Transcript City Health Presentation by the City of Cape Town

City of Cape Town
DIRECTORATE: CITY HEALTH
Primary Health Care
Presented by: Dr Ivan Bromfield
Executive Director: City Health
Content
Context in the metro
Some selected outcomes
Mandate
City Resources
Challenges
Discussion on Way Forward
EIGHT
Context in Metro
There are two authorities responsible for PHC
i.e. City Health and Metro District Health Services (PGWC)
Have agreed on cooperative management structures i.e. a District Executive
(DEX) and eight Integrated Sub-district Management Teams (ISDMT’s)
Have developed:
• Joint District Health Plan - Includes a District Health Expenditure Review
(DHER) and the setting of joint priorities, programmes and targets.
• Signed Service Level Agreement dealing with current funding arrangement
for clinic services.
• Provincial Act on the establishment of a District Health Council – still to get
operational date proclaimed
• Established Metro Health Forum (community structure) but the framework in
which it should operate has yet to be approved by the Provincial Health
Council.
Infant Mortality Rate
Babies dying < 1 yr of age, out of 1,000 live births
25
2003
24
2004
22
21
20
20
21
2005
2006
2007
2008
2009
Cape Town: % of births to women <18yrs
2007-2009
5.3
5.2
5.2
4.4
2006
2007
2008
2009
Cape Town Metro: STIs-New, 2004-2010
80 571
2004
72 506
2005
73 132
2006
STIs-New
59 102
63 482
63 489
59 620
2007
2008
2009
2010
Linear (STIs-New)
Male Condom distribution, 2004-2010 (millions)
This looks good, but…
64.3
62.1
58.7
52.2
47.3
26.2
21.9
2004
2005
2006
2007
2008
2009
2010
Male Condom distribution, 2004-2010 (millions)
116
We set stretch targets:
2 condomsX52 weeks=104 condoms/male >15yrs/year
58.7
64.3
52.2
47.3
21.9
2004
62.1
26.2
2005
2006
2007
2008
2009
2010
Target
TB Case-finding and New Smear+ Cure Rate
30,000
29,000
28,000
27,000
26,000
25,000
24,000
23,000
22,000
80
78
77
2004
2005
2006
2007
2008
No. of TB cases registered for treatment
2009
83
82 82
81
80
79
78
77
76
75
74
2010
Cure rate (%)
Q2 10
Q1 10
Q4 09
Q3 09
Q2 09
Q1 09
Q4 08
Q3 08
Q2 08
Q1 08
Q4 07
Q3 07
Q2 07
Q1 07
Q4 06
Q3 06
Q2 06
Q1 06
Q4 05
Q3 05
Q2 05
Q1 05
Q4 04
Q3 04
‘Get tested’ & HCT campaigns
100 000
90 000
80 000
70 000
60 000
50 000
40 000
30 000
20 000
How do we get it right?
Decentralized management – 8 Sub-Districts
Flat structure (few managerial levels)
Integrated approach: personal & environmental health fall under same SD
Manager maximise collaboration (not separate divisions)
Management systems and processes geared for service delivery on the
ground.
Lean middle management with a strong sense of purpose and skills in
project & change management.
Flexibility, innovation and creativity encouraged.
Lots of horizontal networks and communication opportunities for adoption
and transfer of innovation
Culture of using ‘information for action’: structured quarterly Plan-DoReview meetings
Extensive feedback and staff recognition (award ceremonies)
Investment in partnerships: Academia, researchers, NGOs/NPOs
Mandate
Our Mandate
Constitution
LG competencies of Municipal Health Services (MHS), Air
Pollution, Business Licensing & Noise Pollution
Health Act
Personal Primary Health care (PPHC) – dealt with in terms
of a signed SLA with Provincial Government Health
Department – continue to improve cooperation and SLA
Other legislation
By-laws
Environmental Health By-law
Air Pollution Control By-law (was adopted by Council in 31
March 2010 and was gazetted in August 2010)
Health Responsibility of 3 spheres of Government
Organisational Aspect
Eight sub-districts
" City Health is responsible for public health in the City of Cape Town. Our
services are delivered on the WHO District Health System (DHS) model
which means that we have divided the City into 8 subdistricts (service
delivery areas) i.e. Southern, Western, Northern, Eastern, Khayelitsha,
Mitchells Plain, Klipfontein and Tygerberg.
Across the City there are:
93 clinics, 18 satellite clinics and 6 mobile clinics (NB: clinic services
delivered in partnership with PGWC metro district health services who
run 47 Community Health Centres)
Approximately 104 Environmental Health Practitioners delivering a
decentralised service to the 8 sub-districts.
Air Quality Management Unit - responsible for 7 monitoring stations
spread across the City (Bothasig, City Hall, Drill Hall, Goodwood,
Khayelitsha, Molteno Reservoir, Killarney.) This service is done in
partnership with Scientific Services who have a monitoring station at
Athlone."
