7-10 MARCH 2000


B1.1. General

  1. Budget data (1st adjustment budget) for 99/00 is shown on the next page as Table 1. Projected expenditure data is shown on Table 2.

It has not been possible within the time available to present the data in exactly the format of table B1. This is partly because:

b) The provincial budget for 2000/01 by program and standard item is shown on Table 3.

c) Although the Health and Welfare branches have combined into a single department in the Western Cape, these figures represent the Health Branch only.

d) A deficit of approximately R36 065 000 is projected for the 99/00 year. This is shown in Table 2 by standard item. The anticipated deficit will be funded as the first charge against the 2000/01 budget. Each institution is to carry their own over-expenditure as an incentive to exercise greater fiscal discipline. Provision for a contingency fund has been made within the 2000/01 budget and this may be used support the process with Treasury, without relieving institutions of their over-expenditure.

Reasons for the deficit are shown in Table 2. Some of the key reasons are:

B1.2 Budget and expenditure in relation to specific policy issues

  1. Total revenue raised from private patients using public hospitals.

1999/2000 = R42,309 million

2000/2001 = R44,847 million anticipated

b and c) B.1.2 HIV/AIDS Budget for years 1999/00

The Western Cape Province had been allocated R1.6 million from the National Directorate HIV/AIDS for NGO’s /CBO’s to conduct HIV/AIDS related activities in the province.

The following is a breakdown of the financial allocation in the 4 regions.



Metro Region R570 000 10

Southern Cape/Karoo R331 349 10

Boland/Overberg R330 000 7

West Coast/Winelands R240 000 6

Provincial Office R130 000 2

The Metropole region (in addition to the R570 000) also funded the following from their budget for the period 1999/2000: NGO’s R1 162 000.00 and AIDS Training and Information Centre (ATIC) R1 000 000.

Total Provincial Health HIV/AIDS program budget for 1999/2000 is R3 762 000. The total cost on HIV/AIDS massively exceeds this, once expenditure within hospitals and primary care centres is added.

HIV/AIDS Budget 2000/20001

The department has topsliced an allocation of R7,276 million for HIV/AIDS in 2000/01. This is besides the amounts still to be received from:

The regions are in the process of allocating funding to NGO’s for the year 2000/2001. Therefore, no figures are available at this point in time. However, there will be a 46% increase in spending on HIV/AIDS in this province during this financial year.

d) TB

T.B.Budget for years 1999/00 and 2000/01

Year 1999/2000

c) Metropole Region -

SANTA National R 126 000

SANTA Tygerberg municipality R 308 700

Medicines R 3 779 000

Southern Cape Region

Transfer payment to Harry Comay R 3 695 000

Boland Overberg

TB Hospital R15 627 000

TB Outreach Programme R 1 232 000

SANTA R 100 000

W/Winelands R 1 645 000

Year 2000/2001

W/Winelands R 1 768 000

Earmarked Allocation R 70 000


Brooklyn Chest Hospital R16 479 000

DP Marais Santa Centre R 6 761 000

TB Medicine: Local Authorities R 3 779 000

TB: NGO’s R 773 000

Earmarked Allocation R 302 000

Boland Overberg

TB hospitals R 16 784 000

TB Outreach Programme R 1 400 000

SANTA R 365 000

Earmarked allocation R 256 000

Southern Cape Karoo

Harry Comay R 3 995 000

Earmarked Allocation R 60 000

Provincial Office

Earmarked Allocation R 10 000

e) Planned expenditure on information systems

The Provincial Administration: Western Cape has centralised all responsibility for information technology with the Chief Directorate: Information Technology, Department of Finance. Budget for Information systems is thus not included in the Health Vote but in the Finance vote in this province.

No allocation has been made to the Health Department for systems development, since the Department of Finance, due to financial constraints, is only funding the new hospital information system that is being installed.

However, the Department of Health is considering the possible, interim extension of the existing Unicare® system at the non-academic hospitals. This will provide additional functionality at thirty hospitals, at a cost to this department of about R3m.

Furthermore, this department has to attend to certain non-critical, non-Y2K-compliant systems this year, at a cost of approximately R0.5m.

The projected expenditure by the health department on information systems for the 2000/2001 financial year will therefore amount to approximately R3.5m.

  1. Planned new capital expenditure 1999/00 and 2000/01

B.1.3. Narrative report

a) Key problems with the budgetary process

Overall the budget process has gone well this year. The only problems we had were:

The introduction of a more performance and output orientated budgeting format (see Western Cape’s GFS book – Budget statements 1,2 and 3) was fairly successful and we are starting to shift the department towards performance based budgeting.

The shift to concurrent use of the new GFS standard item format is still new and unfamiliar to most managers.

b) Ability to realise national policy objectives generally

Generally satisfactory.

c) Implementation of revenue retention policy



1. Over-expenditure

The over-expenditure has been covered in section B.1.1 a.

No disciplinary action is envisaged at present but a policy decision has be taken that institutions will carry their own over-expenditure into the next financial year.

2 and 3. Departmental progress according to benchmarks and performance targets by directorate and chief directorate

As the financial year is not yet complete and an evaluation of achievements not done, the following documents are attached in the interim.

These documents contain performance targets as well as progress reports. Since the documents are lengthy only a single copy has been submitted to the chairperson of the Portfolio Committee.

B2.2. Specific policy issues

  1. HIV / Aids
  1. The Western Cape Provincial HIV AIDS strategic plan for the period 2000-2005 has set the following broad goals:
    1) delaying the age of first sexual contact
    2) Reducing the incidence of mother to child transmission of HIV
    3) De-stigmatizing HIV and improving social awareness amongst the community and
    4) Ensuring a co-ordinated commitment from all sectors of government and non-government organisations.

    Within these broad aims the following specific targets have been set:

    1) Establishing one youth friendly health center within 5km from each residence in 30% of areas by 11/00, 60% of areas by 5/01 and 100% of areas by 11/01.
    2) Reducing the number of HIV positive babies born by 5% per year
    3) Get voluntary testing and counseling available in 30% of health care units by 7/00, 60% of units by 12/00 and 100% of units by 12/01.

    (b) To what extent are NGO's used as part of your provincial strategy?
    We have one member of the provincial AIDS team (Bulelwa Juta-Leeuw) allocated full-time to liasing with NGO's. The NGO's are included in and integral to the majority of our meetings and programs e.g. Lifeskills, Home based care, provincial AIDS meetings, Interministerial Committee. We endeavor to work with them in all aspects of the program.

(c) What process has been introduced to deal with interministerial co-operation and co-ordination?
The Interministerial Committee(IMC) on HIV/AIDS in the Western Cape Province was started in 1998 through the collaborative efforts of NACOSA and the Department of Health, in an attempt to gain support and approval from political leadership. A needs assessment and evaluation report compiled in 1998 established what policies and programs were in place within different Government departments at the time. On 1/12/98 the provincial cabinet signed a pledge and the IMC on HIV/IDS was launched. During 1999 the IMC met four times. There has been good representation from various departments, although attendance by ministers has been weak. There has been increased sharing and monitoring what each department is doing in relation to HIV/AIDS. Greater collaboration and interaction between government departments has been promoted. Designated staff within each department who will be responsible for the HIV/AIDS component have been identified. It has been proposed that HIV/AIDS be placed on the weekly cabinet agenda.

(d) What access is available to hospices for AIDS patients in your province? Is there a policy to improve the access?
St. Luke's Hospice are willing to and do take AIDS patients. They have a central hospice unit in Kenilworth, CT. We don't have specific plans to increase the number of hospice beds available to AIDS patients, and this is something that needs to be looked at fairly urgently.

(e) Is there a strategy to provide home based care for AIDS patients? Provide details of policy decisions, existing or envisaged process, and time scales.
St Luke's hospice offers community hospice services (no beds, but counseling, support groups, home visits, etc) at Athlone, City Bowl, Constantia, False Bay Hospital, Mitchell’s Plain, and West Coast. The Red Cross Society does home based care, but do not have hospice beds. Our strategic plan includes the aim of spending R500 000 on home based care, starting in June 2000, to increase the number of home based care structures, and the number of AIDS patients taught self help. This area is receiving priority attention within the regions.

(f) Provide a detailed report on the implementation of the HIV/AIDS education program in your province. Include information on the process, as well as the number of schools and pupils reached.

The thrust of HIV/ADS education within the province has been through the life skills program. During 1997 and 1998 129 master trainers were trained who in turn trained 816 teachers from 433 high, intermediate and special schools. A more recent situational analysis revealed that there were 575 trained teachers left out of the 816 in the service. Positive aspects of the program which were identified included information sessions with the staff, offering the program to learners as part of academic subjects, during guidance periods or as part of life orientation curriculum, pupils playing a part in the school development policy, use of audio-visual material by teachers, informal talks, involvement of the NGO's, health personnel and students from universities and technikons, as well as peer educators, peer counseling, creation of HIV/AIDS awareness, the establishment of HIV/AIDS forums and the Old Mutual "I have hope" program. During 2000-2002 the program will be extended into the primary schools. During March and April, 5 workshops are being held to "train the trainers". The program is being managed and driven by the education department . The budget for the financial year 2000-2001, which is administered by the education department, is R8m for the province.

