Community empowerment within case management
Tembisa Provincial Tertiary hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
. Background of the project (including problem) (500) Problems encountered before the implementation of the initiative The current revenue management practices then did not meet compliance expectations and these were challenges in areas of Patients registration, administration, ICT systems, Billing Procedures and systems that ultimately compromised the effectiveness and efficiency with which revenue-related operation was executed. The audit findings were as follows: Root cause: Revenue collection • Knowledge deficit Relating to classification, processes and procedures of patients enrolled on medical aid after funds have been depleted or exhausted from the Private Sector/clinics patients are then transferred to the Public hospitals and classified as HI -R40 per 30 days H2 paying R40 per days) instead of being classified as Private medical aid patients and be charged as per Uniform Patient Fee Schedule tariffs and according to level of care that means: ICU-Intensive care unit-patients are charged R3060 for every twelve hours,Highcare-R1232 every twelve hours and General ward –R851 per day. Prescribed Minimum Benefits (PMB) knowledge deficit on PMB processes and procedures led to loss of revenue Customer dissatisfaction resulted from unnecessary cost being imposed on them by medical aids to pay for medical services incurred whilst in hospital and core payments Debts piled up leading to stress and anxiety Foreign Policy-Incorrect /Erroneous patient classification of private foreigners without proper documentation led to depletion of financial resources, tracing impossible since they move from one place to another/ or province to province even to informal settlement, the outcome write offs debts. Loss of revenue, customer dissatisfaction since some had to pay cost being imposed on them by medical aid was the main concern • Average Length of Stay (ALOS) extended due to chronic conditions e.g. diabetes stroke HIV/AIDS/TB led to overcrowding impacted negatively on bed occupancy rates. • Measures The Department of Revenue and Budget Administration was faced with a huge over-expenditure on voted budget which necessitated a mind shift towards and more aggressive and strategic approach to generate revenue in Public hospitals. Inaccurate capturing of pertinent data and ICD 10 Coding on the PAAB system especially patient enrolled on medical aid led to rejection of claims or stale accounts submitted for settlement to the Fund The above mentioned issues were of public concern and affected the South African Catchment population of close to 3 million according to 2011 census not considering foreign nationals BUT deeply affected unemployed and low income group and there was a dire need to solve them. Creative/innovative ideas Case managers at Tembisa Hospital laid down a foundation for case management and independently developed Vision, Mission Statement, Protocols in line with the National Core Standard M16 Assessment Tool, Procedure Manual Medical Scheme Act 38 of 1998 etc. Gauteng Department of Health established case management services at public hospitals to facilitate, communication and coordination of services between the service provider, and funders to promote quality, safe and cost effective health outcomes for the individual patient (482 word count)

B. Strategic Approach

 2. What was the solution?
2. What was the solution? • Restructuring of the Revenue and Budget Administration Department and the proposal of case management in the Public Sector as a TURNAROUND Strategy to generate and augment revenue. • Constitutional Mandate to identify patient’s needs and introduction of alternative means of hospitalization by CASE MANAGER led to reduced Average Length of Stay thus reduced Cost and Patient Day Equivalent • Introduction of National Core Standard /Office of the Compliance Standards to promote quality, safety and access for customer care with accountability ,responsibilities and excellence outcomes ( Assessment Tool M16)

