Executive summary 2

Mission 2

Strategic objectives 3

Budget and expenditure review 5

Tables of MTEF 6-12

Explanations of 2001/01 budget by subprogram 13-18

Budget and expenditure for 2000/01 19-23

Revenue 24-27

Strategic service areas 28

Primary Health Care 29

District hospitals 30

Regional hospitals 31

Psychiatric hospitals 32

Academic hospitals 33

Nursing colleges 34

Emergency medical and rescue services 35

Personnel issues 39

Key health problems 40

HIV 41-44

Rape 45

TB 46-49

Cataracts 50

Termination of pregnancy 51-52

Legislation 53

In 2001/02 the Western Cape’s share of the equitable share decreases from 9.6% to 9.4%. The Departments budget increases by 4.2% which is less than the CPI of 7%. The department has downsized 9349 posts (28.1%) since May 1995 and this stringent action results in the department coming within budget for the 2000/01 year.

Features of the departmental budget include:

• Doubling of dedicated HIV funding and further doubling in 2002/03.
• Purchase of 25 new ambulance vehicles in 2001/02
• Equipment budget exceeds R50 million
• Capital projects include upgrading at Vredenberg, Tygerberg, Worcester, Valkenberg, Lentegeur
• Opening of specialist OPD department at GF Jooste
• New CHC in Worcester
• TB cure rates improving
• New top management structure

Particular priorities identified for 2001/02 include:

• Financial & Personnel Delegations (establishment changes, virement)
• District Health System to Local Government

• Address the waiting lists of targeted conditions: cataract surgery, hip replacement surgery and provision of assistive devices such as artificial limbs, spectacles and hearing aids
• Improve on the waiting times at Primary Health Care level
• Improve the waiting room environment of patients at PHC level (R3mil)

• Performance agreements
• Key measurable objectives

• Director appointed
• 25 new ambulance vehicles

Trends in the budget of the Western Cape Department of Health are shown in table 1.

• Overall 4.2% increase is less than inflation (CPIX 7.6% in year to Dec)

• Health’s share of the provincial budget decreases from 29.9% (99/00) to 28.3% (03/04). Shift towards economic sector and infrastructure in the province.
• 99/00 over-expenditure has been settled by Provincial Treasury (R34.3m)
• Once exceptional once off payments in 2000/01 are removed, increase is 6.8% in 2001/02.
• Equitable share formula fully phased in by 2003/04

Detail of the budget from 99/00 (actual expenditure), 2000/01 (adjustments estimate budget, estimated actual) through the MTEF and standard items by program are shown over the following 7 pages.

Explanations for changes in the 2001/02 budget compared to 2000/01 follow on the subsequent 6 pages. Some key objectives are also shown against the subprograms.

The department will come in budget in the 2000/01 year. This is an important achievement given previous deficits and the declining equitable share. Details of 2000/01 budget and projected expenditure by program and standard item showing reasons for deviations follow for a further 6 pages.

Details of revenue are shown in appendix 3 and are summarised below. The figures shown for 2001/02 merely reflect the revenue targets given to the Department by Treasury.

The department has embarked on a range of initiatives to generate additional revenue above these targets. These include:

a) 50% revenue retention operalisationed. Memo drafted to Provincial Executive Committee to authorise 100% retention but currently not resolved with Provincial Treasury.

b) Business manager appointed.

c) Revenue above target by R12mil for first time this year.

d) Revenue retention implemented internally for the first time in 2000/01 - has had major effect on turning around perceptions and culture around revenue.

e) Private wards and beds - interest shown by quite a number of hospitals - examples at Tygerberg (29 beds), GSH, Karl Bremer (77), False Bay (16), Clanwilliam, Vredendal (21) hospitals.

f) Trading account concept successfully piloted at Karl Bremer Hospital. Revenue retention at 100% through administrative route is preferable for widespread implementation.

g) UPFS (uniform patient fee system) implemented successfully in Northern Cape. We will be piloting soon.

h) Our new billing systems are being developed as part of HIS.

i) Significant initiatives with medical schemes.

j) Developing contract for Preferred Provider agreements with medical schemes. Required to set up a number of good pilots where private funders can be convinced their patients will get quality care, not wait in endless queues etc.

k) Developing new post of case managers to facilitate interaction with medical schemes and manage issues such as authorisation, length of stay etc.

l) Medical schemes have expressed willingness to fund IT aspects in pilot hospitals.

m) Debt collection has been partially out-sourced.

