Overberg District - District Health Plan 2018/2019 to 2020/2021 - National Department of Health

 
Overberg District - District Health Plan 2018/2019 to 2020/2021 - National Department of Health
Overberg District

    Western Cape

             District Health Plan
             2018/2019 to 2020/2021
Overberg District - District Health Plan 2018/2019 to 2020/2021 - National Department of Health
1.        EXECUTIVE SUMMARY BY THE DISTRICT
          MANAGER

The Overberg District withstood the most pertinent of changes in the
past MTEF period, both values, structure and functions.

This district has accepted and assimilated the call on implementing
efficiencies across all levels of healthcare services. Each healthcare
worker in our service ambit has shown remarkable resilience and
leadership through this process. We will together as a team continue
to pursue the vision of achieving quality health care for all and
embed the principles of Healthcare 2030.

2018/2019 does not excuse itself from continued financial discipline, as we navigate the volatile
economic climate globally.

The district has successfully complied with all cost efficiencies and achieved outstanding health
care outcomes as well as accolades for clinical services and audit outcomes alike. This is akin to a
workforce who is focused, committed and passionate.

In the previous financial year, we as management, committed to recognising and rewarding staff
in across the district health service platform. In 2017/18 Overberg District received the following
awards:

-        Cecelia Makiwane Award (Ms G Smith – Overstrand Sub-district)
-        Health Outcomes Award for the Community Orientated Primary Audiology Care
-        Team recognition for donation of Mobility Assistive devices

Infrastructure:

With great joy we celebrate the completion of the construction of the Napier Clinic towards the
end of 2017. The Clinic commenced operations on 06 November 2017.

We look forward in participating in the newly legislated Facility Boards and Clinic Committees. By
working together we can only grow, positively impacting the lives of the citizens in the Overberg
District.

The focus areas for 2018/2019 and beyond:

            Implementing the COPC concept in 3 pilot areas (and look at rolling out to the rest of
             the district)
            Strengthening of operational services
            Enhance Intersectoral collaboration
            Centralize certain Corporate function to District Office and strengthen support to Sub-
             districts
            Implement cost saving projects.

Change will never be easy and to navigate through this difficult time, we commit to continuous
and open communication, support and respect to all staff within the district

Ms W M Kamfer
District Director: Overberg District
Rural District Health Services

                                                                                                  2
2.   ACKNOWLEDGEMENTS

     Chief Director: Rural Districts: Dr R Crous

     Director: Overberg District: Ms W Kamfer

     Director Overberg Emergency Medical Services & Team

     District Health Council Members

     Professional Support: Ms RLC Zondo & Team

     Comprehensive Health: Ms P Robertson & Team

     Pharmaceutical Services: Ms H Brits & Team

     Finance and Supply Chain Management: Mr A Niekerk & Team

     People Management: Mr C Matshoza & Team

     Information Management: Mr L Benjamin & Team

     Sub District Management Teams

                                                                3
3.     OFFICIAL SIGN OFF

       It is hereby certified that this District Health Plan:

             Was developed by the district management team of Overberg District with the technical
              support from the Chief Directorate: Rural District Health Services and the Strategic Planning
              unit at the provincial head office.
             Was prepared in line with the current Strategic Plan and Annual Performance Plan of the
              Western Cape Department of Health.

Ms WM Kamfer
District manager: Overberg District                                             SIGNATURE

                                                                                   DATE

Cllr A Franken
Chairperson: Overberg District Health Council                                   SIGNATURE

                                                                                   DATE

Dr R Crous
Chief Director: Rural District Health Services                                  SIGNATURE

                                                                                   DATE

Dr K Cloete
Chief of Operations                                                             SIGNATURE

                                                                                   DATE

Dr B Engelbrecht
Accounting officer (Head of Department)                                         SIGNATURE

                                                                                   DATE

                                                                                                         4
4.       TABLE OF CONTENTS

1.        EXECUTIVE SUMMARY BY THE DISTRICT MANAGER ............................................................. 2
2.        ACKNOWLEDGEMENTS .......................................................................................................... 3
3.        OFFICIAL SIGN OFF................................................................................................................. 4
4.        TABLE OF CONTENTS ............................................................................................................... 5
5.        LIST OF ACRONYMS ................................................................................................................ 6
6.        EPIDEMIOLOGICAL PROFILE .................................................................................................. 8
6.1       GEOGRAPHIC OVERVIEW ...................................................................................................... 8
6.2       DEMOGRAPHIC OVERVIEW ................................................................................................... 8
6.3       SOCIAL DETERMINANTS OF HEALTH .................................................................................... 11
6.4       CAUSES OF MORTALITY ........................................................................................................ 13
6.5       BURDEN OF DISEASE ............................................................................................................. 15
7.        SERVICE DELIVERY PLATFORM AND MANAGEMENT ......................................................... 17
7.1       HEALTH FACILITIES PER SUB-DISTRICT .................................................................................. 17
7.2       HUMAN RESOURCES FOR HEALTH (FILLED POSTS) ............................................................. 18
7.3       BASELINE DATA 2016/17 ...................................................................................................... 19
8.        QUALITY OF CARE ................................................................................................................. 26
9.        ORGANISATIONAL STRUCTURE OF THE DISTRICT MANAGEMENT TEAM .......................... 31
10.       DISTRICT HEALTH EXPENDITURE ............................................................................................ 32
11.       DISTRICT PERFORMANCE INDICATORS ............................................................................... 33
11.1      DISTRICT HEALTH SERVICES .................................................................................................. 33
11.2      DISTRICT HOSPITALS .............................................................................................................. 40
11.3      HIV AND AIDS, STIs AND TB CONTROL (HAST) ................................................................... 44
11.4      MATERNAL, CHILD AND WOMEN’S HEALTH (MCWH) AND NUTRITION............................ 49
11.5      DISEASE PREVENTION AND CONTROL ................................................................................ 57
12.       DISTRICT FOCUS FOR THE YEAR ........................................................................................... 60
ANNEXURE A: OVERBERG DISTRICT POPULATION ESTIMATES BY AGE ........................................ 64
ANNEXURE B: TARGETS FOR SDG 3 – “GOOD HEALTH AND WELL-BEING” ................................. 65
ANNEXURE C: FACILITY LIST ............................................................................................................. 66
ANNEXURE D: TECHNICAL INDICATOR DESCRIPTIONS ................................................................. 68
ANNEXURE E: COMMUNICATION PLAN ......................................................................................... 80

                                                                      5
5.   LIST OF ACRONYMS

     AIDS         Acquired immune deficiency syndrome
     ALOS         Average length of stay
     APL          Approved post list
     APP          Annual Performance Plan
     ART          Anti-retroviral treatment
     BANC         Basic antenatal care
     BUR          Bed utilisation rate
     CBS          Community-based services
     CDC          Community day centre
     CDU          Chronic dispensing unit
     CHC          Community health centre
     CHW          Community health worker
     COPC         Community oriented primary care
     COPD         Chronic obstructive pulmonary disease
     DHC          District Health Council
     DHER         District Health Expenditure Review
     DHP          District Health Plan
     DHS          District Health Services/Systems
     DR TB        Drug resistant TB
     EC           Emergency centre
     EDR          Electronic drug-resistant TB register
     EMS          Emergency medical services
     EPWP         Expanded Public Works Programme
     ETR.net      Electronic TB register
     GSA          Geographic service area
     HAST         HIV and AIDS, STIs and TB control
     HCBC         Home and community based care
     HCT          HIV counselling and testing
     HIV          Human immunodeficiency virus
     HPV          Human papillomavirus
     HR           Human resource
     ICD-10       International classification of disease coding
     ICT          Information and communication technology
     ID           Infectious diseases
     JAC          Electronic Pharmacy Management Inventory System
     LG           Local government
     M&E          Monitoring and evaluation
     MDG          Millennium development goal
     MDR-TB       Multi-drug resistant tuberculosis
     MHS          Municipal Health Services
     MMC          Medical male circumcision

                                                                    6
MOU        Midwife obstetric unit
MTEF       Medium-term expenditure framework
MTSF       Medium-term strategic framework
NCS        National core standards
NDP        National Development Plan
NHLS       National Health Laboratory Services
NIMART     Nurse Initiated Management of Anti-retroviral Therapy
NPO        Non-profit organisation
OPD        Outpatient department
OSD        Occupational specific dispensation
PACK       Practical Approach to Care Kit
PCE        Patient centred experience
PCR        Polymerase chain reaction
PCV        Pneumococcal conjugate vaccine
PDE        Patient day equivalent
PHC        Primary health care
PHCIS      Primary Health Care Information Systems
PMTCT      Prevention of mother-to-child transmission
PPIP       Perinatal problem identification programme
PTB        Pulmonary tuberculosis
QIP        Quality improvement plan
RCS        Rural clinical school
RDHS       Rural District Health Services
RIC        Retention in care
SAM        Severe acute malnutrition
SCM        Supply chain management
SD         Sub-district
SDG        Sustainable development goal
STI        Sexually transmitted infection
TB         Tuberculosis
TIER.net   HIV electronic register
VPUU       Violence Prevention through Urban Upgrading
WCG        Western Cape Government
WCGH       Western Cape Government Health
WCCN       Western Cape College of Nursing
WHO        World Health Organisation
WoW        Western Cape on wellness
XDR-TB     Extreme drug resistant tuberculosis
YTD        Year to date

                                                                   7
6.    EPIDEMIOLOGICAL PROFILE

6.1   GEOGRAPHIC OVERVIEW

      The Overberg is one of five rural district municipalities in the Western Cape Province and is
      the smallest district in the province, making up only 9% of its geographical area.

