FREE STATE HEALTH STORY WEDNESDAY 21 OCTOBER 2009 Departement Sentrum Department Centre UNIVERSITEIT VAN DIE VRYSTAAT UNIVERSITY OF THE FREE STATE YUNIVESITHI YA FREISTATA Tel (051) 401 3000 E-mail: info@ufs.ac.za www.ufs.ac.za
Agenda Main Issues Consultation Process Background Population issues Universitas Hospital Pelonomi Hospital Recommendations Closure
Main Issues Financial crisis less undergraduate MBChB students Intern training posts less interns No new registrars in all the disciplines (less) The status of Pelonomi hospital - HPCSA The CMSA National Examination - 2010 Future of School of Medicine(?) due to lack of a training platform, decreased number of students, decreased National subsidy for training
Consultation Process Concern expressed 2007 (FSDoH, UFS) Position Statement July 2008 Letter of Heads of Department to Minister of Health- October 2008 Visit to Head of Health 22 Dec 2008 Letter to Minister of Health 10 Jan 2009 Meeting with FSDoH 19 January 2009
Letter to Minister of Health 20 January 2009 Discussion with Minister of Health 5 March 2009 Letter to Premier- 19 May 2009 Position statement as press release 22 May 2009
Council of UFS press release June 2009 Article in SAMJ- 15 June 2009 Emergency meeting FSDoH 17 June 2009 Follow up meetings (about 10!) Invitation to National Minister to visit Meeting with Premier 21 October 2009
Background Decline in Health Care Delivery Decline in Health Care Indicators Decline in Life Expectancy - Mortality figures unacceptably high Perceived collapse of Prim. Health Care Crisis at Pelonomi Hospital Destruction of Training Platforms
Approach of the Free State Health Department No coherent plan or policy 15 Years of neglect Inefficient planning and management Marginalizing of Academic Institutions Disregard of patients rights Disregard for quality medical education Lack of resource allocation Disillusioned patients and staff members
Funding Confusion Historic funding models were followed Lack of per capita funding models Lack of data Failure to protect Training and Tertiary Care Budgets Strategic personnel/consultants not appointed
Fundamental Questions: Faculty workshop Is Health Care a Priority in the Free State? What does the Constitution say? What is Government doing? What are the rights of Health Care workers? What are the rights of Patients?
Fundamental Legal Principles -1 Is Health Care a Priority in the Free State Province? Clearly not! Why not?
Fundamental Legal Principles - 2 What does the Constitution say? Free Access Services limited by available resources What does that mean and how does it translate to service, training and research institutions? How did TAC succeed in the Free State?
Fundamental Legal Principles -3 What is Government doing about: Maternal mortality, Paediatric mortality figures Life expectancy Collapse of Systems TB/HIV/Primary Health Care Hospital services Training platforms Research Human Resources present and future
Fundamental Legal Principles -4 What are the rights of Health Care workers? Quality and quantity of service delivery Medico-legal position of personnel Working conditions (e.g. HIV, Safety) Remuneration packages
Fundamental Legal Principles - 5 What are the rights of Health Care workers? Training accreditation- HPCSA, SAQA, Higher Education Commission Training Institutions CMSA, UFS, Deans Committee Societies SAMA and Affiliates Ombudsman Departments of Treasury, Education and Health (provincial and national)
Fundamental Legal Principles - 6 What are the rights of Patients? Human Rights Commission Ethical Committee of HPCSA Ethics SA Ombudsman Human Rights Law and Ethics SAMA
General Considerations Government and Medical Profession at loggerheads Constitution provides guidance Statutory bodies protects professionals and population Issues : Training and Research, Service Delivery, Working Conditions Patients Rights
Position Statement Approved by Heads of Departments Supported by UFS (Vice-Chancellor) Press release from UFS FS Dept of Health response will not respond to allegations by Faculty in public nor communicate via Press No public statement or contact by 4 June 09 No formal inputs at Health Summit
Mid-year population estimates per province, 2006
Mid-year population estimates - breakdown for the Free State Province, 2006
Health Indicators
EC FS GP KZN LP MP NC NW WC SA
Per capita health funding trends (Rand per capita) Rand million Eastern Cape 02/03 03/04 04/05 05/06 06/07 07/08 08/09 Real annual growth 02/03-08/09% 748 851 927 955 1 066 1 175 1 280 4.6 Free State 938 1 069 1 133 1 229 1 276 1 354 1 446 2.8 Gauteng 1 161 1 218 1 287 1 508 1 561 1 638 1 756 2.4 KwaZulu- Natal 898 967 1 029 1 206 1 335 1 444 1 549 4.7 Limpopo 629 720 808 914 1 031 1 110 1 218 6.8 Mpumalan ga Northern Cape North West Western Cape 603 715 798 935 1 014 1 103 1 206 7.3 885 1 144 1 103 1 417 1 652 1 778 1 728 6.9 619 686 772 875 1 006 1 099 1 151 6.0 1 183 1 340 1 506 1666 1 831 1 946 2 089 5.1 Total 867 960 1 023 1 175 1 284 1 379 1 482 4.5 Source: National Treasury
