1. 1 DEPARTMENT OF CORRECTIONAL SERVICES OVERVIEW OF HEALTH CARE DELIVERY & MANAGEMENT IN DCS 18 NOVEMBER 2009

2. 2 CONTENT 1.Mandate 2.Background 3.DCS responsibility 4.Establishment 5.Areas of Health Care Delivery 6.Most Prevalent Conditions 7.Services & programmes 8.Constraints 9.Measures to improve situation 10.Conclusion

3. 3 1.MANDATE According to international norms & standards, “offenders must have access to same quality & range of health care services as general public receives from National Health Services”. Person’s capacity to access these services should not be compromised by reasons of incarceration since all people have basic right to health, nutrition, clean & safe environment.

4. 4 2.BACKGROUND Historically Department (inmates) received onsite access to personal (medical, psychiatric & oral [dental]) health care services, which was provided, as “FREE” service by then Department of Health, Welfare & Pensions’ District Surgeons Effective 1 April 1980 some health services ( e.g. forensic, secondary & tertiary care) devolved to then four (4) Provincial Administrations in accordance with Section 14(2) of Health Act, 1977 (Act No. 63 of 1977) 1994 Constitutional changes - establishment of nine (9) Provincial Administrations - no measures put in place to replace District Surgeons Services - personal health care services to inmates compromised

5. 5 BACKGROUND (cont) From 1999 provinces indicated that due to capacity limitations “FREE” services to inmates would be ceased as from 2000 Department managed to enter into service level agreements only with Western Cape & Gauteng Provincial Department of Health, other provinces indicated capacity & resource limitations With transformation of DoH, Districts were established, & in 2006 then DG of Health approved incorporation of Department of Correctional Services health facilities into Districts

6. 6 3.DCS RESPONSBILITY To facilitate & establish effective system for provision of comprehensive primary health care services (i.e. health, pharmaceutical, nutritional, personal & environmental hygiene services) to all categories of offenders, awaiting trial detainees, children & babies with their incarcerated mothers based on all applicable international & national legislation, policies, guidelines, standards & protocols

7. 7 4.AREAS OF HEALTH CARE DELIVERY Preventive care Promotive care Curative care for acute & chronic communicable & non communicable diseases Rehabilitative care Referral services for secondary & tertiary levels of care Discharge planning

8. 8 5.SERVICES & PROGRAMMES Department ensures access to & provide comprehensive primary health care services on 24 hour basis which include: –Promotive & preventive services (health education) –Curative services for acute minor ailments, injuries, endemic diseases, communicable diseases (e.g. tuberculosis, sexually transmitted infections which includes HIV & AIDS), & non- communicable diseases (e.g. diabetes, epilepsy, hypertension) – Reproductive health (women & maternal health) –Youth health –Pharmaceutical services –Mental health care –Basic oral/dental health care

9. 9 SERVICES & PROGRAMMES (Cont’) Provision of medico legal services (rapes, sodomy, deaths, suicides, assaults) Nutritional services Integrated Management of Childhood Illnesses Basic rehabilitation & physical therapy Basic optometry Medical services Palliative care for terminally ill Personal Hygiene Services Environmental Hygiene services Emergency medical services Specialist services

10. 10 SERVICES & PROGRAMMES (cont’) Facilitate access to supplementary health services i.e. laboratory, physiotherapy, radiography, speech, hearing & occupational health services Establishment of referral systems within Correctional environment & with public health sector at local/district & provincial levels, at times with private health care providers (depending on need for services) Partnership & co-operation with internal & external partners (Government departments, NGOs, CBOs, private institutions, etc.) Health monitoring mechanisms/systems & quality assurance programs to improve quality of health care rendered to offenders

11. 11 6.MOST PREVALENT CONDITIONS Most prevalent diseases include following; –Seasonal viral infections –Mental health conditions, (e.g. hypertension, diabetes) –Neurological conditions (epilepsy) –Cardiovascular conditions –Respiratory conditions (e.g. TB, pneumonia, asthma, bronchitis) –Ear, nose & throat conditions –Gastrointestinal conditions (e.g. ulcers, gastritis) –Muscular skeletal conditions –Sexually transmitted infections including HIV & AIDS –Cancer & –Skin conditions

12. 12 7.SERVICE HIGHLIGHTS Despite constraints following were achieved: – number of policies & procedures have been developed & approved after being reviewed & aligned to DoH's policies & guidelines –Training - 150 officials were trained as Environmental Hygiene Supervisors, 54 officials trained in Basic Food Service Management, 291 health professional trained in Dispensing Course, 250 health professionals trained in medicine management in order to equip them with relevant skills & knowledge –19 Correctional health facilities accredited as Wellness sites by National Department of Health to increase access to prevention, care, support & treatment by inmates

13. 13 SERVICE HIGHLIGHTS (cont’) Health professionals in Department has benefited in their relevant Occupational Specific Dispensations as one of measures to retain their skills Participated in commemoration of International (World AIDS Day, World TB Day) & National Health Calendar events ( STI week, Mental Health Awareness Month etc) as part of prevention activities Department made presentation to Provincial Heads of Health (DDGs) on challenges experienced in terms of health care delivery & areas of assistance required Department (KwaZulu/Natal Region) has signed MoU with Hospice & Palliative Care Association of South Africa for provision of palliative care to patients

14. 14 SERVICE HIGHLIGHTS (cont’) Financial support & assistance received from USA Government - President’s Emergency Plan for AIDS Relief (PEPFAR) for TB & HIV & AIDS initiatives; PEPFAR funded activities: - –Training of professional nurses in comprehensive management of HIV & AIDS, professional staff in VCT, offenders in Peer Education –Procurement of equipment for 212 Correctional health facilities, equipment for 12 Correctional Pharmacies –Refurbishments of identified health facilities in preparation for accreditation –Appointment of Management Area HIV & AIDS Coordinators

