Five-year objectives
The concepts have been extended since the adoption of the Planning Framework and the Revitalisation of Hospitals hasbecome a total concept that embraces developing the skills of managers and management systems, so that physical improvements are sustained and maximised and other aspects of quality assurance begin to kick in simultaneously.
Key objectives for 2001/2
Hospital Service Data Set
In the last two years a Hospital Service Data Set has been developed and this is beginning to generate basic planning information. All public hospitals in the country are required to submit standard data on a monthly basis.
The data set is relatively simple. It does not include all the data that would be useful to manage a hospital, nor does it provide an overview really adequate for provincial planning. However, it is a major step forward, as all hospitals now collect data according to nationally agreed definitions. This means national and provincial departments can determine the volume of servicesdelivered, compare services and calculate some simple performance indicators. It also provides facility managers with basic information that enables them to manage and plan more effectively.
FIGURE 10: PUBLIC (AND SEMI-PRIVATE) HOSPITAL BEDS PER THOUSAND POPULATION UNCOVERED BY MEDICAL AID SCHEMES
Well over 90% of hospitals have submitted data on a monthly basis since April 2000. However, there are still some problems with the quality of data. There are many examples of hospitals submitting inaccurate data, but the major problem is the poor performance of two entire provinces that continue to submit incomplete data.
Without losing sight of the limitations noted above, the patterns shown in Figures 10, 11 and 12 and Tables 20 and 21 suggest that there are still major issues to be addressed in terms of equity, access and efficiency.
Information collated indicates that nearly 4-million patients per year are admitted to our public hospitals or to hospitals contracted by the public sector. The number of patients admitted is estimated to have remained broadly unchanged between 2000 and 2001.
FIGURE 11: AVERAGE LENGTH OF STAY BY PROVINCE
Tertiary care: An uneven landscape The purpose of the Review of Highly Specialised Services in Public Sector Hospitals was to describe, quantify and cost the provision of tertiary care. Completed in June 2001, the report yielded an imperfect but nevertheless illuminating overview of services provided in 531 units at 62 hospitals. Cumulatively the tertiary services reviewed had a workload of over 436 000 admissions a year, nearly 95 000 day cases and over 1,6-million outpatient visits. Services in Gauteng and Western Cape accounted for 28% and 24% of admissions respectively . These highly specialised services took place in designated central hospitals – which received national funding for tertiary care – and in other hospitals that did not receive such funding. The total spending on tertiary care at central hospitals was R3,2-billion nationally, while that at other sites amounted to R1,73-billion. An estimate was made of per capita national spending on tertiary care for various provinces, allowing for the very limited referral of residents of under-served provinces across provincial boundaries. Residents of Limpopo received about R23 per person per year from national tertiary care grants while those of Gauteng received R270 and Western Cape R325. The value of equipment in use in highly specialised services was estimated. Out of a total list of 43 specialties, just a handful – radiation oncology, diagnostic radiology, complex and interventional cardiology, neo-natal intensive care and intensive care – contained more than 50% of equipment by value. In terms of equipment, the KwaZulu-Natal and Eastern Cape did not fall much below Gauteng and Western Cape. The age of equipment in certain specialties and a few provinces indicated a fair proportion of obsolete equipment was in use. |
Table 20: National average length of stay in days
| District | Regional | Central | |
| Apr 2000 to Mar 2001 | 4,7 | 5,1 | 6,7 |
| Jan 2001 to Dec 2001 | 4,6 | 5,2 | 6,6 |
Using data based on the 1996 Census and the 1998 October Household Survey, an analysis was completed of the number of public beds available to the population that is not covered by medical aid schemes. (Figure 10)
Although central hospitals are technically "national assets" to be accessed by citizens of South Africa, the analysis includes central hospitals because they are currently used predominantly by the population in the province where they are situated. The analysis also makes a number of assumptions and is based on data that is known to be incomplete for some provinces. However, it does nevertheless give a good indication of the inequities in bed distribution.
There are wide variations between provinces in access to hospital beds and even wider variations in access to different types of hospitals. For example, beds per 1 000 population varies from 3,5 in KwaZulu-Natal to 1,6 in Mpumalanga. In addition, access to district hospital beds varies from 1,4 beds per 1 000 population in Eastern Cape to 0,5 in Western Cape and only 0,3 in Gauteng. This latter under-provision results in regional and central hospitals being used inappropriately.
Comparing the average length of stay in hospitals in 2001(Figure 11), there are some predictable variations. Stays are shorter than the national average in Western Cape and Gauteng, and longer than average in Limpopo and Eastern Cape.
At a national level, there has been virtually no change in lengths of stay since April 2000. (Table 20). However, at provincial level, there has been a sharp increase at district hospitals in KwaZulu-Natal (from 4,9 days to 6,5 days) and decreases in the length of stay in district and regional hospitals in Northern Cape.
Compared to the financial year 2000/01, bed utilisation rates were much higher in 2001. (Table 21) Part of this may be due to data quality problems in 2000, but part of this increase does appear to be real. Particularly large increases in bed occupancy occurred in district hospitals in Eastern Cape, Free State and Gauteng, and in central hospitals in all provinces.(Figure 12) However, rates remain lower than accepted international norms.
Integrated Health Planning Framework
The foundation for transformation in the hospital sector is the Integrated Health Planning Framework.
Specific objectives are to ensure:
FIGURE 12: BED UTILISATION BY PROVINCE
Table 21: National average bed utilisation rates by hospital type
| District | Regional | Central | |
| Apr 2000 to Mar 2001 | 64% | 73% | 71% |
| Jan 2001 to Dec 2001 | 57% | 68% | 78% |
Development of the Framework continues even as some of its recommendations are put into practice. It deals with the volume of care needed at various levels and in various specialist services, plus the referral systems that link various levels and forms of service.
