30th Alma Ata CelebrationThe South Africa National Conference on

Primary Health Care, 10 -11 April 2008

Alma Ata and Primary Health Care Where are we now? Monitoring progress

Fiorenza Monticelli, Health Systems Trust

Alma Ata and Primary Health Care Where are we now? Monitoring progress

• Information and health systems research are key tools required for:– monitoring progress in the achievement of PHC goals – assisting with decision making – ensuring that managerial decisions are based on

objective and high quality evidence.

• Data collated from the DHIS and StatsSA and other primary sources, are made available through the District Health Barometer (DHB) in a cohesive, easily understandable and accessible way to aid management decisions and monitoring.

Alma Ata and Primary Health Care Using information to monitor progress

• Using information from the DHB, this presentation demonstrates progress made in selected key components of PHC.

• To illustrate this, a number of examples which include some of the most important elements of PHC, have been selected. These examples are:

Adequate supply of safe water and basic sanitation (social determinants of health)

Maternal and child health Control of local endemic diseases (e.g. TB & HIV) Equity (in resource allocation)

Alma Ata and Primary Health Care

The Social Determinants of Health

% Households with access to piped water in SA

2001 84.5%

2005 85.8%

Adequate supply of safe water and basic sanitation

YET: still more than a 30% point difference exists

between the highest and lowest province

% Households with access to piped water by province

Eastern Cape Limpopo Western Cape

2001 62.4% 78.0% 98.3%

2005 67.4% 75.8% 98.9%

Alma Ata and Primary Health Care

The Social Determinants of Health

% Household access to piped water by district

2001: 71.3% point difference between the highest and lowest district

– Central Karoo 98.9%– O R Tambo 27.6%

2005: 55.7% point difference between highest and lowest district

– City of Cape Town 99.2%– O R Tambo 43.5%

Alma Ata and Primary Health Care

The Social Determinants of Health Basic sanitation

% Households with no toilet in SA

2001 12.4%

2006 9.5%

% Households with no toilet by provinceEastern Cape Gauteng Free State

1996 29.1% 2.5% 8.8%

2006 24.3% 4.4% 3.2%

A 21.1% point difference between the highest and lowest province in 2006 vs 26.6% point difference in 2001 - Equity is improving at both provincial and national level

Alma Ata and Primary Health Care

Maternal and Child Health

Perinatal mortality rate* in facilities in rural and metro districts 2003/04 – 2006/07

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

South Africa 37.0 37.9 34.5 33.8

ISRDP average 43.9 56.6 44.7 40.1

Metro average 34.9 31.5 34.1 30.1

Whilst the rate is declining the ISRDP districts are not improving relative to the rest.* Stillbirths and neonatal deaths < 8 days old per 1000 births in a facility

18.6%

33%

Alma Ata and Primary Health Care

Control of Local Endemic Diseases

Proportion of Antenatal Clients Tested for HIV 2003/4 -2006/07

Proportion of Antenatal Clients Tested for HIV

67.972.6

60.9

0

20

40

60

80

100

South Africa ISRDP average Metro average

Perc

en

tag

e

2003/04 2004/05 2006/07

Alma Ata and Primary Health Care Control of Local Endemic Diseases

TB cure rate by province 2003 and 2005

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Eastern Cape

Free State

Gauteng

KwaZulu-Natal

Limpopo

Mpumalanga

Northern Cape

North West

Western Cape

South Africa

percentage

2005

2003

Despite falling well below the

WHO target for TB cure rate in developing

countries (85%), most provinces are improving

slowly; although much more needs

to be done, especially in the

North West, KwaZulu-Natal and Northern

Cape

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

55.6%

31.4%

83.6%

TB Cure Rate by District 2005

Alma Ata and Primary Health Care Control of Local Endemic Diseases

TB cure rate by district - the highest and lowest by year

31.4

77.9

23.7

83.6

0

20

40

60

80

100

2003 2005

Per

cen

tag

e

Eden Sisonke Overberg Nkangala

Both the values of

the highest and lowest cure rates

improved as well as the

gap between them, but values are still far from

the 85% WHO target

54.2% points

difference in 2003

vs

52.2% points in

2005

Alma Ata and Primary Health Care

Control of Local Endemic Diseases TB Smear Conversion Rate

Smear Conversion Rate (new smear +ve)

49.9

67.2

69.2

48.4

54.3

44.4

48.4

48.1

66.9

55.8

0 10 20 30 40 50 60 70 80 90 100

Eastern Cape

Free State

Gauteng

KwaZulu-Natal

Limpopo

Mpumalanga

Northern Cape

North West

Western Cape

South Africa

Percentage

2006

2004

Alma Ata and Primary Health Care Equity in resource allocation

Allocation of PHC spend per province and districtsNon- hospital Per Capita Expenditure on Primary Health Care

(2006/07 prices)

2001/02 2005/06 2006/07

South Africa R222 R243 R256

Provinces:

2001/02 a 4.4 fold difference between highest and lowest

Western Cape – R418 and R95 in Mpumalanga

2006/07 a 1.9 fold difference between highest and lowest

Western Cape - R354 and R189 in Mpumalanga

Alma Ata and Primary Health Care Equity in resource allocation

Districts : An improved equity in per capita expenditure on non- hospital PHC between districts from 2001/02 to 2006/07

2001/02 •9.3 fold difference•Ekurhuleni (GP) – R418 and R55 Gert Sibande (MP)

2006/07 • 3.3 fold difference•Namakwa (NC) – R497 and R151 Siyanda (NC) (most inequitable province in 2006/07)

Equity between district spending within most provinces has improved in 2006/07eg: Mpumalanga: less than 10% difference between the highest and lowest spending district in 2006/07 vs a 3 fold difference in 2001/02

Non-hospital PHC 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

Alma Ata and Primary Health Care Where are we now? Monitoring progress

Conclusions:Universal access to care and equity is one of the principles

of PHC as set out in the Alma Ata declaration. From the data presented it can be seen that equity has improved in many areas, but quality of care needs attention.

One of the essential components of PHC is functional information management and technology – It is therefore of great importance to have the highest quality of data to monitor progress and make management decisions – if inconsistent or of low quality, then it becomes impossible to measure or effect change in a positive way.