NTSG allocations (2006/07 prices)* Province 2004/05 2005/06 2006/07 2007/08 Eastern Cape 388,059 396,961 392,913 392,913 Free State 475,003 485,900 480,945 480,878 Gauteng 1,935,188 1,979,585 1,959,399 1,959,399 KwaZulu- Natal 760,076 776,695 768,078 768,078 Limpopo 78,247 75,932 71,648 71,648 Mpumalanga 46,415 47,479 46,995 46,995 Northern Cape 83,931 98,005 107,975 107,975 North West 74,627 73,600 70,509 70,509 Western Cape 1,335,239 1,350,038 1,322,744 1,322,744 Total 5,176,783 5,284,195 5,221,206 5,221,139 * Based on the Division of Revenue Acts for 2005/06 and 2006/07
Challenges Specialist Training Prof Wynand van der Merwe Chair: Deans Committee
Trends in health sector employees
Trends in Public Sector Health Professional Employees 2001-2007 01/02 02/03 03/04 04/05 05/06 06/07 Chang e 5 year Change % Medical officers 7 261 7 399 7 665 8 341 8 709 9 588 2 327 32.0% Medical specialists Total doctors 10,88 4 3 619 3 625 3 431 3 552 3 559 3 765 146 4.0% 11,029 11,101 11,901 12,278 13,411 2,527 23.2% Source: National Treasury
Specialist trends per province 2003 2006* Medical Specialists per 100 000 population EC FS GP KZN LP MP NC NW WC SA 2003 2.3 9.2 19.7 6.0 1.0 0.7 2.7 1.5 32.6 8.9 2005 2.3 13.8 18.3 6.2 1.5 0.5 2.5 1.9 29.1 8.8 2006 2.3 13.3 20.8 6.2 1.4 1.3 3.1 1.9 31.3 9.2 Percentage Medical Specialist- posts vacant 2006 36.1 33.6 20.9 34.3 26.8 38.5 53.4 29.9 12.6 29.9 Source: SAHR 2006 * Public sector posts compared with non-medical aid population (public sector dependent population)
HPCSA AND SAMA STATISTICS OF GENERAL PRACTITIONERS AND SPECIALISTS IN THE STATE AND PRIVATE SECTORS HPCSA statistics SAMA database Public sector Private sector Total Public sector Private sector Total General practitioners 7 987 (42%) 11 208 (58%) 19 195 (100%) Specialists 3 298 (37%) 5 727 (63%) 9 025 (100%) 2 154 (32%) 4 573 (68%) 6 954 (100%) D Kahn et al. SAMJ 2006;44:88-92
Where should we be?
Workforce Planning for Physicians: DoH Professional category Medical Practitioner Duration of Training Current yearly production Proposed annual production 5 6 years 1 200 2 400 by 2014 Significant shortages and extreme mobility of medical doctors necessitate that production is increased. This production must also feed into specialist training Medical Specialist 4 5 years * * Large variety of specialisations in medicine with each category experiencing a decline in numbers trained. Training targets will be decided after detailed discussions with provinces, universities and the Education Department Human Resources for Health (DoH, 2006)
Good Population Health Status Poor? 15 Specialists Population (per 100 000)
Assumptions and projected need for Medical Specialists Training 2000 to 2010 Medical Specialists 1. Currently employed 3,578 2. Population growth % per year 1.8 3. Retirement at age 65 % per year 7.1 4. Attrition due to illness and death % per year 2.8 5. Other exits % per year 1.0 7. Current staff norm (per 100,000) Ratio 8.7 8. International staff norm (per 100,000) 9. Target staff norm (per 100,000) Ratio 20.0 Ratio 15.0 Source: Financial & Fiscal Commission: Submission for the Division of Revenue 2007/08 10. Planned increase (from 2004) % per year 5.0
Current Public Service Specialist Deficit Current vacant posts 30% = 1 533 posts (SAHR 2006) 3 578 filled posts = 8.7/100 000 population 15 Specialists /100 000 population = 6 168 specialists Deficit = 2 590 specialists (FFC modeling) Faculty outputs 450/year
Bridging the gap training requirement Assumptions No influence by private sector demands (or other need/demand drivers) No change in current staff exit trends Static population figures Filling the current vacancy gap over 15 years* = 34% increase in current registrar admissions Achieving a 15 specialist/100 000 population norm in 15 years* = 58% increase in registrar admissions * Bridging the gap will only commence after years of increased intake (immediate increase in intake assumed)
Universitas Hospital 36% of specialist posts vacant of 1998 staff establishment Only 60% of 2008 theatre time available Specialist Clinics closed from Nov 2008 June 2009 in some cases At clinics see more follow up defaults because of lack of medication on PHC level Late advertisement of registrar posts
Pelonomi Hospital Failure to appoint staff Solutions: We need to decide what services for how many patients (up to 2020) and allocate enough posts for those services. We can then decide on the appropriate budget There should be some relationship between different disciplines (e.g. no point in having surgeons, but no anaesthetists). Appointment process needs to be streamlined - delegations to hospital management re-instituted. Continued attention to salaries and working conditions, with Department of Health willing to listen and respond to problems.