During 2000/1, various norms for hospital services were developed. In the year under consideration, there was an engagement with provinces to test how sustainable these norms would be if implemented. The process yielded an understanding of the shifts in resource allocations that would be needed.
A significant area of research that was completed during the year was that on highly specialised services in public sector hospitals. The research revealed that:
The national funding of tertiary services has been concentrated in conditional grants to central hospitals on the assumption that they are providing the bulk of tertiary care on a national basis. Accordingly, the Western Cape and Gauteng (with most central hospitals) received 73% of conditional grant funding. But the study revealed they were only delivering 56% of the total volume of tertiary care services.
The research on highly specialised services will provide the basis for policy development in areas ranging from more rational planning of tertiary care to referral procedures, human resource planning and training for specialist medical care. But the most immediate policy implication concerned the restructuring of conditional grants for tertiary care in order to promote equity.
This aspect was considered by the Health Minmec and the principle of "like for like" funding of tertiary care across provinces was adopted for implementation from 2002/3. The mechanisms for achieving this, through the restructuring of relevant conditional grants, are described on page 76.
The Revitalisation Projects
As mentioned above Revitalisation of Hospital Services is now a programme that integrates components relating to the physical rehabilitation of buildings, the acquisition and management of equipment, the development of management expertise and systems and institution of quality assurance.
It is not financially possible to adopt this comprehensive approach wherever capital building projects are contemplated so a process of prioritisation has been pursued. During 2001/2 nine pilot hospitals were selected and implementation of the programme will commence there in 2002/3.
The hospitals are:
Under the parallel rehabilitation and reconstruction programme, expenditure was committed to projects in order to address the maintenance backlog. Since this programme started in 1998, a total of R605,3-million has been spent on 492 completed projects in 141 hospitals. A further R486,3-million is committed to an additional 474 ongoing projects in 210 hospitals. Details of the provincial distribution are provided in Table 22.
The major construction programmes for the three new academic hospitals progressed
significantly. Construction was completed at the Nelson Mandela Hospital in
Umtata and the Nkosi Albert Luthuli Hospital in Durban, while phase three of
the Pretoria Hospital was about to start. The completed hospitals are well-designed
top class facilities and both are due to be opened in the year ahead.
The following progress was made in relation to building management capacity
in the year under review:
Decentralisation of management functions to hospitals-
A draft policy was developed and consultations produced further refinements. Delegation of authority to hospital executives has occurred in seven provinces.
Re-engineering of hospital management.
Draft organisational development guidelines were produced and
arebeing discussed with relevant managers in provinces.
Systems development.
In relation to information systems:
The Department continued to support provinces and hospitals in improving financial management and accountability and initiated a situational review of progress on the establishment of cost centre accounting in hospitals.
Other systems receiving attention are mechanisms for labour relations and hospital governance.
HEALTH TECHNOLOGY
The availability and utilisation of appropriate health technology have a critical impact on hospital services - in terms of equity, effectiveness of care and efficiencies. Work progressed during the year to establish the nature of challenges in this previously neglected area of public hospital management.
Detailed audits of equipment were completed at a sample of hospitals in two provinces - the Eastern Cape and Limpopo. They yielded useful information in terms of the rate at which equipment is being replenished, the ratios of obsolete and nonfunctioning equipment, the downtime for maintenance and inappropriate acquisitions.
The audit suggested that good management can make a critical difference to the adequacy of equipment. Limpopo and the Eastern Cape are fairly comparable in many ways - but the former came reasonably close to meeting international equipment norms, while the latter lagged well behind.
TABLE 22: NATIONALLY FUNDED CAPITAL BUILDING PROJECTS AT HOSPITALS
| Province | Expected cost | Total projects planned | Completed 31 March 02 | ||
| Rand mill | Projects | Hospitals | Projects | Hospitals | |
| EC | 744 | 153 | 45 | 80 | 37 |
| FS | 191 | 27 | 20 | 3 | 2 |
| GP | 598 | 352 | 31 | 227 | 27 |
| KZN | 695 | 158 | 52 | 89 | 36 |
| LP | 909 | 127 | 43 | 43 | 12 |
| MP | 314 | 68 | 16 | 19 | 9 |
| NC | 88 | 10 | 8 | 2 | 1 |
| NW | 418 | 39 | 20 | 12 | 10 |
| WC | 137 | 32 | 14 | 17 | 7 |
| Total | 4094 | 966 | 249 | 492 | 141 |
Of management and machines... Without effective management money spent on health technology may be
a wasted investment. The difference between provinces was noticeable. The audit put the equipment value in the Eastern Cape at about R1-billion - but established that 25% was not functional. In Limpopo, the investment was smaller with equipment worth R900-million. But only 7 - 10% was not functional. In essence, Limpopo had spent less and was getting more back - due to better maintenance of equipment and purchases appropriate to service needs and skills of personnel. The audit covered a sample of hospitals and yielded a room-by-room classification of devices -labelling each as new or requiring preventive maintenance only or requiring correction maintenance or needing to be condemned. A gap analysis was done for each facility, identifying additional equipment that was critically needed -- taking into account patient load, the range of services and existing equipment. The audit is an extremely useful planning tool for hospitals and provinces in the pilot. It will be extended to all provinces. But even at the pilot stage critical nationwide issues have been identified:
Currently there are over 200 suppliers to the public health sector. |