(g) Indicate your province’s strategy to deal with discrimination against HIV positive people in the public sector, public hospitals and clinics and in the community.

The 5-year strategic plan of the provincial AIDS program includes several strategies that will help to destigmatize the disease in the above settings:

Strategic goal #3 is specifically to "de-stigmatize HIV … amongst the community". Under this goal, the following activities are envisaged:

(h) Provide specific details, time scales, and performance targets associated with any advertising campaign

Publicity and "advertisement" mainly centres around the national days/ weeks such as National AIDS day (1.12) and National Condom/ STD week (February). The publicity for these events is managed by the health promotion staff at both provincial and regional level, and by the many NGO’s who take part.

The Department of Transport has embarked on an HIV/AIDS billboard campaign along the major routes, as part of their involvement in the Interministerial Committee.

Certain local authorities have been conspicuous in the placement of advertisements in prominent places around HIV/AIDS. The City of Cape Town sponsored numerous posters along major road routes, and hung a 40 foot picture of a condom from the civic center for passing motorists to see, as part of their

Effort from World AIDS day last year.

(i) Provide specific policy and targets in relation to providing counseling and testing services

The 5-year strategic plan of the provincial AIDS program includes provision to improve access to voluntary counseling and testing. R3 million has been allocated to VCT in the 2000/2001 budget. The target, as mentioned above, is to have VCT services in 30% of facilities by 7/00, 60% by 12/00 and 100% by 12/01.

(j) Provide details indicating how your province's STD services are to be used to provide an integrated strategy for HIV/AIDS.
Under Strategic Goal #2 of the provincial plan for 2000-2005, objective #4 is "to reduce the transmission of HIV by appropriate management of STD’s" R500 000 has been allocated for the training for GP’s in the management of STD’s, and treatment of STD’s in pregnancy. The training will start in June 2000 and continue until December 2000. The plan further states that the R500 000 could be used to supply drugs to pharmacies and the number of prescriptions counted as part of surveillance.



2.1.a District Management Structure

The focus in the province has been on developing consensus on the content of the DHS as a first step, and the setting up of District Management Structures forming a second step. To this end, a Bi-Ministerial Task Team involving the Departments of Health and of Local Governments, as well as the officials of a large number of local authorities both in urban and rural areas, was set up 3 years ago. The participatory process led to the production of a report setting out the steps for the transfer of Primary Health Care Services to local authorities. This transfer will take place across the province on 1st July 2001. The next steps are being developed in conjunction with the local government restructuring processes.

In the mean-time, an incremental transfer of services has taken place over-time in the rural regions : for example, in the Southern Cape, where a PHC provincial post becomes vacant, the funding and post were transferred to the local authority. As a result, only 260 staff from the rural regions will need to be transferred in July 2001.

2.1.b Process for achieving equity in the allocation of PHC services

The Province commissioned a study on equity in 1999. This showed that equity across regions was less of a problem than originally thought, in particular due to urbanisation and significantly faster population growth rate in the Metro, compared to the rural regions. Given the fragmentation of PHC services, it has been difficult to assess properly resources allocated and services rendered. The province is committed to Equity and plans to move increasingly towards a population-based resource allocation formula. Work in this regard has already started.

2.1.c. Relationship with local government structures

This relationship has been strengthened through the work of the Bi-Ministerial Task Team and is taking various forms :

2.1.d New fixed clinics

Over the past five years, 55 new fixed clinics have been built and 34 significantly upgraded. These are mainly in previously disadvantaged communities. All of them are operational. Delft, Kraaifontein, Vanguard CHCs have now been commisssioned to include a 24 hour service.

2.2. Primary care core package

Building on the national PHC Core Package, a PHC Core Package has been developed in the Western Cape over an 18 months period of consultation of all stake-holders, including local governments. It has been approved by the province and an implementation strategy will be finalised by May 2000. The aim is for this package to be incrementally implemented with full implementation across the province within 5 years. A detailed costing of the package will be carried out before September 2000.

2.3. Management of drugs


  1. A Pharmaceutical Advisory Committee has been set up under the chairmanship of the Superintendent General of Health and Social Services. This committee will investigate and advise on improving all aspects of pharmacy practice including the distribution and procurement of medicines.
  2. Manufacturers delivering drugs directly to major institutions. The benefits are;
  1. lower stock holding at institutional level
  2. lower stocks and a reduced demand on working capital at the CMD
  3. better batch tracking control via the private sector
  4. less opportunity for misappropriation of stock
  5. delivery time that is markedly shorter than from the CMD.
  1. Privatisation of the distribution of drugs from the CMD to all end users. A tender will be awarded shortly to a private distribution company to collect orders at the CMD and deliver to all hospitals, clinics and District Surgeons in the province. The benefits of this are
  2. (a) faster

    (b) better controlled service

    (c) less opportunity for theft

    (d) risk has been transferred to the private sector.

  3. All intravenous solutions are purchased by hospitals directly from the tenderer who then delivers directly to the hospitals. Intravenous solutions are heavy and bulky, thus requiring a large storage area. Therefore frequent deliveries reduce the need for storage space.
  4. Adequate staffing at all levels.

At the CMD, staffing is dependent on the trading account. In order to be able to employ more staff the interest paid on the trading account capital must be abolished. This will free up ±R1.5 million per year. This is being currently investigated.

6. An increase in the trading capital of the CMD has been requested. This will mean that larger stocks of essential drugs can be held thus avoiding stock outs should the tenderer be delayed in supplying.

  1. All hospitals are to be linked via the Medvas system to the CMD. This will speed up the ordering time and improve distribution.
  2. All institutions have been instructed to use stock cards for the bulk stock to improve control. It is an inventory management system which will assist the pharmacist in deciding what the re-order level and quantity to be ordered should be. If ordering patterns are improved, distribution from the CMD and tenderers will improve.
  3. Intensify the Essential Drug Programme implementation at hospital level. This will mean fewer drugs on the formulary and thus there will be more funds to purchase larger amounts of the essential drugs and thus ensure availability for distribution.
  4. All pharmacy staff are to have training in Drug Supply Management. The Metropole Region is arranging 3 courses a year for ±24 people each time.
  5. Regional depots are to be established e.g. South Cape/ Karoo Region will find it more efficient to have drugs delivered directly.
  6. Regional tenders to be considered. Manufacturers could then plan production more effectively. These tenders would encourage manufacturers to stay in business and then there would be more than one source of supply in the event of supply problems. They would create opportunities for small –medium manufacturing enterprises and encourage job creation.
  7. Careful checking of orders. At regional level all clinics have a limited range of drugs available. Any orders placed are first vetted by the Regional pharmacist before being ordered electronically from the CMD.
  8. The number of drugs not available at CMD for distribution has improved from ±300 in October to 70 at the end of February 2000.
  9. Any drug that is available commercially in a ‘patient ready pack’ will be purchased rather than having it packed at the Prepack Unit. This will give the Unit more time to pack other drugs and thus ensure distribution of a wider range of prepacks.



The re-structuring of the Central Hospitals i.e. Groote Schuur, Tygerberg and Red Cross Children’s Hospitals is a dynamic, ongoing process. There are 3 major factors that influence re-structuring and the future shape of these institutions.

(a). These are all teaching hospitals providing training on a graduate and post-graduate level to 3 universities, 3 Technicons and the Western Cape Nursing College.

(b). There are no large regional hospitals (largest 260 beds) in the Western Cape so the Central hospitals necessarily have to provide certain regional level services.

(c). In line with national and provincial health policy, the relative proportion of the budget spent on Central hospitals has diminished considerably.


It is clear that this province cannot afford to support the full range of tertiary and quaternary services at each of the central hospitals to meet particularly the post-graduate requirements of the two universities with Medical Schools.

To rationalise these sophisticated facilities , the management of the hospitals is co-ordinated by an executive officer and the hospitals are jointly known as the Associated Academic Hospitals (AAH). The Heads of the hospitals together with their nursing and administrative components make up the Extended Executive of the AAH.

Clearly apart from clinical areas there are other areas for joint administration such as procurement, pharmacy management, transport etc. There is ongoing and close liaison between the hospitals regarding personnel and finance.

This process of rational management of scarce facilities started 2 years ago with the appointment of the first (acting) Chief Executive Offficer. Initially, given historical linkages with universities and totally different historical management styles dating over decades, the process was slow, but is now gaining momentum and clearly is the strategic direction to be followed.

Key to the process was the delinking of a particular university from a particular hospital and the establishment of a joint teaching platform providing equitable access to all three universities and other institutions of higher education. While largely accepted in principle, the actual application of this system by the universities has been slow and one of the main reasons for the initial inertia – this is improving.

In terms of affordability, the health branch has no doubt that the further strengthening of the Association of these hospitals is the management path to follow.


The Central hospitals could esentially not operate without the Conditional Grants. They have been central in stabilising the AAH and maintaining these centres of excellence, who have lost approximately 5000 staff over the last three years.


The policy of 50% Retention of Revenue above the current targeted revenue for an institution has recently been introduced.

