Fiorenza Monticelli, HST Monitoring Health Systems Strengthening Dar es Salaam, 16-17 April 2008

The District Health Barometer

Collates, simplifies, displays, compares and monitors health and socioeconomic data at a district and province (sub-national) level 1) Compares equity issues between districts and between provinces; improvements & deterioration over the last few years 2) Highlights quality of data and monitors improvements 3) Reviews trends over time, monitoring progress towards goals.

4) Is used at national, province and district level and influences attitude to M&E and attitude to data quality for decision making

The District Health Barometer Year 1

• Pilot published in in 2005 (2003/04 data) • Provides 15 Health indicators and 1 year of data comparing: – 53 Health districts – 6 Metropolitan areas – 13 Rural Nodes – 9 Provinces Short analysis and narrative, indicator definitions

The District Health Barometer 2006/07

• Published in 2007 (3 rd year) • 27 Indicators – socioeconomic and health • Up to 4 years of data • Profile for SA, 9 provinces and 52 districts with colour coded ranking • CD with full data file, resources and definitions • A web-enabled GIS District Health Barometer

http://webgis.hst.org.za:8081/

• Internship programme

Achievements

• Effective communication of district level data to a wide range of users including the non-health sector (politicians, the lay press, Treasury) • Acceptance and use of the publication by the National Department of Health (e.g. by displaying it on their website, quotations, discussed at national conferences) • Growing awareness of the importance of quality of data at sub-national level, improved interrogation of data by managers.

• Improved level of transparency

Process

Data collected from Treasury, StatsSA, DHIS, TB register, private sector facilities register Financial data is coded, data scrutinised, averages calculated, DI calculated, maps and graphs produced Authors write district profiles and narrative based on data provided (gaps and data irregularities are noted) Publishing process, launch to NDHSC and press, notifications, dissemination and presentations Advisory committee meet (DOH, Academic sector, consultants & HST

)

The District Health Barometer 2006/07

1. Socio-economic Indicators

e.g. Household access to Water , Deprivation index

2. Input Indicators

e.g. Per Capita Expenditure on Primary Health Care, Cost per Patient Day Equivalent in District Hospitals

3. Process indicators

e.g. Clinic Supervision Rate, Nurse Clinical Workload

The District Health Barometer 2006/07

4. Output Indicators

e.g. Male Condom Distribution Rate PMTCT Indicators : Proportion of antenatal clients tested for HIV HIV prevalence rate amongst antenatal clients tested Nevirapine uptake rate among HIV+ve pregnant women Nevirapine uptake rate among babies born to HIV+ve pregnant women

5. Outcome indicators

e.g. Incidence of new Sexually Transmitted Infections TB Smear conversion rate TB cure rate (new smear +ve)

6. Impact indicators

e.g. Perinatal Mortality Rate (PNMR)

Examples of data improvement

• Financial data: e.g. Non-Hospital Primary Health Care Per Capita Expenditure (HST – more experienced at working with and coding the data) • DHIS data: Nurse Clinical Workload (districts in KZN, NW, NC provinces have improved their data since 2003/04 and WC now provide this data) • Proportion of antenatal clients tested for HIV –national ANC prevalence survey data now available at district level allows for comparison and validation.

Change in Per Capita Expenditure 2001/02 and 2006/07 (real 2006/07 pric es ) South Africa Ekurhuleni Bophirima City of Cape Town City of Johannesburg Central Karoo West Coast Eden Namakwa Overberg Southern Cape Winelands uMgungundlovu City of Tshwane eThekwini Sisonke Metsweding Umkhanyakude Ugu Pixley ka Seme West Rand Central Zululand Sedibeng Uthungulu Uthukela Amajuba Xhariep Bojanala Kgalagadi Mopani Amathole Frances Baard Ehlanzeni Umzinyathi Nelson Mandela Bay Motheo Waterberg Vhembe iLembe Chris Hani Siyanda Lejweleputswa O.R. Tambo Fezile Dabi Greater Sekhukhune Capricorn Alfred Nzo Thabo Mofutsanyane Cacadu Ukhahlamba Nkangala Gert Sibande 0 50 100 150 200 250

Rand

300 350 400 SA = R222 NC NW WC SA EC FS GP KZN LP MP South Africa Namakwa West Coast City of Cape Town Xhariep Eden Central City of Tshwane Bophirima Southern Central Karoo Umkhanyakude City of Johannesburg eThekwini Motheo Bojanala Ekurhuleni Pixley ka Seme Cape Winelands Kgalagadi Sisonke Amathole Chris Hani Frances Baard Nelson Mandela Bay Metro Overberg Mopani UMgungundlovu Umzinyathi Cacadu Uthungulu Fezile Dabi West Rand Ugu Zululand iLembe Thabo Mofutsanyane Ukhahlamba Waterberg Alfred Nzo Vhembe O.R. Tambo Sedibeng Nkangala Uthukela Lejweleputswa Capricorn Gert Sibande Ehlanzeni Amajuba Metsweding Greater Sekhukhune Siyanda 450 500 0 SA= R256 50 100 150 200 250

