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ASSIGNMENT COVER PAGESURNAME: Brinkmann                                                INITIALS: ASTUDENT NUMBER: 17573602...
REPORT AND RECOMMENDATIONS        PREPARED FOR CONSIDERATION BY THE EXECUTIVE MANAGEMENT COMMITTEE: Western Cape          ...
TABLE OF CONTENTS   1. WESTERN CAPE GOVERNMENT: STRATEGIC OBJECTIVES   1.1 ACHIEVING THE WELLNESS OBJECTIVE   1.1.1 DEFINI...
1.   WESTERN CAPE GOVERNMENT: STRATEGIC OBJECTIVESThe Western Cape Provincial Government has developed a Provincial Strate...
1.1.2   THE SOCIAL DETERMINANTS OF HEALTH AND WELLNESS IN CONTEXT OF POVERTY ALLEVIATION,        ECONOMIC DEVELOPMENT AND ...
Government resources are stretched to the limit to fulfil its mandate of dealing with theconsequences of societal decay an...
The strategic objectives are clustered into three sectors i.e. human development, economic andinfrastructure, and administ...
delivered in the maternity services and 6 909 cataract operations performed [Western Cape          Department of Health. M...
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5    SPACE MODEL MATRIX ANALYSIS: WESTERN CAPE DEPARTMENT OF HEALTH AND STRATEGIC    PARTNERSHIPS5.1 CONTEXTIt is generall...
5.2 ENVIRONMENTAL STABILITY5.2.1   RATIONALISING THE RATINGSThis aspect of the matrix provides rather a conundrum, in that...
outlook and sentiment for South Africa. We have just recently seen a downgrading of by Standardsand Poors.In contrast and ...
5.3 INDUSTRY ATTRACTIVENESS5.3.1 RATIONALISING THE RATINGSHealth and Education are rated as the top priorities not only fo...
More and more donors, partners, corporates, NGO‟s and organisations are approaching theStrategic Partnerships portfolio vi...
Given that the Strategic Partnerships portfolio has had the privilege of building robust relationshipsacross all three sph...
5.5 FINANCIAL STRENGTH5.5.1   RATIONALISING THE RATINGSAs alluded to earlier in this document and substantiated by the fin...
Cash flow is well managed and when entering into any form of partnership, a clear exit strategy isagreed up-front so as to...
   Thereafter, it follows that I would do an External Factor Evaluation [EFE], so as to confirm and        evaluate the c...
7. REFERENCES: STRATEGIC MANAGEMENT ASSIGNMENT: EDP 2012Anderson B, Phillips, H. 2006. Adult mortality (age 15‐64) based o...
Day, C. Barron. P. Montecelli, F. Sello, E. [editors] 2009. The District Health Barometer 2007/8. Durban:Health Systems Tr...
National Committee on Confidential Enquiries into Maternal Deaths. 2008. Saving mothers2005‐2007. Fourth Report on Confide...
Segall, M. May 1999. “The Bottle Is Half Full”: Policy Oriented Overview of The Main Findings of aReview of Public Health ...
APPENDIX A: NATIONAL DEPARTMENT OF HEALTH: ANNUAL PERFORMANCE PLAN: HIGHLIGHTS[National Department of Health. March 2012.]...
n general, NDOH has agreed to the Health Sector Negotiated Delivery Agreement, which has 12outcomes in total. NDOH is resp...
APPENDIX B: STATE OF THE NATIONAL HEALTH CARE SYSTEM: SITUATIONAL ANALYSIS[Harrison, D. December 2009]      Improvements ...
Prevention and treatment needs underscore the urgency of new health financing models,    pushing the consideration of the ...
7.1.19 MORTALITYThe completeness of death registrations has improved from 67% to 82 % [Stats SA. 2009 a]. The realnumber o...
2008]        28
   Death rates for many, but not all, categories of non-communicable diseases [NCD] have    increased. The time frame for...
mortality rates for hypertensive and ischaemic heart diseases show little change. It is    nevertheless important to note ...
   HIV/AIDS is however projected to account for about 75% of premature deaths in South        Africa in 2010. [ Bradshaw....
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   In 1996, NDOH commissioned the Council of Scientific and Industrial Research to undertake    a national audit of healt...
   By 2008 there were 40 participating hospitals but by 2009, this number was reduced to 27 as    a result of a sharp red...
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Devolution of management authorityThere are two urgent priorities with respect to devolution of authority, namely the inst...
management of primary health facilities and community outreach. A number of initiatives havestrengthened their capacity, i...
• Leadership, and in particular, political leaders as well as managers in the health system, mustclearly articulate and co...
partners. And the elimination of missed opportunities for PMTCT provides an obvious source ofincidence reduction in 2010.H...
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Key Strategic Issues: Health Sector Negotiated Service Delivery AgreementGovernment has adopted an outcome-based approach ...
These are (1) Increasing Life Expectancy; (2) Reducing Maternal and Child Mortality Rates; (3)Combating HIV and AIDS and d...
APPENDIX D: PROPOSED NHI STRUCTURE: CHALLENGES AND REQUIREMENTS FOR IMPLEMENTATION                                        ...
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APPENDIX E: SOUTH AFRICA‟S HEALTH CARE UNDER THREAT: PUBLIC VERSUS PRIVATE HEALTHCARE[Biermann, J. 2006.]                 ...
By the governments own admission its health sector is not coping with the demand for health care.The [then] Minister of He...
   Planning interventions in the form of national, provincial and district health plans.      Economic interventions in ...
So, for example, South African doctors will be prohibited from opening medical practices in areasthat government health-ca...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEX...
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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEXT OF THE HEALTHCARE SECTOR IN SOUTH AFRICA AN ANALYSIS OF THE POTENTIAL COMPETITIVE ADVANTAGES AND STRATEGIC IMPERATIVES AND DIRECTIO

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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEXT OF THE HEALTHCARE SECTOR IN SOUTH AFRICA
AN ANALYSIS OF THE POTENTIAL COMPETITIVE ADVANTAGES AND STRATEGIC IMPERATIVES AND DIRECTIONS REQUIRED TO ACHIEVE THE STRATEGIC OBJECTIVES OF THE WESTERN CAPE GOVERNMENT AND SPECIFICALLY OF THE Western Cape DEPARTMENT OF HEALTH
HEALTH, WELLNESS and SOCIAL DEVELOPMENT AS DRIVERS OF ECONOMIC GROWTH, DEVELOPMENT, POVERTY ALLEVIATION AND REDUCTION OF INEQUALITY
PARTNERSHIPS, COLLABORATION, CO-CREATION, CO-PRODUCTION: CREATING AN ENABLING ENVIRONMENT
TOWARDS ACHIEVING NATIONAL, PROVINCIAL, LOCAL AND SOCIETAL STRATEGIC OBJECTIVES AND OUTCOMES WITHIN RESTRICTED BUDGETARY ENVIRONMENT

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STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEXT OF THE HEALTHCARE SECTOR IN SOUTH AFRICA AN ANALYSIS OF THE POTENTIAL COMPETITIVE ADVANTAGES AND STRATEGIC IMPERATIVES AND DIRECTIO

  1. 1. ASSIGNMENT COVER PAGESURNAME: Brinkmann INITIALS: ASTUDENT NUMBER: 17573602TELEPHONE NUMBER: 0828900663PROGRAMME NAME: EDP 2012MODULE: Strategic ManagementFACILITATOR: Prof WestwoodDUE DATE: 8 October 201217 excluding references, Appendices andAttachmentNUMBER OF PAGES:CERTIFICATIONI certify the content of the assignment to be my own and original work and that all sources have beenaccurately reported and acknowledged, and that this document has not previously been submitted inits entirety or in part at any educational establishment._________________________SIGNATUREOR6701130018085_________________________ID number for assignments submitted via e-mail FOR OFFICE USE DATE RECEIVED:
  2. 2. REPORT AND RECOMMENDATIONS PREPARED FOR CONSIDERATION BY THE EXECUTIVE MANAGEMENT COMMITTEE: Western Cape DEPARTMENT OF HEALTH [WCDOH] 8 OCTOBER 2012 STRATEGIC AND BUSINESS ANALYSIS OF THE WESTERN CAPE DEPARTMENT OF HEALTH AND THE STRATEGIC PARTNERSHIPS FUNCTION IN CONTEXT OF THE HEALTHCARE SECTOR IN SOUTH AFRICA AN ANALYSIS OF THE POTENTIAL COMPETITIVE ADVANTAGES AND STRATEGIC IMPERATIVES AND DIRECTIONS REQUIRED TO ACHIEVE THE STRATEGIC OBJECTIVES OF THE WESTERN CAPE GOVERNMENT AND SPECIFICALLY OF THE Western Cape DEPARTMENT OF HEALTH HEALTH, WELLNESS and SOCIAL DEVELOPMENT AS DRIVERS OF ECONOMIC GROWTH, DEVELOPMENT, POVERTY ALLEVIATION AND REDUCTION OF INEQUALITYPARTNERSHIPS, COLLABORATION, CO-CREATION, CO-PRODUCTION: CREATING AN ENABLING ENVIRONMENT TOWARDS ACHIEVING NATIONAL, PROVINCIAL, LOCAL AND SOCIETAL STRATEGIC OBJECTIVES AND OUTCOMES WITHIN RESTRICTED BUDGETARY ENVIRONMENT PREPARED BY: AMANDA BRINKMANN ADVISER TO THE MINISTER OF HEALTH: WESTERN CAPE GOVERNMENT HEAD OF STRATEGIC PARTNERSHIPS: WESTERN CAPE GOVERNMENT 2
  3. 3. TABLE OF CONTENTS 1. WESTERN CAPE GOVERNMENT: STRATEGIC OBJECTIVES 1.1 ACHIEVING THE WELLNESS OBJECTIVE 1.1.1 DEFININING WELLNESS AND HEALTH 1.1.2 THE SOCIAL DETERMINANTS OF HEALTH AND WELLNESS IN CONTEXT OF POVERTY ALLEVIATION, ECONOMIC DEVELOPMENT AND GROWTH OUTCOMES 1.1.3 THE COST TO GOVERNMENT AND SOCIETY OF CONTINUING WITH A „ BUSINESS-AS-USUAL‟ APPROACH 1.1.4 PROVINCIAL TRANSVERSAL MANAGEMENT SYSTEM [ PTMS] 2. WCDOH VISION 2020 – PARTNERING AND PARTNERSHIP AS A STRATEGIC PRIORITY 3. WCDOH: CONSTRAINTS – RATIONALISING THE NEED FOR INNOVATION AND PARTNERSHIPS 4. STRATEGIC PARTNERSHIPS: WESTERN CAPE GOVERNMENT: A vision of an ideal future of health and wellness: 2020 and beyond 5. SPACE MODEL MATRIX ANALYSIS: WESTERN CAPE DEPARTMENT OF HEALTH AND STRATEGIC PARTNERSHIPS 5.1 CONTEXT 5.2 ENVIRONMENTAL STABILITY 5.2.1 RATIONALISING THE RATINGS 5.3 INDUSTRY ATTRACTIVENESS 5.3.1 RATIONALISING THE RATINGS 5.4 COMPETITIVE ATTRACTIVENESS 5.4.1 RATIONALISING THE RATINGS 5.5 FINANCIAL STRENGTH 5.5.1 RATIONALISING THE RATING 5.6 THE OUTCOME – WHERE IT ALL COMES TOGETHER – CONCLUSIONS AND RECOMMENDATIONS 6. CONCLUSION 7. REFERENCES 3
  4. 4. 1. WESTERN CAPE GOVERNMENT: STRATEGIC OBJECTIVESThe Western Cape Provincial Government has developed a Provincial Strategic Plan with elevenprovincial strategic objectives in order to effectively pursue the vision of creating an „openopportunity society for all‟. [WCDOH. March 2012]The provincial strategic objectives are closely aligned with the national outcomes particularly inrelation to concurrent functions such as health.The provincial strategic objectives are:1) Creating opportunities for growth and jobs2) Improving education outcomes3) Increasing access to safe and efficient transport4) Increasing wellness5) Increasing safety6) Developing integrated and sustainable human settlements7) Mainstreaming sustainability and optimising resource use efficiency8) Promoting social inclusion and reducing poverty [SO8 and 9 are being combined)Increasing social cohesion [SO8]Poverty reduction and alleviation [SO9]9) Integrating service delivery for maximum impact10) Increasing opportunities for growth and development in rural areas11) Building the best-run provincial government in the world.The Western Cape Department of Health is responsible for the implementation and stewardship ofStrategic Objective 4: Increasing Wellness1.1 ACHIEVING THE WELLNESS OBJECTIVE1.1.1 DEFININING WELLNESS AND HEALTHDictionary.com [Accessed September 2012] defines health as follows: • The general condition of the body or mind with reference to soundness and vigour: good health; poor health. • Soundness of body or mind; freedom from disease or ailment: to have ones health; to lose ones health. • Vigour; vitality: economic health.Earthzense.com [Accessed September 2012] defines and described wellness as follows:Wellness is a term that has become extremely popular in recent years, so much so that thedefinition of wellness has also rendered different meanings to different people. Most definewellness as simply “being physically well” most of the time.All inclusive, the generally accepted definition of wellness is:To stay in good condition physically, mentally, and spiritually, especially through healthy choices inthose areas – a balance in all of these areas indicates wellness in an individual. This definition ofwellness seems to imply that wellness is a lifestyle choice.And it defines wellness to include not just being healthy physically, but embraces a holistic conceptof health that encompasses our whole being - body, mind and spirit. Wellness is a natural humancondition that has become negatively conditioned throughout the passages of time by the lifestylechoices we make. 4