 3. How did the initiative solve the problem and improve people’s lives?
Community Empowerment The burden of chronic diseases is likely to rise with our rapidly ageing population and changing lifestyles, and will present profound challenges to the poor of the poorest resulting in morbidity and high mortality rates impacting negatively on healthcare delivery and financing systems over the next 20 to 30 years. The containment and optimal management of these conditions require a strong emphasis on: • Patient education and • Development of integrated models of healthcare delivery in place of the present uncoordinated, compartmentalised way of delivering healthcare. Case mangers observed an increase in trauma, • increase in non-communicable disease(hypertension, diabetes complicating into diabetic leg ulcers • Increase into communicable disease for example: (HIV/AIDS/TB) results in nosocomial infection resulting in overcrowding of the hospital To reduce mortality, morbidity and complications, and improving functional status through alternative means of hospitalisation Case manager came up with innovative ideas: Identification of patients needs is a Constitutional Mandate Embarked on Community Empowerment gave health education/talk to the families/patients during visiting hours highlighting the importance of compliance to treatment thus reducing complications and cyclical readmissions to the acute setting TARGET AUDIENCE Chronically ill patients (Senior Citizens) not on proactive treatment diagnosed as having stroke and terminally ill patients diagnosed as having cancer, these patients need not be admitted to Tertiary hospital but may be referred to alternative means of hospitalization i.e. step down facilities, Home based care , Rehabilitation /Step-down/ Palliative or /Hospice centers which are 24/7 with doctor and nurses on duty for constant nursing interventions like observations, position changing to avoid bedsores, feeding and daily full wash. Goal of health talk/education • Adjust to living as independently and safety as possible • To reduce cyclical patterns of short-term readmission to acute facility thus reduce cost • To reduce chances of patients developing nosocomial infections South Africa Social Security Agency, Where beneficiaries can get different types of grants. ‎Older Persons · ‎Child Support Grant · ‎Disability Grant · ‎Care Dependency Grant Must be resident in South Africa and must be 18 to 60 years of Must be a South African citizen, permanent resident or refugee Women and youth were referred to Masakhane Clinic for voluntary testing of HIV/AIDS/TB. Packages of female and male condoms were provided (see attached attended register) Community Empowerment reduced average length of stay from 27.8 days to 10 days e.g. (HIV/AIDS/TB) thus saved cost (See attached Medikredit report) Terminally ill patients and HIV/AIDS/TB were referred to rehabilitation centres with nurses and doctors 24/7 OUTREACH PROGRAMS: Wounds referred to clinics and Home based care Some were referred to Old age home within the community in Tembisa Township The non-existence of down referral facility prompted the idea of Out Patients Wound Management Clinic to address service delivery challenges in the work place Embarked on a new wound clinic project to reduce overcrowding thus reduce nosocomial infection which delay wound healing. STRATEGY IMPLEMENTATION PULL AND PUSH STRATEGY (Marketing Strategy) • Aggressively promoting the concept of Case Management, PMB (Prescribed Minimum Benefit) and building a reputation with customers thus generate revenue. TOOLS USED • Uniform Patient Fee Schedule Tariff guide • Charge sheet • Prescribed Minimum Benefit • Training and development of staff • Mentoring and one-on-one interviews OBJECTIVES/GOALS • To determine whether the ongoing services are reasonable, medically necessary, and covered by the benefits • To establish protocols to manage financial risks for payment of care protect and mitigate against unnecessary cost being imposed on patients when funds become exhausted or depleted • To reduce average length of stay thus minimize nosocomial infection and cost • To reduce claims rejections and stale accounts (Word count 590)

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Tembisa Hospital is known as the centre for Benchmarking on case management for the whole of Gauteng Province also Cross Border Province-St.Ritas Limpopo Province Promotes learning and exchange of knowledge and expertise on innovation and created a competitive edge amongst staff in the public sector LIST THE IINOVATIVE Reduced average length of stay: HIV/AIDS/TB from 27.50 days to 10 days Preferences : there is a Paradigm shift, customers /patients enrolled on medical aid are now consulting at Tembisa Hospital outpatients/family medicine which is 24/7 with doctor and nurses on duty and had become the “thee’ Designated Service Provider (DSP network) The Survey conducted showed that perception and staff attitude was modified Revenue collection Collaboration with Billing displayed efficiency in Revenue generation and collection ensuring that expectations and targets are met e.g. Target set for Tembisa hospital 2014/2015 was: R19180103 Revenue collected by the end of March: R20444613.86 Over collected by R1, 127,000 which was beyond our expectation Competitive Edge: Case Management project created a competitive edge amongst staff and stimulated internal motivation for staff to enter for different competitions to improve quality performance and raised a bar and efficiency in the standard of nursing care. (195 word count)