      The district consists of four local municipalities, namely: Cape Agulhas, Overstrand,
      Swellendam and Theewaterskloof.

      The district office for Western Cape Government: Health (WCG: Health) is situated in
      Caledon in the Theewaterskloof Sub-district. There are 42 primary health care (PHC) facilities
      in the district of which 19 are fixed facilities. There are four district hospitals (one in each sub-
      district) and no regional or TB hospitals.

      Figure 1: Map of Overberg District

      [Source: https://municipalities.co.za/map/146/overberg-district-municipality]

6.2   DEMOGRAPHIC OVERVIEW

      The National Department of Health distributed revised population estimates during 2017,
      based on the mid-year population estimates received from Stats SA for 2002 to 2016 and the
      short term projections for 2017 to 2021.

      The revised population estimates reflect financial years rather than calendar years as was
      previously the case. These estimates will be implemented from 2018/19 going forward and is
      reflected in the tables below.

                                                                                                         8
Table 1: Sub-district population size and density 2016/17

Sub-district           Town(s)                       Total                 Geographic area Population
                                                     population(A)         (per km²)(B)            density (per
                                                                                                   km2)
Cape Agulhas           - Agulhas                                  34 168                   3 471              10
                       - Arniston
                       - Bredasdorp
                       - Elim
                       - Klipdale
                       - Napier
                       - Protem
                       - Struis Bay
                       - Suiderstrand
Overstrand             - Betty's Bay                              94 734                   1 675              61
                       - Birkenhead
                       - De Kelders
                       - Fishershaven
                       - Franskraal
                       - Gans Bay
                       - Hawston
                       - Hermanus
                       - Kleinmond
                       - Onrus
                       - Pearly Beach
                       - Pringle Bay
                       - Rooi-Els
                       - Sand Bay
                       - Stanford
                       - Van Dyks Bay
                       - Vermont
Swellendam             - Barrydale                                37 457                   3 835              10
                       - Buffeljagsrivier
                       - Infanta
                       - Malagas
                       - Suurbraak
                       - Swellendam
Theewaterskloof        - Bot River                              115 664                    3 259              36
                       - Caledon/Myddleton
                       - Genadendal
                       - Grabouw
                       - Greyton
                       - Riviersonderend
                       - Theewaterskloof
                       - Villiersdorp
District total                                                  282 022                   12 239              24
[Source A: Circular H11/2018: Population data]

[Source B: https://municipalities.co.za/overview/146/overberg-district-municipality ]

                                                                                                                  9
Overberg District is the rural district with the second lowest population. The sub-districts
consist of several towns and small dwellings that are spread out over a large surface area
which results in a lower population density. The population density in Overstrand is
significantly higher than the other sub-districts.

Figure 2: Sub-district population distribution in Overberg District 2016/17

                                                       Cape Agulhas
                                                          12.1%

                              Theewaterkloof
                                  41.0%

                                                               Overstrand
                                                                 33.6%

                                               Swellendam
                                                 13.3%

[Source: Circular H11/2018: Population data]

There is a decrease of 4.1% between the total population estimates for 2018/19 (i.e. all age
groups) that were release in 2014 and 2017 respectively. Overberg District is the only district
in the Western Cape for which the estimated population under 1 year is in line with the
previous estimates (there is a 0.7% difference). Provincially, there is an 8.9% increase in the
estimated population under 1 year.

For more detailed information on the population breakdown per age group for the district,
refer to Annexure A.

                                                                                            10
Figure 3: Overberg District population pyramid for 2016/17

        80 years and older
               75 - 79 years
               70 - 74 years
               65 - 69 years
               60 - 64 years
               55 - 59 years
               50 - 54 years
               45 - 49 years
               40 - 44 years
               35 - 39 years
               30 - 34 years
               25 - 29 years
               20 - 24 years
               15 - 19 years
               10 - 14 years
                 5 - 9 years
             Under 5 years

                          -15 000       -10 000       -5 000           0           5 000            10 000         15 000

                                                         Male     Female

      [Source: Circular H11/2018: Population data]

6.3   SOCIAL DETERMINANTS OF HEALTH

      Social determinants may have an impact on the health status outcomes of the district
      population.

      Table 3: Household dynamics in the Overberg District 2016

      Age groups                                  Cape                                            Theewaters-
                                                                Overstrand Swellendam                                District
                                              Agulhas                                                kloof
      Households                                     11 321          35 718          11 678             33 118              91 835
      Average household size                             3.2               2.6              3.4              3.5                3.1
      Female headed households                       34.0%            33.8%           28.3%              30.5%              31.9%
      Formal dwellings                               88.1%            79.0%           96.0%              77.5%              81.8%
      Housing owned                                  76.5%            52.7%           65.9%              33.6%              50.5%
      [Source: https://municipalities.co.za/overview/146/overberg-district-municipality ]

      Note: The highest and lowest value for each item is coloured orange and green respectively.

                                                                                                                              11
Figure 4: Overberg District education levels 2016

                                                      Education levels by sub-district

                                                                                          32.0%
 35.0%

                                                       29.4%

                                                                                                                                                                 27.7%
                      27.6%
 30.0%

                                                                                                                                24.7%
 25.0%

                                                                  15.6%
 20.0%

 15.0%

                                                                                                                                                                              9.7%
                                                                                                    7.1%
                                 6.9%

                                                                                                                                          6.6%
 10.0%

                                                                                                                       4.4%
                                                                                3.7%

                                                                                                                                                       3.2%
                                              2.3%
             1.5%

  5.0%

  0.0%
            Cape Agulhas                      Overstrand                        Swellendam                          Theewaterskloof                           District

                                               No schooling                    Matric               Higher education

[Source: https://municipalities.co.za/overview/146/overberg-district-municipality ]

Figure 5: Overberg District household services 2016

                                                Household services by sub-district
 120.0%
                                                                                                        96.9%
                                      96.5%

                                                                       95.7%
                                                      94.0%

                                                                                93.9%

                                                                                                                                                                               93.9%
                     90.2%

                                                                                                                                              90.1%
             87.4%

                                                                                                                                                              87.1%
                                                                                                                                                      86.7%
                                                                                        86.5%
                                              86.3%

                                                                                                86.3%
                              84.5%

                                                                                                                      84.3%

 100.0%
                                                                                                                              78.7%

                                                                                                                                                                      78.6%
                                                               77.6%

                                                                                                                                      75.0%

  80.0%

  60.0%

  40.0%

  20.0%

    0.0%
             Cape Agulhas                       Overstrand                      Swellendam                          Theewaterskloof                           District

           Flush toilet connected to sewerage                                                                   Weekly refuse removal
           Piped water inside dwelling                                                                          Electricity for lighting

[Source: https://municipalities.co.za/overview/146/overberg-district-municipality ]

                                                                                                                                                                                       12
Figure 6: Main economic sectors in Overberg District

                      Community, social                                                         Other, 1.3%
                        and personal
                        services, 4.2%

         Transport, storage
        and communication,
               8.3%                                               Finance, insurance,
                                                                    real estate and
                                                                   business services,
         Construction, 8.5%
                                                                         25.1%

                                   General
                               government, 10.5%

                                                                           Manufacturing,
                                                                              16.3%
                                    Agriculture, forestry
                                     and fishing, 12.1%
                                                        Wholesale and retail
                                                        trade, catering and
                                                          accommodation,
                                                               13.7%

      [Source: https://municipalities.co.za/overview/146/overberg-district-municipality ]

6.4   CAUSES OF MORTALITY

      Table 4: Leading underlying natural causes of death, Western Cape, 2015

                   Cape                                                                                           Western
        Rank                   Central Karoo    Cape Town           Eden          Overberg       West Coast
                 Winelands                                                                                         Cape

                               Chronic lower                                     Ischaemic
                                                  Diabetes                                                        Diabetes
                HIV disease     respiratory                     Tuberculosis        heart       Tuberculosis
          1                                        mellitus                                                        mellitus
                   (7.2%)        diseases                          (7.0%)          diseases        (7.9%)
                                                   (7.5%)                                                          (7.2%)
                                  (9.1%)                                            (7.1%)