  5. 5. 1.1.2 THE SOCIAL DETERMINANTS OF HEALTH AND WELLNESS IN CONTEXT OF POVERTY ALLEVIATION, ECONOMIC DEVELOPMENT AND GROWTH OUTCOMESIn its Burden of Disease Study [Myers, Naledi, et al.2007] the Western Cape Department of Health[WCDOH] identified the upstream, socio-cultural factors that impact downstream health outcomes.The upstream risk factors touch on issues of development, such as: inequity, poverty, low incomeand unemployment, homelessness, social inclusion, and justice. These determinants fall outside ofthe direct ambit and control of the WCDOH‟s primary mandate.The findings of this report are further supported by the Rio Declaration on the Social Determinants ofhealth [World Health Organisation. 21 October 2011], which was in turn an outflow of the WorldHealth Organisation [ WHO] Conference on the Social Determinants of Health, which was held inBrazil in 2011. The Rio Declaration reached the following agreements:  Social and health equity can be achieved through action on the social determinants of health and well-being. This should be attainable via a comprehensive, inter-sectoral approach.  It was agreed that health equity is a shared responsibility that requires engagement of all sectors of government, all sectors of society and all members of the international community in an „ all for equity‟ and „health for all‟ global action.  Three overarching recommendations were adopted: * to tackle the inequitable distribution of power, money and resources; * to improve daily living conditions * to measure and understand the problem and assess the impact of action.In the WHO report titled, Macroeconomics and Health: Investing in Health for EconomicDevelopment [Sachs, J, D. 20 December 2001] it is further confirmed that health is a developmentaloutcome.“Whilst it is accepted that health is a developmental outcome, the opposite view that health canbe a driving force for development and economic upliftment has not been fully recognised. TheCommission on Macroeconomics and Health asserts that, if upstream risk factors were controlled inconjunction with improved health services to address the downstream risk factors,… impoverished families could not only enjoy lives that are longer, healthier, and more productive,but they would also choose to have fewer children, secure in the knowledge that their childrenwould survive, and could thereby invest more in the education and health of each child…theimprovements in health would translate into higher incomes, higher economic growth, andreduced population growth [Sachs, 2001].”To address the burden of disease, one needs to understand that determinants of healthencompass both downstream biological and behavioural risk factors, and upstream societal andstructural risk factors.The importance of the MDGs in health is, in one sense, self-evident. Improving the health andlongevity of the poor is an end in itself, a fundamental goal of economic development. But it is alsoa means to achieving the other development goals relating to poverty reduction. The linkages ofhealth to poverty reduction and to long-term economic growth are powerful, much stronger than isgenerally understood.1.1.3 THE COST TO GOVERNMENT AND SOCIETY OF CONTINUING WITH A „ BUSINESS-AS-USUAL‟ APPROACHThe Western Cape Government is essentially caught in the proverbial „Catch 22‟ situation, where itis compelled to spend the majority of the available budget on things that are entirely preventable.The list is nearly never-ending: * Crime * School drop-out * Substance and alcohol abuse *Teenaged pregnancies * Welfare * HIV/AIDS * Burden of Disease * Unemployment * Inter-personalviolence * Collective Depression – and so the list continues. Governing is effectively reactive. 5
  6. 6. Government resources are stretched to the limit to fulfil its mandate of dealing with theconsequences of societal decay and the resultant un-wellness of its citizens. The cycle ofgovernment spending can be likened to constantly putting Band-Aids on gaping wounds. In someinstances, 90% of available budget and resources are spent on the things that could be prevented,if only systemic, future-focused interventions were implemented in partnership with the whole-of-society.The private sector, philanthropic and global donors have been funding a plethora of NGO‟s andprogrammes and yet, outcomes are, at the very least moderate. This can be ascribed to the factthat there is no strategic model that seeks to address the systemic causes of the cycle of poverty,despair and hopelessness that continues to perpetuate itself in a ubiquitous cycle of behaviouraland socialisation repetition. Government, funders, NGO‟s and researchers are all working inisolation of one another, rather than to collaborate and partner to amplify outcomes. Suchcollaboration would more than likely lead to duplications in funding and programmes beingeradicated as well as to improve overall outcomes, whilst using fewer resources.By imaging that by putting more resources into health and education any of the developmentaloutcomes will change, we are fooling ourselves and doing nothing more than to assuage ourconscience that we are at least doing SOMETHING.The answer to creating societal wellness, breaking the cycle of poverty and all of theconsequences that are ultimately dealt with mainly by departments of Health and society as awhole, lies in an implementation model that seeks to disrupt the circumstances that children areborn into as well as the socialisation process that nearly pre-determines their future by virtue ofthese circumstances. Just on 16 million patient contacts at Primary Health Care sites in the WesternCape alone, provides an indication of the un-wellness of our citizens. Add to that the fact thatestimates put undiagnosed mental illness, such as depression as high as 17% and one startsunderstanding that a great many patients that are presenting at state facility may indeed besomatising. If they were correctly diagnosed and treated, but moreover, if the cycle of depressionand despair were interrupted at an early and systemic stage, the savings to the health care systemand society would be immense.The Strategic Partnerships Portfolio within the Western Cape Government was given the freedom todefine the scope and boundaries of its work and to find transversal solutions to societal challenges.In the course of the 3 year process of working across all three spheres of government, with civilsociety, the private sector, academia, research institutions, philanthropic donors and the citizens ofthe country and province, the writer has developed and piloted a model and methodology called:A PASSPORT TO WELLNESS© A roadmap out of poverty, towards growth and development[Brinkmann, A. February 2010 onwards]. [Appended]This model disrupts and intervenes within the socialization process to move from current future toideal future in a practical and pragmatic manner. This strategy has been adopted by the WesternCape Government, has support from civil society and donors and will, over time, have the effect offreeing up capacity within health facilities, release funds spent on all of the issues that arepreventable, so that in five, ten and fifteen years from now, government and society are able tospend more of their resources on growth and development outcomes.1.1.4 PROVINCIAL TRANSVERSAL MANAGEMENT SYSTEM [ PTMS]The PTMS provides a structured opportunity to mobilise role players outside of health to addressthese upstream determinants of health and wellness. The Provincial Transversal ManagementSystem is a priority of the Western Cape Government, providing political support for effective inter-sectoral collaboration within the provincial government.This is informed by the philosophy that acting in a united manner around a common set ofobjectives as a “whole of society” and a “whole of government” will promote delivery. This furtherevidenced and demonstrated within the PASSPORT TO WELLNESS model [Brinkmann, A. February2010 onwards]. 6
  7. 7. The strategic objectives are clustered into three sectors i.e. human development, economic andinfrastructure, and administration and inter-governmental. Each of the strategic objectives has asteering group to co-ordinate the working groups within the strategic objective.2 WCDOH VISION 2020 – PARTNERING AND PARTNERSHIP AS A STRATEGIC PRIORITYIn November 2011, WCDOH released its Vision 2020 – The Future of Health care in the WesternCape: A Draft Framework for Dialogue [WCDOH. November 2011]“Seven guiding principles have been identified to guide the 2020 strategy:1. Patient-centred quality of care2. A move towards an outcomes-based approach3. The retention of a Primary Health Care philosophy4. Strengthening the District Health Services model5. Equity6. Affordability7. Building Strategic Partnerships “The document deals very expressly with what should be done differently and what the case forchange is. Some of the compelling motivations for change include: * changes in the provincialdemography * socio-economic determinants of health and the burden of disease * advances intechnology * global, national and provincial environments * extreme tightening of the fiscalenvelope, necessitating innovation and different ways of doing things * sustaining existing goodpractice and improving on others * cost effective interventions within limited resources * preventionof disease and promotion of wellness.Building Strategic PartnershipsIt is essential that the provincial government seeks out and builds creative partnerships with role-players in the private sector, civil society, higher education, labour movement, other spheres ofgovernment and internationally. There is a realisation that improving the health status of thepopulation requires a whole-of-society approach and that the capacity and resources within theprivate sector need to be engaged, given the disparity between what is spent versus thepopulation coverage in the public and private sectors.The provincial Ministry of Health, via its Head of Strategic Partnerships has already started anexciting engagement with the private sector, which has shown a willingness to invest in the publicsector. Commercial opportunities are being investigated that can be mutually beneficial. A public– private health forum exists which provides a structured opportunity for engagement with theprivate sector. The Health Foundation was also recently established by the private sector, on asimilar basis as the Red Cross Children‟s Trust, with the intent of assisting the Strategic PartnershipsPortfolio and WCDOH in achieving its objectives and outcomes via a range of partnerships andcollaborations.A range of diverse partnerships have already been realised and the benefits and outcomes for allparties involved have surpassed expectations. This provides a strong foundation upon which tobuild. One of the key differentiators in respect of how the private sector and partners are engagedis that it is done with business, economic growth and mutually beneficial outcomes in mind. TheStrategic Partnership Portfolio functions as though it is a private sector entity and has thereforedeveloped a common and understandable language between the public and private sector.3 WCDOH: CONSTRAINTS – RATIONALISING THE NEED FOR INNOVATION AND PARTNERSHIPS3.1 The Western Cape accounts for 10.4% of population or 5. 287 million citizens of which an estimated 80%+ are served by the public health system.3.2 In 2012/13, it is projected that 16 348 182 patient contacts will be managed at Primary Health Care [PHC] level, 511 367 patients admitted to the department‟s hospitals, 135 018 patients treated with anti-retroviral therapy, 487 781 patients transported in ambulances, 98 500 babies 7