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Case manager at Tembisa Tertiary hospital implemented the initiative. Population of close to 3 million according to 2011 census not considering foreign nationals (See attached map) DESCRIPTION OF THE ORGANIZATION AND HOW MANY PEOPLE IT BENEFITED • The hospital was established in 1972 is It is situated in the Ekurhuleni Metro There are 840 approved and useable beds • Catchment population of close to 3 million according to 2011 census not considering foreign nationals. • Approved Personnel Establishment of 1865 • Provide both Generalised and Specialised Services • Supported by 1 Community Health Centre and 1 Memorandum of Understanding and 22 local clinics with no extended hours of service, no referral district or regional hospital. • Tembisa Hospital is overburdened with high BUR which is compounded by lack of primary health facilities like the district hospital. • Social Challenges like substance abuse always lead to high incident of crime, stabs, gunshot etc. which overburdens service demands on the hospital. • Other challenges of socio-economic nature like illegal connection of electricity, results in serious injuries like severe burns which further place strain on the hospital. • The catchment area of the hospital spread across three Metros meaning that political interventions at community level cannot be uniform. Johannesburg, Tshwane and Ekurhuleni areas forms part of the hospital catchment area. • Observed was an increase in trauma, • increase in non-communicable disease(hypertension, diabetes complicating into diabetic leg ulcers • Increase into communicable disease for example: (HIV/AIDS/TB) results in nosocomial infection. • The non-existence of down referral facility prompted the idea of Out Patients Wound Management Clinic to address service delivery challenges in the work place. The hospital plans to use proper referral system with aligned Protocols and procedures for management of wounds and burns post discharge. • There need to be proper communication between hospital and the community clinics so as to enable for review of patients that need to dress at the clinics. • Currently patients with diabetic leg ulcers, bedsores, stab wounds, burns are discharged via Outreach Programmes Teams for dressings. • Children are referred and dressed back to the ward 21 paediatrics dept. WHAT TO DO • Financial support for infrastructure as outlined • Sponsoring by companies of certain amounts towards the realisation of the project • Companies to donate furniture, equipment and other things necessary to ensure wound clinic success • A training program for nurses in wound care • Partnership towards facilitating, and supporting a sub-cluster approach in wound within Ekurhuleni. • Assistance with research programs on wound care (399 WORD COUNT)
 6. How was the strategy implemented and what resources were mobilized?
Funded by Tembisa Hospital CEO FACILITY PREPAREDNESS ACTIVITY START DATE EDD DATE BY WHO Status Comments Background of the facility and abstract Makwela M Identify risks Identify (people)key individuals and competent staff Review minimum requirements for the position Identify a purpose/goals Recruitment and Selection Develop the hierarchical structure Makwela M Develop training programme for the staff Identify all task required Makwela M Identify documents ,policies and standards for training Makwela M Identify the Target audience Makwela M Hardware: Arrange and purchase hardware, equipment and computers/or use old repaired ones to save cost Makwela M Identify original operating systems for effective usage and develop other systems Makwela M Identify Tools means to generate and augment revenue Makwela M Develop a protocol to effect mitigation as an advocacy to protect patients from unnecessary cost being imposed on them and not having access to care in line with National Core Standard Makwela M Develop a Marketing Strategy Makwela M Identify means to control average length of hospital stay, save cost and per day equivalent Community Empowerment: Health education for the family/patients respectively to reduce ALOS and Patient Day Equivalent Makwela M Attach attended register Provide alternative means of hospitalisation for example: Rehab, Step-down 24/7,Hospice for terminally ill patients and pain control Palliative care Makwela M Referral means to OUTREACH programmes to reduce ALOS and overcrowding Makwela M Evidence monthly statistics of all referred patients Mention ways to sustain the project for example: ongoing training and development Makwela M Attach attended register Mention challenges and set solutions to solve them Makwela M Define the replicability and its outcome IMPLEMENTATION Launch the project and its programs Makwela M Develop processes steps for the project Makwela M Interview personnel and draw hierarchical structure as per organization Makwela M Conduct orientation and induction for new staff on the project Makwela M Attach attended register Educate and provide practical training for healthcare providers Makwela M Attach attended register Involve Private Public Partnership agents to provide in-house training for the staff to enhance the skill, in capturing of pertinent date and ICD 10 CODING Makwela M Attach attended register Meetings, in-service, demonstrations conferences Makwela M Attach attended register Embark on Client satisfaction survey Makwela M Submit survey report to the CEO and Executive Develop Mission, Vision and Objectives in line with the Six Quality Priorities and of the organization To signed by the CEO of the organization PERFORMANCE MEASURES Admissions: in-patients and all externally funded patients Makwela M Daily, Weekly ,monthly statistics Makwela M Discharged patients Makwela M Health Information for data collection Makwela M Monthly report Monthly revenue collection from BAS Makwela M Monthly revenue report from BAS central office Estimated Target set for the department year financial end March 31 2015/2016 indicate if over collected or under collected the revenue Makwela M Indicate total number of staff underwent training Makwela M Attach attended register MARKETING STRATEGY It may take 3-6month to see the return on marketing efforts Makwela M PUSH AND PULL STRATEGY Makwela M Promote the concept of case management and for Executive ,staff to buy-in Makwela M Ensure organizational Leadership understand if it takes time to build the right foundation MONITORING AND EVALUATION Checking of results monthly Track the key performance areas Embark on customer/employee satisfaction survey Makwela M Interview customers on service delivery Makwela M Submit report to the CEO Monitor monthly revenue generation Makwela M Evidence report if reached set target met Create a momentum , Celebrate success and reward the team Makwela M (WORD COUNT 576)

