Strategic Planning in District X, South Africa

Transcription

1 2015 Strategic Planning in District X, South Africa Mr. J., the Manager for the District X Health Department, described the current annual strategic planning process for his district: The National Department of Health (DOH) and Provincial Health Department set priorities for the coming year. The priorities set by the National DOH are non-negotiable so they are my first priority. I then try to target additional District efforts to critical pressure points like the availability of medicine. So we take the imperatives from National and Provincial, and then incorporate our own priorities based on our local knowledge/information. For instance, cleanliness in the facilities has to be managed by the District; we have to figure out the operating details. Communication is also a key skill in the planning process, especially when communicating our local needs and our performance to the people above us in the organization. Our message can easily get distorted; the way something gets communicated can be more important than the message. You need to develop a strategy, a plan, before talking to the next level up. But often it feels like no one is listening. Background on District X The largely rural District X, one of about 50 districts throughout the nine provinces of South Africa, had a population of close to 1.5 million people, of whom 96% were uninsured, 88% lived below the poverty line of R283 per month, 1 and 70% were unemployed. Over half the population was under age 25. The adult illiteracy rate was roughly 40%. The housing stock reflected the rural nature of the district as well as its high poverty levels: only 36% of households had access to potable water, 40% to sanitation, and 27% to electricity. Roughly 30,000 people lived in informal settlements near the few urban areas. The top causes of death in District X included tuberculosis, HIV & AIDS, hypertension, diabetes mellitus, circumcision-related complications, motor vehicle accidents, waterborne diseases, cancer, chronic obstructive airway disease, and malnutrition. The under-five mortality rate was roughly 12 per 1000, and 16 per 1000 in the population under 1 year of age. The incidence of diarrhea, pneumonia, and malnutrition among infants and young children was quite high. The 1 The South African Rand is roughly.09 to.10 dollars US by the President and Fellows of Harvard College (revised 2015). This case was written by Nancy M. Kane, DBA, Harvard T.H. Chan School of Public Health, as the basis for class discussion and education rather than to illustrate either effective or ineffective handling of an administrative or public health situation. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard T.H. Chan School of Public Health.

2 male condom distribution rate was 12 14% of the eligible population in the sub-districts reporting it. HIV prevalence among year-old pregnant women was 30%. Close to 15% of teenage girls under age 18 had given birth. Only a quarter of pregnant women had an antenatal visit before 20 weeks. Maternal mortality rates were close to 150 per 100,000 deliveries, well above the target rate of 37. Within District X which had four sub-districts were nine district hospitals, staffed by generalist physicians and nurses. One regional hospital, providing specialist and surgical care, and two tertiary hospital centers offering advanced specialist and surgical care, were all located in the only urban area of the district. Primary care within the district was provided by 113 clinics staffed with nurses and community health workers, and 10 community health centers open 24/7, as well as close to 60 health posts and mobile units staffed by nurses and/or community health workers. The rural nature of the district coupled with poor basic infrastructure meant that many District primary care clinics were without electricity, continuous piped water supply, and proper sanitation or telecommunications systems. Road infrastructure was poor; in some areas, health providers walked for 2 5 hours to reach members of communities that were not accessible by vehicle. Some 24-hour clinics were not open at night because of uninhabitable facilities and poor security. Maternity patients often bypassed the clinics and referred themselves to the regional hospital for deliveries. Such self-referral overloaded the regional and tertiary hospitals with primary health care cases. Health service utilization rates were low, averaging 2.7 visits per person per year compared to a target rate of 3.5. Hospital bed utilization rates averaged 54%, despite a usable bed/1000 population rate of only The District X Health Department employed close to 4,500 people, but nearly half of their posts were unfilled. It was particularly hard to recruit physicians; in most of the sub-districts, no physicians staffed the clinics, and less than a third of community health center physician positions were filled. Pharmacists and pharmacy assistants were also hard to find few clinics had them at all, and only about one-third of the pharmacy assistant positions posted in the community health centers were filled. The District experienced a 15% combined personnel turnover and absenteeism rate per year. See Exhibit 1 for more information on the health system in South Africa. The Strategic Planning Process Ms. Y., the District X Officer for Health Planning and Reporting, added to Mr. J s description of the strategic planning process (see Exhibit 2): In April of, the National Department of Health sends out their planning priorities for the fiscal year (FY). Fiscal years begin in April, so FY -12 has just begun 2