               Cerebrovasc                                                      Cerebrovasc       Diabetes
                                Tuberculosis    HIV disease     HIV disease                                     HIV disease
          2    ular diseases                                                    ular diseases      mellitus
                                   (6.7%)          (6.3%)          (6.7%)                                          (6.1%)
                  (6.9%)                                                           (6.6%)          (7.4%)

                                                                                  Malignant
                                                 Ischaemic                                                       Ischaemic
                 Diabetes       Cerebrovasc                     Cerebrovasc     neoplasms of    Cerebrovasc
                                                    heart                                                           heart
          3       mellitus      ular diseases                   ular diseases       resp &      ular diseases
                                                   diseases                                                        diseases
                  (6.7%)           (6.2%)                          (6.6%)       intrathoracic      (7.2%)
                                                    (5.7%)                                                          (5.8%)
                                                                                organs (6.5%)

                                                                 Ischaemic                      Chronic lower
                                                Cerebrovasc                       Diabetes                      Cerebrovasc
                Tuberculosis     HIV disease                        heart                        respiratory
          4                                     ular diseases                      mellitus                     ular diseases
                   (6.6%)           (5.2%)                         diseases                       diseases
                                                   (4.9%)                          (6.1%)                          (5.6%)
                                                                    (6.4%)                         (6.6%)

               Chronic lower                                                    Chronic lower    Ischaemic
                                  Diabetes                        Diabetes
                respiratory                     Tuberculosis                     respiratory        heart       Tuberculosis
          5                        mellitus                        mellitus
                 diseases                          (4.5%)                         diseases         diseases        (5.3%)
                                   (5.2%)                          (6.2%)
                  (6.2%)                                                           (5.6%)           (5.8%)

                                                                                                                         13
Cape                                                                                             Western
  Rank                     Central Karoo    Cape Town          Eden         Overberg           West Coast
            Winelands                                                                                           Cape

            Ischaemic                      Chronic lower Chronic lower                                       Chronic lower
                           Hypertensive                                                     Hypertensive
               heart                        respiratory   respiratory      Tuberculosis                       respiratory
    6                        diseases                                                         diseases
              diseases                       diseases      diseases           (5.0%)                           diseases
                              (5.2%)                                                           (4.6%)
               (5.5%)                         (4.4%)        (5.8%)                                              (5.1%)

                                                             Malignant
            Malignant       Malignant       Malignant      neoplasms of     Malignant                         Malignant
                                                                                               HIV disease
    7       neoplasms       neoplasms       neoplasms          resp &       neoplasms                         neoplasms
                                                                                                  (4.6%)
              (5.0%)          (4.1%)          (4.2%)       intrathoracic      (4.9%)                            (4.5%)
                                                           organs (4.9%)

             Malignant       Malignant       Malignant                                                         Malignant
           neoplasms of    neoplasms of    neoplasms of     Malignant      Hypertensive        Malignant     neoplasms of
    8          resp &          resp &          resp &       neoplasms        diseases          neoplasms         resp &
           intrathoracic   intrathoracic   intrathoracic      (4.6%)          (4.0%)             (4.4%)      intrathoracic
           organs (5.0%)   organs (4.0%)   organs (4.2%)                                                     organs (4.5%)

                                                                                              Malignant
                            Ischaemic                      Other forms     Other forms
           Hypertensive                    Hypertensive                                     neoplasms of     Hypertensive
                               heart                        of heart        of heart
    9        diseases                        diseases                                           resp &         diseases
                              diseases                      disease         disease
              (3.3%)                          (4.1%)                                        intrathoracic       (4.0%)
                               (4.0%)                        (3.7%)          (3.3%)
                                                                                            organs (3.7%)

           Other forms      Other forms     Other forms                                        Other forms    Other forms
                                                           Hypertensive    Influenza and
            of heart         of heart        of heart                                           of heart       of heart
   10                                                        diseases       pneumonia
            disease          disease         disease                                            disease        disease
                                                              (3.4%)            (2.8%)
             (3.2%)           (3.8%)          (3.1%)                                             (2.5%)         (3.2%)

[Source: Mortality and causes of death in South Africa, 2015: Findings from death notification, Statistical Release
P0309.3]

HIV and TB predominate in Age-Standardised Mortality Rates, due to their preponderance in
younger age group. For non-Standardised Rates, Cardiovascular causes of Mortality
predominate in the Overberg District. A sub-district breakdown of the underlying natural
causes of death was not included in the above publication.

Table 5: Institutional maternal mortality rate (iMMR) in Overberg District

                                              2011                2012                    2013                2014
Deaths during pregnancy,                        0                     1                    2                    0
childbirth and puerperium
iMMR                                            0                 34.59                 66.87                   0
[Source: Saving Mothers, 2014]

Note: The source listed above is the latest published Saving Mothers Report.

Table 6: Infant and child mortality in Overberg District

District                           Infant mortality rate (< 1 year)             Child mortality rate (< 5 years)
                                  2011           2012            2013           2011              2012           2013
Overberg                          30.5              27.7         22.7           38.2               33.7          26.5
[Source: Western Cape Mortality Profile 2013]

Note: The source listed above is the latest published Western Cape Mortality Profile.

                                                                                                                        14
6.5   BURDEN OF DISEASE

      DISTRICT HIV AND AIDS PROFILE

      Figure 7: Antenatal Survey HIV prevalence: South Africa vs Western Cape; 1990 - 2015

                              35.0

                              30.0

                              25.0
         HIV prevalence (%)

                              20.0

                              15.0

                              10.0

                               5.0

                               0.0
                                     1990
                                            1991
                                                   1992
                                                          1993
                                                                 1994
                                                                        1995
                                                                               1996
                                                                                      1997
                                                                                             1998
                                                                                                    1999
                                                                                                           2000
                                                                                                                  2001
                                                                                                                         2002
                                                                                                                                2003
                                                                                                                                       2004
                                                                                                                                              2005
                                                                                                                                                     2006
                                                                                                                                                            2007
                                                                                                                                                                   2008
                                                                                                                                                                          2009
                                                                                                                                                                                 2010
                                                                                                                                                                                        2011
                                                                                                                                                                                               2012
                                                                                                                                                                                                      2013
                                                                                                                                                                                                             2014
                                                                                                                                                                                                                    2015
                                                                                         Western Cape                                  South Africa

      [Source: National Antenatal Sentinel HIV & Syphilis Survey Report, 2015]

      Figure 8: HIV prevalence among antenatal women, 2010 - 2015

                                                                        HIV prevalence among antenatal women
                              35

                              30

                              25
         HIV prevalence (%)

                              20

                              15

                              10

                               5

                               0
                                            2010                          2011                             2012                         2013                          2014                            2015

                                                                        South Africa                              Western Cape                              Overberg

      [Source: National Antenatal Sentinel HIV & Syphilis Survey Report, 2015]

                                                                                                                                                                                                                           15
SUB-DISTRICT HIV PREVALENCE – OVERBERG

          District                2012              2013                 2014             2015                2016
                                  16.6               16.1                15.2             18.9                 -
        Overberg
                              (13.8 - 19.5)      (13.3 - 19.3)      (11.8 - 18.6)     (15.5-22.4)              -
                                  11.3               8.9                 10.0             2.5                  -
      Cape Agulhas
                               (3.8 - 18.8)      (1.8 - 16.0)       (1.02 - 19.0)      (0.2- 7.2)              -
                                  23.8               20.7                14.9              25                  -
       Overstrand
                              (17.9 - 29.6)      (14.9 - 26.5)      (9.2 - 20.6)      (19.1-31.2)              -
                                   7.9               12.7                13.0             6.5                  -
       Swellendam
                               (2.1 - 13.7)      (5.3 - 20.0)       (3.6 - 22.4)        (0-13.4)               -
                                  15.8               15.8                17.4             17.1                 -
     Theewaterskloof
                              (11.5 - 20.1)      (11.2 - 20.3)      (12.1 - 22.7)     (15.4-27.6)              -
*No survey done in 2016

DISTRICT TB PROFILE

 Overberg district TB profile       2010         2011        2012         2013        2014          2015       2016
 Population *                       248 610      253 667    259 163       264 745     270 406       276 168    282 022
 All PTB cases                           2 412     2 266         2 138      2 062       2 074         2 171        1 906
 New Smear positive cases                 524        527          718           853       784          627           577
 Incidence /100 000                       211        208          277           322       290          227           205
 Prevalence/100 000                       970        893          825           779       767          786           676

* [Source: Circular H11/2018: Population data]; Population estimates per financial year

                                                                                                                     16
7.    SERVICE DELIVERY PLATFORM AND MANAGEMENT

7.1   HEALTH FACILITIES PER SUB-DISTRICT

      Table 7: Health facilities per sub-district as at 31 March 2017

      Sub-district

                                                                                                                                                Central/tertiary
                                                                                                      District hospital
                                            outreach team
                               Ward based

                                                                                                                                                                              TB hospital
                                                                                                                          Regional
                                                                                                                                     hospital

                                                                                                                                                                   hospital
                                                                     Satellite
                                                            Mobile

                                                                                 Clinic

                                                                                          CDC

                                                                                                CHC
           Cape Agulhas                -                    2         2          3        -     -       1                      -                          -                   -
             Overstrand                -                    1         4          4        1     -       1                      -                          -                   -
             Swellendam                -                    3         0          5        -     -       1                      -                          -                   -
          Theewaterskloof              -                    8         3          5        1     -       1                      -                          -                   -
             District total            -                    14        9          17       2     -       4                      -                          -                   -
      [Source: Sinjani]

      Overberg District renders health services on a District Health Services platform. The focus is
      on Primary intervention. The main locus of service delivery is based around the Primary
      Health Care facilities, which are based in the communities where citizens reside and work.
      Overberg District implements community based health care moving towards a COPC
      concept. The Overberg District does not have Ward based outreach teams.