  8. 8. delivered in the maternity services and 6 909 cataract operations performed [Western Cape Department of Health. March 2012]. 3.3 Both Gauteng and the Western Cape will continue to experience shifts in demography and population distribution related to inward migration from the Eastern Cape and Limpopo – this inward migration places additional stress and pressure on already over-burdened state 3.4 An asset/equipment backlog exists generally within the WCDOH, but specifically at the three [3] Tertiary, Central Hospitals: Groote Schuur Hospital, Tygerberg Hospital and Red Cross Hospital. 3.5 Some, or all, of the facilities managed by the WCDOH have a shortage of equipment and/or ageing or obsolete equipment that need to be upgraded or replaced. 3.6 There are real costs, financial and non-financial, associated with the lack of necessary equipment in certain facilities. 3.7 The budget allocated by Treasury to the WCDOH is currently not sufficient to meet the annual equipment demands of all facilities, and by inference, insufficient to reduce and/or eliminate the existing backlog. [Botha, T. 26 March 2012] 3.8 There are significant maintenance and infrastructure backlogs, which despite the accelerated infrastructure spend over the past 3 years, will not be dealt with within the constrained budget as allocated by National Treasury. 3.9 Strategic Partnerships, efficiency, innovation, stretching the healthcare rand and patient- centricity are all at the very heart of achieving the objectives of the WCDOH. [ Botha, T. 26 March 2012] 3.10 National Treasury has issued a notice indicating a tightening of the budgetary envelope. The estimated time horizon is anticipated to be three to five years. [National Treasury Department: South Africa. August 2012] 3.11 Notwithstanding the above, negative impact on service delivery is not an option as is evidenced by the Strategic Objective Four of the WCDOH as set out within the Annual Performance Plan 2012/13[Appendix F:Western Cape Department of Health. March 2012] as well as with the spirit, content and objectives of Vision 2020 [WCDOH. November 2011]. This is reiterated within the content of the WCDOH Budget Speech 2012 [Botha, T. 26 March 2012]. It is therefore vital, now, more than ever, to engage in mutually beneficial partnerships and collaborations with a deep and broad range of role players so as to deliver on the objectives of the WCDOH and society as a whole. 4 STRATEGIC PARTNERSHIPS: WESTERN CAPE GOVERNMENT: A vision of an ideal future of health and wellness: 2020 and beyond “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” Richard Buckminster Fuller [1895-1983]“In order to change an existing paradigm you do not struggle to try and change the problematic model. You create a new model and make the old one obsolete.” ― Richard Buckminster Fuller “I am enthusiastic over humanity‟s extraordinary and sometimes very timely ingenuity. If you are in ashipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday‟s fortuitous contriving as constituting the only means for solving a given problem.” ― Richard Buckminster Fuller 8
  9. 9. 9
  10. 10. 5 SPACE MODEL MATRIX ANALYSIS: WESTERN CAPE DEPARTMENT OF HEALTH AND STRATEGIC PARTNERSHIPS5.1 CONTEXTIt is generally considered to be unusual to apply the Space Matrix analysis to a government entity.In this case, I have taken up the challenge that was laid down, given that I have spent the majorityof my career in the private sector as an entrepreneur, in advertising, marketing, business consulting,construction, forex trading, importing and exporting and management consulting. I wasspecifically approached to give life, shape and form to the Strategic Partnership Portfolio becauseof my commercial and entrepreneurial bent, my ability to work at the highest levels of complexitywith ease and to therefore understand the inter-relatedness and inter-connectedness of all things.I also speak the language of business, whilst having a strong social bent and am motivated by astrong sense of purpose and meaning to be part of the positive change in the world. The role andwork that I do is not about me, but rather about what I can contribute to the overall benefit ofsociety. In my opinion, there is always a way to ensure that benefits accrue to all parties involved –such mutual benefits are found by structuring wants, needs, expectations, boundaries andlimitations up-front and being honest and forthright about what each party desires and what theyare prepared to contribute and/or concede to reach their objectives. Innovation, often movinginto the realm of blue-skying, lies at the core of imaging all that could be – without limitations orrestrictions. I am yet to encounter a challenge or problem for which there are not multiple possiblesolutions. It is with this mind-set, years of evidence-based experience and a need to be thechange in this world, that I am tackling this analysis – essentially using a hybridised version of theSpace Matrix Modelling – so as to accommodate the unique idiosyncrasies of a portfolio thatensure that I am not a government official, do not tow any party lines and no interest or objectivesother than to improve quality and access to services, quality of life, wealth, health and prosperityfor all involved. Bearing this brief background in mind, let us proceed to the unpacking of thevarious elements of the Space Model Analysis: 10
  11. 11. 5.2 ENVIRONMENTAL STABILITY5.2.1 RATIONALISING THE RATINGSThis aspect of the matrix provides rather a conundrum, in that one has to, by inference, comparethe environmental stability of the country as a whole and thereby, the National Department ofHealth, with the same metrics in the Western Cape and WCDOH. I had to make intuitivedeterminations in regards to which metrics would be most appropriate to compare in this manner.I would imagine that given more time and further thought and engagement with this analysis,having the ability to do a current as well as future-focused SWOT analysis of National Departmentof Health, WCDOH and the Strategic Partnerships portfolio, I would at the very least find asupportive basis for the findings within this particular model.Social trends with the Western Cape and Western Cape Government can be described as stable,when compared with the rest of the country, and specifically, when compared to some of themore troubled provinces and health departments.The Economic climate in South Africa is hovering on the verge of instability, given the currentwildcat strikes, the jostling for political position pre-Manguang as well as the smouldering powderkeg that is the unemployed youth bulge. Because of demography, the Western Cape is slightlymore insulated against instability than for instance KwaZulu-Natal and Gauteng. In the main, theeconomic climate within the Western Cape remains stable due to relatively consistent growth anddevelopment, inward investment and a government that has achieved unqualified audits in all ofits 24 departments and Special Purpose Vehicles. Legal compliance is therefore also high.Unemployment is also lower in the Western Cape than in the rest of the country. The WCDOH isvery stable from a financial perspective, as is evidenced by its financial statements, unqualifiedaudits and ability to deliver quality services within limited budgets.Political change is strongly linked to the economic outlook and it is evident that the power strugglewithin the ruling party, the fragmentation of the alliance and labour, the reports of politicalpatronage, corruption and rent-seeking behaviour is negatively impacting on the economic 11
  12. 12. outlook and sentiment for South Africa. We have just recently seen a downgrading of by Standardsand Poors.In contrast and in comparison, even when taking the alleged “Project Reclaim” that seeks todestabilise the province into account, it would seem that the political landscape is, for now,relatively stable with little chance of significant change on the cards.The province has embarked on a phased project to ensure technological advances in theknowledge economy, but specifically, in connectivity for all of its citizens over the next 5 years. Thegovernment itself has had to deal with a legacy ICT system that was less than satisfactory and so acomprehensive Microsoft migration is in process, thereby improving business efficienciessignificantly. Statistics show that there is a direct link between connectivity and technologicaladvances and growth in GDP and development.On the metrics of demand variability, barriers to entry and competitive pressure, I have chosen tofocus on the unique value proposition that my portfolio, open door approach as well as access tothe Executive of the province, city and national government offers prospective partners. I do notperceive rank or file, have built a supportive shadow network within the structures and together, weare able to keep the end goal of societal benefit in mind so as to find new and innovative ways ofdoing things. In fact, one of the maxims by which I work with all of my colleagues, is to remindthem that we are here to serve the people of this province, that it is by their grace and tax moneythat we wake up every morning and have a purpose and that when we look at any piece oflegislation, regulation or policy, we must not only look at what is in front of us, if what is in front of usseems to hamper the achievement of the desired outcomes. We must rather look at what weshould change, adapt or alter, in order to make such outcomes possible. Any barriers to entry aredealt with by employing the „break it to fix it‟ and „find the ONE way in which this can happen‟approach.No other province seems to have established a portfolio with the scope, mandate and access thatthe Strategic Partnerships portfolio has and in fact, there have been advances to assist in settingsimilar structures up in other provinces, due to the perceived competitive advantage that thisconveys on WCDOH and the province as a whole.It is important to note that the appointment is non-political, non-partisan and on a contractualbasis, meaning that no agendas other than the improvement of the lives of the people of theprovinces are in play. This is vital to the success and credibility of the portfolio and its work andoutcomes. 12
  13. 13. 5.3 INDUSTRY ATTRACTIVENESS5.3.1 RATIONALISING THE RATINGSHealth and Education are rated as the top priorities not only for government spending, but by agreat many corporate and philanthropic donors, as well as Non-Governmental Organisations[NGO‟s]. Both of these areas are key drivers of growth and development.In general, growth and investment in the Western Cape has remained stable with growth in certainsectors, such as for instance Green Manufacturing and Health Biotechnology. The WCDOH is mid-life-cycle, from the perspective that it has made significant advances over the past decade, is thehighest functioning health system in South Africa and has already achieved most of the objectivesthat the NDOH has set out to be achieved in the rest of the country over the next decade.There is however more work to be done to improve on best practice, work on staff morale,upgrade infrastructure in collaboration with a range of partners and enter into innovativetransactional partnerships that would have the net effect of increasing service access points forstate patients, whilst assisting in generating annuity revenue for WCDOH over time, so as tobecome less reliant on the fiscus as its sole source of income.The WCDOH and WCGOV is perceived as being differentiated from the other provinces by virtue ofits geographic location, its unique demographic and psychographic profile, its cultural andreligious diversity, its natural beauty and of course, the high functioning nature of the stateinstitutions in regards to service delivery. 13