These areas are covered in summative sheets comparing 2000/01 attainment of objectives and 2001/02 plans. The areas covered in the sheets are per page:

• Primary health care
• Emergency medical and rescue services (EMS)
• District Hospital services
• Regional Hospital services
• Academic hospitals
• Psychiatric Hospital services
• Nursing Colleges

The Department has downsized over the last five years and lost approximately 9349 staff since 1995, which is approximately 28.1% of the workforce in the Department. This was done mainly through the Voluntary Service Process (VSP) and of necessity exacerbated human resource distortions into the services. The situation has stabilised considerably and only 67 posts have been shed in the course of 2000/01 till 1 February 2001.

The Department currently has 24011 staff in total (1/2/01). 22,9% of the posts are vacant. The reasons for the vacancies vary from financial stringency to inability to recruit certain categories of personnel e.g. pharmacists, psychiatric nurses.

Community service posts are shown below:

The Department has developed a normative approach to providing staffing guidelines for our institutions especially the hospitals. The norms are revised on an ongoing basis.

The model we use analyses all categories of staff in different proportions to each other within a health team to obtain the best skills mix for the different levels of the service. The norms are based on workloads.

The strategy of the department is to strive to correct these distortions in staff mix over the medium to long term within affordability limits.

The main shortage is in the nursing categories. We have a shortage of 1495 nurses against norm (Professional nurses: 784; staff nurses: 434; nursing assistants: 277) and a shortage of pharmacists (24). The tertiary hospitals and the metropolitan region bear the brunt of the shortages. These are global figures for the province. There are categories where excesses and deficiencies occur across institutions and the appropriate redeployment of staff needs to be considered. The shortages described above can only be addressed through deployment or through decreases of personnel in other categories where numbers exceed the norms utilised.

The main emphasis for 2000/01 has been generic training with a focus on Batho Pele and Computer training.

A Workplace Skills Plan for the department is being completed currently. Skills Development Facilitators are being trained per region to assist with the process.

The Department has increased the intake of nurses at the Nursing College to 300 in 2001 and 400 in 2002 from 245 in 2000 to partially address the shortages described above. Post-basic courses (47 students) and bridging courses (11 students) will be expanded.

A focus area will be the accredited training of pharmacy assistants to dispense medicines. This will be a major boost in relieving pharmacists as well as reducing the waiting times of patients for medicines. We aim to train 200 pharmacy assistants. A funding request for R528 000 is being evaluated.

0.5% of personnel expenditure will be spent on training.

Some example of numbers of persons trained are given in the following 2 tables.

1. Correcting the staff mix and the appropriate deployment of staff at the right levels of care.
2. Improving the morale of staff :

• Employee Assistance programmes are being piloted this financial year in identified parts of the service
• Decentralised management – to give greater powers to lower levels of management and the frontline staff to make a difference at the coal face of patient care.
• Address the equipment backlogs which is especially demoralising for the professional staff – a start has been made in the last financial year with earmarked funding.
• Improve communication between different components of the Department and with external stakeholders.
• Greater recognition of staff efforts
• Improving the physical facilities for staff and patients.

1. Addressing the skills gap that will be identified by the Skills Plan eg. doctors at CHCs and District Hospitals to have capacity to deliver a wider package of care at these levels as opposed to referring patients to higher levels.

1. The public service needs to consider flexibility in creating attractive packages to recruit and retain certain categories of professional staff e.g. pharmacists.
2. The possible exemption from the BCOE act for government departments needs to be resolved by the Departments of Labor /DPSA and the unions. Departments cannot financially afford to comply.
3. Introduction of performance agreements through all levels of the service and appropriate incentives for achievement.
4. Wage Creep on an annual basis which makes it difficult to reduce personnel expenditure. Our personnel expenditure will go up from 62,9% in 2000/01 to 63,7% in 2001/02.

The table below shows large escalations in average cost per post over several years.

These are covered in the following sheets pertaining to:

• HIV
• TB
• Sexual abuse
• Cataracts

Progress on drafting provincial legislation and implementing recent national legislation is attached.