Fiorenza Monticelli, HST Monitoring Health Systems Strengthening

Dar es Salaam, 16-17 April 2008

The District Health Barometer

Collates, simplifies, displays, compares and monitors health and socioeconomic data at a district and province (sub-national) level1) Compares equity issues between districts

and between provinces; improvements & deterioration over the last few years

2) Highlights quality of data and monitors improvements

3) Reviews trends over time, monitoring progress towards goals.

4) Is used at national, province and district level and influences attitude to M&E and attitude to data quality for decision making

The District Health Barometer Year 1

• Pilot published in in 2005 (2003/04 data)• Provides 15 Health indicators and 1 year of data

comparing:– 53 Health districts– 6 Metropolitan areas– 13 Rural Nodes– 9 Provinces

Short analysis and narrative, indicator definitions

The District Health Barometer 2006/07

• Published in 2007 (3rd year)• 27 Indicators – socioeconomic and health• Up to 4 years of data• Profile for SA, 9 provinces and 52 districts with

colour coded ranking• CD with full data file, resources and definitions • A web-enabled GIS District Health Barometer

http://webgis.hst.org.za:8081/• Internship programme

Achievements

• Effective communication of district level data to a wide range of users including the non-health sector (politicians, the lay press, Treasury)

• Acceptance and use of the publication by the National Department of Health (e.g. by displaying it on their website, quotations, discussed at national conferences)

• Growing awareness of the importance of quality of data at sub-national level, improved interrogation of data by managers.

• Improved level of transparency

ProcessData collected from Treasury, StatsSA, DHIS, TB register,

private sector facilities register

Financial data is coded, data scrutinised, averages calculated, DI calculated, maps and graphs produced

Authors write district profiles and narrative based on data provided (gaps and data irregularities are noted)

Publishing process, launch to NDHSC and press, notifications, dissemination and presentations

Advisory committee meet (DOH, Academic sector, consultants & HST)

The District Health Barometer 2006/07

1. Socio-economic Indicators

e.g. Household access to Water , Deprivation index

2. Input Indicators

e.g. Per Capita Expenditure on Primary Health Care, Cost per Patient Day Equivalent in District Hospitals

3. Process indicators

e.g. Clinic Supervision Rate, Nurse Clinical Workload

The District Health Barometer 2006/074. Output Indicators e.g. Male Condom Distribution Rate

PMTCT Indicators : Proportion of antenatal clients tested for HIV HIV prevalence rate amongst antenatal clients tested Nevirapine uptake rate among HIV+ve pregnant women Nevirapine uptake rate among babies born to HIV+ve pregnant women

5. Outcome indicators e.g. Incidence of new Sexually Transmitted Infections

TB Smear conversion rate TB cure rate (new smear +ve)

6. Impact indicators e.g. Perinatal Mortality Rate (PNMR)

Examples of data improvement

• Financial data: e.g. Non-Hospital Primary Health Care Per Capita Expenditure (HST – more experienced at working with and coding the data)

• DHIS data: Nurse Clinical Workload (districts in KZN, NW, NC provinces have improved their data since 2003/04 and WC now provide this data)

• Proportion of antenatal clients tested for HIV –national ANC prevalence survey data now available at district level allows for comparison and validation.

Per capita expenditure, 2006/07

0 50 100 150 200 250 300 350 400 450 500

Gert SibandeNkangala

UkhahlambaCacadu

Thabo MofutsanyaneAlfred NzoCapricorn

Greater SekhukhuneFezile Dabi

O.R. TamboLejweleputswa

SiyandaChris Hani

iLembeVhembe

WaterbergMotheo

Nelson Mandela BayUmzinyathiEhlanzeni

Frances BaardAmathole

MopaniKgalagadi

BojanalaXhariep

AmajubaUthukela

UthunguluSedibengZululand

CentralWest Rand

Pixley ka SemeUgu

UmkhanyakudeMetsweding

SisonkeeThekwini

City of TshwaneuMgungundlovu

Cape WinelandsSouthernOverberg

NamakwaEden

West CoastCentral Karoo

City of JohannesburgCity of Cape Town

BophirimaEkurhuleni

South Africa

Rand

EC

FS

GP

KZN

LP

MP

NC

NW

WC

SA

Change in Per Capita Expenditure 2001/02 and 2006/07 (real 2006/07 prices)

Per capita expenditure, 2006/07

0 50 100 150 200 250 300 350 400 450 500

SiyandaGreater Sekhukhune

MetswedingAmajuba

EhlanzeniGert Sibande

CapricornLejweleputswa

UthukelaNkangalaSedibeng

O.R. TamboVhembe

Alfred NzoWaterberg

UkhahlambaThabo Mofutsanyane

iLembeZululand

UguWest RandFezile DabiUthungulu

CacaduUmzinyathi

UMgungundlovuMopani

OverbergNelson Mandela Bay Metro

Frances BaardChris Hani

AmatholeSisonke

KgalagadiCape Winelands

Pixley ka SemeEkurhuleni

BojanalaMotheo

eThekwiniCity of Johannesburg

UmkhanyakudeCentral Karoo

SouthernBophirima

City of TshwaneCentral

EdenXhariep

City of Cape TownWest Coast

NamakwaSouth Africa

Rand

EC

FS

GP

KZN

LP

MP

NC

NW

WC

SA

2001/02 2006/07SA = R222 SA= R256

Per Capita Expenditure – ISRDP nodes 2001/02 – 2006/07

The difference between the highest

and the lowest values moved from a 6.8 fold difference in

2001/02

to a 1.9 fold difference in 2006/07

Per capita expenditure, ISRDP nodes 2001/02 - 2006/07 (real 2006/07 prices)