  14. 14. More and more donors, partners, corporates, NGO‟s and organisations are approaching theStrategic Partnerships portfolio via referrals and word-of-mouth. In fact, it is fair to say that I havenot had to make one pro-active appointment in three years. This is both a good and bad thing ofcourse. Good, in the sense that we have been over-run with proposals and offers of pilot projects,partnerships and collaborative engagements; bad – because a great many opportunities mayhave been lost due to not having the luxury and time to take a breath and plan pro-actively andcapitalise on existing as well as pre-existing relationships. This situation has now however beenaddressed by the narrowing of the scope of the portfolio and by agreeing very specificperformance indicators and objectives.By nature, the „profit‟ potential for government and WCDOH is generally high within the partnershipspace, specifically when working within the CSI space. But even then, we try to innovate by forinstance making a fully equipped, state-of-the-art theatre complex, donated and funded for themost part by a range of partners, available as their showroom in South Africa and Africa. Byexposing surgeons and registrars in training to the new technology, it is common knowledge thatthere is some influence on future purchase decisions and specifications, if said equipment showreal benefit and value in terms of clinical and patient outcomes. We also ensure that we provideas many publicity opportunities as possible to our partners, so that they reap the benefit of thegoodwill with their prospective customers.5.4 COMPETITIVE ATTRACTIVENESS5.4.1 RATIONALISING THE RATINGSThe WCDOH serves approximately 75-80% of the population in the Western Cape – which prettymuch ensure market dominance in the health care industry. Having said that, the Western Capehas one of the highest concentrations of private health facilities in the country and is also thedestination of choice for clinicians to settle with their families, due to the quality of life issuesattached to living in the province. The province also benefits from semi- and retired clinicians howoffer their services to mentor and train clinicians across the province. 14
  15. 15. Given that the Strategic Partnerships portfolio has had the privilege of building robust relationshipsacross all three spheres of government and with a myriad of role players and partners, its position iscurrently relatively uncontested.In terms of product quality, one always pushes towards improvement and excellence, so as tosurpass your best efforts of the day before. WCDOH certainly feels the pressure of improving onand strengthening the foundation it has laid over the past decade and is making a paradigm shiftfrom curative to preventative health, as well as patient-centricity.The product quality of the Strategic Partnership portfolio is evidenced through daily written andverbal feedback related to the speed of service, the level of innovation, the passion and energyfor the task at hand, the grasping of a plethora of options and opportunities and the conversioninto real action and implementation in the shortest time possible. The role is also known forunlocking and unblocking red tape and clearing speed bumps with some haste, when these issuesare holding up positive momentum. In my humble opinion, the quality of service, guidance,assistance, counsel and relationships are held in high esteem by most of the „ partners‟ that I havehad the honour and privilege to engage with. Customer and partner loyalty is therefore very highand trusting relationships exist.WCDOH has a 4.1% staff vacancy rate - far lower than all other provinces. There are challengesrelated to absenteeism due to stress and staff churns of about 14%. WCDOH is however working onstaff retention strategies as well as succession planning, aligned with improved performancemanagement.Given that infrastructure and maintenance backlogs are estimated at R 1 billion and given that thisfunding is not on budget, there is a high level of investment required from a range of partners inorder to achieve modernisation of infrastructure and equipment. We have however identified 16potential areas of partnership – from straight forward cause marketing, adopt-a-facility or ward totransactional relationships involving the possibility of exploring co-locations and co-ownership ofniche medical facilities adjacent to state health facilities, the availability of for instance minisupermarkets at health facilities – rendering a service to communities, staff and patients, whilstcreating annuity revenue for the facility and department so as to expand and/or maintain levels ofservice delivery during fiscally constrained periods. The notion of selling the „naming orcommercial‟ rights to key facilities to brands is also not out of the question. A range of innovativeoptions are currently in exploration and/or pilot phases.It goes without saying that asset utilisation is high – and will continue to be so in the foreseeablefuture, as the demand for services grow in the short term, but hopefully start declining in the mid- tolonger-term as the preventative and wellness outcomes start realising. The level of investment hasto be relatively high so as to convert the WCDOH into the most modern public health system on thecontinent so that we are able to attract, train and retain the best possible clinical skills in ourprovince, country and continent.Level of control is a contradictory term and perhaps begs exploration – there are mechanisms putin place that allows our partners control in terms of where their funding is spent, what the outcomesare and how transparent processes are. At the same time, the WCDOH is highly governed andtherefore controls and manages efficiencies. From the perspective of Strategic Partnerships, thecontrol is more subtle and involves using a strong and committed internal shadow network tomonitor the progress of projects and to ensure that they move through the system as swiftly aspossible towards implementation. 15
  16. 16. 5.5 FINANCIAL STRENGTH5.5.1 RATIONALISING THE RATINGSAs alluded to earlier in this document and substantiated by the financial statements and auditstatus of the WCDOH and WCGOV, the province and department are financially strong and stable.Compliance and fiscal management are non-negotiable and qualified audits will not be tolerated.The Ministers of all departments are well aware of the fact that if they receive a quaified audit, theyshould not bother to greet the Premier on the way out; they should pack their belongings and exitthe building post haste. A great many of the Ministers jokingly [ but with some seriousness] point outthat their political party does not have a redeployment strategy in the case of failure on thegovernance front.As discussed earlier, one of the hallmarks of partnership agreements is to ensure that there isequitable return on investment for all parties involved. All negotiations are done based on soundbusiness principles and benefits therefore accrue accordingly.The liquidity of WCDOH and WCGOV is managed with an iron fist – but does happen within aseverely constrained fiscal envelope. It is therefore one of the strategic objectives of the StrategicPartnerships portfolio to innovate operationally, in order to stretch the health care rand as far aspossible. One of the proposals that has recently been tabled involves the adoption of a moderateOperating Leasing strategy, so as to release net cashflow in years when the department decides togear. In the assumptive modelling, an effective gearing factor of 4.5 was assumed in the yearsthat a portion of high technology, high redundancy, high maintenance equipment would beacquired via operating leasing. Financing costs would be mitigated by the upfront purchase ofmaintenance agreements by the vendor, ensuring savings of up to 25% and Extended ProducerResponsibility and Green Procurement provisions would be built into the lease contracts, includingthe donation of the assets to the department, via The Health Foundation, for deployment into lowertiered facility, where the equipment can live out the rest of its useful life. Central or traininghospitals would therefore constantly be able to renew equipment required for teaching andimproved patient prognosis. 16
  17. 17. Cash flow is well managed and when entering into any form of partnership, a clear exit strategy isagreed up-front so as to ensure that the department can plan over the Medium-Term ExpenditureFramework to bring operational and any other related costs into the budget. This ensuressustainability of services.Given the level of governance, quality of management and professional, business-like approach ofWCDOH and Strategic Partnerships the risks involved in doing business with WCDOH are low – if notnon-existent.5.6 THE OUTCOME – WHERE IT ALL COMES TOGETHER – CONCLUSIONS AND RECOMMENDATIONS  From the graph above, it is evident that doing business with and partnering with the WCDOH through its Strategic Partnerships Portfolio is highly desirable.  The department and portfolio both rank highly on all four quadrants of the matrix – which provides a fair amount of comfort to potential partners and investors.  The scope of this particular report does not allow for a comprehensive and in-depth discussion and analysis of all of the competitive dimensions that I would ideally like to analyse in order to plot a clear and comprehensive strategy.  In an ideal world, I would have started the process with a current as well as future SWOT analysis of NDOH, WCDOH and Strategic Partnerships. This would be the first phase of my base analysis.  These analyses would complement Porter‟s Five Forces Model – which would look at the industry growth overall.  The BCG Analysis would confirm the direction of the marketing orientation and strategy and provide a clear direction on which projects and priority areas most of the resources should be directed at and also, our market share and growth relative to our largest competitor.  I would then have proceeded to an Internal Factor Evaluation [IFE] to educate myself as to the strengths and weaknesses in the functional areas of the business and the relationships between these areas. 17
  18. 18.  Thereafter, it follows that I would do an External Factor Evaluation [EFE], so as to confirm and evaluate the current business and trading conditions that I am functioning within, visualise and prioritise opportunities and threats facing the organisations and portfolio and of course, include a comprehensive PESTEL analysis for good measure, as further benchmark and baseline.  What makes these two models attractive from a multi-basing perspective, is the fact that one is able to add a great many relevant elements, weight them and therefore bring a more factual and numeric measure into the mix.  The natural progression for me would be to move to the Internal-External Model, which combines the IFE and EFE, so as to assess the available strategic options.  If there are multiple strategy options, I would proceed to the Quantitative Strategic Planning Matrix [QSFM] to establish where the real competitive „edge‟ is located.  I would more than likely end with the Balanced Scorecard to ensure that a performance framework is put in place to ensure that that right decisions are taken and that there is constant monitoring of the achievements against the strategic objectives of the organisation – internally and externally.  All of these analyses, read together with the Space Matrix Model would provide the multiple dimensions required so as to move forward with confidence and comfort.  It must of course be said that one is also led by your instinct and intuition in issues of strategy and so common sense would still prevail in the midst of the potential analysis paralysis.6 CONCLUSIONI have found this exercise interesting, informative, instructive and thought-provoking and havealready started the process as described above, against a range of strategic objectives, so as totrial various combinations of methodologies and to compare their outcomes.It has been satisfying to use the Space Matrix Model within the public sphere. The caveat in thisinstance is of course that this is not necessarily „government-as-usual‟ in the traditional sense. Thestructure, mandate, scope and business-like approach demonstrated by the WCDOH andStrategic Partnerships may have skewed the outcome of the analysis and it would be extremelyinteresting to in fact complete a comprehensive analysis as described within the section before –by analysing and comparing NDOH, WCDOH, ECDOH and Strategic Partnerships and its successesand innovations as part of the Unique Value Proposition of WCDOH and WCGOV.In the final analysis, the Space Matrix Analysis process did however provide sufficient proof orratification that we are on the right track and that we should continue to explore, exploit and growour competitive advantage – not only in the interest of the people of our province, but with theintent of building best practice models that could be scaled and replicated where it is mostneeded, in the rest of the country. 18