In general, this is a good policy . The operational application of the policy needs to be worked through in detail. As an incentive to all staff members to assist in improving revenue generated by a hospital, there must be tangible benefits. It is vital therefore that aside from various revenue generation initiatives, the priorities and plans to spend the retained revenue must be determined in advance in consultation with all stake holders. For instance, 20% improvement in staff facilities, 40% improvement in patient facilities and 40% on capital equipment.

The potential for revenue generation in state hospitals is great and in direct competition with the private sector for the health rand. In the Western Cape certainly in the central hospitals and on an increasing basis in regional hospitals, we are able to compete in the areas of:

All of the above are in place, but to generate revenue the following deficits need to be addressed to a greater or lesser extent.


The geographical proximity of the Western Cape to the Eastern and Northern Cape provinces provides the ongoing basis for sharing of expertise and services.

This province continues to provide tertiary services in Cape Town to large numbers of patients from the Eastern Cape, particularly in the fields of Paediatrics and Oncology amongst many others..


With the establishment of the Associated Academic Hospitals in 1998, an acting Chief Executive Officer was appointed and support staff seconded to the Associated Academic Hospitals from the Head Office and Institutional establishments. This management structure comprises 5 people and addresses the strategic management of the central hospitals.

In addition, horizontal management has been instituted to manage programs across the Associated Academic Hospitals. These programs currently include Obstetrics, Gynaecology and Neonatology, Orthopaedics, Tertiary Dental Services and Pharmaceutical Services. This endeavour will be further extended in future.

Funding has also been available from the European Union and has been used for the appointment of consultants to address key management issues such as information management, cost-centre accounting and middle and top management training.

Management links between the Associated Academic Hospitals, Metropolitan Region, Universities, Clinicians and other service providers have been established and benefits of integrated management of services in the interest of patient care have been realised.


Insofar as the Western Cape Central Hospitals are concerned all primary health care activities have ceased and been relocated to the district level of Community health centres, clinics etc.

While we would wish to confine activities to tertiary and quaternary priority areas of health care, this is not easily achieved for the reasons outlined in the introductory paragraph. As mentioned, the regional hospitals in Cape Town (5) have a total of approximately 1200 active beds, necessarily therefore the Central hospitals (Total 3000 beds) continue to shoulder a considerable load of patients which could be classified as regional category patients (+/- 35%). Two other factors play a role. The number and severity of Trauma cases on the Central hospitals is playing a major role in distorting the mix of patient in the hospital as also holding elective cases from admission. The second factor is that due to budgetary constraints there have been additional bed closures to the degree that the activity level of patients has risen dramatically.

In spite of these constraints however, there are initiatives in hand to reduce waiting times in outpatients, achieve a greater throughput of patients by increasing day surgery, the introduction of hotel wards etc.


In spite of the limitations of bed capacity relating to the Regional hospitals, services are progressively being upgraded at these hospitals to the extent that less patients are being referred to Central hospitals. As an example, George hospital refers less than 6% of in-patients to a Tertiary hospital.

In terms of management there has in recent times been a significant movement of specialist personnel to provide services at Regional hospitals. A long-standing successful example of this is the Somerset Regional hospital and recently the G.F. Jooste hospital in Manenberg where all basic specialties are now available.

There is no doubt that as equipment improves in Regional hospitals it will be possible to move services from central to Regional hospitals.


Due in a large part to the new funding formula to Provinces, the National and Provincial health plans to promote primary and secondary level services and rationalise services at tertiary level, as well as salary bracket creep, the Associated Academic Hospitals have had to reduce staffing levels radically.

In April 1996 the three academic hospitals had 14,532 filled posts compared with 12, 742 in April 1997, 10, 943 in April 1998 and 9, 657 in April 1999.

While staff numbers have reduced dramatically to levels now regarded as critical, the instruments to attain this such as the Voluntary Severance (VSP) and natural attrition have distorted the staffing profile and staff ratios.

Certain categories of staff, notably nursing staff and pharmacy personnel, have been lost through the VSP, active recruitment from overseas countries and attracted to the private sector through higher salaries, better benefits and more congenial working conditions. These issues will have to be addressed as a matter of urgency to attract staff to academic central, and in fact, all public sector hospitals.

Many of the higher salaried staff remained, notably medical professional staff, while lower categories of support staff were lost. This has further distorted the personnel profile and further rationalisation will have to be effected. One hopes that sensible mechanisms will be negotiated in order to make this possible.


While the Academic institutions are progressively introducing curricula more synchronized with the National health care initiatives, this primarily will affect undergraduates. In this regard there is an increasing academic program-taking place outside the Central hospitals.

It must be recognised, however, that in the specialist and sub-specialist areas the maintenance of well-equipped, correctly staffed Central hospitals is an absolute requirement. Equally important, the patient mix must be of such a nature as to allow comprehensive teaching and procedures to take place. This is presently not the case due to deficits in equipment and the influence of the number of trauma cases etc.

As a result particularly to satisfy this need for post-graduate education, both Tygerberg and Groote Schuur hospitals have made unused space available to the universities in a Public Private initiative to address discipline specific problems.


One of the main managerial problems experienced was the rapid reduction of staffing levels to meet financial targets. This was aggravated by the general salary adjustments, improvement of conditions of service and was further exacerbated by the system of commuted overtime and expenditure related to that. Personnel expenditure, despite the reduction of personnel numbers still forms a too great portion of total expenditure (70 plus %) and inhibits the ability of the Associated Academic Hospitals to provide the range of services required.

The required reduction has also eroded the capacity of the central hospitals to maintain certain services to the desired levels. These include cleaning services, pestering services, auxiliary support services, general and maintenance services and certain allied health support services.

The services shortage of certain categories of professional staff as detailed earlier have also eroded the ability to provide clinical services to the desired level.

The acuity levels of patients have increased as has the numbers and severity of trauma cases, which has curtailed the capacity of the central hospitals to provide the range and scope of patients for teaching and training.

Rationalisation of the central hospitals has progressed within the existing constraints. The inability of the universities to rationalise especially post-graduate training is impacting on service delivery.

Further problems, which will have to be addressed as a matter of urgency, relate to the age and lack of equipment. The central hospitals can no longer keep abreast of developments, especially high technology, expensive items of equipment, which reduces the efficiency of clinical treatment, teaching, training and research. The lack of an integrated hospital information system and integrated management system has also affected the management of the hospitals and the Associated Academic Hospitals. This is currently being addressed.

Maintenance of buildings, equipment and plant is also a major challenge facing central hospitals and will have to be seriously addressed in future years.

3.2 Regional Hospitals

3.2.a Future Strategic Directions :

The vision for regional hospitals functions in the Province is geared towards increasing access to specialised services, whilst ensuring that patients are treated at the lowest level of care possible, given their condition. In this perspective the following initiatives are being planned :

3.2.b Improved Management

In order to strengthen financial systems and recruit or retrain appropriate financial/admin personnel, the department has earmarked an amount of R11 million. A significant proportion of this sum will be for use by hospitals with focus on stock control, billing systems and debt recovery. These measures will in turn help increase revenue generation.

A number of measures are being planned, and some of them already being implemented, to increase quality and performance of the services whilst staying within budgetary allocations : reorganisation of OPD services, development of day surgery in all hospitals, pharmacy direct issue, implementation of discharge for the week-end, where possible and development of hotel-type beds.

3.2.c Service Reprioritisation

This point has been covered in section 3.2.a

3.2.d Retention of Revenue Policy

This aspect is covered in detail under section B.1.3.c

3.2.e Rationalisation of Staff

A study is under way to assess the specific categories of staff which are in demand or in excess in each hospital. The need or excess is established using as a reference a normative model which builds on the Hospital Strategy Project model and adapts it for affordability. The hospitals have been badly hit by the implementation of the VSP policy, and there is a severe shortage of nurses.

3.2.f. Serious problems encountered during 99/00

Common to all regions, has been the shortage of beds. Regional hospitals also function as district hospitals for the local catchment area, in particular in the rural regions. As a consequence, the occupancy rate is very high and the pressure on beds means that referrals from district hospitals cannot always be admitted.

Another common issue is that of shortage of pharmacy staff, which affects regional hospitals and regions as a whole. Due to the poor level of salary for that class of professionals, it is extremely difficult to recruit and retain pharmacists. This not only affects the performance of pharmacy services, but also is costly as control on dispensing is inadequate.

Due to severe reductions in the budget over the past four years, maintenance and replacement of equipment has been very limited, reaching crisis level. Earmarked funding in the 2000-2001 budget will help address this issue.

Following are additional specific problems encountered by each region for their regional hospitals :

South-Cape : George Hospital

Staffing : Shortage of nursing staff, in particular professional nurses

Shortage of, and inappropriately trained Financial Administration staff

I.C.U. : The hospital badly needs an ICU unit, due to the 500 km

distance from the tertiary hospitals in Cape Town.

Boland-Overberg : Eben Donges Hospital

Staffing : Shortage of Specialists : Anaesthetist and Psychiatrist

Service : The very high casualty load poses serious problems to the hospital.

Discipline : The backlog of disciplinary cases is beginning to be addressed with the new powers available. This has already resulted in some dismissals.

Facilities : Besides the shortage of beds mentioned above, inadequate pharmacy facilities creates serious management problems.

