
Number of WBOT registered March
2014
Number of WBOT registered January
2015
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
CHWs trained in Cellphone Technology to Improve Reporting
DISTRICT Teams trained No of CHWs
uMgungundlovu 4 63
Thabo Mofutsanyana 30 178
Dr Kenneth Kaunda 18 158
Gert Sibande 12 99Cacadu 16 81Total 80 579
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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
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 NO. OF TEAMSEastern Cape 65Free State 20Gauteng 62KwaZulu-Natal 147Limpopo 47Mpumalanga 32Northern Cape 3North West 25Western Cape 43Total 444
PHC Facility Renovations
PHC Facility - Renovations
PHC Facility - Renovations
Photo’s of Dr Consulting RoomsBoiketlo Clinic (FS)
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Photo’s of Dr Consulting Rooms Delekile Khoza clinic (NW)
35
Human resources for health
Information management and systems support
Patient Administration Rationalisation of RegistersAssesment 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 statusProvinces Total number of
registers delivered to facilities
Total number of surplus registers to districts
Grand Total
Eastern Cape 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
• 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 SystemPrimary 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)
Primary Health Care Patient Information Primary Health Care Patient Information SystemSystem
• 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
HPRS Certification of Competency
Focus on Patient RegistrationReception Desk Support
Integrated Team Approach
Daily Data Capture Onsite TrainingRIPDA
ProvinceCaptured at Beta
Sites
Imported from
registersTotal
OR Tambo District 27 355 6 856 34 211Tabo Mofutsenyane 47 348 4 191 51 539Tshwane 29 002 18 182 47 184Umzinyati and Umgundlovu 125 754 28 067 153 821Vhembe 44 335 7 731 52 066Gert Sibande 1 014 12 085 13 099Pixley ka Seme 4 008 1 805 5 813Dr K Kaunda 37 590 2 133 39 723
Grand Total 316 406 81 050 397 456
Verification TypeTotal verified
Patients
Asylum seeker - Section 22 permit 199Drivers licence card 602Legal refugee - Section 24 permit 27Passport 1 672Refugee ID book 87RSA ID book 206 255RSA smart card 1 311Grand Total 210 153
Number of Patients Registered in 50 Beta Sites in the NHI Pilot Districts
• As at 31 May 2015
Nancefield
MoraraMasisi
TebangMarakangHarrismithHob House
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
-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 RegistryHealth 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 doctor service 2014
% coverage 2014
Clinics with doctor service 2015
% coverage 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%
OR Tambo143 0 0.00% 0 0.00%
Umzinyathi34 14 41.18% 17 50.00%
Umgungundlovu 59 40 67.80% 47 79.66%
Tshwane89 38 42.70% 51 57.30%
Thabo Mofutsanyana67 28 41.79% 34 50.75%
Eden 58 47 81.03% 57 98.28%
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.
Central Chronic Medicines Dispensing and Distribution Program
Project Specific Expenditure 2014-15
Project Specific Expenditure 2014-15Project Expenditure Source
School Health Service Mobiles 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 1652907.58 EU
Support for Human Resource, Financial and Health Information Management
104 724 238.28 EU
Broadband Connectivity for 50 PHC Facilities 6 490 000.00 Global Fund
Central Chronic Medicines Dispensing and Distribution Program
Global Fund
NHI Pilot Sites Appraisal
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