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Gauteng Department of Health: Revenue Management unit proposed the establishment of case management units in 2011. It was the revenue enhancement strategy by the department. Tembisa Hospital was the first Regional hospital to establish this unit and it now upgraded to Tertiary hospital offering specialised services to patients. The unit was composed of one registered nurse, one enrolled nurse and a 1 administration clerk. The implementation of the project was initiated by case management unit at Tembisa hospital. Trained staff: Doctors, nurses, administration clerks, on the concept of case management in the Public sector and for them to buy-in. Tembisa case management unit went an extra mile and involved the Community in understanding access to care and benefit of medical aid for example Prescribed Minimum Benefit .Advocacy: case managers mitigated against cost being imposed on patients unnecessary and gained customer loyalty and satisfaction. (See attached letter) Private Public Partnership involved especially in ongoing training on capturing of pertinent data relating to medical aid members, authorizations, process of claims and payments for example: GEMS ,Transmed and Medikredit company Non-Governmental Organizations were invited from Ekurhuleni Metro for smooth referral post discharge to their facilities for continuation of care namely: Palliative pain control facility for cancer patients Arebaokeng Centre, Edenvale Hospice/Rehab centre for HIV/AIDS/TB (See attached letter) Ekurhuleni Metro: CEO Dr Pekane invited them to be involved in the process of implementation for referrals of post discharge patients diagnosed as having strokes, wounds and bedsores for Homebased care (244 WORD COUNT)

 8. What were the most successful outputs and why was the initiative effective?
8.1 COMMUNITY EMPOWERMENT Empowering the community about their chronic conditions, care how to prevent complications by being compliant to treatment thus reduced cyclical patterns of short term readmissions to the acute facility. Life expectancy of the community enhanced up to 75 years Women in their reproductive age and young girls were given health talk about the prevention of HIV/aids and use of condoms and abstinence Thus reduce average length of hospital stay thus saved cost and per day equivalent Minimized nosocomial infections HIV/AIDS/TB patients ALOS from 27.5 days to 10 days (see Medikredit report attached) New cases of HIV/AIDS reduced to only 13 in 2016 from April to December 8.2 REVENUE GENERATION: the inception of the unit resulted in an increased revenue generation for example: target set for Tembisa 2015/2016 was R19, 180,103, revenue collected was R20444613. The hospital surpassed the set target beyond expectation. 8.3 Prescribed Minimum Benefit (PMB) Patients transferred in from Private sector/clinic to Public hospital because funds are exhausted or depleted denying them access to care , case managers are able to advocate for the patients ,obtain authorisation under a PMB condition and may also qualify for surgical operations to specialised hospital e.g. Steve Biko Academic for heart operations 8.4 BENCHMARKING Tembisa Provincial Tertiary Hospital is known as the center for Benchmarking on Case management for the whole of Gauteng Province, even Cross Border namely: St.Ritas Regional Hospital in Limpopo ensuring that the concept of case management is known and acknowledged. 8.5 COMPETITIVE EDGE Case Management project created a competitive edge amongst staff and stimulated internal motivation for staff to enter for different competitions to improve quality performance and raised a bar and efficiency in the standard of nursing care. Case management unit entered for competitions and won the following: • Dinaledi Service Excellence Awards 2013-Face of Government and Best National Core Standards in Case Management • Khanyisa Awards won first prize in National Core standards 2014 • Central Public Service Innovation Award-First Prize 31 /10/2014 awarded a gold/silver plated trophy and a R10,000 from sponsor DATA CENTRICS • Dinaledi Service Excellence Awards 2013-Face of Government • CMASA NATIONAL Awards at Cape Town 15th May 2013 (case study) • CMASA NATIONAL Awards at Indaba Hotel 18th April 2012 (case study) • Khanyisa Awards the best in Case Management July 2012 (377 word count)