  19. 19. 7. REFERENCES: STRATEGIC MANAGEMENT ASSIGNMENT: EDP 2012Anderson B, Phillips, H. 2006. Adult mortality (age 15‐64) based on death notification data in SouthAfrica: Statistics South Africa. Report No. 03‐09‐05. Pretoria: Statistics South AfricaAndrews G, Pillay, Y. 2005. Strategic Priorities for the National Health System 2004‐2009. In Ijumba P,Barron P [Eds]. South African Health Review, 2005. Durban: Health Systems Trust.Badri, M. Cleary, S. Maartens, G. Pitt. J. Bekker, L.G. Orrell, C. Wood, R. 2006. When to initiate highlyactive antiretroviral therapy in Sub‐Saharan Africa? A South African cost‐effectiveness study.Antiviral Therapy 11(1):63‐72Barron P (2008). A fifteen year review of the health sector in South Africa. Prepared for theDepartment of Health, unpublished (December 2008)/ Barron P, Strachan K (1997). The Year inReview. In Barron P (ed). South African Health Review 1997. Health Systems Trust.http://www.hst.org.za/uploads/files/sahr2007.pdf [Accessed September 2012]Biermann, J. 2006. South Africa‟s Health Care under Threat. International Policy Framework andFree market Foundationhttp://www.healthpolicyunit.org/downloads/Health_Care_under_Threat.pdf [Accessed October2012] [Appendix E]Botha, T. 26 March 2012. Western Cape Health Budget Speech 2012 by Mr Theuns Botha, Minister ofHealth at Western Cape Provincial LegislatureBradshaw D (2008). Chapter 4: Determinants of health and their trends. In Barron P, Roma‐ReardonJ (Eds). South African Health Review 2008. Health Systems Trust.http://www.hst.org.za/uploads/files/sahr2008.pdf [Accessed September 2012]Bradshaw D, Norman R, Lewin, S et al (2007). Strengthening public health in South Africa: Building astronger evidence base for improving the health of the nation. South African Medical Journal 97:643 ‐ 649Bradshaw, D. Groenewald, P. Laubscher. R. Nannan, N. Nojilana, B. Norman. R. Pieterse, D.Schneider, M. 2003. Initial burden of disease estimates for South Africa, 2000. Burden of DiseaseResearch Unit, Medical Research Council.http://www.mrc.ac.za/bod/bodestimates.pdf [Accessed October 2012]Brinkmann, A. February 2010 onwards. A PASSPORT TO WELLNESS© A roadmap out of poverty,towards growth and development. [Attached]Centre for Scientific and Industrial Research (1996). National Health Facilities Audit. Division ofBuilding Technology, CSIR, in association with Department of Health and Raubenheimer & Partners.Boutek research Report Bouc 5a, April 1996Chopra, M. Lawn, J. Sanders, D. Barron, P et al. 2009. Achieving the health Millennium DevelopmentGoals for South Africa: challenges and priorities. The Lancet 374: 1023 ‐ 1031Cleary, S. 2009. Long term costs and implications for sustainable budgeting. Health Economics Unit.Presentation August 2009. http://www.alp.org.za/Presentations [Accessed August 2012]Cleary, S. McIntyre, D. Boulle, A. 2006. The cost‐effectiveness of antiretroviral treatment inKhayelitsha, South Africa – a primary data analysis. Cost Effectiveness and Resource Allocation4:20. Doi:10.1186 1478‐7547‐4‐20. http://www.resourceallocation.com/content/4/1/20 [Accessed April 2011]Daviaud, E. Chopra, M. 2008. How much is not enough? Human resources requirements for primaryhealth care: a case study from South Africa. Bull World Health Organ. 2008 Jan; 86(1):46‐51.http://www.who.int/bulletin/volumes/86/1/07‐042283.pdf [Accessed July 2011] 19
  20. 20. Day, C. Barron. P. Montecelli, F. Sello, E. [editors] 2009. The District Health Barometer 2007/8. Durban:Health Systems Trust 35Day, C. Gray, A. 2008. Health & Related Indicators. In Barron P, Roma‐Reardon J (Eds). SouthAfrican Health Review 2008. Health Systems Trust. http://www.hst.org.za/uploads/files/sahr2008.pdf[Accessed November 2009]Development Bank of Southern Africa. 2008. A Roadmap for the Reform of the South African HealthSystem. A process convened and facilitated by the Development Bank of Southern Africa.Dorrington, R. Johnson, L. Bradshaw, D. Daniel, T. 2007. The Demographic Impact of HIV/AIDS inSouth Africa: National and Provincial Indicators for 2006. Cape Town: Centre for Actuarial Research,Medical Research Council and Actuarial Society of SA.Harrison,D. December 2009. An Overview of Health and Health Care in South Africa 1994-2010:Priorities, Progress and Prospects for New Gains. A Discussion Document Commissioned by theHenry J. Kaiser Family Foundation to Help Inform the National Health Leaders‟ Retreat, Muldersdrift,January 24-26 2010 [Appendix B]Harrison, D. 2009. Rationale for the National Operational Plan for HIV Prevention. Pretoria:Department of Health. http://www.doh.gov.za/ [Accessed July 2012]Hirschowitz, R. Orkin, M. 1995]). A national household survey of health inequalities in South Africa.The Community Agency for Social Enquiry (CASE) for the Henry J. Kaiser Family Foundation, MenloPark, CA.http://dictionary.reference.com/browse/health. Define: Health. Accessed September 2012Kevany, S. Meintjies, G. Rebe, K. Maartens, G. Cleary, S. 2009. Clinical and financial burdens ofsecondary level care in a public sector antiretroviral setting (G F Jooste Hospital). South AfricanMedical Journal 99: 320 ‐ 325Lawn, S. Churchyard, G. 2009. Epidemiology of HIV‐associated tuberculosis. Current Opinion in HIVand AIDS 4:325‐333Lawn, S. Wood, R. 2007. When should antiretroviral treatment be started in patients withHIV‐associated tuberculosis in South Africa? South African Medical Journal 97: 414 ‐ 415Lewin, S. Norman, R. Nannan, N. Thomas, E. Bradshaw, D and the South African Comparative RiskAssessment Collaborating Group. 2007. Estimating the burden of disease attributable to unsafewater and lack of sanitation and hygiene in South Africa in 2000. South African Medical Journal 97:755 – 762Mayosi, B. Flischer, A. Lalloo, U. Sitas, F. Tollman, S. Bradshaw, D. 2009. Health in South Africa 4: Theburden of non‐communicable diseases in South Africa. The Lancet 374: 934‐47McIntyre, D. Bloom, G. Doherty, J. Brijlal, P. 1995. Health Expenditure and Finance in South Africa.Durban: Health Systems Trust and World BankMyers, J. Naledi, T. et al. 2007. Western Cape Burden of Disease Reduction Project: ReportNational Department of Health Strategic Plan 2010 – 2013.Nannan, N. Norman, R. Hendricks, M. Dhansay, M. Bradshaw, D and the South African ComparativeRisk Assessment Collaborating Group. 2007. Estimating the burden of disease attributable tochildhood and maternal under nutrition in South Africa in 2000. South African Medical Journal 97:733 ‐ 739 20
  21. 21. National Committee on Confidential Enquiries into Maternal Deaths. 2008. Saving mothers2005‐2007. Fourth Report on Confidential Enquiries into Maternal Deaths (Expanded ExecutiveSummary). http://www.doh.gov.za/docs/reports‐f.html. [Accessed February 2010]National Department of Health. 24 May 2012. Strategic Plan for Maternal, New-born, Child andWomen‟s Health [MNCWH] and Nutrition in South Africa 2012-2016National Department of Health. 4 March 2012. Annual Performance Plan 2012/13 – 2014/15.APPENDIX A: EXCERPTSNational Department of Health .2009a. Annual Report 2008/9. Pretoria.http://www.doh.gov.za/docs/reports/annual/2009 [Accessed September 2012]National Department of Health. 2009b. Strategic Plan 2009/10 – 2011/12. Pretoria.http://www.doh.gov.za/docs/strategic09‐11‐f.htm [Accessed September 2012](Accessed November 2009)National Department of Health .2009c. Operational Plan for HIV Prevention (in final draft,December 2009). PretoriaNational Department of Health and Medical Research Council. 2008. South Africa Demographicand Health Survey 2003.http://www.doh.gov.za/docs/reports‐f.htmlNational Department of Health. 2008. Annual Report 2007/8. Pretoria.http://www.doh.gov.za/docs/reports/annual/2008 [Accessed October 2012]National Department of Health. 2007. A policy on quality of health care in South Africa. Pretoria.http://www.doh.gov.za/docs/policy/qhc.pdfNational Department of Health. 2006. A National Human Resources Plan for Health to provide skilledhuman resources for healthcare adequate to take care of all South Africans; 2006.URL: http://www.doh.gov.za/docs/discuss/2006/hrh_plan/index.htmlNational Department of Health. 2005. The Charter of the Health Sector of the Republic of SouthAfrica (Draft revised 28 October 2005).http://www.doh.gov.za/docs/misc‐f.htmlNational Department of Health. 1997. White Paper for the Transformation of the Health System.Pretoria: Government PrinterNational Treasury South Africa. 22 February 2012. 2012 Budget Speech Minister of Finance PravinGordhanNational Treasury Department: South Africa. August 2012. Medium Term Expenditure FrameworkGuidelines. Preparation of Expenditure Estimates for the 2012 Medium Term Expenditure Framework.Norman, R. Bradshaw, D. Schneider, M et al. 2007. A comparative risk assessment for South Africa in2000: towards promoting health and preventing disease. South African Medical Journal 97: 637 ‐641Sachs, J, D. 20 December 2001. Macroeconomics and Health: Investing in Health for EconomicDevelopment. Report of the Commission on Macroeconomics and HealthScott, R. Harrison, D. 2009. A gauge of HIV prevention in South Africa. Johannesburg: loveLife Trust.http://www.lovelife.org.za/prevention_gaugeSeedat, M. van Niekerk, A. Jewkes, R. Suffla, S. Ratele, K. 2009. Violence and injuries in South Africa:Prioritizing an agenda for prevention. The Lancet 374: 1011‐ 1022 21
  22. 22. Segall, M. May 1999. “The Bottle Is Half Full”: Policy Oriented Overview of The Main Findings of aReview of Public Health Service DeliveryStatistics South Africa. Statistical Release P0302. 27 July 2011. Mid-year Population Estimates 2011.http://www.statssa.gov.za/Statistics South Africa. 2005. Mortality and causes of death in South Africa, 1997 – 2003. Statisticalrelease PO309.3.http://www.statssa.gov.za/publications/P03093/P03093.pdf. [Accessed February 2012]Statistics South Africa. 2009a. Mortality and causes of death in South Africa, 2007. Findings fromdeath notification. Statistical release PO309.3.http://www.statssa.gov.za/publications/P03093/P030932007.pdf. [ Accessed March 2011]Statistics South Africa .2009b. Road traffic accident deaths in South Africa, 2001 – 2006: Evidencefrom death notification. Report no. 03‐09‐07. Pretoria:http://www.statssa.gov.za/publications/Report‐03‐09‐07/Report‐03‐09‐07.pdfStatistics South Africa .2009c. Gross Domestic Product Annual Estimates 1993 – 2008: Third Quarter2009. Statistical release PO441.http://www.statssa.gov.za/publications/P0441/P04413rdQuarter2009.pdfTaylor, B. 2007. Rationing of Medicines and Health Care Technology. In Harrison, S. Bhana, R. Ntuli,A. (Eds). South African Health Review 2007. Health Systems Trust.http://www.hst.org.za/uploads/files/sahr2007.pdf [Accessed September 2012]Van Holdt, K. Murphy, M. 2007. Public hospitals in South Africa: stressed institutions, disempoweredmanagement. In Buhlungu, S. Daniel, J. Southall, R. Lutchman, J. State of the Nation: South Africa2007. Cape Town: HSRC PressVan den Heever, A. 2009. The determinants of medical scheme membership. In CMS News. IssueNo. 2 of 2009 – 2010. Pretoria: Council for Medical Schemes. http://www.medicalschemes.comWestern Cape Department of Health. November 2011. Vision 2020 – The future of health care in theWestern Cape: A Draft Framework for Dialogue [Appendix G]Western Cape Department of Health. March 2012. Annual Performance Plan 2012-2013Western Cape Department of Health. August 2012. Annual Report 2011-2012Western Cape Department of Health. 8 November 2011. The Cape Town Declaration on Wellness:Wellness Summit [Appendix H]World Development Report (2006). Equity and Development. Washington DC: The World Bank.http://www.worldbank.orgWorld Health Organisation. 4 April 2011. South Africa Health profile. www.doh.gov.za.[ AccessedSeptember 2012]World Health Organisation. 21 October 2011. Rio Political Declaration on the Determinants ofHealth. http://www.who.int/sdhconference/declaration/en/. [Accessed September 2012]www.earthzense.com/Definition-of-wellness. Define: Wellness: Accessed September 2012 22