      The four District Hospitals provide a higher level of care that PHC Facilities refer to. There are
      no tertiary services rendered within the Overberg District. Secondary health care needs are
      referred outside the District to Worcester and respectively Cape Town CBD. Secondary
      health services are augmented by a Monthly Specialist, Outreach and Support Team (6
      basic disciplines) from Worcester Hospital. The six disciplines are Internal, Surgery, Psychiatry,
      Obstetrics &Gynaecology, Paediatric and Anaesthetics.

                                                                                                                                                                               17
7.2   HUMAN RESOURCES FOR HEALTH (FILLED POSTS)

      Table 8: Filled posts as at 31 March 2017

      Sub-district

                                                                                                                                                                                             Physiotherapist
                                                                                  Enrolled nurse

                                                                                                                                                                  Occupational
                                                      health worker

                                                                                                       Professional
                                          Community

                                                                                                                                                                                                                                    Audiologist
                                                                                                                                       Pharmacist

                                                                                                                                                                                 therapist

                                                                                                                                                                                                                        therapist
                                                                      assistant

                                                                                                                                                                                                               Speech
                                                        Nursing

                                                                                                                                                    Dentist
                                                                                                                              Doctor
                                  Admin

                                                                                                                      nurse
      OVERSTRAND                    38                -               23                 27                           59         11             4         1                      1                 1                    -                  -
      TWK                           37                -               30                 20                           57         10             5         2                      1                 1                    -                  -
      SWELLENDAM                    29                -               18                 13                           26           4            1         1                      1                 1                    -                  -
      CAPE AUGULHAS                 13                -               15                       9                      26           3            1             -                  -                    -                 -                  -
      DISTRICT OFFICE               23                    -               -                        -                   6           2            1             -                  -                    -                 1                1
      District total               131                -               86                 69                    174               30         12            4                      3                 3                    1                1
      [Source: PERSAL] * Community Health worker -NPO Funded

      Swellendam and CA SD shared services with Dental & Allied Health Services

      TWK SD manages the Speech & Audiology Services, as well as the district.

      Illustration of Sessional appointment which are not represented in the above table:
      Psychologist, Medical Officers, Radiographer,

                                                                                                                                                                                                                                    18
7.3    BASELINE DATA 2016/17

Table 9: Performance indicators for District Health Services

                                                                                        District wide                                                        Theewaters-     Province wide
      Programme performance indicator                           Data source /   Type                       Cape Agulhas     Overstrand       Swellendam
                                                    Frequency                               value                                                               kloof            value
                                                                 Element ID
                                                                                            2016/17          2016/17         2016/17          2016/17         2016/17          2016/17
 SECTOR SPECIFIC INDICATORS
 1.     Ideal clinic (IC) status rate                Annual                      %              47.4%            33.3%           80.0%            40.0%            33.3%            17.2%
                                        Numerator                    3                                9                1                 4              2               2                47
                                   Denominator                       2                                19               3                 5              5               6             273
 2.     PHC utilisation rate (annualised)           Quarterly                   No                2.6               2.9             2.7              2.7             2.4                 2.3
                                        Numerator                    6                        731 769           100 649         254 018          100 348         276 754        14 413 350
                                   Denominator                       7                        282 022            34 168          94 734           37 457         115 664         6 318 281
 3.     Complaint resolution within 25              Quarterly                    %              96.5%            89.7%           98.6%            98.3%            91.7%            95.6%
        working days rate (PHC facilities)
                                        Numerator                    10                           273                  35          146                  59              33           3 175
                                   Denominator                       8                            283                  39          148                  60              36           3 320

                                                                                       19
Table 10: Performance indicators for District Hospitals

                                                                                    District wide                                                           Theewaters-       Province wide
      Programme performance indicator                         Data source    Type                       Cape Agulhas      Overstrand       Swellendam
                                                  Frequency                             value                                                                  kloof              value
                                                              / Element ID
                                                                                      2016/17             2016/17          2016/17          2016/17          2016/17            2016/17
 SECTOR SPECIFIC INDICATORS
 1.    Hospital achieved 75% and more on          Quarterly                   %            100.0%             100.0%           100.0%           100.0%           100.0%               69.7%
       National Core Standards (NCS) self-
       assessment rate (district hospitals)
                                      Numerator                    3                                4                1                 1               1                  1               23
                                    Denominator                    4                                4                1                 1               1                  1               33
 2.    Average length of stay (district           Quarterly                  Days               2.8                 3.0              2.3              3.2              3.1                3.2
       hospitals)
                                      Numerator                    7                       51 172               7 369          16 930           11 878            14 996             909 893
                                    Denominator                    8                       18 528               2 431            7 468            3 744            4 885             280 580
 3.    Inpatient bed utilisation rate (district   Quarterly                   %             68.9%              66.5%            64.4%            63.8%             82.2%              84.8%
       hospitals)
                                      Numerator                    7                       51 172               7 369          16 930           11 878            14 996             909 893
                                    Denominator                    9                       74 225             11 073           26 283           18 617            18 252           1 072 731
 4.    Expenditure per PDE (district hospitals)   Quarterly                   R           R 2 094             R 1 911          R 2 229          R 1 941          R 2 147             R 2 139
                                      Numerator                   10                 164 453 263           23 362 147       62 433 620       33 726 468       44 931 028       2 923 677 427
                                    Denominator                   16                       78 533             12 225           28 009           17 372            20 928           1 366 831
 5.    Complaint resolution within 25 working     Quarterly                   %             99.6%              95.2%           100.0%           100.0%           100.0%               90.4%
       days rate (district hospitals)
                                      Numerator                   19                          283                   20            163                 37               63              1 501
                                    Denominator                   17                          284                   21            163                 37               63              1 661

                                                                                                                                                                                       20
Table 11: Performance indicators for HIV and AIDS, STIs and TB control (HAST)

                                                                                    District wide                                                   Theewaters-    Province wide
        Programme performance indicator                       Data source    Type                   Cape Agulhas     Overstrand     Swellendam
                                                  Frequency                             value                                                          kloof           value
                                                              / Element ID
                                                                                      2016/17         2016/17         2016/17        2016/17         2016/17         2016/17
STRATEGIC GOAL: Promote health and wellness.
1.1.1    TB programme success rate                Quarterly                   %             90.9%          81.5%           92.0%          90.0%            92.0%           80.4%
                                     Numerator                     1                        1 971            154             587            217            1 013           34 651
                                   Denominator                     2                        2 169            189             638            241            1 101           43 099
2.1.1    ART retention in care after 12 months    Quarterly                   %             68.0%          71.8%           74.4%          64.0%            63.0%           72.2%
                                     Numerator                     3                        1 237            102             495            110             530            33 307
                                   Denominator                     4                        1 820            142             665            172             841            46 120
2.1.2    ART retention in care after 48 months    Quarterly                   %             66.1%          71.3%           72.9%          59.3%            61.1%           60.7%
                                     Numerator                     5                          722               62           293               64           303            19 700
                                   Denominator                     6                        1 093               87           402            108             496            32 455
SECTOR SPECIFIC INDICATORS
1.       ART client remain on ART end of month    Quarterly                  No            10 397            721           4 245            856            4 575          230 931
         - total
                                        Element                    7
2.       TB/HIV co-infected client on ART rate    Quarterly                   %             84.3%          53.8%           90.6%          97.8%            81.5%           89.6%
                                     Numerator                     8                          632               21           242               44           325            14 902
                                   Denominator                     9                          750               39           267               45           399            16 637
3.       HIV test done – total                    Quarterly                  No            74 349         10 976          20 934         11 404           31 035        1 379 375
                                        Element                   10
4.       Male condoms distributed                 Quarterly                  No         6 536 300        771 000        2 012 700       927 200        2 825 400      113 913 868
                                        Element                   12
5.       Medical male circumcision – total        Quarterly                  No               616               71           213               74           258            11 687
                                        Element                   16

