NHI in South Africa: Feedback from a Pilot Site: UMgungundlovu District KZN Dr Tim Kerry Family Physician DCST Umgungundlovu District
NHI National Health Insurance Family Physician, not a Health Economist. Been involved in NHI start-up, but only parts of NHI Green paper on NHI gazetted in August 2011 Good documents (Esp. the Green paper) on NHI available on KZN and NDoH Intranets White paper on NHI about to be presented Phases described with initial work starting in 2012 10 pilot sites identified with 1 in each Province and 2 in KZN: UMzinyathi (around Greytown/ Dundee) and UMgungundlovu (around Pietermaritzburg)
NHI Districts in other Provinces of SA Oliver Tambo Dx in Eastern Cape around Mthatha Thabo Mofutsanyana Dx in FS Witsieshoek/ Bethlehem Tshwane Dx in Gauteng around Pretoria Vhembe Dx in Limpopo around Thohoyandou Gert Sibande Dx in Mpumalanga around Ermelo KK Kaunda Dx in North West around Klerksdorp Pixley ka Seme Dx in Northern Cape - around de Aar Eden Dx in Western Cape Garden Route
Umgungundlovu District Population 1 087 084 7 Sub-Districts/ Municipalities 84 wards DM is Mrs Zuma Mkhonza
Health services: Umgungundlovu District 51 PHC Clinics 14 FHTs 23 SHTs 17 Mobile Teams 854 CCGs (NB: SAM screening and follow up; Ante and Post-Natal care) 3 CHCs 2 District Hospitals 1 Regional/ District Hospital 1 Regional/ Tertiary Hospital 2 TB Hospitals and 3 Psychiatric Hospitals 6 Private Hospitals
A: The Overall NHI Plan A way of providing good health care for all by sharing the money available for health care amongst all our people. Also better distribution of resources such as health workers. Free health care NHI will keep the overall costs of health care reasonable Health prevention and promotion E.g. FHTs and PHC facilities in clinics and eventually GP practices Financed by an NHI fund mainly from tax base Excellence in health care: Health facilities to meet standards set by OHSC: Office for Health Standards Compliance. NCS National Core Standards Patients to enter health system at primary level and be referred as necessary
Why NHI? SA Currently spends 8.3% of GDP on health highish 4.1% is spent on the private sector 4.2% is spent on the public sector on which 68% of people depend for the health needs A 14 year NHI plan SA is plagued by the Quadruple burden of disease: Maternal and Child Health TB and HIV Non-communicable disease: HPT, diabetes etc. Violence and injury (Lancet 2009)
Why NHI Cont d? (From NHI Pamphlet)
Phase 1 first 5 years Strengthening of the health system and improving the service delivery platform especially in the public health system Infrastructure and medical equipment development access to quality health facilities. Still gaps E.g. Hopewell, rural towns, farms Improve the quality of the health services, HRM and SCM PHC Reengineering: (NB: not exclusive to NHI pilot sites) PHC based on DHS FHTs and SHTs DCST in each Dx in SA (4 in our team: PHC Nurse, Pediatric Nurse, Advanced Midwife, FP) Contracting MPs (GPs) into the PHC system. It can be difficult to glamorize PHC. Move from hospi-centric to primary care Decrease the burden of disease especially with M&CH. Policy and legislative reform
Ward-based Outreach Teams (WBOTs) FHTs The FHTs will collectively facilitate community involvement and participation in identifying health problems and behaviors that place individuals at risk of disease or injury; vulnerable individuals and groups; and implementing appropriate interventions.. (NHI Green Paper) There are supposed to be 84 Teams for our 84 Wards. In UMG high level of professional care but poor coverage. (Mopane Dx in Limpopo has 122 of 125 Wards covered but with less high level of professional care) 14 Family Health Teams (FHT) do sometimes cover > 1 Ward. Go out into the community with a vehicle. Very effective in finding patients with serious health and social problems and who do not come to the clinics. Work with CCGs.