  23. 23. APPENDIX A: NATIONAL DEPARTMENT OF HEALTH: ANNUAL PERFORMANCE PLAN: HIGHLIGHTS[National Department of Health. March 2012.]In its Annual Performance Plan 2012/13 – 2014/15, [National Department of Health. 7 March 2012]the following highlights and priorities are iterated: 7.1.1 One of the focal areas remains dealing with the Quadruple Burden of Disease [BOD]: HIV/AIDS, TB, Violence & Injury and Non-Communicable Diseases [NCD]. 7.1.2 The focus on dealing with NCD will be: * Reducing tobacco smoking * Reducing of harmful alcohol consumption * Promoting physical activity * Addressing unhealthy diets. 7.1.3 It is recognised that to deal with inter-personal, gender-based violence and injury, a broader, inter-sectoral, societal approach will be required. 7.1.4 Infrastructure continues to crumble and there are huge backlogs in maintenance, upgrades, equipment that need to be dealt with in order to strengthen the healthcare system. 7.1.5 Primary Healthcare [PHC] re-engineering, district health, PHC outreach programmes and school health will be put in place. Human Resources for Health [HRH] strategy and plan have been put into place to deal with the shortage of clinical staff in South Africa. 7.1.6 After the national audit of all health facilities, it has been determined that there is an urgent need to train and up skill the management at health facilities. 7.1.7 There is also an urgent requirement to strengthen health information systems. 7.1.8 Furthermore, there is a need to accelerate collaboration with other government departments so as to expedite the national turnaround strategy. 7.1.9 All efforts are focused on the eventual roll-out of the National Health Insurance [NHI] and Universal Healthcare for all. 7.1.10 In terms of refocusing on the re-engineering of the PHC system, the social determinants of health must be dealt with; this was agreed at the World Health Organisation [WHO] Conference on the Social Determinants of Health, held in Brazil in October 2011. This led to the Rio Declaration on the Social Determinants of Health [World Health Organisation. 21 October 2011]. 7.1.11 It is anticipated that this Declaration will be the basis for the development of a framework and plan that would seek to deal with the social determinants of disease – the starting point being to firstly establish and agree what these determinants are and how they should be dealt with. 7.1.12 NDOH plans to deploy at least 5000 Community-based Healthcare Workers to assist District Teams. 7.1.13 There will be a renewed focus on school health with nurses being deployed to the 8000 schools in the lowest quintiles and supplementation with mobile health units to provide packages of health screening and treatment – including oral, dental, 7.1.14 In Grades 8-10 there will be a focus on HIV/AIDS prevention and education, prevention of teenaged pregnancies and drug abuse; the focus will be on prevention and health promotion. 7.1.15 Public Private Partnerships are viewed as one of the ways in which the delivery of health infrastructure could be accelerated. 7.1.16 The Baseline for Under Five Infant Mortality is currently 56 in 1000 live births; a target of 50 in 1000 live births has been set for 2014/15. 7.1.17 The Baseline for Infant Mortality is currently 40 in 1000 live births; a target of 36 in 1000 live births has been set for 2014/15. 7.1.18 The Baseline for Maternal Mortality is currently 310 per 100 000 births; the target for 2014/15 has been set at 270 per 100 000 births. 23
  24. 24. n general, NDOH has agreed to the Health Sector Negotiated Delivery Agreement, which has 12outcomes in total. NDOH is responsible for the achievement of Outcome 2 namely: A long andhealthy life for all South Africans.NDOH has furthermore committed to the delivery of the Health-related Millennium DevelopmentGoals: * to eradicate extreme poverty and hunger * Promote gender equality and empowerwomen * Reduce child mortality * Improve maternal health 24
  25. 25. APPENDIX B: STATE OF THE NATIONAL HEALTH CARE SYSTEM: SITUATIONAL ANALYSIS[Harrison, D. December 2009]  Improvements have been achieved in terms of access, rationalisation of health management and more equitable health expenditure  However, 15 years later, these gains have been eroded by a quadruple burden of disease and more specifically, the strain that HIV/AIDs is placing on the health system, generally weak health systems management and low staff morale.  The overall result is poor health outcomes relative to the total health care expenditure in the public health sector in South Africa  The burden of HIV on mortality and the health system is enormous and managing the HIV/AIDS epidemic will more than likely continue to dominate during the next decade and beyond.  A balance will have to be found between the ability to finance the prevention and treatment of HIV/AIDS on a national basis, whilst improving service efficiency and quality of care.  Funding formulas to make the proposed National Health Insurance [NHI] a reality will pose further challenges.  There are opportunities for significant systems improvements as well as on focusing on specific policy priorities.  Given the dire state of the health care system in general, the challenge for policymakers is to demonstrate rapid improvement in the quality of care and service delivery indicators, such as waiting time, patient satisfaction, whilst at the same time addressing the intractable health management issues that continue to bedevil efficiency and drive up costs.  Even though a district-based system can be considered as one of the biggest post 1994 innovations, the success has been hamstrung by the failure to devolve authority fully and by erosion of efficiencies through lack of lack of leadership and low staff morale.  Re-engineering or retooling of district health management to improve local service delivery would therefore seem to be one of the „breakthrough strategies‟ that could be accomplished fairly easily.  Other chronic disease epidemics such as TB and alcohol abuse and their effect on the health system, cannot obscure the burden of disease related to other chronic diseases. 25
  26. 26. Prevention and treatment needs underscore the urgency of new health financing models, pushing the consideration of the NHI to the fore of policy priorities. Grand policy initiatives can therefore only be applauded if they are implemented effective and can produce demonstrable benefits. Proposed strategies are laid out systematically in the diagrams that follow. They start off with key policy programmes and service priorities to reduce the burden of premature death in South Africa. It then goes on to outline some of the most important policy and management instruments to improve the state of the health system. 26
  27. 27. 7.1.19 MORTALITYThe completeness of death registrations has improved from 67% to 82 % [Stats SA. 2009 a]. The realnumber of deaths in South Africa has increased sharply since 1998; Figure 1 below indicates thatthe figures have in fact almost doubled. To date, AIDS has resulted in the deaths of at least 2.6million South Africans, mostly children under five and young adults.The number of deaths registered for children younger than five has doubled over this period oftime, whilst the figures for those aged between 20 and 39 years old, has trebled [Figure 2]. This hasresulted in the median age of death having fallen significantly. The infant mortality rate hasincreased significantly since 1980. The expansion of the Mother-to-Child transmission preventionprogramme has assisted in reverting back to mortality levels of 1994 [Health Systems Trust. 1995- 27
  28. 28. 2008] 28
  29. 29.  Death rates for many, but not all, categories of non-communicable diseases [NCD] have increased. The time frame for review of these trends was relatively short and so accurate 29
  30. 30. mortality rates for hypertensive and ischaemic heart diseases show little change. It is nevertheless important to note that these conditions now disproportionally affect poorer people in urban areas [Mayosi et al. 2009]. On the other hand, the trend in other diseases, such as stroke, diabetes mellitus and chronic kidney disease has increased upwards considerably. Based on the age profile related to mortality attributed to NCD‟s, it suggests that the apparent increase in deaths from NCD‟s is AIDS-related. The real increases in mortality from diabetes mellitus, chronic kidney disease and cancer of the prostrate are more than likely unrelated to HIV.[ Mayosi et al. 2009] This reinforces the fact that South Africa is facing a quadruple burden of disease [BOD] associated with AIDS, other diseases of inequality and poverty, diseases of transition and a persistently high fatality rate from injury and other external causes. 30
  31. 31.  HIV/AIDS is however projected to account for about 75% of premature deaths in South Africa in 2010. [ Bradshaw. 2003]  The four greatest disease priorities in reducing premature mortality in South Africa are:  HIV/AIDS and TB  Injuries from inter-personal violence and road traffic accidents  Other infectious diseases and conditions related to poverty, mostly affecting children  Cardiovascular conditions and other chronic diseases of lifestyle  Together, these account for 90% of premature deaths 7.2 Trends in underlying risk factorsThe National health risk profile, calculated in relative contribution to risk factors to disability adjustedlife years [DALYS] – mirrors the mortality profile. 31
  32. 32. 32
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  34. 34. 34
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  36. 36. 36
  37. 37.  In 1996, NDOH commissioned the Council of Scientific and Industrial Research to undertake a national audit of health facilities [CSIR.1996]. The audit concluded that about R 7.6 billion was needed to restore the estate to acceptable conditions. In some provinces, the situation was much worse. In Limpopo, almost a quarter of facilities needed to be replaced or condemned. Substantial capital funding was made available for the worst-off provinces. In 1998, the Hospital Rehabilitation and Reconstruction Programme was initiated, including the replacement of equipment and facilities in hospitals across South Africa. It also included the construction of 11 district and regional hospitals and three new academic complexes. As part of the 10 point plan, this programme sought to simultaneously improve infrastructure, health technology, organisational management and service quality. 37
  38. 38.  By 2008 there were 40 participating hospitals but by 2009, this number was reduced to 27 as a result of a sharp reduction in infrastructure funding. [ NDOH. 2009 b] A further limitation to progress has been the availability and appointment of suitable staffing. 38
  39. 39. 39
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  46. 46. 46
  47. 47. Devolution of management authorityThere are two urgent priorities with respect to devolution of authority, namely the institutionalisationof the district health system and devolution of staffing, budgeting and expenditure control ofhospitals to hospital management.Some of the key challenges are described below:District health system:Since 1994, the district health system has been recognised as the main mechanism forimplementation of primary health care (Owen 1995). Yet it has failed to be properly institutionalised.District management teams have been appointed and are responsible for day‐to‐day 47