City Health Resources
2009/2010 Financial Year
OPEX: R 666,723,341 – Spend 98.5%
CAPEX: R 26,313,979 – Spend 97.2%
STAFF: – 1,438
Challenges
Increasing Burden of Disease and patient numbers with no
additional resources (staffing & opex)
Increasing costs of pharmaceuticals and laboratory tests above
parameter budget increases
Uncertainty over governance of PHC (clinic services)
Current issues
“Relationship” strain
Staff burn out.
PHC at Sub-District Level
‘Healthy
City for
All’ vision
not
fulfilled
Worsening
community
health status
Public bypassing the PHC
system
Public
confusion,
Dissatisfacti
on, lack of
trust
Tertiary &
specialized
hospitals
District Hospitals:
•More serious medical
conditions
•Increased admissions
•Increased costs: both
to services & patients
MDGs
will not
be met
No political
will to resolve
the situation
MDHS Community Health Centres:
•Doctor intensive, more complex
•Misuse of scarce staff resources: nurse
clinical skills underutilized
•Fragmentation & duplication
•Increased service costs
•Poor efficiency & effectiveness
City PHC Facilities
•Providing variable packages of care with serious omissions
•Nurse-based, without daily doctor support – reduces the package
•Patient delays due to difficulty in accessing PHC services
•Clinical deterioration, unnecessary increased morbidity & mortality
•Staff stress, anxiety, fatigue, absenteeism & attrition
•Smaller and easier to manage
Two authorities more
costly and doesn't
facilitate seamless
service provision
Resources not where
they are most
needed & difficult to
shift them
PROBLEMS TO ADDRESS
Resolve the funding strategy problems
•
•
•
•
Resources shortage to be resolved
Assessment of staff shortages at the various
CoCT sites
Within resource constraints, prioritization of 1-2
problems per sub-district to be addressed every
year
CoCT financial contribution from rates and taxes
to be increased
PGWC criteria for disbursing funds between the
2 authorities to be made available
Or funding to come directly from National to
CoCT
Update of total transfer payments to CoCT
Organizational culture
Exclusion from strategic positioning
•
•
•
Strategic planning discussion /sessions to be
implemented at CoCT
Develop a focussed plan of action
Health Care 2020 to acknowledge and include
the presence of CoCT, until such time that it
ceases to provide PHC.
•
•
•
•
•
Develop assertiveness
Withdraw from toxic relationship with MDHS substructures
Negotiate harmonization of services with MDHS
Each authority to be responsible for own
improvement plans and accountable for own
performance results
At PDR, HCT meetings, etc each authority to be
questioned separately for own performance in
relation to targets
Principles in favour of Local Government Providing PHC
PHC approach demands that communities be meaningfully involved in controlling
its own health services. LG is the democratically elected local representatives of
the community.
Multi-disciplinary and intersectoral approach - Will lose link with hard engineering
services (Water, Sanitation, Solid Waste)
City currently renders a very effective “clinic services” component of the PHC
package
City currently contributes to the provision of clinic services from rates. If clinic
services were to be under the authority of PGWC they would have to identify
additional funding to cover this gap as this income from rates would be lost to
clinic services.
The reality is that the fundamental issue revolves around funding. If LG could
obtain funding directly from National to make up the funding gap, the City would
then still be in a position to contribute additional funds over and above this
towards PHC from rates.
Approach to Way Forward
We need to understand what local government should be doing as guided by
the principles of the Constitution, the Systems Act and the Structures Act. It is a
sphere of government in its own right which must provide basic services and be
developmental in nature.
The matter should be looked at from a developmental service delivery aspect
based on the needs of the community – NOT just a ‘unfunded mandate’
perspective.
Based on what local governments objectives are as outlined in the Constitution
and the two Acts we should be asking:
• What should we be doing for PHC?
• What is our role in cross cutting matters?
• Who should be responsible for funding of PHC?
Way Forward
There is general agreement that health services in the country should be
based on the Primary Health Care (PHC) approach, and that public health
services should be organised in terms of the DHS model.
Municipal health services (MHS) is defined in the Act and a high court
decision in April 2008 concluded that the definition is, “capable of a
construction that incorporates such primary health care services as
municipalities provided before the Act came into force.”
The relevant MEC must assign such health services to a municipality in his
or her province in terms of section 156(4) of the Constitution i.e. if that
matter would most effectively be administered locally and the municipality
has the capacity to administer it.
From the above it is clear that the legislation allows for the City of Cape
Town to render PHC in its broader sense as opposed to the narrow
environmental health interpretation of MHS.
Conclusion
There must be active engagement
with those metros who indicate a
willingness to offer PHC services
involving all three spheres of
government.
Thank You