WBOTs SHTs 23 School Health Teams (SHT) do cover > 1 Ward School health services will be delivered by a team that is headed by a PN. The services will include health promotion, prevention and curative health services that address the health needs of school-going children.. (NHI Green Paper) Cover Quintile 1 and 2 schools The policy details which tasks should be done at which Grade
B: What has been achieved so far in UMG? NHI improvements over the last 3 years have addressed the 18 non-negotiables Budget awarded and to be spent in prescribed manner difficult. Addresses broad health requirements: 1. Infection Control, Cleaning Materials and Services 2. Sufficient Medical Supplies 3. Provision of required Medicines 4. Medical Waste Management 5. Accessible Laboratory Services 6. Availability of Blood Services 7. Quality Food Services and Relevant Supplies 8. Secure environment through sound Security Systems 9. Effective Laundry Services 10. Essential Equipment and Maintenance thereof 11. Appropriate Infrastructure Maintenance 12. Availability of Children s Vaccines 13. Managing HIV/AIDS epidemic 14. Accessible Child Health Services 15. Accessible Maternal and Reproductive Health Services 16. Full complement of FHTs and SHTs 17. District Specialist Teams fully appointed 18 Registrars appointed in Specialized Disciplines
NHI Grant Allocation
NHI achievements Medical Equipment: Equipment for ex-municipal clinics: Resus trolleys, Ambubags etc. Essential medical equipment for other clinics: Cusco s, CTGs, ADE defibrillators Medical equipment for hospitals IT equipment for clinics Mobile Vehicles for SHTs Linen and linen services Cleaning equipment, elbow taps etc. Waste management equipment
NHI achievements cont d Training: Advanced management development Financial and Project Management, Data Management Training of WBOT teams by UP Assessments/ Projects: NHI Project manager NHI baseline assessment by UKZN Mahlutshini Clinic Ward-based profile socioeconomic and health determinants Community-based child deaths KPMG SCM assessment Digital pen project improvement of DHIS data
NHI achievements: Infrastructure cont d We want all our facilities to look like St Anne s or Mediclinic! Getting there with new additions to Edendale ED and CDC; Also the new clinics that have been built (Emambedwini, Mahlutshini) or renovated (Nxamalala or Grange) In the clinics we want consulting rooms to be clean and look professional with excellent equipment and good records systems. The Annexes have this with good equipment: wall mounted diagnostic sets, X-Ray boxes, patellar hammers, Snellen s charts, examination couches with screen curtains etc. Budget awarded for renovation of ex-municipal clinics - delays
Better PHC facilities New Emambedwini Clinic (Umshwathi) Renovated Nxamalala Clinic (Impendle)
NHI achievements cont d Infrastructure: New Registry at NDH Annexes for extra 6 consulting rooms for 11 clinics Annex at Grange Clinic
Achievements Cont d: 2 Ideal Clinics: Everything is ideal and present (Just the basics!) Extra input E.g. Electronic patient administration systems Introduction of ICDM Integrated Chronic Disease Management Patheni Clinic (Richmond) Efaye Clinic (UMshwathi)
Achievements cont d: Special projects Improved medical waste management and practitioners Improved security services at Clinics and hospitals Decentralized Chronic Disease management overwhelming the clinics. More than 100 community pickup points have been developed Improved medicine supply - 13 Pharmacy Assistants appointed into clinics Food supply services improved at hospitals 104 000 Health Books printed Used for general PHC PHR cards Extension of RtHB Given to post natal women with MCR discharge summaries
Professional Records E.g. Health Book
MPs in PHC Clinics Prior to 2013 we had a medical team of 10 full time doctors that worked in the PHC Clinics as follows: 2 senior MOs 4 ARV Roving MOs 4 CSOs Some sessional MOs We aimed to consult in every clinic at least weekly concentrating on rural and peri-urban clinics. Is a need to balance travel fatigue especially on long gravel roads UMG had just taken over 20 ex-municipal Clinics and was not able to cover these clinics, but they were mostly situated in urban areas with relatively easy access to health services
MPs in PHC Clinics cont d Doctors need to focus more on M&CH very easy to be overwhelmed by NCDs. Target of doctors seeing every antenatal woman at least once in her pregnancy Booking system with a booking book patients booked by nursing staff and by the doctor for future follow up. 5 patients per hour as minimum. Approximately 80% of patients to be seen are booked, leaving 20% of patients to be seen as walk-ins on the day. Important for nursing staff to be free to do informal consults with Clinic doctors on the day. Telephonic consultation. Limit number of grant related consults. SASSA doctors in clinics.