  48. 48. management of primary health facilities and community outreach. A number of initiatives havestrengthened their capacity, including management training and tools for budgeting andexpenditure analysis. But they have acted as units of a de‐concentrated provincial system, ratherthan as management entities with delegated authority. The effect has been accountability toprovincial government – often largely driven by the imperatives of the Public Finance ManagementAct – and insufficient accountability to the people of the district for health service provision.The National Health Act of 2003 made provision for the appointment of district health councilscharged with ensuring „co‐ordination of planning, budgeting, provision and monitoring of allservices that affect the residents of the health district for which the council was established.‟ It alsorequired provinces to legislate for the functioning of district health councils and to enter intoagreements with municipalities where certain PHC services are provided by the latter. To date, onlyone province has legislated for district health councils.Devolution of staffing, budgeting and expenditure control to hospitals:The high degree of management centralisation at provincial level sets up a vicious cycle:competent managers are frustrated by the lack of autonomy and leave – while provinces arereluctant to devolve management authority to junior or less competent managers. This cycle willonly be broken if there is clear definition of the delegations of authority to hospital managers, linkedto performance monitoring (van Holdt & Murphy 2007). Similarly, the sense of exclusion fromdecision‐making experienced by many senior clinicians in central and provincial hospitals will needto be addressed.Specific delegations need to include control over the staff establishment (staff numbers & mix),hiring and firing of personnel, budgeting and control of expenditure and greater control ofprocurement ‐ in a streamlined system of interaction with provincial systems of monitoring andaccountability. Without clear delegations of authority, the Inspectorates of Health Establishmentswill have no teeth, because hospital managers will be able to point to protracted delays inprocurement, budget approval and staff appointments beyond their control. Good examples of agency‐led support for quality improvement include the Initiative forSub‐District Support of the Health Systems Trust, the Youth Friendly Clinic Initiative (DoH andloveLife), and the accelerated plan for PMTCT.2.2.9 Health worker moraleA five year review of the public health sector conducted in 1999 found that, with respect to humanresources, “the single most consistent finding in our field studies in all parts of the country is thatmorale among health workers is low, especially among nurses” (Segall 1999). It concluded thatalthough nurses ascribed their morale to overwork, this was probably not the main factor – and thata sense of neglect and lack of support was at the heart of problems of low morale. Unfortunately,reviews of the health system since then have tended to reach the same conclusions.Strategies that could improve health morale fairly rapidly include:• A national campaign to affirm the value of health workers (linked to rewards and recognition);• Re‐asserting the primary role of the district management team in supporting personnel within thedistrict (as opposed to interacting with provincial and national processes);• The simplification of paperwork, including a brutal trimming of the national health informationminimum dataset and condensing annual business plans and programme reports;• Facilitated processes of in‐service support to health workers that go beyond occasional trainings;and• Incentivising further study and personnel development, through for example a dedicatedprogramme linked to the National Students Financial Aid Scheme (NSFAS).There are undoubtedly places of excellence and dedicated health workers in clinics and hospitalsacross the country, rendering high quality services even in the face of constrained resources. Acommon denominator in all these exemplars is strong and motivated leadership within the healthfacility and it is now imperative that the type of leadership training that has been provided to seniorand middle‐level health managers should now be extended to clinic managers.But, ultimately, the morale of health workers will only improve if they have a real sense of missionand personal fulfilment, which to a large extent depends on the ability of national and provincialmanagers to articulate a clear vision and plan of action.2.2.10 Leadership and innovationAndrews and Pillay (2005) identified a number of factors critical to success of the implementation ofthe 2004‐2009 Strategic Plan, including: 48
  49. 49. • Leadership, and in particular, political leaders as well as managers in the health system, mustclearly articulate and communicate a vision and a mission that will resonate with front line healthworkers.• A programme of action that is developed with, and that captures the imagination of, thosecharged with its implementation. This would require greater empowerment of leaders at the locallevel to drive the change agenda.These critical success factors are just as relevant today. To these, a third should be added – namelya mechanism for leadership development and public innovation in the health sector. Thismechanism – an agency (or agencies), working with provincial and district managers ‐ would beable to provide „horizontal support to the district management team and health workers at facilitylevel. In this way, an agenda of change would remain on the front burner, even as pressing concernsand management crises inevitably take up the time of senior health service managers. But neithershould the latter abdicate responsibility: a mechanism of „horizontal support‟ will only work if itenjoys the backing of senior management. A commitment by senior management to visit healthfacilities at least once a month to share the vision and provide encouragement could rebuild asense of common purpose.PROSPECTS FOR NEW GAINSThe review of successes presented in section 2.1 above shows that many of the breakthroughswere achieved through bold policy initiatives. Not surprisingly, many of them were accomplished inthe first five years of democratic government, which presented a singular window of opportunity forpolicy development and implementation.The squeeze on public spending in the late nineties knocked the wind out of the sails of healthsystems transformation. But the loss of momentum was not only the result of financial constraints:Failure to regulate the private sector properly, coupled with the inability to motivate staff across thepublic sector, accelerated the drain of health professionals in the first few years of the newmillennium.The advent of the mortality phase of the AIDS epidemic – noticeable from about 1998 – signalled aperiod of growing pressure on the health system, and growing frustration from both health workersand civil society alike at the apparent ambivalence of Government to deal with it effectively.Nevertheless, it should be noted that, even during this phase, there were some importantbreakthroughs in health policy, including anti‐tobacco legislation and community service forgraduating health professionals. There were also incremental improvements in health systemsmanagement and rationalisation in a number of provinces, which received little media attention.The time and effort taken to unravel and restructure the fragmented health services of apartheidshould not be underestimated. But now, the South African public health system stands on the edgeof a chasm, which can only be bridged by new resources and decisive leadership. There is no waythat the public health system will be able to be sustained at current levels of funding – if the rolloutof the ART programme is to continue.To some extent, the resources may be obtained by better use of the public resources and servicesof the private sector. To a large extent, it will require new funding.This is the intent of the proposed national health insurance (NHI) system. There is however the riskthat the NHI will be viewed as the panacea for both financing shortfalls and health servicedeficiencies, and sight should not be lost of the fact that the NHI is essentially a financingmechanism. In this regard, it would be injudicious to rule out the option of sourcing new fundingthrough general taxation – as opposed to a dedicated payroll tax – until the implications of thelatter are fully understood.The pressures on the health system over the next five years imply that there will be little margin fortrial‐and‐error. Some of important factors to consider in decisions about an NHI are presented inAppendix 1, but the key point is that an NHI (and/or other financing mechanisms) will enable theimplementation of policies and programmes that address national health priorities. Of itself, it is nota national health priority. These are described below.HIV prevention:If health planning is informed by an analysis of the burden of disease, there is no doubt that thegreatest health priority is to prevent new HIV infection. This will require the full and urgentimplementation of the comprehensive strategies outlined in section 2.1. An urgent priority for thefinancial year 2010/11 is to saturate the demand for condoms in high prevalence districts andmost‐at‐risk groups. The big gaps in coverage of community‐level behaviour change programmewill need to be urgently addressed – requiring additional funding from Government and its bilateral 49
  50. 50. partners. And the elimination of missed opportunities for PMTCT provides an obvious source ofincidence reduction in 2010.HIV treatment:With such significant residual mortality – at least 250,000 deaths per annum even at 90% coverage(see Figure 14) – serious consideration will need to be given to simplifying the model of care forpatients on ART. In particular, the routine use of laboratory tests to monitor progress (CD4 and viralload, in the absence of other clinical indications) will need to be reviewed. The trade‐offs betweenearlier initiation of treatment and higher levels of coverage will need to be evaluated at policy,service management and clinical levels.Furthermore, the non-sustainability of a donor‐dependent ART programme needs to be fullyrecognised.Combating alcohol abuse: Morbidity and mortality data point strongly to the fact that the country can no longer ignore theimpact of alcohol abuse, which contributes to injury, HIV transmission, domestic violence and childabuse. The experience of other countries and the precedent of the national anti‐tobaccoprogramme in South Africa both point to potential new gains if this risk factor is taken seriously. Thiswill require collaboration across government departments and sectors of society and will need fullpolitical support.Preventing non‐communicable disease:The immediacy of the HIV epidemic means that the focus on non-communicable disease must beon their prevention. In this regard, further reductions in the prevalence of tobacco smoking remaina priority.As community‐level adherence support for TB and HIV prevention and treatment become moreentrenched, there will be opportunity to integrate community‐level care for all chronic conditions.But it would be risky to attempt such integration now – when the priority must be integration ofTB‐HIV services.Improving the quality of care:Clear priorities will need to be established in terms of both health programmes and facilities. Theyinclude prevention of mother‐to‐child transmission, ART adherence support, TB prevention andmanagement, syndromic management of sexually transmitted infections, and maternal andperinatal care.In terms of health facilities, the findings of the maternal and perinatal mortality review point to theneed to focus on district hospitals in particular. As discussed earlier, improving the quality of carewill require both systems of monitoring and support to health workers. These require theestablishment of deliberative programmes driven by dedicated agencies.Most importantly, efforts to improve the quality of care need to be driven from the front, by politicaland health service leaders who can communicate the mission and inspire health workers to havethe biggest possible impact on the health of the communities they serve.APPENDIX C: NATIONAL DEPARTMENT OF HEALTH: ANNUAL PERFORMANCE PLAN: 2012-2014:EXCERPTS – GRAPHS AND STATISTICS 50