3 when the planning process for starts. Soon after, the Provincial Health Department sends out its Annual Performance Plan for , which describes the expectations that the Province has for the District for These two plans the National and Provincial do not always have the same priorities. Between April and August/September of, District X completes a first draft of its District Health Plan and its Annual Performance Plan for , based on the National and Provincial priorities. The District Health Plan also incorporates a review of the District s performance for the year, which ended in March of. In August of, as District X is developing its plan for FY , it receives a first draft of its budget from the DOH. Between August and October/November a back and forth discussion among the National, Provincial, and District levels of government occurs; in addition, each subdistrict within District X does its operational planning in accordance with the draft District Health Plan. Over the same period the draft budget for FY is further developed; the national budget allocation to each province must be approved by the provincial legislature, which then allocates that budget among the various districts. District X gets its final budget for FY in January of The District then finalizes the District Health Plan and Annual Performance Plan in March of The planning cycle for the next year then begins again in April. Some of the challenges noted by the District X office staff included the following: Sub-district managers were too overwhelmed by operational issues to spend time working on plans for the following fiscal year, so the District Officer for Planning often did it for them. The National and Provincial plans were not coordinated and their priorities often differed. Each program funded by the DOH (e.g., HIV, Primary Health Care, etc.) had a manager at the national and provincial levels, all of whom came to the district to try to influence the people involved in the planning process. The plans were not connected to the budgeting/resource allocation process. District X s own information systems about financial and human resources were often inaccurate. The national budget allocation process was highly politicized and generally favored the provinces with the greatest economic wealth. One of the sub-district managers of District X added his perspective of what happened at the sub-district level during this process: Planning is a key sub-district responsibility every year we must make plans for next financial year. We have to plan targets for each program and then monitor ourselves with how we are doing in HIV, TB, Maternal and Child Health (MCH) programs, and in reengineering primary care. We come up with operational plans for all of these programs. However, the sub-districts are never able to produce the documents required for planning. For instance, there are 200 schools in District X needing school health 3

4 services; however, the sub-districts have not been able to provide the required scan of the environment for resource identification such as retired nurses, the numbers of vehicles, etc., nor are they able to collect the parental consent forms for every student in each school. The senior financial manager of the sub-district chimed in on the relationship between the planning process and the budgets received: Each hospital facility develops and submits its own budget, but funding is allocated to hospitals based on whatever they got before. The submitted hospital budget is completely ignored. Hospital managers are all clinicians and don t really want to spend time understanding the budget, so they delegate to low-level staff the responsibility of developing and monitoring the budget performance. Mr. J., the District X Manager, summarized the challenges: Everything we ask for must be in our operational plans, which then must be captured in the strategic plan. But planning is driven by the budget, not vice versa. We get our budget allocation and then try to prioritize what we will do. Unfortunately, the Annual Performance Plans do not get adjusted for how we end up prioritizing after receiving the budget allocation. The Performance Monitoring Process Data Collection Process at the District and Sub-district Level District X s Information Officer, Ms. M., described her role: I coordinate the health information coming in from the various sub-districts. We have a National Indicator Dataset which defines which indicators are to be collected where, and then the province adds its own set. We get data from primary health care clinics, hospitals, imaging, environmental health, the electronic TB registry, ARV (antiretroviral) program management, etc. For instance, we collect 210 primary health care metrics and 110 hospital metrics. There are various reporting times from weekly to quarterly; much of the data is gathered manually as there are not enough computers, and the electronic data cannot be consolidated across facilities without a ton of work. The sub-districts combine the data coming from various facilities to evaluate it, and try to put any missing information into the reports before they come to me for analysis. Program managers such as the HIV program manager and TB manager also use the data. Everything gets presented to the District management team, and I help to highlight areas that might need fixing. We then share the data at all levels of the organization. The local program managers have to report to their sub-district managers in person on what they have done/plan to do, etc. The District X Program Coordinator commented on the quality of the data used in the District s Performance Reports: 4