2013: NDoH MPs Started to employ about 10 MPs (called GPs in NHI literature) in October 2013. Not dependent on DoH posts or Dx funds MPs were interested in this process by Roadshows done by the Dr Motsoaledi at Greys Hospital. We had also developed a data base of GPs in the Dx from sources E.g. SAMA. Contracted and paid by NDoH: Formal 2 year contract with a local SLA. Paid DPSA sessional rates. Paid for km travelled Appointed by myself. Contracts signed by DM and NDoH. Administratively managed by a senior clerk at Dx Office Initially payment done by NDoH went very badly Changed to professional administration company CPI Corporate Payroll Institute Payments done smoothly since then. A lesson to be learned! Orientation done (with HST) for MP & OM focus on M&CH & HIV
Training of MPs & OMs Dr Richard Cook giving the bigger picture Drs given up-to-date resources as hard copies or on a flash drive OMs and MPs grappling with IMCI
NDoH MPs cont d All doctors introduced to the clinic teams Benefits have improved: Payment of time travelled, all doctors paid at the level of Grade 3 MO an incentive Now we have 18 NDoH MPs working (none full time) 8 actual GPs - mainly work in urban clinics 7 Retired doctors 3 young mothers the work suits them A handful of MPs left because of payment issues or unsuitability With the GPs, it appears to be very much a goodwill situation as the practice overheads still have to be covered and even Grade 3 MO is small payment. So, a halfway house for NHI. 2 retired Obstetricians working in clinics and CHCs (1 NDoH) So, UMG now had much better coverage of clinics, including ex-municipal clinics and 2 CHCs
2 of the NDoH MPs Dr Ellis at Grange Clinic Dr Khanyile at Efaye Clinic
2015: Foundation for Prof. Dev. (FPD) MPs NDoH wanted to use a different model FPD through smaller NGOs (Aurum in UMG) wanted to aim at a total of 50 MPs in each Dx a shock to us!! Process started late 2014 with orientation & interviews AHP were very effective in recruitment. We wanted to take no doctors from DoH in other Districts in KZN, especially rural Dx s NB Interviews done: AHP, MO, PHC Nurse, FP. Choosy. Local Started working in January 2015 on a FPD contract More comprehensive package than NDoH one Close supervision by Aurum. Good payment systems Not dependent on DoH posts or Dx funds
FPD MPs cont d More full time doctors good for the busier clinics: Clinics are very busy with M&CH, a lot of NCDs, HIV and TB, MHCUs etc. Breakdown: 15 MPs in total 10 full time and 5 part time who are all GPs Full time at busier clinics: Richmond, Caluza, Gcumisa, Howick, Mpophomeni, Taylors, Gomane, Northdale Clinics. Less CSOs now due to the NHI MPs All 48 allocated clinics consulted at weekly or better except for Mahlutshini. 13 clinics consulted at daily. Started to link Mobile Clinic support to specific local doctors This is FANTASTIC coverage!