                                                                                                                                                                            21
District wide                                                      Theewaters-     Province wide
      Programme performance indicator                         Data source    Type                    Cape Agulhas     Overstrand       Swellendam
                                                  Frequency                             value                                                             kloof            value
                                                              / Element ID
                                                                                      2016/17          2016/17         2016/17          2016/17         2016/17          2016/17
6.     TB client 5 years and older start on       Quarterly                   %            101.3%           96.2%          122.3%            97.9%            94.6%            92.9%
       treatment rate
                                      Numerator                   19                        1 119             102             291              188             538             21 007
                                   Denominator                    20                        1 105             106             238              192             569             22 612
7.     TB client treatment success rate           Quarterly                   %             90.9%           81.5%           92.0%            90.0%            92.0%            80.4%
                                      Numerator                   21                        1 971             154             587              217            1 013            34 651
                                   Denominator                    22                        2 169             189             638              241            1 101            43 099
8.     TB client defaulter / lost to follow up    Quarterly                   %              3.2%            7.9%            3.4%             4.1%             2.0%            10.5%
       rate
                                      Numerator                   23                            69               15              22               10              22            4 514
                                   Denominator                    22                        2 169             189             638              241            1 101            43 099
9.     TB client death rate                        Annual                     %              3.2%            3.2%            2.7%             4.1%             3.3%             3.9%
                                      Numerator                   24                            69               6               17               10              36            1 693
                                   Denominator                    22                        2 169             189             638              241            1 101            43 099
10.    TB MDR treatment success rate               Annual                     %             29.1%           25.0%           14.3%            23.1%            35.5%            44.6%
                                      Numerator                   25                            16               1                 1              3               11               738
                                   Denominator                    26                            55               4                 7              13              31            1 653

                                                                                                                                                                                22
Table 12: Performance indicators for MCWH and Nutrition

                                                                                     District wide                                                          Theewaters-       Province wide
     Programme performance indicator                          Data source /   Type                       Cape Agulhas     Overstrand       Swellendam
                                                  Frequency                              value                                                                 kloof              value
                                                               Element ID
                                                                                       2016/17             2016/17         2016/17          2016/17          2016/17            2016/17
SECTOR SPECIFIC INDICATORS
1.    Antenatal 1st visit before 20 weeks rate    Quarterly                    %             78.0%              88.3%           76.2%            82.2%             75.5%              61.0%
                                     Numerator                     1                         3 310                444             974              402             1 490             60 384
                                 Denominator                       2                         4 244                503            1 279             489             1 973             99 069
2.    Mother postnatal visit within 6 days rate   Quarterly                    %             69.8%              67.7%           65.2%            52.3%             80.3%               6.3%
                                     Numerator                     3                         2 144                270             745              184               945              6 026
                                 Denominator                       4                         3 071                399            1 143             352             1 177             95 337
3.    Antenatal client start on ART rate           Annual                      %             85.1%              96.7%           92.3%            87.5%             77.1%               6.3%
                                     Numerator                     5                           387                   29           169                 21             168              6 026
                                 Denominator                       6                           455                   30           183                 24             218             95 337
4.    Infant 1st PCR test positive around 10      Quarterly                    %              0.0%               0.0%            0.0%             0.0%              0.0%               1.9%
      weeks rate
                                     Numerator                     7                                 0               0                 0                0                 0             242
                                 Denominator                       8                           494                   29           258                 17             190             12 617
5.    Immunisation coverage under 1 year          Quarterly                    %             71.8%              89.5%           74.5%            73.0%             64.9%              84.5%
                                     Numerator                     9                         3 294                440            1 138             453             1 263             89 202
                                 Denominator                       10                        4 585                492            1 527             620             1 946            105 611
6.    Measles 2nd dose coverage                   Quarterly                    %             91.7%             111.9%           83.4%            98.1%             91.0%               1.9%
                                     Numerator                     11                        4 313                565            1 307             624             1 817                242
                                 Denominator                       12                        4 705                505            1 568             636             1 996             12 617
7.    Diarrhoea case fatality rate                Quarterly                    %              0.0%               0.0%            0.0%             0.0%              0.0%               0.2%
                                     Numerator                     16                                0               0                 0                0                 0               12
                                 Denominator                       17                          292                   15           115                 75               87             7 528
8.    Pneumonia case fatality rate                Quarterly                    %              0.0%               0.0%            0.0%             0.0%              0.0%               0.4%
                                     Numerator                     18                                0               0                 0                0                 0               27
                                 Denominator                       19                          546                   70           236                 77             163              6 395

                                                                                                                                                                                      23
District wide                                                          Theewaters-       Province wide
      Programme performance indicator                            Data source /   Type                       Cape Agulhas     Overstrand       Swellendam
                                                     Frequency                              value                                                                 kloof              value
                                                                  Element ID
                                                                                          2016/17             2016/17         2016/17          2016/17          2016/17            2016/17
9.     Severe acute malnutrition case fatality       Quarterly                    %              0.0%                0.0%            0.0%             0.0%             0.0%               2.2%
       rate
                                       Numerator                      20                                0               0                 0                0                 0               14
                                    Denominator                       21                            32                  5                 5                6              16               634
10.    School Grade 1 - learners screened            Quarterly                   No                     0             458             832              199            1 842                  27
                                          Element                     22
11.    School Grade 8 - learners screened            Quarterly                   No                     0             215             642              511            1 159                  27
                                          Element                     24
12.    Delivery in 10 to 19 years in facility rate   Quarterly                    %     Not required         Not required    Not required     Not required     Not required              64.0%
                                                                                            to report            to report       to report        to report        to report
                                       Numerator                      26                                -                -                -                -                 -       1 072 570
                                    Denominator                       4                         3 071                 399           1 143              352            1 177          1 676 161
13.    Couple year protection rate (Int)             Quarterly                    %             97.2%              102.5%           92.3%           106.2%            96.8%              64.0%
                                       Numerator                      27                       74 439               9 302          23 366           10 623           31 148          1 072 570
                                    Denominator                       28                       76 569               9 077          25 305           10 003           32 185          1 676 161
14.    Cervical cancer screening coverage            Quarterly                    %             57.1%               82.7%           46.3%            59.2%            57.7%              57.7%
       30 years and older
                                       Numerator                      29                        4 026                 746           1 160              545            1 575             87 397
                                    Denominator                       30                        7 055                 902           2 504              921            2 728            151 456
15.    HPV 1st dose                                   Annual                     No                     0             134             510              191              747                  27
                                          Element                     31
16.    HPV 2nd dose                                   Annual                     No                     0             136             480              208              762                  27
                                          Element                     33
17.    Vitamin A 12 - 59 months coverage             Quarterly                    %             52.6%               70.2%           45.4%            55.1%            53.1%              44.4%
                                       Numerator                      34                       20 120               2 878           5 782            2 850            8 610            378 972
                                    Denominator                       35                       38 219               4 098          12 733            5 170           16 219            852 972

                                                                                                                                                                                         24
District wide                                                               Theewaters-          Province wide
      Programme performance indicator                         Data source /      Type                            Cape Agulhas      Overstrand       Swellendam
                                                  Frequency                                      value                                                                      kloof                 value
                                                               Element ID
                                                                                               2016/17              2016/17          2016/17          2016/17              2016/17               2016/17
18.    Maternal mortality in facility ratio        Annual                       No per                   89                   0               152                   0                 79                   69
                                                                                100 000
                                      Numerator                    37                                        3                0                 2                   0                     1                66
                         Denominator / 100 000                     40                                 0.034              0.004            0.013            0.004                0.013                  0.963
19.    Neonatal death in facility rate             Annual                     No per 1 000                   7                15                5                11                       5                10

                                      Numerator                    43                                    22                   6                 6                   4                     6            1 049
                            Denominator / 1 000                    38                                 3.193              0.393            1.270            0.358                1.172                108.779

Table 13: Performance Indicators for District Health Services

                                                                                             District wide                                                              Theewaters-           Province wide
      Programme performance indicator                         Data source /      Type                            Cape Agulhas      Overstrand       Swellendam
                                                  Frequency                                      value                                                                     kloof                  value
                                                               Element ID
                                                                                               2016/17             2016/17          2016/17          2016/17             2016/17                2016/17
SECTOR SPECIFIC INDICATORS
1.     Cataract surgery rate (in uninsured        Quarterly                     No per                       0                0                 0               0                     0                1 553
       population)                                                              million
                                      Numerator                    1                                         0                0                 0               0                     0                7 122
                       Denominator / 1 000 000                     2                                 0.202              0.026            0.063            0.028                0.085                   4.585
2.     Malaria case fatality rate                 Quarterly                        %                  0.0%                                0.0%                                  0.0%                   0.0%
                                      Numerator                    3                                         0                0                 0               0                     0                     0
                                    Denominator                    4                                         3                0                 2               0                     1                    68

