BRIEFING TO SELECT COMMITTEE ON APPROPRIATIONS

Expenditure on National Health Insurance Grant

and NHI Pilot sites 2014 /2015

9 JUNE 20159 JUNE 2015

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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

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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

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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)

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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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