West-Coast Winelands : Paarl Hospital

Staffing : Shortage of Specialists : Anaesthetist and Orthopaedic Surgeon.

Great difficulty in recruiting appropriately trained Financial Management staff

Metro Region : 6 regional hospitals

The main issue in this region is that of the acute shortage of beds and nurses, combined with the poor condition of the hospitals.





Expand demonstration and training districts to cover whole Province. i.e. 24 Districts

All districts expected to be demonstration and training districts by 01/10/2000.

Monitor 2/3 months conversation rates new and retreatment smear positives.

All regions expected to reach target of 80% for new and 70% for retreatment smear positives.

Community directly observed treatment shortcourse (DOTS).

All targets expected to be reached.


Introduction of Electronic TB Register.

4 Pilot Districts expected to be set up by 31/03/2001.

Maintaining 100% reporting from treatment points.

100% Reporting expected to be maintained.


Maintain Turn Around Times (TAT).

Target of 80% < 48 and 100% < 72 hours expected to be maintained.

Reduce Treatment Interruption Rate (TIR) to 18% Metro and 12% for other 3 Regions.

Targets expected to be reached.


Support visits to all Regions in Province.

Targeted visits should be completed.

Maintain 100% bacteriological coverage.

100% coverage will be maintained.

Training around guidelines and TB Management in all Regions in conjunction with National TB Programme.

Targets expected to be reached.



Expansion of Community DOTS. Training to Farms, Fishing Fleets.

Targets expected to be reached.


Introduction of NGO accountability and reporting of outcomes.

Targets expected to be reached.


2/3 Months conversation rates.

All 4 Regions 80% or > 80% for new smear positives and 70% for retreatment smear positives.

All expected to reach.

80% conversion @ 2/3 months for new smear positives and 70% for retreatment smear positives.

Development of Intersectoral Collaboration.

Continious – targets particularly with HIV/AIDS, Farmers Unions and Fishing Fleet Companies expected to be reached.

Monitor Multi Drug Resistant (MDR) TB.

Quarterly reports will be submitted.

Treatment Outcomes.

Metropole Region 70% cure rate.

West Coast / Winelands 80% cure rate

Boland / Overberg 80% cure rate

South Cape / Karoo 75% cure rate

Expected to be achieved.




District TB Co-ordinators in all "Districts" or Substructures.

Co-ordinators in all Districts and Substructures (not full time).

Monitoring of 2/3 months conversion rates at all treatment points.

2/3 Months conversation rates submitted by all treatment points.

Regular supervisory visits to regions.

All Regions visited by Provincial Co-ordinator.

Introduction of unique patient number.

Put a hold pending introduction of Electronic Register.

Simplification of TB register TB Forms and introduction of Electronic Register.

Process progressing rapidly with Electronic Register expected to be piloted by end of 2000.

Adherence to guidelines on sputum taking and submission.

All health units adhering to protocols.

Reduced loss of sputum results due to leakage.

Leakage reduced by 50%.

Improvement of reporting rate to 100%.

100% reporting rate achieved.

Devolve TB training to Regions.

TB training devolved to Regions and ongoing.

Distribute Health Workers TB Training Manuals.

TB Training Manuals distributed and used at training sessions.

Peipherialisation of Microscopy Service.

Completed – adequate Microscopes in place at most suitable locations.

Bacteriological coverage of 100%.

Bacteriological coverage average 98%. 100% in most areas.

Turn around times of 24 –48 hours for 100% specimens.

Not yet achieved – being accurately measured as demonstration districts are being expanded estimated 80% within 48 hours.

Establish 8 new demonstration and training districts.

8 New demonstration districts designated and established with possibility of another 11 before 31/03/2000.

85% Conversation at 2/3 months in existing Demonstration and training "areas".

Not achieved – conversion rate ranges 68% - 80%.

Train 4 new demonstration districts in TB Management.

4 New districts trained.


Introduce and distribute new 4 drug combination TB tablet flush out old TB tablets from system.

New combination tablet introduced, old tablets successfully flushed out.


MDR Policy / Guidelines.

Completed – policies agreed and being implemented.

Monitoring of TB adverse drug reactions.

Policy agreed and being implemented.

Develop collaboration with HIV Subdirectorate and HIV/AIDS Organisations.

Initiated and being developed.


Develop Community DOTS.

Accredited training started in conjunction with Cape Technicon.

75 Community DOTS trainers trained.

Manuals developed and printed.

Community DOTS supported being trained and deployed with accountability to clinic sisters.

Community DOTS started on Farms and Fishing Fleets (at see).

Cure rate.

75% Average for Province by end of 1999 / 2000.

Cure rate will not be known for some time yet.




Appoint Provincial TB Co-Ordinator

Appointed WEF 1 April 98

Identify and appoint district TB Co-ordinators.

District TB Co-ordinator (CDC) identified and operative in Regions but only spending 2 – 5% of time on TB.

Provincial Supervisory Plan.

All Regions + 65% of district visited.

Improve Microscopy Service (peripherialisation of service)

4 Flourseence Microscopes supplied and distributed.

Improve bacteriological coverage to 95%.

93% coverage attained.

85% 2/3 months conversion rates for demonstration areas.

Not achieved varies from 50% to 70%.

Evaluation of existing demonstration and training areas.

Evaluated and lessons learnt applied.

Develop expansion plan for demonstration districts.

Developed for implementation in 1999.


Development of Provincial Training Plan.

Decision made to devolve to Regions.

Develop Health Workers Training Manual.

Develop and printed.

Develop Standardised DOTS Supporters Trainers Manual and DOT Supporters Manual.

Developed and funding for printing being look at.


Introduce 2/3 months conversion rate reporting from all treatment units and get local health personnel to manage programme better based on outcomes.

Introduced late 1998 and being used to manage programme locally. Improvement will only be apparent 12 – 18 months later.

Strengthen advocacy.

TB Advocacy strengthened with reorganised group called United Action Against TB. World TB Day activities very successful in all Regions.

85% Cure rate.

Not attained range 65% to 68% through out province.





Appoint Provincial TB Technical Advisor.

Appointed W.E.F 1 April 1997.

Identify 4 demonstration and training districts.

4 Demonstration and training "areas" identified.

Develop and implement Microscopy Service Plan for Province.

Developed and implemented in phases depending on availability of funds.

Improve Turn Around Turnes (TAT) using fax machines in clinics.

Fax machines purchased and installed in clinics as per plans from regions.

Arrange supervisory visits to demonstration areas.

Supervisory visits carried out at least twice / quarter.

Improve standard or quarterly reports and use of register.

Training successfully carried with accuracy and delivery of reports improving considerably.

Identify Regional TB Co-ordinators.

Regional TB Co-ordinators identified – not full time but spending 2 – 5% of time on TB.

Initiate quarterly meetings with Regional TB Co-ordinators.

Quarterly meetings initiated and taking place regularly.

Set up Task Force to develop Standardised Manual for Community DOTS Workers.

Set up and operative.


Set up information meetings with different Government Departments etc.

Information briefing given to all Government Departments etc.

85% Cure rate.

Not attained cure rates mid – 60%.



5.1. General

  1. Human resource restructuring

During April 1996 total filled posts on the staff establishment of the Branch health was 32212. On 1 February 2000 the total filled posts were 23639. A loss of 8573 filled posts for the period April 1996 – February 2000.

A total of 6683 staff members left due to the VSP

A total of 3036 staff members left due to natural attrition since 1 April 1998

b) Human resource strategy

A system is in place to analyse and monitor staff establishments on institutional level. Model staff establishments have also been developed for each type of hospital. These measures have enabled the department to adopt a normative approach in the allocation of resources to ensure equity. Surpluses and shortages in specific categories of staff were identified and could be addressed. The 2000/2001 budget, for example, makes provision for an additional 58 primary health care nurses and 188 finance related administrative posts. There is a serious shortage of nurses in the hospitals in the metropole which is not primarily budget related . The department is in the process to develop strategies to address the shortage in pharmacists and health therapists. There still exist minor surpluses in non-clinical elementary occupations.

It must be noted that the HR strategies are fully becoming more integrated with the strategic and service delivery improvement plan of the department. To facilitate the process of decentralised management, software packages have been developed to serve as HR management tools on institutional level. These took integrate HR management with financial and output indicators. The process of installing the software and training will be finalised in June 2000.