PHC and NHI doctors PHC clinics are wonderful places to work Great first contact medicine, continuity of care, real family and community care, good team work (nurses, doctors, clerks, therapists) Real career paths for doctors and family physicians in PHC Meet 2 nd Friday afternoon of month to do PHC Training and discuss issues E.g. drug supply. (A way of getting to all Drs) Training in last year (CPD points awarded): IMCI, ETAT, IMAM Antenatal care and PMTCT New ARV Guidelines, ARV Resistance, TB, MDR TB Diabetes, Asthma, PC 101, Mental Health Care Patient Records Minor and practical procedures and conditions (E.g. VKC) Now are over 40 doctors working in PHC Clinics
Patients seen by Doctors Steady increase in patients seen by doctors 2010 2014 (2015?) High numbers in Municipalities where there are CHCs with full time Drs Low numbers in rural, farming and under-resourced Municipalities Impendle Mkhambathini Umshwathi 250000 200000 150000 100000 50000 0 Pts seen by Dr Year 2010 to 2014 No. Pts
C: What challenges have been faced? NHI Budget has been quite specific about how it can be spent this makes it difficult to spend on time Need project management skills Children U5 are 15% of our total head count of patients in the Clinics and CHCs. However doctors working in the Clinics are seeing a much lower percentage of children U5 when compared to their overall work:? Because IMCI empowers the PHC nurses. Doctors seem to come out of medical school with a low regard for IMCI and do not use it!? Because the clinic set up is not making referrals internally and doctors too busy with NCDs. (In clinics, doctors often end up confirming IMCI signs or seeing non-imci problems dermatology, neurological and developmental, social, HIV-related, eye and surgical problems)
IMCI Gives good direction for PHC nurses and doctors. Works well with IMAM and HIV medicine
Challenges cont d Doctors also not seeing enough antenatal patients. FPD had an issue with antenatal care and medical protection largely resolved. Timing of CPD meetings so GPs can attend. Clinics overwhelmed by NCDs very demanding patients. Clinics MUST focus on M&CH. Referrals are difficult with children. Poor communication between PHC and hospital level. This does not need to be so as the RtHB is a fantastic tool we just need to use it correctly: How? Staple discharge summaries into the RtHB, probably the back page Make a summary of a hospital outpatient visit in the RtHB this should become mandatory in the interests of continuity of care
Challenges cont d We had few guidelines on how to employ these NHI doctors this was tasked to the DCST Family Physicians takes the FP away from their primary work often where there is no DCS Pediatrician or Obstetrician No specific manager for the NHI doctors. This makes it very difficult to supervise all the doctors who are new to PHC. Medicine supply expansion of PHC order list; Special form made to access special medicines; but basic medicines are often out of stock E.g. ferrous sulphate for pregnancy Slow pace of renovating older and ex-municipal clinics. Some clinics are in very poor condition. MPs object Need for a new Maternity Wing for Appelsbosch and new East Boom CHC
Challenges cont d Not enough Pediatricians working in DCSTs Currently no place for Family Physicians to be paid as specialists by NHI in clinics Relatively poor uptake on Phila Mtwana Centres for child growth monitoring based on MUAC. May be need for scales to measure weight. Are doctors in clinics drawing patients away from PMT Centres? How are we going to reach the informal settlements? A big issue: The NHI MPs should not be seen as a project it should become business as normal: We cannot ask communities to go from the current daily doctor service back to a once a week service
D: Lessons learned? We should plan to spend NHI money early on in achievable ways NHI has given us flexibility to give really good coverage of the PHC facilities. Patients are coming around to utilizing the local clinic such as Sinathing Local doctors are better. Have a good interview system. Have an efficient local administrator Have a good payment system for MPs NDoH cannot do this efficiently a lesson for the future when state patients will be seen in GP practices. Could be an important role for medical aid administrators CPD program for NHI and PHC Drs has been very worthwhile Drs, especially GP to start work at a clinic at 8, not 7.30
How to walk the talk of NHI? The train of NHI is moving from the station. Lets get on it: It needs our wisdom and support Be positive about NHI, especially with our colleagues in the private sector Continue to build M&CH services at PHC and Community level. In a clinic, make space for children in the booking book. How if you work at a hospital? Reply to all referrals; Use the RtHB Build relations with clinic staff, CCGs and FHTs. Phone, give feedback, visit a clinic or a home Become a DCS Pediatrician! Work in a clinic!