 9. What were the main obstacles encountered and how were they overcome?
KNOWLEDGE DEFICIT On case management concept and computer literacy to nursing staff IT Department was involved in on going in-house training on computers and their skill was enhanced ERRONEOUS CLASSIFICATION of patients and application of Foreign Policy for foreigners in South Africa Case managers conducted ward rounds daily identified the gaps and spot teaching done with ward clerks, efficiency and competency enhanced PRESCRIBED MINIMUM BENEFIT lack of knowledge and procedures to access benefits funds Case managers conducted orientation and induction of staff to highlight them on case management concept ,processes and procedure on medical aid how to identify chronic disease list and be able to classify patients as private patients as per Uniform Patient Fee Schedule Tariff Rates thus generates revenue NON-DISCLOSURE Patients enrolled on medical aid do not disclose in time, hide cards and disclose on discharge in need of fit for duty letters or when they sign Refusal Hospital Treatment to be admitted at private clinics Ward Clerks are now probing questions, any patients that signed Refusal hospital treatment are followed-up, traced and obtain authorizations from their fund. Shortage of Hardware resources for example: individual computers in each department for nursing staff and ward clerk. Case managers entered into Central Public Service Innovation competitions and won first prize R10, 000 sponsored by DATA CNTRIX and was able to buy Computer, Fax, copier scanner printer machine color and black and white printer Overcrowding and non-traceable of foreigners Tembisa community has grown up to Midrand/ Diepsloot. Daily consultations at Out-patient =2000 and average admissions per day 700. The community and foreigner’s by-pass the referral system and patients cannot be turned back to the clinics once inside the hospital. Perception and staff attitude was the main obstacle due to resistant to change (292 word count)

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
10. What were the key benefits directly resulting from this initiative for people? Had a positive impact on delivery of services especially on Benchmarking with other public hospitals Promotes learning, exchange of knowledge, expertise on innovation and creation of ideas that works in the public sector. Community Empowerment Improved life expectancy of the communities by allowing case managers to refer their loved ones to an expertise facility for continuation of health care services with excellence outcomes Case manager coordinated and facilitated the process of smooth transition of care by referring patients that are terminally ill and difficult to be nursed at home by referring them to the : Hospice/Palliative care Step-down and rehabilitation centres with nurses and doctors 24/7 (see attached evidence) Out Reach Programmes post discharge nearer their residential areas if could not afford to pay for private clinics for example: wound dressing and bed sores Home based care where Team of nurses consult with all their patients at their residential homes without being charged a fee. HIV/AIDS/TB average length of stay in 2015 was 27.50 days but reduced to 10 days in 2016 (Evidence Medikredit report) Case management unit was assessed and evaluated on customer service delivery and upholding the Six Quality Priorities in line with National Core Standard set out by the Department of Health and rated 100% on M16 ASSESSMENT TOOL (Evidence attached) Made it possible for the communities to access financial assistance especially Social Grant were the families are unemployed, young girls fell pregnant in their teens and no money to buy foods they are being referred by case managers to social workers within the hospital and access social grant prior discharge from the hospital Medical aid funds being exhausted or depleted: The community benefit from case manager’s health education on chronic conditions that they can access affordable care. Debts incurred whilst in hospital case managers mitigate on behalf of the patient, teaching them about the Ex-gratia which is financial assistance from the Principal Officer of the Scheme be paid in time and stress levels relieved REVENUE GENERATION Target revenue set for Tembisa hospital by the end of 31 March 2014/2015 financial year: R19, 127,057 Revenue collected at the end of March 31 end financial year: R20444613.86 Over collected by R1, 127,000 which was beyond our expectation SUSTAINABILITY • Top-down management support from the CEO to the Executive management level to strengthen and motivate staff to attain set objectives for the organization • Invest in on-going training and development of staff / health talk / education to patients and their families for excellent outcomes • Marketing strategy: Strategy Implementation-Pull and Push Strategy as a long term • Attend seminars, workshops and conferences to enhance the skill in case management • Private Public Partnership –Medikredit/GEMS/Alexandra Forbes consulted for in-service lecture for Tembisa Administration clerks /Case Managers to enhance the skill on capturing of pertinent data (461 WORD COUNT)