5.2. Students and trainees

a) Final year medical students (not on staff establishment – 380 (UCT 139; U/S 141)

b) Medical Interns - 196

c) Dental Interns - None

d) Nurse student by type of student

Table 1:

Total number of undergraduate (full time) student nurses funded by the Western Cape Provincial Department of Health & Social Services for training at the Western Cape College of Nursing (WCCON) and the Universities of the Western Cape (UWC) and Stellenbosch (US) for the year 2000

Study year




Grand Total

1st year





2nd year





3rd year





4th year





Total Number of 1st to 4th year students / training institution





Source: Directorate: HRD / WC Department of Health & Social Services / March 2000


Table 2

Total Number of Registered Nurses funded by the Western Cape Provincial Department of Health & Social Services, studying for part-time Post Basic Clinical Nurse Training Programs at Universities, Technikons

Study program

Educational Institution


Theatre Nursing

Netcare (Private sector)


Community Health Nursing

Technikons (20)

University (02)


PHC Clinical Skills



Diabetes Management



Pediatric Nursing



Critical Care Nursing






Psychiatric Nursing



Grand Total



Source: Directorate: HRD / WC Department of Health & Social Services / March 2000


* Budget for the above training is allocated to the Directorate: HRD in the

Department of Health & Social Services

* All Registered Nurses studying for the above programs are full time employees from

various provincial health facilities

Table 3

Total Number of Registered Nurses studying for part-time Post Basic Clinical Nurse Training Programs paid for by bursary awards – allocated by the Administration to the Western Cape Provincial Department of Health & Social Services: Health Branch

Study program

Educational Institution


Psychiatric Nursing

Universities (Diploma 6)


Community Health Nursing

Technikons / Universities (Diploma 6; Degree 1)


Critical Care Nursing

Universities (Diploma)


General Nursing

Netcare / Universities (Diploma 5; Degree 1)


Occupational Health

Universities /Technikons (Diploma 2; Degree 1)



University (Diploma 1)


Grand Total



Source: Directorate: HRD / WC Department of Health & Social Services / March 2000


* Budget for the above training is allocated to the Directorate: HRD (Health Branch)

e) Allied staff by type of student

Student radiographer : 160 (GSH 75; TGH 85)

Pharmacy Interns 13

Student Med Techno 6

Student Clinical Techno 10

Clinical Psych. Intern 27

6. Information systems

a) Minimum reporting requirements for hospitals and clinics

i) Hospitals

Authorised Beds

Actual Beds

In-Patient Admissions (Hospital Patients)

In-Patient Admissions (Private Patients)

Deaths (Hospital Patients)

Deaths (Private Patients)

Discharges (Hospital Patients)

Discharges (Private Patients)

In-Patient Days (Hospital Patients)

In-Patient Days (Private Patients)

Normal Deliveries (Hospital Patients)

Normal Deliveries (Private Patients)

Complicated Deliveries (Hospital Patients)

Complicated Deliveries (Private Patients)

Operations Less Than 30 Min (Hospital Patients)

Operations Less Than 30 Min (Private Patients)

Operations More Than 30 Min (Hospital Patients)

Operations More Than 30 Min (Private Patients)

Detached OPD Head Counts (Hospital Patients)

Detached OPD Head Counts (Private Patients)

OPD Head Counts (Hospital Patients)

OPD Head Counts (Private Patients)

OPD Visits (Hospital Patients)

OPD Visits (Private Patients)

Trauma /Emergency Attendances (Hospital Patients)

Trauma /Emergency Attendances (Private Patients)

Patients X-Rayed (Hospital Patients)

Patients X-Rayed (Private Patients)

ii) Clinics


<6 years

=>6 years


# babies examined for 1st time up to and including 6 weeks

# children <6 who had development assessments done

# children <6 with developmental Delay


# Primary Course completed <1 year


# <3rd%ile & =>60% EWA

# <60% EWA

# growth faltering/failure


# seen by Medical Officer

# seen by Professional Nurse

# seen by PN and referred to MO

# children <6 years

# children <6 with diarrhoea

# children <6 with Acute

Chest Infection

# STD (new cases)

# Penile Urethral Discharge (new cases)


Couple Year Protection Rate

# oral contraceptives

# Depo Provera

# Nuristerate


# Sterilisations

# Vasectomies

# condoms

# Emergency contraception

# Referred for TOP


# cervical smears 30 - 59 years


# Grade 1 children seen


# of visits

# new clients seen

# clients referred to 2nd level

# clients referred to 3rd level


# assistive devices required

# assistive devices issued

# home visits done

# referrals to 2&3 levels


# antenatal visits

# booking visit

# booking visit <20 weeks

# live births

# still births

# unbooked deliveries

# deliveries <18 years

# live births <2500gms

# women who deliver >34 years

# women who deliver with parity > 4

Both the hospital and clinic minimum reporting requirements are under revision, in accordance with national guidelines, and a new set will be implemented by July 2000.

b) Hospital Performance Indicators

Reported data Item/Indicator


Auth Beds

Number of Authorised Beds

Actual Beds

Number of Actual Beds

Average Actual Beds

Average number of Actual beds as reported monthly during the financial year

In-Patient Admissions (Hospital)

Number of In-patients admitted who are considered hospital patients.

In-Patient Admissions (Private)

Number of In-patients admitted who are considered private patients.

Total In-Patient Admissions

The sum of the Hospital and Private admissions.




Number of patients who are discharged

In-Pat Days (Hospital)

Number of In-patient Days (Hospital Patients)

In-Pat Days (Private)

Number of In-patient Days (Private Patients)

Total In-Pat Days

Number of In-patient Days (Hospital and Private Patients)

Patient Day Equivalents

In-patient days plus one third of out patient headcounts plus one third of casualty headcounts. N.B. in the past, visits rather than headcounts were used in the denominator. This has been changed as from this year to remove the confusion caused by "visits", to improve the accuracy of the data, and to make the data comparable to the data that will be collected by the National Department in future. All references to PDE’s from previous years referred to in this report, use the re-calculated PDE’s using OPD headcounts in the denominator.

Bed Occupancy (Actual Beds)

Bed Occupancy using the Actual Beds

Average Length Of Stay

Average Length Of Stay (Days)

Normal Deliveries Hospital

Normal Deliveries; Hospital patients

Normal Deliveries Private

Normal Deliveries; Private patients

Normal Deliveries Total

Normal Deliveries; Hospital and Private patients

Complicated Deliveries Hospital

Complicated Deliveries; Hospital patients

Complicated Deliveries Private

Complicated Deliveries; Private patients

Complicated Deliveries Total

Complicated Deliveries; Hospital and Private patients

Total Normal & Complicated Deliveries (Hosp)

Total Normal & Complicated Deliveries; Hospital patients

Total Normal & Complicated Deliveries (Priv)

Total Normal & Complicated Deliveries; Private patients

Total Normal & Complicated Deliveries

Total Normal & Complicated Deliveries

Operations Less Than 30 Min

Operations <30 Minutes Hospital and Private patients

Operations More Than 30 Min

Operations >30 Minutes Hospital and Private patients

Total Operations Hosp

Total Operations; Hospital patients

Total Operations Priv

Total Operations; Private patients

All Operations Total

All Operations; Total Hospital and Private patients

Detached OPD Head Counts

Detached Out Patient Department: Number of Patients (Hospital and Private patients)

Detached OPD Visits

Detached Out Patient Department: Number of patient visits (Hospital and Private patients)

Detached OPD Visits Per Patient

Detached Out Patient Department: Number of patient visits (Hospital and Private patients) for each Head Count

OPD Head Counts (Hospital)

Number of hospital out patients who attend the facility

OPD Head Counts (Private)

Number of private out patients who attend the facility

OPD Head Counts

Number of all out patients who attend the facility

OPD Visits (Hospital)

Number of visits to out patient sections within the facility by Hospital patients

OPD Visits (Private)

Number of visits to out patient sections within the facility by Private patients

Total OPD Visits

Number of visits to out patient sections within the facility by Hospital and Private patients

OPD Visits Per Patient

Number of out patient visits (Hospital and Private patients) for each out patient Head Count

Trauma /Emergency Attendances (Hospital)

Trauma/Emergency Attendances; Hospital patients

Trauma /Emergency Attendances (Private)

Trauma/Emergency Attendances; Private patients

Trauma /Emergency Attendances

Trauma/Emergency Attendances; All patients

Patients X-Rayed

Hospital and Private patients X-Rayed

Personnel Expenditure

Personnel Expenditure (Some provincial aided hospitals contract out their services, in which case this is not the true personnel expenditure)

Stores Expenditure

Expenditure on Stores

Total Expenditure.

Total Expenditure

Personnel Expend. As A Proportion Of Total Expend.

Personnel expenditure divided by total expenditure, expressed as a percentage.

Filled Posts: Specialist

Number of all Specialists. Note - this only reflects the specialists employed by the Department. There may be private specialists who work at the hospital.

Filled Posts: Medical Officer And Registrar

Number of Medical Officers (all ranks). Note - this only reflects the doctors employed by the Department. There may be private practitioners who work at the hospital.