0 50 100 150 200 250 300 350 400 450 500

Greater Sekhukhune 06/07

Greater Sekhukhune 01/02

O.R. Tambo 06/07

O.R. Tambo 01/02

Alfred Nzo 06/07

Alfred Nzo 01/02

Ugu 06/07

Ugu 01/02

Chris Hani 06/07

Chris Hani 01/02

Ukhahlamba 06/07

Ukhahlamba 01/02

Central Karoo 06/07

Central Karoo 01/02

South Africa 06/07

South Africa 01/02

Rand

Data improvement Example: Nurse Clinical workload

Province District 2003/04 2004/05 2005/06 2006/07

NC Kgalagadi 137.2 50.9 49.9 36.4

NW Bojanala 127.4 80.9 47.1 22.6

KZN Uthungulu - 55.1 28.6 23.2

2007/8 report - currently investigating application of statistical methods e.g. regression, imputation to fill in missing data, graphing & visualization to detect outliers.

HIV prevalence among ANC clients tested

95% CI

PROVINCE DHIS 06/07National HIV

survey 06lower upper

Eastern Cape 22.8 28.6 26.8 30.4

Free State 25.4 31.1 29.2 33.1

Gauteng 28.3 30.8 29.6 32.1

KwaZulu-Natal 26.1 39.1 37.5 40.7

Limpopo 17.2 20.6 18.9 22.3

Mpumalanga 29.6 32.1 29.8 34.4

Northern Cape 12.5 15.6 12.7 18.5

North West 26.4 29.0 26.9 31.1

Western Cape 14.1 15.1 11.6 18.7

South Africa 23.7 29.1 28.3 29.9

TB Cure rate, 2005

0 10 20 30 40 50 60 70 80 90 100

NkangalaAmathole

UguUMgungundlovuFrances Baard

WaterbergeThekwini

UmkhanyakudeUthungulu

UthukelaGert Sibande

Alfred NzoSisonke

SouthernNelson Mandela Bay Metro

SiyandaBojanala

Greater SekhukhunePixley ka Seme

SedibengNamakwa

UkhahlambaMopaniiLembeCacadu

MetswedingFezile Dabi

O.R. TamboEhlanzeniBophirimaEkurhuleni

City of TshwaneAmajuba

CentralUmzinyathi

ZululandMotheo

KgalagadiCapricorn

LejweleputswaCity of Johannesburg

City of Cape TownXhariep

Thabo MofutsanyaneWest Rand

Central KarooCape Winelands

Chris HaniVhembe

BohlabelaWest Coast

EdenOverberg

South Africa

Percentage

EC

FS

GP

KZN

LP

MP

NC

NW

WC

SA

57.6%

31.4%

83.6%

TB Cure Rate by District 2005

Challenges• Too much data collected at district level which impacts heavily

on quality of the DHIS data e.g. data elements for routine collection at facility level = approx 493.

• Insufficient monitoring of the data collected by various programs

• Insufficient validation and checking of data from district – province – national level – Treasury

• Adjustments to data in DHIS made at frequent intervals throughout the year

• Key indicators unavailable at district level e.g. Mortality data, HR data

• Ownership

The Birchwood National Consultative Health Forum Declaration on Primary Health Care

We, the members of the National Consultative Health Forum, representing government, public and private health sectors, statutory bodies, academic and research institutions, community organisations, civil society, non-governmental organisations and organised labour, in our meeting at Birchwood conference centre, Gauteng Province, held on 10-11 April 2008, on Primary Health Care to commemorate the 30th anniversary of the Alma Ata Declaration, hereby:

Note:1. The achievements that have been made in the implementation of the Alma Ata declaration globally, including

improving access to Primary Health Care services and equitable allocation of resources. 2. The Kopanong Declaration on Primary Health Care in 2003 which, inter alia, resolved to implement concrete

strategies and processes, with clear targets, to reduce inequities in the allocation of resources for primary health care with a focus on both horizontal and vertical equity.

3. That there have been many achievements in the delivery of Primary Health Care services in South Africa, but there are still many challenges including availability of adequate human resources for health, improving quality of care, strengthening district management and community participation.

Reaffirm1. Our commitment to the principles in the Declaration of Alma Ata, adopted in September 1978. 2. That health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or

infirmity, and that access to healthcare is a fundamental human right. The attainment of the highest possible level of health is a most important worldwide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector.

Resolve That the revisioned and revitalized primary health care strategy for South Africa will include:

1. Advocating for an increase in the resource allocation for primary health care, by at least doubling the current per capita expenditure over the next ten years.

2. Better alignment at district level of key interventions that impact on health, notably provision of water and sanitation, early childhood development, recreational programmes, health education and other activities that focus on encouraging healthy lifestyles especially amongst the youth in particular.

3. Strengthening the role, responsibilities, authority and accountability of the district health management team so as to achieve improved health outcomes.

4. Strengthening the health information system to generate good quality data for monitoring health outcomes and informing decision making.

THANK YOU

We acknowledge the National Department of Health, Treasury and all other providers for access to and use of their data for this publication and Atlantic

Philanthropies for funding the project.