15. 15 SERVICE HIGHLIGHTS (cont’) Partnership established with NDoH at different levels & Department invited to participate in several forums & task teams, e.g. Comprehensive Management for HIV & AIDS, Prevention, Care Support & Treatment, Mental Health, National Outbreak Response Team (NORT), National TB Programme, where management of different diseases is discussed

16. 16 SERVICE HIGHLIGHTS (cont’) Feasibility study into outsourcing of pharmaceutical services has been finalized & decision will be taken in due course Department approved headhunting framework for health professionals to improve time it takes to fill in vacant posts Participated in session with Gauteng Health to develop protocols for referrals & feedback

17. 17 8.CONSTRAINTS Human Resources : Inability to recruit and/or retain/ high turnover of health care professionals (professional nurses, medical practitioners, pharmacists & psychologists) Lack of mechanisms to address training needs for emerging diseases & new treatment guidelines, hence Department is dependent on over-stretched Districts Lack of adequate custodial officials to accompany inmate patients for referral purposes

18. 18 ESTABLISHMENT: HEALTH CARE SERVICES AS ON 30/08/2009 EstablishmentFilledVacant Primary Health Care 1023 ( Nurses) 48 ( Medical Practitioners ) 810 11 213 37 Pharmaceutical Services 39 Pharmacists 19 CSPs (in contract posts) 1326 Nutritional Services 764 Food service officials 512252 Environmental hygiene supervisors 12210 Dietitians 000

19. 19 CONSTRAINTS (cont’) Services & Programmes: Inadequate management of acute, chronic & communicable diseases such as diabetes, tuberculosis, mental illness & HIV & AIDS Provision of appropriate nutrition for HIV & AIDS patients & other diseases Difficulty in maintaining positive clinical improvement in order to strengthen quality of care, & enhancing disease prevention strategies Inability to increase focus on outcome based health care increase in burden of diseases which are becoming complex to manage Limited access to ARVs

20. 20 CONSTRAINTS (cont’) Legislation: Impact of new health legislation on Department such as Mental Health Care Act & Criminal Procedure Act which requires that mentally health care users & observation cases must be incarcerated in designated institutions Poor compliance & inability to ensure compliance with legislation, policies, procedures & protocols due to lack of adequate resources, e.g. provision of mental health care by appropriately trained personnel such as psychiatric nurses

21. 21 CONSTRAINTS (cont’) Lack of clear policy (roles & responsibilities) by National Department of Health & Provincial Departments of Health with regard to Correctional health care issues There is lack of adequate nurses trained in Primary Health Care in department & therefore not possible to implement Section 56 of Nursing Act, Act 33 of 2005 i.e. physical examination, diagnosis, keeping of medicines & their supply, administering & prescribing, prescribing, keeping & dispensing of medication by nurses where there are no pharmacists & medical practitioners in facility

22. 22 CONSTRAINTS (cont’) Target Population : Overcrowding undermines rights of offenders to conditions of detention which are consistent with human dignity (violation of privacy, spread of communicable diseases, compromised hygiene standards etc) Participation of offenders in high risk behaviors & practices Increase in youth population (with their unique needs) due to type of aggressive crimes they commit & increase in lengthy sentences passed by courts High turnover of awaiting trial detainees contributes to inadequate management of diseases Limited self care opportunities

23. 23 CONSTRAINTS (Cont’) Information : Department’s health information system is not aligned to National Health Information System of South Africa thus poor information management Transport Lack of proper transport to carry patients to external health facilities Infrastructure : Lack of adequate primary health care clinics & in- patient facilities. (equipped clinics, in-patient facilities & isolation cells)

24. 24 BED CAPACITY PER REGION RegionNo of Management Areas Total Bed Capacity Average Bed Capacity Eastern Cape0652770 Gauteng08998125 Free State & Northern Cape 0731244

25. 25 BED CAPACITY PER REGION RegionNo of Management Areas Total Bed Capacity Average Bed Capacity Kwa-Zulu/ Natal0749470 LMN0845256 Western Cape0841051

26. 26 CONSTRAINTS WITH DoH Lack of policy on licensing of departmental nurses with PHC Inability to allocate Medical Practitioners & Dentists to DCS due to limited resources Requirement from Department to pay for ARVs & TB (MDR & XDR) medication Lack of adequate specialists to provide secondary & tertiary levels of care Turn around time for laboratory results Lack of adequate capacity to admit state patients & observation cases timeously Ineffective referral & feedback mechanisms Inability to admit MDR & XDR-TB patients

27. 27 9.MEASURES TO IMPROVE SITUATION Training of nurses in PHC & management of clinical conditions Facilitation of licensing of nurses trained in PHC DCS implementing risk mitigation plan for HIV & AIDS as well as pharmaceutical services Department to create posts based on staffing norms for Primary Health Care (PHC) Creation of posts for Nursing Assistants & Staff Nurses

28. 28 MEASURES TO IMPROVE SITUATION (cont.) Establishment & maintenance of partnerships with Departments of Health at all levels for assistance as well as use of civil organizations in delivery of health care services to inmate population Alignment of Department’s Health Information System with NHIS-SA or procurement & alignment of existing information systems Strengthening existing partnership & cooperation with both internal & external partners Proposal for creation of Communicable Diseases Coordinators posts in all Management Areas

29. 29 10.CONCLUSION To improve quality & outcome of health care delivery in DCS, there is strong need for collaboration & strengthening of some of existing partnership between DoH & Department from political to district levels & other relevant stakeholders

30. 30 Together doing more & better to break cycle of crime