                                                                                                                                                                                                       25
8.   QUALITY OF CARE

     Table 14: Top 20 worst performing Ideal Clinic elements in PHC facilities 2017/18 YTD

     Nr    Worst performing elements                          Comments
     1.    Adolescent and youth friendly services are      Training on Adolescent and youth friendly
           provided                                        services still need to be rolled out.
                                                           Clinic committees not in place- need to have
                                                           adolescent representation on the committee.
     2.    Staffing needs have been determined in          Western Cape does not implement WISN.
           line with WISN
     3.    Staffing is in line with WISN                   Western Cape does not implement WISN.
     4.    There is a functional clinic committee          Currently in the process of being advertised.
     5.    Contact details of clinic committee             Currently in the process of being advertised.
           members are visibly displayed
     6.    There is an official memorandum of              Not available from Provincial Office.
           understanding between the district
           management and Cooperative
           Governance and Traditional Affairs
           (CoGTA)
     7.    All external signage in place                   Challenges with Municipalities to put up
                                                           geographical location signage. In process to
                                                           address.
     8.    The National Policy for The Management Of       Not available from National Department of
           Waiting Times is available                      Health.
     9.    The facility has a dedicated budget             Only Sub-District budget, not on facility level.
     10.   Building is compliant with safety regulations   Older clinics do not have occupancy and
                                                           electrical certificates.
     11.   The National Referral Policy is available       Not available from National Department of
                                                           Health.
     12.   There is an official memorandum of              Not available from Provincial Office.
           understanding between the PDOH and the
           Department of Social Development
     13.   Patient record content adheres to ICSM          Training given in record keeping
           prescripts                                      In the process of the roll-out of integrated
                                                           stationary
     14.   Clinic space accommodates all services          Dedicated areas for Health Care Risk Waste are
           and staff                                       being built.
                                                           Older clinics do not have dedicated dirty utility
                                                           rooms.
     15.   Immunisation coverage under one year            Some immunizations were out of stock.
           (annualised) is at least 87% or has increased   Immunization schedules have changed.
           by at least 5% from the previous year           Catch ups are being done currently.
     16.   All staff has received in-service training on   Currently busy with informal training.
           infection control standard precautions that     Formal training with University of Stellenbosch on
           is in-line with the Standard Operating          hold for two years.
           Procedure in the last two years.

                                                    26
Nr     Worst performing elements                            Comments
 17.    Staff are trained on the use of essential         No evidence of previous training.
        equipment                                         Programme to train staff is in place.
 18.    Clinical audit meetings are conducted             Clinical audits are being conducted now on a
        quarterly in line with the guidelines             regular basis.
 19.    Maintenance plan for essential equipment          Maintenance plans rolled out.
        is adhered to
 20.    Six monthly district/sub-district clinical        M&E being distributed to clinics.
        performance review report with action plan        Must draw up an individualized action plan
        from clinical quality supervisors available
[Source: Ideal Clinic Quality Improvement Plan 2017/18]

*WISN is not implemented provincially

Table 15: Top 20 worst performing National Core Standards in district hospitals 2017/18 YTD

 Nr               Worst performing elements                                    Comments
 1.     There are quarterly emergency drills done.        Evaluation training conducted last year to
                                                          ensure staff is competent.
                                                          Outstanding drills are being conducted.
 2.     The health establishment conduct at least         Evaluation training conducted last year to
        yearly drills to test the preparedness of their   ensure staff is competent.
        disaster plan including emergency/disease         Outstanding drill are being conducted
        outbreak/fire/natural disaster.
 3.     A fire certificate for the health                 One hospitals infrastructure not compliant to
        establishment is available.                       safety regulations
 4.     Maintenance records show that                     Continuous quality improvement plans was put
        recommendations of annual inspections             into place
        reports on safety hazards and maintenance
        needs are implemented.
 5.     A pre-placement examination is performed          SHERQ policy being rolled out.
        before commencement of duty or within 14          Pre- placement medicals currently not being
        days of employment if relevant.                   done, only in the process of establishing annual
                                                          medical surveillance.
 6.     There are records of mandatory pre-               Pre- placement medicals currently not being
        employment tests for food handlers.               done, only in the process of establishing annual
                                                          medical surveillance.
 7.     The Health Care Risk Waste (HCRW)                 Monthly HCRW audits now being conducted.
        management report undertaken in the               Results must be included in continuous quality
        previous two years shows management’s             improvement plan.
        plan and measures undertaken to address
        identified risks.
 8.     There is evidence that a hand wash drive or       One drive was done but no evidence was in
        campaign is held at least annually in the         place.
        establishment                                     Emphasis placed on having evidence.
                                                          All other drives had to be conducted.

                                                                                                           27
Nr                 Worst performing elements                               Comments
9.     Security measures are adequate to               Cameras that were not working had to be
       safeguard new-borns and unaccompanied           replaced.
       children including restricted access and exit   Too many access doors to these areas.
       monitoring in wards /identification of new-     Needs to be access controlled with specific
       borns/children and their parents.               monitoring of children.
10.    The entries in the schedule 5 and 6 drug        Training was done by nursing managers.
       books are complete and correct and              Balances and two signatures has to be in place.
       include date/name of person who
       administered it and balance in stock.
11.    All staff wear PPE as needed in different       Training on PPE given.
       departments.                                    Importance of ordering correct PPE as well as
                                                       wearing it correctly.
12.    There are clean water and disposable cups       Had to order water and cups for all waiting
       available for patients in waiting areas.        areas and not only main waiting areas.
13.    Systems in place to ensure safe entry e.g.      Cameras that were not working had to be
       Security guards/CCTV                            replaced.
14.    Security measures are positioned at             Security only at main entrance and no security
       vulnerable patient areas such as                cameras.
       maternity/paediatric/psychiatric and            Must be ordered
       emergency units and access and egress
       points.
15.    Patients can be consulted in a                  Document were outstanding: Standard
       room/cubicle or receive treatment in a          Operating Procedure written and now be in
       ward I a manner which allows for privacy        place
       either through closed doors, screen or
       curtains.
16.    Health professionals/providers are wearing      Name tags must be ordered for all staff.
       name tags
17.    Educational materials are available relating    Standard educational material not available
       to the treating unit.                           from Provincial office.
                                                       Pulled resources from other hospitals.
18.    Managers have a leadership and                  Competency assessments only requested as part
       management competency assessment                of recruitments process.
       performed in the past two years.                Only compulsory as part of recruitment process.
19.    There is a system in place to reduce waiting    Card system was put into place.
       times for files.
20.    The stock control systems shows minimum         Therapeutic support services will be included in
       and maximum or re-order levels for medical      audits to ensure that stock levels are monitored.
       devices.
[Source: WebDHIS National Core Standards]

                                                                                                        28
Table 16: Top 10 challenges reported by patients in patient surveys and patient complaints
2017/18 YTD

Nr   Challenges         Comments                   Patient complaints      Comments
     reported in
     patient surveys
1.   Visiting hours     Responsiveness             Care and professional   Health care professionals
     were not long      assessed. Staff must       treatment               adhering to the prescribed
     enough             be able to look at                                 protocols, referring patients
                        individualized needs                               for second opinions where
                        without compromising                               indicated.
                        the hospitals rules.                               Staff that went the extra
                                                                           mile to take care of
                                                                           patient’s personal needs is
                                                                           commended.
2.   I was very         Outsource activities       Waiting times           System must be in place to
                                                                           reduce waiting times for
     bored at the       for patients to
                                                                           files.
     hospital           respective NGO’s.                                  Integrate services in PHC
                        Develop and include                                facilities.
                        in contract                                        Short waiting times in
                                                                           queues at service areas
                                                                           Elderly and disables persons
                                                                           are given priority treatment
3.   I did not feel     Security guards must       Staff attitudes         Strengthening of staff
     safe at night at   be visible.                                        morale with Integrated
     the hospital       Security cameras must                              Wellness Support
                        be in working order                                -   Wellness Days
                        and utilized                                       -   Interventions (
                                                                               debriefing, Conflict,
                                                                               Communication, Team
                                                                               Building and Cohesion)
                                                                           -   Implementation of the
                                                                               Values
                                                                           -   Training on courtesy.
4.   I had to wait a    System must be in          Other                   Complaint couldn’t be
     long time to get place to reduce                                      categorized in another
     my folder          waiting times for files.                           category must be handled
                                                                           according to that
                                                                           complaint.
5.   The hospital did   Lack of adequate           Food services           This indicator is applicable
     not assist me to   Public Transport                                   to hospitals.
     get a lift home    System                                             Dietician to assist with
                                                                           complaints.
6.   Visiting hours                                Care and professional
     were not long                                 treatment
     enough