50% reduction in beds since 2008 in some disciplines (Internal Medicine) 8 patients in 4 bed wards -standard Nursing staff huge concern for Fac. Workload 38% vacancy Overcrowded wards Moral
Theatre time reduced by 55 % from 2008 No dedicated Trauma and Orthopaedic theatres Medical consumables still regularly out of stock Basic equipment problems- 2 weekends ago no working ECG machine in whole hospital!!!!!
Failure to supply medicines, disposables Solutions: There must be an adequate budget Major overhaul of supply chain (?centralize?decentralize) Adequate stock of supplies to cope with financial and similar emergencies. (For how long? Our view: 6 weeks)
Failure to maintain and replace equipment Solutions: Adequate budget allocation over next 10 years Campaign for additional National funding Plan priorities now, and budget accordingly. Institute adequate service contracts for equipment e.g. lifts, power tools, radiology equipment to prevent breakdowns and avoid crisis situations.
Building Programme Must plan structure of future hospital services in Bloemfontein now and plan for expansion in later years. Catalogue existing buildings and decide what can be upgraded at acceptable costs (e.g. nursing home at National Hospital Pelonomi hospital have enormous space and are totally unused). Re-establish establish technical support and maintenance teams presently understaffed, and unskilled.
Poor support by regional hospitals Must devise incentives for specialist services to expand at regional hospitals to relieve the pressure on Bloemfontein. Critical evaluations of Outreach Programmes (Is it cost effective? Is it acceptable for intervention / surgery if support staff is inadequate?)
Pelonomi Hospital The impact of non-accreditation of the Pelonomi hospital is significant, not only locally, but also nationally. The following issues should be sorted out: The total number of undergraduate MBChB students needs to be decreased for 2010 with at least 33 % if not more Intern training posts will have to be decreased in the Province with 50-75%. No new registrars in all the disciplines (no new specialist trainees) can be appointed.
The status of Pelonomi hospital as College of Medicine examination site will expire The College of Medicine National examination of May 2010 will have to be cancelled. Closure of the School of Medicine because of a lack of training platform, decreased number of students, decreased National subsidy for training.
At Pelonomi Hospital To turn around the crisis in Pelonomi Hospital and to prevent the 6 major issues as listed in the beginning of the document, the following recommendations are tabled for urgent attention (4 weeks): The filling of all critical professional staff vacancies at Pelonomi Hospital with immediate effect. To appoint fulltime members in all senior positions where there are acting persons To ensure sufficient funding for all activities at Pelonomi Hospital To address all medication and medical consumable items that are out of stock
To institute an urgent plan for addressing the backlog in infrastructure upgrading The improvement of the maintenance programmes The opening of all beds that were closed during the last 24 months The opening of all theatre lists that were stopped the last 24 months The institution of a 24-hour Emergency theatre to deal with the trauma burden as Trauma centre To upgrade all outdated service delivery equipment In the medium term to address the underfunding of Pelonomi Hospital as regional/academic platform Institution.
Recommendations Address underfunding of Health Services Address deficiencies on all levels of service including primary health care Include all stakeholders in strategic planning Restore Academic Platform Fill critical Core posts registrars, specialists and professional nurses
Address outdated equipment Ensure sustainable medical consumables and medicine supply chain Improve contract and tender management Address maintenance backlog
Do proper HR Planning Work together as teams
Conclusion Thank you for OSD and the role you played We are not just talking on behalf of Academic medicine but on all three levels Talk about our, and on behalf of our patients We have only one opportunity in the country to correct these problems! Please help us doing it today!!!!!!!
Ke Leboa / DANKIE /Thank you Departement Sentrum Department Centre UNIVERSITEIT VAN DIE VRYSTAAT UNIVERSITY OF THE FREE STATE YUNIVESITHI YA FREISTATA Tel (051) 401 3000 E-mail: info@ufs.ac.za www.ufs.ac.za