They have taken over from their poor cousins in the Eastern Cape, OR Tambo and Alfred Nzo districts, which were bottom of the pile in 2006/7 but have since clawed their way up to third and fourth bottom respectively for 2007/8.

‘€œDeprivation’€ is defined as a combination of indictors including unemployment rates, access to piped water and electricity, female-headed households with high numbers of children and low education levels, according to the Health Systems Trust which produces the Barometer.

Of the 52 districts in the country, nine of the 10 poorest ones are in KwaZulu-Natal and the Eastern Cape while the other is Limpopo’€™s Greater Sekhukhune.

As to be expected, the 10 districts with the worst access to piped water were also the poorest. Slightly more than a third (35.6%) of households in OR Tambo have access to piped water, which is the worst rate in the country where on average of 88% of households can get piped water.

In contrast, six of the top 10 least deprived districts are in the Western Cape, with West Coast in top position followed by Namakwa in the Northern Cape. Three metros ‘€“ Cape Town, Nelson Mandela Bay (Port Elizabeth) and Johannesburg ‘€“ are also in the top 10.

Four of the six top performing Western Cape districts also spent over R400 per person a year on primary healthcare (PHC), way over the national average of R302.

The Free State spent the least per person on PHC, with three of its five districts in the bottom 10. Per capita expenditure in the province has actually dropped from R251 in 2006/7 to R233 for 2007/8. Bottom of the pile was the Lejweleputswa district in the Free State which spent less than R200.

In contrast, Limpopo had the greatest increase in expenditure, upping its payments by an average of R58 per person.

Nurses in Fezile Dabi in the Free State work the hardest, seeing over 44 patients a day, while nurses in Limpopo’€™s Waterberg are under-utilised and only see around 12 patients a day. However, nurses’€™ workloads had dropped by an average of four patients a day since 2004/5.

Cape Town nurses are the third busiest in the country, seeing around 41 patients a day ‘€“ almost double their counterparts in Johannesburg. The Nelson Mandela Bay metro has down the best to reduce its’€™ nurses’€™ workload, cutting their burden by 17 patients a day.

The biggest single expense for districts is hospitals, but costs per patient per day varied substantially. In Chris Hani district in the Eastern Cape, for example, patients were treated for R744 a day whereas in Frances Baard in the Northern Cape, the cost was a massive R2 363, which indicates inefficient use of resources.

An important measure of efficient use of hospitals is the bed utilisation rate. In the Western Cape, over 80% of beds were in use at all times. Cape Town is under the most pressure, with district hospitals almost 90% full at all times.

‘€œThis is indicative of a shortage of district beds in the metro and is a message to the management to fast track the building of additional district hospitals,’€ said researchers.

In contrast, Frances Baard was the least used, with a bed occupancy rate of less than 40 percent ‘€“ which accounts for why it is the most expensive district hospital in the country.

How long patients stay in hospital is also a measure of both quality and efficiency. As district hospitals are supposed to refer complicated cases to secondary and tertiary hospitals, patients are not expected to stay for very long while very short stays could indicate the quality of care has been compromised.

On average, patients stayed four-and-a-half days in hospital. The 10 districts where patients stayed for long periods were all in the Eastern Cape and KwaZulu-Natal, while the average stay in OR Tambo being a staggering eight days.

‘€œThis could be an indication of a lack of doctors who can discharge patients timeously,’€ note the researchers.

DHB researchers say there are ‘€œlarge scale inefficiencies in the district hospital system’€ and suggest that provinces investigate changing poorly used hospitals into community health centres.

Clinics are doing well to immunise babies, with over 85% children being reached.

On average, 15.6% of deliveries at district hospitals were Caesarean births. The rates in Nelson Mandela Bay (32.8%) and Cape Town (32.5%) were more than double the national rate, while the lowest was Frances Baard (2%).

Six out of the 10 districts with the highest rates were in KwaZulu-Natal, which may be because more women there had complications due to HIV.

Judging by the condom distribution rate (11.8% per man a year), the health department apparently expects people to confine sex to a monthly actively. The least lucky were men in Kgalagadi, who got 1.7 condoms a year while mostly lucky were Cape Town men, who can almost have weekly sex on their annual condom ration of 55.2.

The DHB records a number of encouraging improvements in health indicators. Fewer people were treated for new sexually transmitted infections (STIs), with an average of 4.4% of those over 15 being treated. However, Limpopo’€™s Vhembe had almost double the national average, and there were high STI rates in all but one of KwaZulu-Natal’€™s districts.

While tuberculosis cases continue to grow, there has been a 5% national improvement in cure rate between 2005 and 2006. All but 12 districts improved their cure rates, an indictment on poor management in these districts.

Cacadu in the Eastern Cape registering the worst incidence rate (rate of new infections) of 673.3 cases per 100 000 people. Surprisingly, despite being ranked the least deprived district, the West Coast has the third worst TB rate.

Ethekwini has the largest number of people with TB in the country (38 142 new cases in 2007) and a poor, but improving cure rate of 52.3% (a 4% improvement).

Diarrhoea in children under five is an important indicator of health and socio-economic conditions. Worst off were kids in Umgungundlovu (Pietermaritzburg), where 702 cases per 1000 kids were reported.

Seven of the 10 worst affected districts for diarrhoea were in KwaZulu-Natal ‘€“ an indicator of both poor access to clean water and the effects of HIV infection. There has also been a sharp increase in the Western Cape since 2003/4.

The Free State remains the province with the highest number of children under 5 not gaining weight, while the Northern Cape’€™s Namakwa had the worst rate of this.

In a further indication of worsening health indicators in the Western Cape, Cape Town had the worst rate of children not gaining weight of the metros.

Stillbirths is measure both the health of pregnant women and the quality of the care they receive during labour. In developed countries, there are about 6 stillbirths per 1000 births. In South Africa, the national average is 23 stillbirths per 1000 births. This rate has improved since 2003/4 when it was 27.8.

The worst district for stillbirths is Amajuba (KZN) with 34.6 stillbirths per 1000 while the best is Overberg (Western Cape) with 13.6. Johannesburg was the best performing metro (17.9) and Ethekwini the worst (26.2). Cape Town, Tshwane and Ekurhuleni all recorded higher stillbirth rates.

The DHB has been recording statistics from districts since 2003/4, and there is now a solid bank of data against which health managers can measure progress and problems.