                                                                                                       29
Nr     Challenges         Comments               Patient complaints   Comments
       reported in
       patient surveys
7.     I was very         Outsource activities   Waiting times        Improve on Patient waiting
       bored at the       for patients to.                            time survey
       hospital           Respective NGO’s.                           Implementation of Patient
                          Develop and include                         Records Management SOP
                          in contract
8.     I did not feel                            Staff attitudes      Strengthening of staff
       safe at night at                                               morale ito Integrated
       the hospital                                                   Wellness Support
                                                                          -   Wellness Days
                                                                          -   Interventions (
                                                                              debriefing, Conflict,
                                                                              Communication,
                                                                              Team Building and
                                                                              Cohesion)
                                                                          -   Implementation of
                                                                              the Values
9.     I had to wait a    Improve on Patient     Food services        This indicator is applicable
       long time to get waiting time survey                           to hospitals. Implementation
       my folder          Implementation of                           of provincial guidelines ito
                          Patient Records                             food service management?
                          Management SOP
10.    The hospital did   Lack of adequate
       not assist me to   Public Transport
       get a lift home    System
[Source: Sinjani]

                                                                                                 30
9.     ORGANISATIONAL  STRUCTURE                                              OF           THE            DISTRICT
       MANAGEMENT TEAM

       Figure 9: Organogram for Overberg District as at 31 March 2017

             Organisational Structure of the District Management Team
                                                                                   MEDICAL MANAGER: OVERSTRAND SUB-DISTRICT
                              OVERBERG DISTRICT
                                                                                                  DR ERMA MOSTERT

                                   DIRECTOR
                                                                                 MEDICAL MANAGER: THEEWATERSKLOOF SUB-DISTRICT

                                                                                           DR MAKONDELELE RAMBIYANA
                               Mrs W M KAMFER
                                                                                 MEDICAL MANAGER: SWELLENDAM & CAPE AGULHAS
                                                                                               SUB-DISTRICTS

                                                                                                 DR JACQUES DU TOIT

     DEPUTY DIRECTOR           DEPUTY DIRECTOR                                  DEPUTY DIRECTOR               DEPUTY
                                                  DEPUTY DIRECTOR
        PEOPLE                                                                                             COMPREHENSIVE
                                PROFESSIONAL         FINANCE                      PHARMACY                    HEALTH
      MANAGEMENT
                               SUPPORT SERVICE
                                                  ASHLEY NIEKERK                  HANLIE BRITS                 PETRO
                                RONELL ZONDO                                                                 ROBERTSON
     CHRIS MATSHOZA

                                                                  ASSISTANT
                                                                  DIRECTOR
                                                                                                       ASSISTANT MANAGER
       ASSISTANT DIRECTOR                                        SUPPLY CHAIN
                                                                                                         FACILITY BASESD
            PEOPLE                                                 JOHLENE                                  SERVICES
          MANAGEMENT                                              HONEYBALL
                                                                                                           ALETTA LUDIK
        WALTER SEPTEMBER

                                                                   ASSISTANT
                                                                   DIRECTOR
                                                                                                            ASSISTANT
                                                                    FINANCE                                 MANAGER
         ASSISTANT DIRECTOR
                                                                 PERCIA LAMOHR                          COMMUNITY BASED
              LABOUR
          RELATIONSPEOPLE                                                                                  SERVICES
            DEVELOPMENT
                                                                                                            ESME HENN
          NICO LIEBENBERG
                                                     ASSISTANT
                                                     DIRECTOR
                                                                                                          HAST MANAGER
                                                     QUALITY
                                                    ASSURANCE                                              EMELIA HANS
         ASSISTANT DIRECTOR
                                                   DUEDONNE LE
          TALENT SOURCING                            GRANGE

          ANNE-MARIE BRITS

                                                    ASSISTANT
                                                    DIRECTOR

                                                  INFORMATION
                                                  MANAGEMENT

                                                  LEON BENJAMIN

                                                                                                                           31
10. DISTRICT HEALTH EXPENDITURE

  Table 17: Summary of district health expenditure 2016/17

BUDGET AND                2014/15                              2015/16                            2016/17
EXPENDITURE
Sub-programme             BUDGET             EXPENDITURE       BUDGET           EXPENDITURE       BUDGET          EXPENDITURE
2.1: District
Management                     21 660 000       24 249 000         24 249 000      23 593 868        25 261 000      25 127 501
2.2: Clinics                 104 948 000         91 87 000          91 87 000      90 127 069        99 583 000      99 112 285
2.3: Community
Health Centres                 31 766 000       55 368 000         55 368 000      51 997 386        59 743 000      56 159 084
 2.4: Community
Services                        4 675 000        4 888 000          4 888 000       5 273 203         5 332 000       5 811 545
2.5: Other Community
Services                                 0                 0               0                  0              0                  0
2.6: HIV/AIDS                  58 259 000       66 148 000         66 148 000      63 706 867        72 062 000      73 808 438
2.7: Nutrition                  2 656 000        2 918 000          2 918 000       2 930 418         3 235 000       3 224 182
2.9: District Hospitals      134 124 000       151 489 000        151 489 000     152 593 714       160 465 000     164 453 263
TOTAL DISTRICT               358 088 000       396 938 000        396 938 000     390 222 526       425 681 000     427 696 298
  [Source: District Health Expenditure Review (2016/17) or BAS]

  Program 2.3: Includes the CDC’s, Oral Health and School health budgets. To take into account
  when looking at the calculated tables.

  Cost Savings measures were relaxed in 2016-2017 after its initial implementation in 2015-16.

  One can notice the year on year growth for the entire Overberg District, this is indicative of the
  growth of the District since its establishment in 2006.

                                                                                                                          32
11. DISTRICT PERFORMANCE INDICATORS

11.1 DISTRICT HEALTH SERVICES

Table 18: Performance indicators for District Health Services

                                                                                                                                                                           Provincial
                                                           Data                                                        Estimated
      Programme performance indicator                                Type     Audited / Actual performance                                Medium term targets                actual
                                              Frequency source /                                                      performance
                                                                                                                                                                          performance
                                                        Element ID
                                                                            2014/15       2015/16       2016/17         2017/18     2018/19    2019/20      2020/21         2016/17
 SECTOR SPECIFIC INDICATORS
 1.       Ideal clinic (IC) status rate        Annual                 %         0.0%          0.0%         47.4%           68.4%      100.0%      100.0%        100.0%         17.2%
                                 Numerator                  3                         0             0             9           13          19          19            19            47
                              Denominator                   2                     24            22            19              19          19          19            19           273
 2.       PHC utilisation rate (annualised)   Quarterly              No          2.5           2.5           2.6              2.5        2.5         2.5            2.5           2.3
                                 Numerator                  6                677 883       698 460       731 769          731 612    746 642     761 617        776 496    14 413 350
                              Denominator                   7                270 406       276 168       282 022          287 777    293 506     299 204        304 859     6 318 281
 3.       Complaint resolution within 25      Quarterly               %        95.5%         98.5%         96.5%           95.1%       95.6%       96.6%         96.0%         95.6%
          working days rate (PHC
          facilities)
                                 Numerator                  10                   253           262           273             253         237         225           218          3 175
                              Denominator                   8                    265           266           283             266         248         233           227          3 320

                                                                                                                                                                                 33
Table 19: Quarterly targets for District Health Services

           Programme performance indicator                 Data source    Frequency   Annual target                            Quarterly targets
                                                           / Element ID                 2018/19         Quarter 1         Quarter 2         Quarter 3         Quarter 4
 SECTOR SPECIFIC INDICATORS
 1.     Ideal clinic (IC) status rate                                      Annual            100.0%                   -                 -                 -         100.0%
                                               Numerator        3                                  19                 -                 -                 -               19
                                            Denominator         2                                  19                 -                 -                 -               19
 2.     PHC utilisation rate (annualised)                                 Quarterly               2.5               2.5               2.6               2.4               2.6
                                               Numerator        6                            746 642         186 514           192 501             173 989         193 638
                                            Denominator         7                            293 506          73 377            73 377              73 377          73 375
 3.     Complaint resolution within 25 working days rate                  Quarterly            95.6%           95.2%             95.3%              94.8%            96.9%
        (PHC facilities)
                                               Numerator       10                                 237               59                61                55                62
                                            Denominator         8                                 248               62                64                58                64