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  60. 60. Key Strategic Issues: Health Sector Negotiated Service Delivery AgreementGovernment has adopted an outcome-based approach to service delivery, which consists of 12outcomes. This is articulated in the revised Medium Strategic Framework (MTSF) for 2009-2014.The 12 Outcomes are as follows:  Improved quality of basic education  A long and healthy life for all South Africans  All people in South Africa are and feel safe  Decent employment through inclusive economic growth  A skilled and capable workforce to support an inclusive growth path  An efficient, competitive and responsive economic infrastructure network  Vibrant, equitable and sustainable rural communities with food security for all  Sustainable human settlements and improved quality of household life  A responsive, accountable, effective and efficient local government system  Environmental assets and natural resources that are well protected and continually enhanced  Create a better South Africa and contribute to a better and safer Africa and World  An efficient, effective and development oriented public service and an empowered, fair and inclusive citizenshipThe health sector is responsible for the achievement of Outcome 2 namely: A long and healthy lifefor all South Africans.The focus of the health sector over the planning cycle 2011/12 – 2013/14 will therefore be on thefour outputs entailed in the Minister‟s Performance Agreement with the President of the Republic,and elaborated on in the Negotiated Service Delivery Agreement for 2010 – 2014. 60
  61. 61. These are (1) Increasing Life Expectancy; (2) Reducing Maternal and Child Mortality Rates; (3)Combating HIV and AIDS and decreasing the burden of diseases from Tuberculosis and (4)Strengthening Health System Effectiveness. Strategies for achieving these are reflected in therelevant medium term plans of the National and Provincial Departments of Health. 61
  62. 62. APPENDIX D: PROPOSED NHI STRUCTURE: CHALLENGES AND REQUIREMENTS FOR IMPLEMENTATION 62
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  64. 64. APPENDIX E: SOUTH AFRICA‟S HEALTH CARE UNDER THREAT: PUBLIC VERSUS PRIVATE HEALTHCARE[Biermann, J. 2006.] 64
  65. 65. By the governments own admission its health sector is not coping with the demand for health care.The [then] Minister of Health, Dr Manto Tshabalala-Msimang, was quoted as stating that the healthsystem was in shambles and Dr Kgosi Letlape, chairman of the South African Medical Association,described the situation in the government health sector as horrendous.In response to the situation, the government has embarked on an on-going programme ofexpanding and upgrading government health facilities and services, while, on the regulatory level,it has adopted the National Health Act 2003, which seeks to establish a unified national healthsystem over which the National Department of Health will wield enormous power.The ostensible aim of the new health legislation is to allow the health department to control andmanage the entire health system, so that it can reallocate and redistribute private and publichealth resources in a "more equitable" manner.The unified national health system envisaged in the legislation is to be characterised by: 65
  66. 66.  Planning interventions in the form of national, provincial and district health plans.  Economic interventions in the form of price controls, compulsory minimum benefit requirements for medical schemes, limitations on risk rating of patients by medical schemes, prohibitions on re-insurance by medical schemes, and the establishment of a system of social health insurance.  Licensing in the form of certificates of need (CON) requirements for the establishment or expansion of facilities and the introduction of new technologies, enabling the Minister of Health to control the number of private hospitals and beds, the location of new hospitals, where doctors may practise, and the dispensing of medicines by general practitioners.  Compulsory public service for medical graduates, prescribed medical education curricula emphasising primary health care over specialist care, prohibition of insurance policies that cover medical expenses, compulsory acceptance of members by medical aid funds, compulsory membership of medical aid schemes and limitations on medical aid funds and insurers, restricting their ability to introduce innovative and more cost-effective services.  The Act introduces South Africas own version of a centrally planned, socialised health system, in which the facilities, the equipment, the doctors, nurses and other medical professionals, and services, whether in the public or private sector, have been regulated, licensed, certified, approved and price-controlled by the government.A Critique of the Recent LegislationThe unified national health system envisaged in the National Health Act 2003 ignores the failures ofthe countrys existing government health sector and the evidence from other countries withgovernment (socialist) health systems which shows that these systems are inefficient, expensive,lack sophisticated medical equipment, have long waiting lists for medical procedures andappointments with specialists, do not provide equal access to and equal treatment for all citizens,provide lower quality health care than private systems, control costs by rationing care and medicaltechnology, and fall far short of attaining their lofty ideals. The experience in the countries thatserve as role models for South Africas health-care plans, such as the United Kingdom and Canada,is particularly relevant.In a fully socialised health system everything is centrally planned, controlled and co-ordinated. Thegovernment owns all the hospitals and medical facilities and government health plannersdetermine how many hospitals and beds there should be, where they should be located, the typeand quantity of services and medicines that will be available, the salaries health-care professionalsmay earn, the amount of money that may be spent on particular procedures and technologies,the type of equipment that may be installed at hospitals and clinics, and the prices that will becharged for health-care procedures and medicines.South Africas new National Health Act subjects its private health-care providers to the samecontrols applied in a socialised health system. Private care, from now on, will thus be private onlyinsofar as health establishments will be privately owned. The government will be planning the entirehealth-care system, with dire consequences for all patients, rich and poor.A government attempting to plan and/or provide health care to an entire nation is confronted bythe insurmountable obstacles faced by centrally planned and co-ordinated systems: theimpossibility of knowing everything necessary to ensure effective, efficient and equitable delivery ofgoods and services, the misallocation of resources that result from the ignoring or obliteration ofsignals provided by prices, the complexity of centralised planning, the difficulty of forecasting thefuture, and the inefficiency of governments in general.Centrally prohibited health careWhen governments impose plans on their citizens, whatever does not fit in with those plansbecomes illegal. This observation led the economist Murray N Rothbard to remark that a centrallyplanned economy is a centrally prohibited economy. Socialised care becomes governmentprohibited health care: nothing may be done without prior government approval. 66
  67. 67. So, for example, South African doctors will be prohibited from opening medical practices in areasthat government health-care planners believe are adequately served. The planners will somehowknow exactly where all doctors should practise and what procedures and equipment they shoulduse in order to meet the needs of all patients.Government health systems are inefficientCompared to its private health-care providers, South Africas government health sector is slow,unwieldy and inefficient because it is not subject to the discipline entailed in making profits,avoiding losses, and earning an adequate return on capital invested.The government sector can always obtain more funds from taxpayers, or, if government healthcosts and demands for service get really out of hand, ration health care.The proponents of government health care regard the economic rationing of health care asinequitable, but regard rationing of health care by governments as justifiable, notwithstanding thepromises to provide health-care services to all who need them. A health department discussiondocument makes this admission:In the government health-care sector, therefore, it is said to be for reasons of equity that healthservices are either limited or not available. However, when economic rationing occurs in theprivate health sector the proponents of socialised health care describe such rationing asinequitable.Government health systems, like all government activities world-wide, are encumbered bybureaucratic procedures and are consequently unavoidably inefficient. They cannot competewith private providers. The contracts awarded to private health-care providers by the BritishNational Health Service (NHS), which is under severe pressure to speed up the provision of medicalcare for the more than one million NHS patients who are on waiting lists for surgical procedures,provides an illustration of the greater efficiency of private providers.South African private hospital groups, Netcare and Life Healthcare are among the companies towhom contracts have been awarded.24 The contracts require the performance of thousands ofmedical procedures annually, such as cataract procedures, orthopaedic surgery (including hipand knee replacements), ambulatory surgical procedures (including arthroscopies), generalsurgical procedures, and ear, nose, throat and oral procedures.Life Healthcare, in a joint venture with Care UK PLC, has been contracted to construct and operatethree Diagnostic Treatment Centres in England, which include consulting rooms, radiology(including X-ray, CT scanner, MRI and ultrasound), pathology laboratories, theatres, ICU beds,general beds ,and a rehabilitation gymnasium.The contracts awarded confirm the superiority of private care over government care as well as thecompetency of South African companies in providing world-class medical care. It is unfortunate forgovernment sector patients that these resources are not being used locally to alleviate the pressureon the government sector.The quality of care and the competitive cost of private health care have made South Africa adestination for medical tourism. Patients come to South Africa from the United Kingdom, wherethey are entitled to free health care, and pay for medical treatment out of their own resources toavoid the long waiting times for medical care in the British National Health Service (NHS).25The knowledge problemProponents of government health systems argue that such systems ensure the optimal andproductive utilisation of the countrys health-care resources. Their arguments are based on thefallacy that there is someone who actually knows how to allocate health-care resources in anequitable manner and what optimal utilisation of health resources would comprise. 67

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