Rand

300 350 400 450 500 EC FS GP KZN LP MP NC NW WC SA

Per Capita Expenditure – ISRDP nodes 2001/02 – 2006/07

Per capita expenditure, ISRDP nodes 2001/02 - 2006/07 (real 2006/07 prices)

South Africa 01/02 South Africa 06/07 Central Karoo 01/02 Central Karoo 06/07 Ukhahlamba 01/02 Ukhahlamba 06/07 Chris Hani 01/02 Chris Hani 06/07 Ugu 01/02 Ugu 06/07 Alfred Nzo 01/02 Alfred Nzo 06/07 O.R. Tambo 01/02 O.R. Tambo 06/07 Greater Sekhukhune 01/02 Greater Sekhukhune 06/07 0 50 100 150 200 250 300 350 400 450 500

Rand

The difference between the highest and the lowest values moved from a 6.8 fold difference in 2001/02 to a 1.9 fold difference in 2006/07

Data improvement Example: Nurse Clinical workload

Province District NC Kgalagadi 2003/04 137.2

2004/05 2005/06 2006/07 50.9

49.9

36.4

NW Bojanala 127.4

80.9

47.1

22.6

KZN Uthungulu 55.1

28.6

23.2

2007/8 report - currently investigating application of statistical methods e.g. regression, imputation to fill in missing data, graphing & visualization to detect outliers.

HIV prevalence among ANC clients tested

PROVINCE Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape South Africa DHIS 06/07 22.8

25.4

28.3

26.1

17.2

29.6

12.5

26.4

14.1

23.7

National HIV survey 06 28.6

31.1

30.8

39.1

20.6

32.1

15.6

29.0

15.1

29.1

lower 95% CI upper 26.8

29.2

29.6

37.5

18.9

29.8

12.7

26.9

11.6

28.3

30.4

33.1

32.1

40.7

22.3

34.4

18.5

31.1

18.7

29.9

TB Cure rate, 2005

South Africa Overberg Eden West Coast Bohlabela Vhembe Chris Hani Cape Winelands Central Karoo West Rand Thabo Mofutsanyane Xhariep City of Cape Town City of Johannesburg Lejweleputswa Capricorn Kgalagadi Motheo Zululand Umzinyathi Central Amajuba City of Tshwane Ekurhuleni Bophirima Ehlanzeni O.R. Tambo Fezile Dabi Metsweding Cacadu iLembe Mopani Ukhahlamba Namakwa Sedibeng Pixley ka Seme Greater Sekhukhune Bojanala Siyanda Nelson Mandela Bay Metro Southern Sisonke Alfred Nzo Gert Sibande Uthukela Uthungulu Umkhanyakude eThekwini Waterberg Frances Baard UMgungundlovu Ugu Amathole Nkangala 0 10 20 30 40 50 60

Percentage

70 80 90 100 EC FS GP KZN LP MP NC NW WC SA 57.6% 83.6% TB Cure Rate by District 2005 31.4%

Challenges

• Too much data collected at district level which impacts heavily on quality of the DHIS data e.g. data elements for routine collection at facility level = approx 493. • Insufficient monitoring of the data collected by various programs • Insufficient validation and checking of data from district – province – national level – Treasury • Adjustments to data in DHIS made at frequent intervals throughout the year • Key indicators unavailable at district level e.g. Mortality data, HR data • Ownership

The Birchwood National Consultative Health Forum Declaration on Primary Health Care

We, the members of the National Consultative Health Forum, representing government, public and private health sectors, statutory bodies, academic and research institutions, community organisations, civil society, non governmental organisations and organised labour, in our meeting at Birchwood conference centre, Gauteng Province, held on 10-11 April 2008, on Primary Health Care to commemorate the 30th anniversary of the Alma Ata Declaration, hereby: Note:

1. The achievements that have been made in the implementation of the Alma Ata declaration globally, including improving access to Primary Health Care services and equitable allocation of resources. 2. The Kopanong Declaration on Primary Health Care in 2003 which, inter alia, resolved to implement concrete strategies and processes, with clear targets, to reduce inequities in the allocation of resources for primary health care with a focus on both horizontal and vertical equity. 3. That there have been many achievements in the delivery of Primary Health Care services in South Africa, but there are still many challenges including availability of adequate human resources for health, improving quality of care, strengthening district management and community participation.

Reaffirm

1. Our commitment to the principles in the Declaration of Alma Ata, adopted in September 1978. 2. That health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, and that access to healthcare is a fundamental human right. The attainment of the highest possible level of health is a most important worldwide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector.

Resolve

That the revisioned and revitalized primary health care strategy for South Africa will include: 1. Advocating for an increase in the resource allocation for primary health care, by at least doubling the current per capita expenditure over the next ten years. 2. Better alignment at district level of key interventions that impact on health, notably provision of water and sanitation, early childhood development, recreational programmes, health education and other activities that focus on encouraging healthy lifestyles especially amongst the youth in particular. 3. Strengthening the role, responsibilities, authority and accountability of the district health management team so as to achieve improved health outcomes.

4. Strengthening the health information system to generate good quality data for monitoring health outcomes and informing decision making.

THANK YOU

We acknowledge the National Department of Health, Treasury and all other providers for access to and use of their data for this publication and Atlantic Philanthropies for funding the project.