                                                                                                                                                                          34
STRATEGIC         ACTIVITIES
OBJECTIVE
Ideal clinic         Supervisory visits monthly monitoring to ensure Essentials & Vital is in place.
                     OPM to focus on what is not in place and put measures in place to become compliant.
                     focus on infrastructure, patient flow,
                     Implementation of Adolescent Youth Friendly Services.
                     Self-assessments according to Annual audit schedule X1.
                     Use results of audits to compile a continuous quality improvement plan.
                     Working with supply chain to order outstanding equipment and consumables.
                     Ensuring all SOP’s are signed and implemented.
                     Implementation of Adolescent Youth Friendly Services.
                     Self-assessments according to Annual audit schedule X1.
                     Ensuring cleanliness of clinic both interior and exterior
Feedback from        Need to embark on communication strategy to educate the community on ways to
community             improve their facility e.g. not to brake a tap, to save electricity, open windows and open
complaints            blinds, design pamphlets.
                     Building trust and rapport with community (implementation of new Complaints &
                      Compliments Guideline in all facilities).
                     Display resolutions (anonymous).
                     One community member serving on the Community Health Forum can attend on an ad
                      hoc basis. In the event that the CCSCs is not a stand-alone committee, but forms part of
                      other committees that deal with quality improvement, complaints should be put as the
                      first agenda point so that members of the Community Health Forum can be excused
                      once the agenda point has been discussed.
                     The monthly or quarterly report that is submitted to the Community Health Forum should
                      include a section on the management of complaint.
                     Media/communication plan( TV PowerPoint) to inform client on how complaints work
                      and to gain trust in the system
                     Verification/feedback system in place to inform operational managers of complaints
                      captured and resolved
                     Conduct a Patient Experience of Care (PEC) in all fixed clinics (19 fixed facilities, i.e.
                      clinics, CDC’s and the 4 district hospitals).
                     Ensure patient satisfaction results are part of Quality Improvement Plans (QIP) and
                      progress is measured regularly (integral part of staff meetings).
                     Focused approach on improving areas of concern or priority areas, especially
                      cleanliness of clinics, staff attitude and professionalism
Complaint            Need to be at 90% resolution within 25 working days for all sub districts.
resolution rate       Need to be at 96%. Info to draw monthly reports. Analyse, feedback, identify gaps.
                     Complaints officer needs to be appointed at all facilities.
                     The procedure for lodging, acknowledgement and investigating a complaint (including
                      telephonic complaints) must be in place.
                     Must determine the required action to be taken according to the severity of the
                      complaint (risk rating)
                     Identify patterns in system failures (categorisation)
                     The procedure for redress and timelines to be adhered to
                     Accurate recording of statistical data on complaints including the indicators for
                      complaints
                     Monitoring mechanisms and their response timelines
                     Mechanism to ensure children’s participation in the complaints process as well
                      vulnerable groups such as disabled people, the elderly, mentally ill people, illiterate
                      people and people speaking foreign languages can easily participate in the complaints
                      process.
                     Striving to resolve complaint within 15 days to ensure time to resolve if complaint has to
                      be escalated to higher level
                     Complaint resolution rate needs to be displayed on all facilities notice board.
                     Media Clippings and a quarterly report- communication –District Health Council

                                                                                                         35
STRATEGIC              ACTIVITIES
OBJECTIVE
PHC utilisation rate      Establish measures to assess access. Formulise strategies to effect continual improvement
                           (COPC mapping).
                          Identify and implement changes at specific facilities.
                          Home Based Care give key messages wrt types of services rendered at clinic.
                          Emphasis on first 1000 days.
                          Look at service flexitimes (staggered working hours for staff) in order for the facilities to
                           increase access (looking at specific times for children, antenatal follow ups).
                          •    Appointment System standards implemented. Communication drive to staff and
                           patients to get a common understanding of what it entails.
                          Need to educate staff on the appointment system and the functionality thereof
                          Improve access to health services through specialized clinics, streamlining service
                           delivery and improving reception services.
                          Improved utilization of the Primary Health Care Information System (PHCIS) appointment
                           system.
                          Improve waiting times for children, elderly/frail and patients with disabilities by fast
                           tracking them in the system( measuring quarterly)
                          Improve access in facilities where immunization/vit A/preventative services targets are
                           not reached, by special time slots/days/CHW recall system and helping every referral
                           from school health/CBS platform
Infection                 IPC training in the Overberg District to all categories of staff.
prevention and            Importance of standard precautions emphasized.
control (IPC)             IPC Officers appointed in each facility
                          Biannual IPC audits conducted and results discussed in the appropriated forums.
                          Annual Hand hygiene campaigns and audits completed per facility
                          Ensure that all HCRW is removed according to SLA
                          Setting standards to provide and maintain a safe and infection-free environment
                          Recommending measures to resolve current and/or potential problems
                          Lowering the risk of health care acquired infections and the potential for infections for
                           patients, personnel, the community and the environment through the establishment and
                           maintenance of preventative and epidemiologically indicated precautions, as well as
                           the notification and management of infections
                          Implementing, monitoring and evaluating policies to guide the infection control
                           programme. Ensure that this and related policies are kept up to date and
                           communicated appropriately.
                          Implementing set policy by ensuring that personnel have the necessary authority and
                           resources to enforce it, and thereby ensuring the co-operation of all personnel
                          Co-ordinating and ensuring the co-operation of different expert departments during the
                           management and/or control of outbreaks of infection
                          Identifying and correcting risky and/or inefficient infection control procedures.
                          Ensuring that the different members of the committee have the necessary expertise in
                           decision making and problem solving. Monitor the implementation of IPC procedures
                           and practices, ensuring that the correct tools are used for measuring compliance with
                           recommended IPC practices
                          Respond to surveillance and audit results by instituting improvements. Ensure that all
                           documentation and reporting requirements relating to IPC are adhered to
                          Ensure that there are always sufficient supplies and equipment in place to comply with
                           recommended IPC practices
                          Ensure that IPC incidents are investigated and managed appropriately
                          Promote the appropriate use of disinfectants
                          Antibiotic stewardship
                          Promote awareness and training on appropriate antibiotic use
                          Basic infection control principles
                          Provide guidelines for antibiotic prescription according to antibiotic resistant patterns
                          Feedback from pharmacy audits discussed at facility level.

                                                                                                                36
STRATEGIC           ACTIVITIES
OBJECTIVE
Occupational           Appointment of 1 QA Managers to fully implement the SHERQ policy
Health and Safety      Functional Quality and OHS committees in all four sub-districts.
(OHS)                  OHS Representatives and 16.2 Appointments to be done in all facilities.
                       Quarterly OHS audits conducted and results discussed in the appropriated forums.
                       Accident prevention, through early identification and elimination of unsafe conditions or
                        acts
                       Staff must be protected from workplace hazards through effective occupational health
                        and safety systems
                       Management and Staff share the responsibility to identify hazards and development of
                        control measures to make the workplace as safe and healthy as reasonably practicable.
                       Each facility will have a documented protocol for Occupational acquired diseases such
                        as TB or HIV or exposure to blood and other bodily fluids
                       When an employee suffers an injury to the extent that he/she requires medical treatment
                        other than first aid, section 24 requires the employer to investigate the incident and
                        complete applicable forms.
                       All staff who have potential contact with Health care risk waste and bodily fluids must be
                        vaccinated against Hepatitis B.
                       All facilities must have a Fire and Disaster/Emergency Plan
                       All facilities are required to have a current fire safety certificate
                       All facilities are required to have service agreement with an accredited provider to
                        check and service fire safety equipment
                       A logbook must be kept as proof of maintenance of fire safety equipment
                       All staff working in the facility will be familiar with procedures in case of fire or
                        emergencies
                       Evidence of staff training in Fire and Emergency management will be available and
                        updated on an annual basis.
                       An incident form must completed for all adverse events causing a risk for Occupational
                        Health and Safety
                       All incidents must be recorded on the monthly Adverse event, Occupational Injuries or
                        Safety and security report.
                       “No Smoking” signs will be visible in all public areas
                       PPE will be available to staff in their working area
                       All staff must be trained in the correct use of appropriate PPE
                       All staff will use PPE as required and directed
                       All staff must be informed about ICAS and method of access
                       Active promotion of ICAS must be encouraged by all
M&M/adverse            Monthly M&M Meetings in all sub-districts.
events                 Include EMS and CFM in all meetings
                       Monthly reporting on AIRMS system
                       Quarterly review of the indicators.
Standardise Home       Support and strengthening the piloting of COPC in the 3 sites for the Overberg District
and Community           (Villiersdorp, Grabouw and Hermanus).
Based Care             Enrolment of Level 3 health promote course
(HCBC)                 Increase focus on wellness activities by CHW’s.
implementation         Quarterly reviews on the set targets
                       Strengthen the NGO and clinic 2 weekly meetings to ensure Continuum of
                        care/feedback of referred patients
                       Quarterly data feedback sessions with NGO/facilities to measure progress w.r.t SLA and
                        targets
                       Continuous data strengthening through verification checks, more involvement of IM,
                        refresher data training
                       NGO Audits, 6 monthly reviews, claims verification and contract management to be
                        shared between HAST co and CBS Co including finance

                                                                                                           37
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