Filled Posts: Nurses

Number of Nurses (all ranks)

Filled Posts: Other

Number of all other personnel

Total Filled Posts

Total Number of all personnel


Total expenditure / patient day equivalents


Total expenditure / average actual beds / 365


Total filled posts / average actual beds


Patient Day Equivalents / 365 / total filled posts


Patient Day Equivalents / 365


Total filled nursing posts / average actual beds


Beds/Nurse (All Categories)

Beds/Medical Officer & Registrar

Beds/filled post of Medical Officer & Registrar



In-Patient Admissions Per Day

In-patient Admissions / Day

In-Patient Admissions Per Post

In-patient Admissions / filled Post

c) Clinic Performance Indicators



Child Case Load


% Children with development delay


% Curative patients


% Children seen for curative purposes


% Curative patients seen by MO


% Clinical Nurse patients referred to MO


Mental health case load


Secondary level referral rates for Mental Health clients


Tertiary level referral rate for Mental Health clients


Proportion of new cases in Mental Health


Assistive Device Delivery


Proportion of booking visits <20 weeks


Antenatal visits per antenatal client


Proportion of deliveries to women >34 years


Proportion of deliveries to women with parity >4


Proportion of live born weighing <2.5 kgs


Proportion of unbooked deliveries


Still birth rate


Teenage pregnancy rate


Staff workload


Medical Officer Workload


Clinical Nurse Workload


d) Health Status Indicators




Birth Weight < 2500g

Proportion of infants born in health facilities with birth weights < 2500g

Live Births < 2500g divided by total Live Births and multiplied by 100

Infant Mortality Rate

Rate of deaths of infants under one year of age

Total deaths under one year of age divided by total live births and multiplied by 1000

Teenage Pregnancy

Proportion of females < 18 years who gives birth

Number of deliveries to females < 18 years of age divided by total deliveries to all females and multiplied by 100

Still Births

Proportion of still births

Number of stillbirths divided by the total number of deliveries and multiplied by 100

Deliveries to women > 34 years

Proportion of deliveries to women aged > 34 years

Number of deliveries women aged > 34 years divided by total deliveries multiplied by 100

Deliveries to women with parity greater than 4

Proportion of deliveries to women with parity greater than 4.

Number of deliveries women with parity greater than 4 years divided by total deliveries and multiplied by 100

Unbooked deliveries

Proportion of women who give birth who have received not antenatal care

Number of unbooked deliveries divided by total deliveries and multiplied by 100

Maternal Mortality Rate

Incidence of maternal deaths within 42 days of the end of the pregnancy

Number of maternal deaths divided by number of deliveries and multiplied by 1000.

Incidence of Penile Urethral Discharge

Proportion of males presenting with PUD at PHC.

Number of penile urethral discharges divided by total male attendences(>6 years) and multiplied by 100 000

Prevalence of HIV

Proportion of positive HIV tests in a sample of Antenatal woman.

Number of positive tests in survey divided by total women sampled and multiplied by 100.

Immunisation Coverage

Proportion of doses given to children under one years of age

Number of doses to children < 1year divided by total children < 1 year and multiplied by 100

Diarrhoeal Disease

Proportion of Children < 6 years diagnosed with diarrhoeal disease

Number of cases of diarrhoeal disease divided by total curative attendences < 6 years multiplied by 100.

Acute Respiratory Infection

Proportion of children < 6 years diagnosed with acute respiratory infection.

Number of cases of ARI < 6 year divided by total curative attendences < 6 years and multiplied by 100

Children with Developmental Delay

Proportion of children < 6 with developmental delay

Number of Children with developmental delay divided by total attendences < years and multiplied by 100

Overall TB Cure Rate

The proportion of pulmonary TB patients who were cured , as proven by bacteriology

Number of patients cured divided by the total known outcomes multiplied by 100

Overall Successful TB Treatment Rate

The proportion patients who completed a full course of TB treatment. This includes patients who have documented proof of cure

Patients who completed treatment plus patients cured divided by total known outcomes and multiplied by 100

New Smear Positive Cure Rate

The proportion of New Smear Positive patients who were cured.

Smear positive new cases cured divided by all smear positive new cases multiplied by 100

Tuberculosis Interruption Rate

The proportion of pulmonary TB patients who interrupted their treatment.

Number of Treatment Interruptions divided by total known outcomes multiplied by 100







Retreatment Smear Positive Cure Rate

The proportion of smear positive Retreatment cases who were cured

Smear positive retreatment cases cured divided by all smear positive retreatment cases multiplied by 100

TB Treatment Failure Rate

The proportion of pulmonary TB treatment failure cases proven by bacteriology

Number of Treatment failures divided by the total known outcomes and multiplied by 100

Immunisation Coverage

The number of immunisations given to children under one as a proportion of the total number of children under one

Number of immunisations to children under one divided by the total number of children under one multiplied by 100

Total Fertility Rate

The average number of children that would be born alive to a woman during her life time, if she were to pass through her childbearing years conforming to the age specific fertility rates of a given year.

The sum of the age specific rates multiplied by 5 and divided by 1000

e) Computer Systems and their Utilisation

  1. Patient administration systems are in place at:

3 academic hospitals (Cape Hospital System)

30 Regional and District Hospitals (Unicare® system)

ii) Several additional modules, e.g. laboratory, stores, etc. are in place at the academic hospitals, and they are currently being replaced by a new Hospital Information System (CLINiCOM®).

iii) Aggregated clinic data is managed by the District Health Information System (DHIS).

  1. Computerised information systems exist at regional and provincial level and are utilised for the management of the following data sets:



Goal: To improve the health status of women and children

Objective: To provide available, accessible, affordable, and user-friendly services for women with unwanted pregnancies

Key Activity 1

    1. Ensure sufficient designated facilities for termination of pregnancy
    2. Establish termination of pregnancy services at all level 1,2 and 3 selected primary care clinics in a phased manner
    3. Establish clear referral system and disseminate information about services available (as new services come on line)








No. of sites designated






No of sites on line






Summary of number of termination of pregnancies performed in the province from 1/2/97 to 31/12/99.


Number of TOPs performed

Feb-Dec 97






    1. A referral system, Provincial policy-guidelines, protocols, referral and client information letters are in place. The policy and protocols are currently being revised based on the experience gathered over the past three years.

Key Activity 2

Provide education and training for health care providers

The Western Cape Province has obtained permission from the South African Nursing Council to conduct the approved curriculum for a 160-hour short course for midwives in Abortion Care and Manual Vacuum Aspiration Technique of termination of pregnancy




Values Clarification


Post-abortion Family Planning Counselling


Manual Vacuum Aspiration Procedure-Physicians


Manual Vacuum Aspiration Procedure-Midwives / Nurses


Other Training (TOP Overview)

Staff & public: extensive numbers

Key Activity 3

Communication: Conduct public and staff awareness campaign:


An extensive Awareness Campaign has taken place and is still continuing by way of Media releases, TV, Radio and Newspaper Interviews and Reports as well as public information sessions and talks to youth groups, school and college groups.

Key Activity 4

Notification of termination of pregnancy:


A set of new TOP/Abortion Notification forms which combine the information from the Gazetted Annexure A form, the GW 8/86 form, consent form and also give additional information to measure outcomes, was piloted and subsequently implemented successfully in June 1998. (See attached AnnexuresA & C).

Key Activity 5



Vertical support is provided to the services on an ongoing basis, e.g. in developing operational plans for designated facilitates and as problems arise as well as generally providing support for staff involved in the delivery of TOP services

The Metropole region engaged in a 3-month support pilot project. The aim was to directly engage with and understand staff attitudes to TOP, with a view to improve quality of care. The Study emphasises the importance of providing support for staff who commence TOP Services. This proved to be an important lesson for all and should be factored into the decentralisation of services.

Key Activity 6


6.1 Promote contraceptive use, especially a dual method, to prevent unwanted pregnancy and sexually transmitted infections (including HIV/AIDS).

    1. Popularise Emergency Contraception


A renewed emergency contraceptive awareness campaign was launched. Two baseline surveys were conducted, one at a tertiary institution and one at a Reproductive Health clinic to determine client knowledge about emergency contraception. Posters and pamphlets were designed, tested and distributed and the mass media was used to disseminate information. However emergency contraceptive usage remain fairly low in-spite-of improved knowledge.

Key Activity 7

Monitoring and Evaluation of quality of care

During 1999 the quality of termination of pregnancy care rendered by the practising trained midwives was assessed according to predetermined National standards and criteria. The care was found to be of a very good quality.


1 Staff resistance and staff shortages:

In spite of the numerous values clarification workshops that have been conducted, staff resistance remains a problem and especially in some non-Metropolitan regions where the communities are far more conservative. Staff resistance combined with the severe personnel shortage situation, lack of finances and the ever-increasing demand for services all contribute in hampering the provision of equitably accessible TOP Services in the Province.

2 Overflow of clients:

Towards the end of 1998 it appeared that a situation was developing in the Metropole Region where an over flow of clients began to build up that could not be accommodated timeously by the facilities that render TOP Services.


A "Help out Service" was put into place at Conradie Hospital (in addition to their regular TOP Service) for a 3 month period from February to April 1999, for the over flow that could not be accommodated by the on line services. The idea was that all the problems will be monitored and evaluated and all the other TOP Services brought in line to deliver sufficient services for all the women in need of it.

The result was that a "roving team" was instituted to render additional services at certain designated facilities. Thus False Bay came on-line and Michael Mapongwana CHC was designated for this purpose and should come on-line by 1/4/2000.

  1. Maternity services
  1. Free Health Care for Pregnant Mothers and children under the age of 6 years.
  2. First point of entry is the Primary Health Care setting e.g. Community Health Centres, Day Hospitals and Clinics.
  3. During health promotion pregnant mothers are encouraged to book early at an antenatal clinic, and attend these clinics at least twice during pregnancy. This will help in the early identification of mothers and babies at risk of developing complications.
  4. Maternal Death Notification System

Provincial Maternal Death Notification Process:

death and receives a case number.

into a register which the co-ordinator keeps in her office.