5 Most of the time the data are not very accurate because the collection process is understaffed. The sub-districts and their facilities can t possibly be doing all of what their reports say they are doing. The original source at clinic will say a number is 4; but in the report, that number is 10. The people producing some of the raw data do not understand what they are doing e.g., they may not understand what a midnight census is and some indicators are ambiguous, such as a half-day patient. And there is no way to figure out what is wrong; we don t have the resources to audit everything so the data is wrong every day. It often undercounts the patient load which then throws the cost estimates off. For instance, a patient sitting in an outpatient clinic all day needs food but isn t counted. Quarterly Performance Reports and Reviews Each sub-district manager reported their data to the District Manager, who, after reviewing it with the sub-district managers, produced a District-wide report for the Provincial Health Department. District X was required to submit quarterly performance reports to the Province in April, July, October, and January. These reports were generally delivered in person by District Managers to the Provincial office, and their performance was reviewed with provincial leadership. The Province then combined the various District reports and submitted them to the National DOH, generally within a week after receiving the Districts reports. Mr. J., the District X Manager, described the challenge of generating the quarterly reports and undertaking the reviews with his sub-district managers: The quarterly performance meetings with my sub-district and facility managers are not always up to the standards we wish they were. They are often used by the sub-district and facility managers as an opportunity to ask for more resources to offset their poor management skills. The challenge is that you have very unskilled people trying to translate political objectives into operational plans and action. When you look below districts and programs to institutions and facilities, there is little clarity regarding what people are supposed to do. For instance, if reducing outpatient employee head count is an objective, you would expect that the hospital CEO would translate that down into the nursing executive s job description, but the linkages are not fully working. And the nursing service manager may not understand how this will impact quality of service for patients. Waiting time reduction is a goal and there is an expectation that the facility manager will figure out ways to do that, such as having a triage person or a booking system for chronic patients. It is this level of translation, however, that does not always happen. Front-line managers, most of whom are clinicians, need training; people are in these positions in administration for reasons other than administrative skills. At the provincial level, other frustrations with the planning and budgeting process emerged. As the Provincial Head of Department (HOD), explained, 5

6 The Department of Health lacks strategic focus. We are so busy following the planning cycle deadlines and we don t miss the deadlines that we have to overwork our executive staff; this adversely affects productivity, quality of planning and service delivery. Also our traditional budgeting is not flexible enough we need short-, medium-, and long-term budgeting. Finally, we need to synchronize all the different reports. We need to train the District Managers and the Provincial executive team to stop pushing paper. The Provincial focus is too operational. We miss the Big Picture. We should let facility managers be operational. We should expect the District Managers in areas with high HIV to ask, What is it that we are doing wrong and what can we do about it? And then the budget should move toward HIV, but that is not reflected in the traditional budgeting process. Looking Ahead Mr. J., the District X Manager, was hopeful that the future would bring increased resources and better health to his local population. It was imperative that the planning and budgeting process support a healthier future in the district. He was wondering what additional skills he needed to learn to better work the system. He also was thinking about whether the system itself might be improved, and if so, how. 6