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
HOW THE INNITIATIVE MADE IT EASIER FOR PEOPLE TO HOLD THE GOVERNMENT ACCOUNTABLEON THE DELIVERY OF SERVICES Department of Health had initiated an office of Standard of Compliance their objective is to support Health care institution of the Gauteng Department of Health to render quality patients care To provide for a system of customer care which includes complaints management, recognition of service excellence and provision of basic information regarding service customers? Quality Assurance involves taking positive action and evaluates performance against agreed, defined standards in order to create and manage a service which demonstrates that desired levels of quality are always present Customer dissatisfaction will be voiced from when the patient enters the hospital until discharged or treated at outpatients departments Case managers are involved and form part of quality assurance committee mange priority quality improvement projects There are complaint boxes in each department, forms to be completed by patient on care they receive whilst in hospital. For example: they may complain about the staff attitude. Patients are interviewed to assess whether they feel that they have been treated in a respectful caring manner Complainants have a variety of objectives in making their grievances known. These objectives need to be at least partially met if the complainant is to be satisfied with the response he/ she receive. Complainants have the following main objectives: • To get acknowledgement: Complainants’ views must be taken seriously. The mere fact that they had reason to complain must be acknowledged. • To receive an apology: As a simple apology can be a very important objective for complainants, such an apology, if warrant it must be given without too long a delay. • To receive an explanation: Information on what happened and why it happened needs to be provided to the complainant. This must be done in a language he/ she understands. The explanation should not deny the complainant’s experience of events and it should also not degenerate into a form of making excuses. • To prevent recurrence: People often complain in an altruistic manner to ensure something is done to prevent their (bad) experience happening to others as well. Getting a commitment to action in this regard becomes the main objective. This commitment must be given and conveyed to the complainant, and all actions committed to must be carried through. • To ask for compensation or special consideration : Often complainants want action to take place that has a more direct bearing on either their own care or the care the patient receives on whose behalf they are complaining. This may include redress such as faster or additional treatment, or even financial compensation. • To seek retribution : Although seeking retribution is rather the exception than the rule, in some cases the complainant does want steps to be taken against individual health workers/ health establishments for their ‘alleged’ wrongful actions or where they (the complainants) feel there is a cover up of mistakes.(evidence attached patient satisfaction survey) (469 word count)

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Health education on HIV/AIDS /TB. Voluntary testing for their partners Case managers will always refer them for counselling, abused they are being referred to the psychologist then to crisis center within the hospital. STATUTORY RAPE AND INCEST: cases are seen supportive of social workers and assisted in opening criminal cases Unwanted pregnancy in women and youth: The policy is in place they are examined by the gynaecologist and referred for sonar to determine weeks of gestation, and then Termination of pregnancy performed. Age 12 they are allowed to sign consent FAMILY PLANNING Injections namely Depo intramuscularly for 3 month or NUR-estrate and condoms INPLANT: INPLANON chip inserted subcutaneously suitable for youth from 18-25years, women 30-45 are screened for: hypertension and diabetes LOW BIRTH WEIGHT BABIES To reduce infant mortality rate by at least 95% Breast feeding is promoted and bottle feeding discouraged only cup feeding to avoid spread of infection by at least 95%. Milk sterile from Feed Preparation Unit. KANGAROO BONDING BY MOTHER LODGERS: infants are undressed and nursed on mother’s chest for warmth, bonding with fathers. Discharged from hospital gained 1.9 kg Handwashing prevent infection. Use of sanitary pads Unmarried apply for Social Grant ADOPTION: to childless parents. (200 WORD COUNT)

Contact Information

Institution Name:   Tembisa Provincial Tertiary hospital
Institution Type:   Government Department  
Contact Person:   Margaret Makoma Makwela
Title:   Case manager  
Telephone/ Fax:   +27 0119232321
Institution's / Project's Website:  
Address:   PRIVATE BAG X07
Postal Code:   1665
State/Province:   GAUTENG

          Go Back

Print friendly Page
video porno.. brasileiros xxx xhamster