Feedback mechanism


In January 1994 this Province introduced the Cervical Screening Policy which has become the National Policy in1999. However, the policy was not implemented by the service providers at the time because they did not understand the rationale for the policy.

Subsequently a series of meetings and workshops were held with the role-players and a trategic plan was formulated. The plan addressed inter alia, staff training, providing extra equipment and raising staff and community awareness. The policy was revised and re-issued for implementation.

The 1998 CANSA situational analysis in the Western Cape reported that the policy was in general not well implemented and gave a variety of reasons for this.

Attached is a bar chart of cervical smears analysed in 1998 per age group by one of the two cytology laboratories in the Province.

When the National policy was issued, a Provincial task team was formed to re-address the matter.

A two pronged strategy was decided upon:

1. A provincial circular was disseminated together with a Cervical Cancer Fact sheet. The circular reminded health care providers of the existing policy and the importance of implementing the policy (See Annexure D).

  1. A model implementation pilot project in one district.

To date a comprehensive situational analysis has been done and the results have been reported to the role-players. The baseline data are currently being used to compile strategic and operational plans and protocols. Implementation of the pilot project is envisaged to commence in April 2000. The project will be monitored continuously and evaluated at the end of the year. If the intervention proofs to be successful, it will be rolled out incrementally.

d) Breast Cancer Screening

The policy in this Province is to teach women self-breast examination for early detection.

The task team has gathered expert opinion on breast cancer screening and has sent comments on this to the National Department of Health. (See attached Annexure E)

Some task team members are meeting with the National Chief Director: Chronic Care on 9/3/2000.


  1. Specific problems and constraints

These have been discussed under the variuos headings through out this report.





13 March 2000


Honorable Members of the Standing Committee.

I am honoured to be here today and to outline the main aspects of the 2000/01 budget of the Health Branch of the Department of Health and Social Services.

I would like to briefly introduce our team: Drs. Mac Mahon, Abdullah, Von Zeuner, Vallabhjee, Blecher, Ms. Abrahams and Mr. Beukes and Titus.


Faced by a drop of its expenditure in real term of just under 10% over the past 4 years, and the loss of over 9000 staff (27%), the Health Branch has effectively managed a crisis, whilst keeping to its objective of reshaping the services. This meant giving priority to Primary Health Care in terms of the 1995 Health Plan, and reorganising hospital services towards a lesser dependency on academic hospitals. Primary Health Care (PHC) attendances increased by 27% over the past 3 years along with the introduction of free primary health care services and the construction of 52 new primary healthcare centres. In accordance with the intended shift of the bulk of the patient load from expensive tertiary academic hospitals to other hospitals, admissions in academic hospitals dropped by 24% while admissions to regional hospitals have increased by 24% over the same period.

I do not wish to dwell on the downsizing and restructuring of the past 4 years and state these merely as background, but to focus on the positive road ahead, which this 2000/01 budget holds for the Western Cape.


Early indicative allocations to this Branch represented a significant further decline on top of the past 4 years downsizing. We were able to successfully negotiate this with our provincial Treasury. I am pleased to be able to report that the Western Cape Branch has received what we regard as a fair and reasonable allocation under the circumstances, and a provincial budget, which I believe the Province can be proud. The 2000/01 budget, represents an additional R 69 million in real terms or a real 2.3% increase as compared to the 1999 budget. This allocation will go a long way to restoring stability in the Dept. after 4 years of downsizing

The Health Branch will carry over-expenditure from the 99/00 financial year into the next financial year. This over-expenditure is located largely in the academic hospitals and in the Community Health Services Organisation (CHSO). In terms of the CHSO the standard item stores and livestock was over-expended due to an influx of an additional million patients. New business plans to address the expenditure reduction required in the AAH over the MTEF period are being compiled.


I would like to briefly cover some of the key innovations in departmental financing in the 2000/01 year.


I will now highlight several key strategic focuses of the budget. The MTEF budget is in real terms lowest in the outer year (when the national equity formula is closest to full implementation) and for this reason particular focus has been placed on once off rather than recurrent expenditure increases. Some of the major features of the budget, which I am particularly pleased to describe include:

  1. Settling of all outstanding local authority debt – R43 204 00-, of which EMS debt comprises R 27 699 and local authority debt R15 505.
  2. Substantial increase in hospital maintenance – the earmarked R44m on the Works vote has been mentioned above.
  3. The departmental equipment allocation increases to R50 185 000, which will begin to make inroads into the backlog on medical equipment. This includes the R33.7m earmarked conditional grant for equipment. This is the largest equipment allocation within Health of the last 5 years.
  4. New funding for HIV/ AIDS prevention and other projects of R7 276 000 from the provincial budget. This excludes the R75m announced recently by Minister Manuel, which is still to be divided between the provinces and additional European Union Funding.
  5. Funding for the commissioning of primary health care services including Kraaifontein, Delft, Bonteheuwel-Langa and Greenpoint community health centres.
  6. Funding for 58 new nursing posts for community health centres in the metropole (R3 mil)
  7. Budgeting for recommisioning of a ward and operating theatre at Westfleur Hospital, Atlantis (R2.7 mil) and a new ward opened at Ceres Hospital.
  8. Increase in expenditure on primary health care by 8.5%.
  9. Funding for improved financial capacity, using the R11m financial grant and provision for a departmental accountant function (R3.8m).
  10. A contingency fund has been introduced to increase financial stability and allow for the reshaping of the service over the MTEF period.


I would now like to present a brief overview of some of the key aspects of the program budgets. I will not do this in any detail, but merely highlight key features that may not be immediately apparent from the White Book and the written documentation we have provided the committee. I will also highlight a number of policy areas pertaining to each program.

Program 1: administration

We have emphasized the need for tighter management and a more business –like approach to revenue. I am proud today to table our departments draft strategic plan for the next 3 years (show copy), which builds on the acclaimed provincial health plan. We will be organising a Health Summit to open this draft plan for wider discussion with a range of stakeholders.


In order to optimise the use of our budget allocation, we are embarking on a program to develop the management skills and systems at all levels. In particular R11 million has been earmarked to strengthen financial systems and recruit or re-train appropriate financial/admin personnel. 188 financial and administrative posts will be filled including in areas such as hospital fee collection, financial administration, provisioning and general administration. While I mention this issue in the context of the Administration Program, most of these posts will in fact be located at institutional level. We want to focus on stock control, billing systems and debt recovery. The Chief Directorate of Finance will be strengthened and the Departmental accountant function is being established at the cost of R3.8 million. These initiatives will assist in improving financial accountability and compliance with the Public Finance Management Act.


We are progressively attempting to strengthen management and improve management efficiency. In addition to the strategic plan every directorate and institution is developing operational plans for the 2000 year with target dates and responsibilities. Performance agreements have been signed with all managers of director level and above.

We continue to decentralise to institutions. A recent nationally funded project has focussed particularly on management decentralisation to the academic hospitals. Draft performance agreements have been drafted with the academic hospitals. Progress has been made with delegations. Legislation to appoint CEOs is in the pipeline. Cost centre accounting systems and improved billing systems are being developed.

Other reasons for budgeted increase in program 1

Some of the additional reasons for the increase in program 1 shown in the White Book pertain to:

Contigency fund

In program 1, we have also temporarily allocated R32m into a contingency fund. The purpose of the creation of the creation of this contigency fund are:

  1. To partially address the over-expenditure from 99/00. Linked to this our experience in the 99/00 year suggests that additional funding will be required to finance specific areas, such as the vast increase in patients seen by the CHSO, the carrying of staff in excess of the required establishment at Groote Schuur Hospital.
  2. To provide for unforseen expenditure in the coming financial year. These might include effects of the Basic Conditions of Employment Act on personnel expenditure and any mismatch of between the amount of ICS already allocated vis a vis the amount still to be negotiated in the Central Chamber.
  3. To create some bridging funding into years 2 and 3 of the MTEF as a result of the decreased allocation, in real terms, in the outer MTEF year.

Program 2

Program 2 (all subprograms) increases by 7.4% (before adjustments). This increase reflects the departments commitment to District Health Services.

Community health service (Primary Health Care)

With respect to the community health services subprogram (2.3), the allocation appears to only increase by 4.3% in the White Book. However when once off payments for deferred debt are taken off, the true budgeted increase for primary health care services is 8.5%.

Our first concern is clearly the health status of the population we serve. Whilst we will maintain the programs we have already embarked upon regarding, amongst others: reduction of infant mortality and maternal mortality, improve nutritional status, manage and prevent chronic diseases, develop mental health services at all levels of the system, we will place added focus on the following areas. These have all been identified as important national priorities:

The HIV/AIDs epidemic is a very central concern. Whilst maintaining our previous activities to control the spread of the disease, we have earmarked R 7.3 million. This is in addition to the amounts announced by Minister Manuel in his budget speech (R75 million still to be divided between the provinces to increase to R125 and R250m over the MTEF and to European Union funding.). These funds will be used for, amongst others, life skills targeted at youth, lay counselling, the Aids Training and Information Centre (ATTIC), in support for NGOs, home-based care, media and other interventions. We have established an HIV/AIDS desk and a Ministerial Advisory Group. We are investigating the potential formation of a new Provincial AIDS Council which will amalgamate the Interministerial Committee with the Advisory Group. We are developing a new strategic plan for HIV/AIDS.