7 Exhibit 1: Background Note on South Africa s Health System The public health system in South Africa has historically been under-funded, existing in parallel with a well-funded private system that, unaffordable for most of the population, primarily serves the minority white population. Fewer than 20% of South Africans can afford private healthcare and rely instead on poorer-quality public facilities and hospitals. The public health sector accounts for about 40% of the country s healthcare spending while providing care for 80% of the population. South Africa s total healthcare expenditure in was 8.5% of the GDP, higher than in many other middle-income countries. (In comparison, China s expenditure was 5.2%, India s 5.0%, and Russia s 5.3%.) Despite this high expenditure, health outcomes remain poor due to high disease burdens, and inequities in resource allocation and in the quality and coverage of health services. The public health system in contrast to the well-equipped, expensive private healthcare sector is complex, fragmented, lacking in infrastructure, and poorly managed at both the strategic and point-of-service levels. Public healthcare is mainly funded by general taxes and heavily subsidized by the government. In the public system, primary healthcare is free for all. Heath services are delivered across three levels: national, provincial, and local/district. Strategic planning follows a top-down approach; the National Department of Health (DoH) oversees the public health system through nine provincial health departments and 50+ district departments. Funding for the system flows into general funds used for administration and for operating hospitals, clinics and community health centers, as well as into funds for specific programs that reflect the DoH s priorities, such as tuberculosis, AIDS, and maternal health. Each program has managers at the national, provincial, and district levels. Budgets are set based on historic costs rather than strategic plans. While the national DoH is responsible for the entire public health sector legislation, policy, norms and standards, and equity provincial departments also deliver services, set priorities, and make decisions. The provincial departments are tasked with developing policies within the national framework, although national and provincial priorities can differ. Local, or district, government delivers municipal health services in alignment with national and provincial policies and priorities. In a similar top-down fashion, districts determine strategies for their sub-districts. Patients first point of contact is with local or provincial primary healthcare clinics, staffed by nurses and community health workers and funded by local or provincial departments of health, respectively. Clinics can refer patients to district hospitals, which make up 2/3 (about 265) of the country s 400 public hospitals. District hospitals are staffed by local doctors and nurses and offer a broad range of in- and out-patient services. Next in the referral chain are regional and tertiary hospitals, funded by provincial health departments, which provide increasingly specialized care and surgical procedures. 7

8 Primary healthcare is concentrated in urban areas, so much of the rural population is without adequate access to clinics and the referral system. Much of the country s poor population, even in more urban areas, relies on traditional healers. The government is currently implementing a national health insurance scheme, and strengthening the public health system to improve access to high quality care for all. The following organizational chart gives an overview of the structure of the health system. Funds are allocated by the National Treasury to the National and Provincial Health Departments; the Provincial legislature then allocates funds to the local Districts. The allocation system is subject to political pressures at multiple points. 8

9 Exhibit 2: Planning, Budgeting Monitoring and Evaluation Processes and Time Lines Apr May Jun Jul Aug Sept Oct Nov Dec Jan 2012 Feb 2012 Mar 2012 Planning for FY Strategic Plans (from National Dept of Health) Annual Performance Plan (from Provincial Health Dept) District Health Plans Planning priorities sent out to provinces and districts Initial plan sent out to Districts 1 st draft 2 nd draft Final 1 st draft 2 nd draft Final 1 st draft 2 nd draft Final Budgeting for FY Provincial Budgets and MTEF District Budgets and MTEF NT issues MTEF Instructions DHER 1 st draft budgets 1 st draft budget 2 nd draft budgets 2 nd draft budget Final budgets Final budget Provincial Quarterly Performance Report 2 nd week 2 nd week 2 nd week 2 nd week Monitoring and Reporting for FY-12 District Quarterly Performance Report District Quarterly Performance Reviews Provincial Annual Performance Reviews District Annual Performance Review 1 st week 1 st week 1 st week 1 st week Conducted Conducted Conducted Conducted Conducted Conducted Provincial Annual Report District Annual Report (FY ) Submitted to Province Submitted to AG Abbreviations: AG: Auditor-General DHER: District Health Expenditure Review MTEF: Medium Term Expenditure Framework NT: National Treasury 9