TB has been identified as a Cabinet priority. We have allocated a further R500 000 to improve co-ordination and management of the disease, to aim at an improvement of the cure rate from 68% to 80% over the MTEF period.

Funding for the Integrated Nutrition program (previously the Primary School Nutrition Program PSNP) is R28.8 million.

In order to decrease meningitis and pneumonia amongst children, we are introducing the Haemophilus vaccine in the immunisation schedule and we will focus on ensuring an improved immunisation coverage. We have to this effect allocated R 2 million in the Metro alone, and smaller amounts for the rural regions.

Increases in this subprogram will also be used to fund amongst others:

We are finalising a package of Primary Health Care services which will be implemented over 5 years across the whole province. This will ensure common minimum standards and scope of services across the province.

In line with our objective of establishing a District Health System, our Biministerial Taskteam report has recently been tabled. Primary Health Care services will be devolved to local governments in July 2001, provided that agreement can be reached with all the necessary role players. This will permit us to meet our objective of allowing all PHC services in a given district to be managed by a single organisation and will reduce fragmentation, inefficiencies and duplication. This is a major piece of restructuring and will involve the transfer of services, personnel and assets to local government. We are entering into that new relationship with local governments by making provision in the 2000 budget to clear all justified out-standing debts.

We are processing with our restructuring of district surgeon services. We have progressively moved to clinic based services and have largely replaced unlimited fee-for-service payments with globally capped budgets. This has achieved a savings of R8-9 million. We are examining mechanisms to improve quality of care delivered by district surgeons.

Emergency ambulance services (subprogram 2.3.)

The ambulance service budget increases by 12.1% on the White Book. This includes R27 699 000 to settle the accumulated ambulance debt. Members will be aware that we are in the process of provincialising ambulance services, and where relevant a system of non-emergency inter-hospital transport will be set up. Once these services are provincialised, we hope the uncontrolled accumulation of ambulance debts will finally be ended.

District hospitals (subprogram 2.4)

In order to ensure the development of lower level hospitals, we are increasing capacity in district hospitals at Ceres, Robertson and Hermanus hospitals in the Boland/Overberg region, at WestFleur and Booth hospitals in the Metro region. In addition a number of district hospitals will become sub-regional hospitals, which means that they will also provide some specialist services. In keeping with these initiatives, the district hospital budget increases by 12%. Would specifically cover:

Program 3

This program funds general and specialised hospitals. The program is very stable with increase of 6.7%.

Regional hospitals

Metro region hospitals have taken the brunt of academic hospital downsizing over the past 3 years (+24% increase in Patient Day Equivalents), and receive a R10 million real increase. Jooste Hospital increases by R4 mil, mainly to provide for the relocation of 26 acute surgical beds from Conradie Hospital. We are also strengthening regional hospitals in the rural areas and increasing the support role played by the specialists from academic hospitals towards regional and sub-regional hospitals.

Specialised hospitals

Among the specialised hospitals, the largest increase is to Lentegeur Hospital, reflecting the relocation of certain forensic services and acute inpatient psychiatric services from Valkenberg Hospital. As with regional hospitals, we are re-organising our psychiatric hospitals to increase their support role to the delivery of mental health at all levels of the system. This approach reduces the number of admissions in academic and psychiatric hospitals.

Program 4

The Academic hospitals budget increases by 6.8%, a significant proportion of this increase comprising increases for equipment (R12 million). It should be noted however that the academic hospitals will overspend in the 99/00 year. Comparison of the 2000/01 budget to 99/00 projected expenditure is unfavourable, particularly when combined with carrying the cost of deferred over-expenditure. This will mean that the academic hospitals will continue to face some pressure in the 00/01 year. We will work with them to develop a comprehensive multiyear plan to deal with financial, management and other aspects of this program.

We are re-organising the services inside our hospitals to improve their performance and efficiency. This includes, amongst others, a central appointment system for academic hospital; increase in day surgery in all hospitals, and measures to discharge patients for the week-end, where possible.

Our academic hospitals face serious waiting lists for cataract operations and heart surgery. R 1 million has been earmarked to address the backlog.

Program 5

This program funds health sciences, mainly the nursing colleges. The budget for this program decreases in nominal terms. The new Western Cape College of Nursing enters the 2000 year having been successfully rationalised from the 4 previous colleges to 1. The reduced student numbers account for the decreased budgetary allocation to the Health Sciences program.. The Reddy Commission is currently investigating whether the function of nursing education should be located with Health or Higher Education. I will be calling for an investigation into the long term training needs and provision of nurses in this province.

Program 6 Support services

This program is very stable with a 6% increase.

The main increase lies in the area of orthotics and prosthetics, in which we have decided to initiate a new outsourced service in the Southern Cape, which has been insufficiently serviced to date. The increase will help to address large backlogs.

The main decrease is in the area of laundries and this reflects savings from the contracting out of the Pinelands service (which has saved R8-10 million) and future efficiency savings particularly at Tygerberg laundry.

Program 7 restructuring

This program was used for supernumerary personnel in 99/00. Since these have been decreased from 328 to only 46 the program will not be utilised in 00/01.



The Branch continued to downsize during the 99/00 year, with the decrease of 1115 filled posts from 1 February 1999 to 1 February 2000. Supernumeraries have been reduced from 328 to 46. At this stage, preliminary calculation suggests that the improved budget will allow for the filling of approximately 500 posts in Health. Of this the focus will be on the filing of posts at:

It is important that the department retain key professional staff. Our human resource planning section is providing valuable information about optimal staff mix and we are in the process of developing a detailed human resources plan to identify and address key personnel gaps. We are in the process of finalising a new cooperative framework with the Universities, which will replace the old joint agreement. We are also in the process of resolving staffing issues pertaining to the UCT Medical Centre and the PPP in Tygerberg Hospitals. The introduction of community service for doctors has helped the supply of doctors particularly in district hospitals and the future implementation for dentists and pharmacists is also likely to be beneficial.


Our services are faced with a very serious backlog regarding medical equipment and maintenance. An amount of R50.2 million has been earmarked to start addressing this issue. This is the largest allocation for equipment made in the Health Department over the past 5 years. A new allocation of R44 million is shown on the Works vote for hospital upgrading and rehabilitation. I am pleased to say that this will contribute significantly to the improvement of our facilities and thank Treasury for this far sighted initiative. This is complemented by the national Hospital Reconstruction and Rehabilitation Program (HRRP) conditional grant for the rehabilitation of hospitals.


I want to state today that my department has increased efficiency levels and continues to strive to do so. For example output per staff member as measured by Patient day equivalents (a measure of workload which incorporates inpatient and a third of outpatient load) per post has increased by 16.9%, and hospital admissions per post have increased by 19.9% over the past 3 years.

Length of stay in hospitals has been reduced from 5.3 to 5 days overall. For district hospitals the reduction is from 3.8 to 3.4 days and for regional hospitals from 5.7 to 4.7 days. Overall 3500 hospital beds have been closed. Several hospitals have been closed for inpatient admissions, in order to more efficiently consolidate the remaining beds within a smaller number of hospitals. In the last year the DP Marais and Westlake Hospital services have been relocated and the property made availbale to the South Peninsula municipality for housing development. Prior to this Princess Alice Orthopaedic Hospital was consolidated into Groote Schuur and Lady Michaelis rehabilitation hospital into Tygerberg and Conradie Hospitals.

A key area where efficiencies have been achieved is by treating patients at a more appropriate level of care. The department has managed to shift admissions significantly (24%) from the tertiary academic to the cheaper regional level of care. At the same time primary health care utilisation has increased by over 1 million visits per year, so that primary health care has become more accessible.


Improving quality of services is an important priority for us. We are rolling out a Batho-Pele and Patients Charter training program amongst all our staff. In order to reduce waiting times, we are introducing an appointment system for all repeat PHC visits and for all out-patients visits. We will also develop processes, norms and standards to improve technical quality in our institutions.

An important aspect of quality is that of community participation. For this purpose, we will table the Health Facility Boards Bill before Parliament in the near future. We are strengthening our communications / public relations component. We are organising a Health Summit to debate our draft strategic plan with a wide range of stakeholders. We are investigating the possibility of a health ombudsperson.


The department recognises that own revenue generation is critical to sustain it – a lifeboat. The department currently generates <3% of it’s own revenue and the amount generated has decreased yearly over the past 3 years. The MTEF allocation is in real terms lowest in the outer year (when the interprovincial equity formula is almost fully implemented) and this represents a dip of approximately R90m in the outer year. If the department were able to generate only 10% of it’s expenditure this would amount to over R300 million per year. This would benefit the entire Administration and not just Health. To this end increasing own revenue is essential. We will place emphasis in the 2000/01 on creating a sustainable framework for revenue growth.

Some of the initiatives that we will undertake include:


A number of public-private partnerships, are being discussed and implemented.


In conclusion, I believe that the 2000/01 allocation will bring much greater stability to Health in the Western Cape Province after 4 years downsizing.

The budget seriously addresses the identified provincial and national priorities and I believe offers managers in this department a fair deal, to which they now need to respond and provide the most efficient quality service possible within this allocation.