10 Exhibit 2, Continued Month Activities Technical Support April to June District to review Audit of previous year s activities (situational analysis together with all quarterly reports) Review Tools: i. District Annual Report ii. District Heath Expenditure Review Confirmation of Provincial Strategic Priorities July to September October to December January to March First draft District Health Plan for the forthcoming financial year To be based upon Annual Report and National and Provincial Priorities First draft of the Provincial Annual Performance for the forthcoming financial year (Inputs from the DHP form the basis for the Programme 2 inputs.) First Draft of MTEF Budget Budget Statement 2 (Inputs from the DHER and the DHP forms the basis for the Programme 2 input) National and Provincial MTEC Hearing 2 nd Draft District Health Plan 2 nd Draft Provincial Annual Performance Plan 2 nd Draft Budget Statement 2 Final Budget Allocation Letter Final APP Final DHP Technical review done for each district: DHER and Annual Report Integrity of data sources to be verified Integrity of analysis and conclusions verified Part A: Identification of challenges and systems gaps Prioritisation Part B: Results based planning technical support Financial review and financial forecasting using the DHER as basis to inform the first submission of Budget statement 2 Interpretation and strategic guidance-new policy directive implications and costing Costing of plans technical review Marginal adjustments to budgets and targets Full technical review of District Plans and feedback Technical support for alignment of plan with confirmed budget Technical support for the operationalization of DHP 10

11 Exhibit 3: National Health Systems Priorities for National Priority Sample District Activities Target Provision of Strategic Leadership and Creation of Facilitate career exhibitions on health at high schools 85 schools Social Compact for Better Recruit students to study medicine in Health Outcomes Cuba 7 students Facilitate access to internal bursary 115 students Implementation of National Health Insurance Improve the Quality of Health Services Revitalization of Infrastructure Accelerated Implementation of HIV/AIDS strategic plan and increased focus on TB and other communicable diseases Mass mobilization for the better health of the population Review of Drug Policy Strengthen research and development Conduct Primary Health Care awareness campaigns Implement NHI Master Plan Assess the implementation of Quality Improvement Plans Facilitate implementation of Quality Assurance Program Facilitate the reduction of the vacancy rate for critical and scarce skills Train Community Health Workers on Reengineering of PHC Urgent implementation of refurbishment and maintenance of district hospitals, CHCs, and Clinics Implement adult and paediatric treatment guidelines at all PHC facilities Intensify health promotion programs Place more focus on programs to attain Millennium Development Goals Conduct awareness campaigns on diseases of lifestyle No related District activities Commission research to accurately quantify maternal and infant mortality Commission research on the impact of social determinants of health 16 campaigns 12 hospitals &10 CHCs 160 programs Reduce from 58% to 45% 324 workers 162 facilities 16 programs 11

12 Exhibit 4: Sample of District Health Plan for Primary Health Care Strategic Goal 01: To facilitate a functional quality-driven primary health care system that provides an integrated and seamless package of health services and is responsive to customer needs. Strategic Challenges: Underutilization of PHC due to bad roads, small facilities; poor drug management at all levels; shortage of personnel, inadequate professional skills; poor maintenance systems; lack of sustainable transport; and poor data quality. Measures of Performance: 10 measures of vacancy rates for skilled professionals (doctors, nurses, pharmacists) 5 measures of vacancy rates for other human resource categories at primary health care facilities 15 measures of patient head count, utilization rates, expenditures per head count, and clinical workload per professional nurse and doctor, and facility supervisory visits Exhibit 5: Budget of District X, 2012 Values in SA Rand Sub Program Provincial Appropriation Budget Expenditure % Over (Under) Spent Variation from Prior Year in Real Terms District Management 100,247,478 90,015,661 (10%) (5%) Clinics 341,030, ,803,880 (3%) 9% Community Health Centers Other Community Services 134,252, ,380,418 10% 25% 461, ,756 6% (68%) HIV/AIDS 82,348,286 71,321,205 (13%) 126% Nutrition 9,855,834 8,127,845 (18%) 51% Subtotal: Primary Health Services 654,864, ,196,836 (2%) 18% District Hospitals 616,630, ,110,193 12% 13% Total District X 1,371,742,934 1,419,322,689 3% 14% 12