Department’s Current Priorities: briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
11 September 2001
DEPARTMENT’S CURRENT PRIORITIES: BRIEFING

Chair: Dr Nkomo (ANC)

Department of Health’s website:

SUMMARY
The Department of Health explaining the its current priorities to the Committee. There was extensive discussion thereafter.

MINUTES
Ms K Chetty, the Deputy Director-General from the Department of Health, asked that it be noted that she had not been given very much time to prepare, and did not have a data projector to enable a presentation using the computer. Her presentation was thus from transparencies and due to the large number of transparencies, the presentation was slightly rushed.

She outlined the strategic plan of the department for 2001/2002, the ten-point plan which is available on the department’s web-site. The plan articulates the vision for the department, and each point in the plan has a number of goals which are set out as necessary to the fulfilment of each of the ten strategic objectives. She went through the ten points of the strategic plan:

Decreasing morbidity and mortality
The first issue here was that of disaster management, and Ms Chetty stated that the department was working together with the Department of Provincial and Local Government, particularly, to develop policy guidelines. Related to this was the issue of emergency medical services. The department is in the process of developing norms and standards, drafting regulations covering both pre- and in-hospital situations. Ms Chetty also pointed out that the department was engaged in provincialising the emergency medical services, with eight out of nine provinces completed or nearing completion.

Non-personal health services
This objective was concerned with health promotion and occupational and environmental health. In terms of health promotion, specific mention was made of the implementation and monitoring of the Tobacco Control Act, and the development of inter-departmental guidelines for health promotion. Medical waste management, in association with the Department of Environmental Affairs; the development of a National Occupational Health Strategy, including an audit of existing services with specific attention given to Port Health Services in the area of vaccination and the drafting of regulations on environmental conditions constituting health nuisances or risks were discussed under the objective of occupational and environmental health.

Chronic diseases, disability and geriatrics
Ms Chetty discussed cancer, stating awareness and health promotion as well as particular attention on cancer among children as the issues in this area. She also stated that the department was in the process of developing guidelines for the management of asthma at hospital and primary health care level and developing a strategy for the management of chronic diseases in children. In terms of disability, the focus was on assistive devices, aiming at a thirty percent reduction in the backlog by, for example, wheelchair repairs rather than replacement, and the development of norms and standards dealing with disability, as well as health promotion and the provision of information to the public about disability. In terms of this last point, the department is currently involved in a project to award certificates of accessibility to health facilities. Another key project in the area of disability, which was discussed by Ms Chetty, was the prevention of blindness. She cited a statistic that, of 240 000 cases of cataracts, it was estimated that 160 000 were correctable. In association with the Ophthalmic Society and various NGO’s, private doctors were offering their services free of charge and in cases where the patient could not afford the cost of new lenses, the Bureau for Blindness in the United States was sponsoring the costs. Linked to this was another project involving doctors from Tunisia, who as part of an agreement between South Africa and the Tunisian government, were engaged in doing similar work in the rural areas, in particular. Here again the aim was on reducing the backlog within a specified time. In terms of projects for older people, Ms Chetty stated that there were a number of projects underway, and one of the areas receiving attention was the development of educational materials aimed at promoting respect and dignity for the aged.

Communicable disease control
In the area of malaria control, Ms Chetty made mention of the fact that South Africa had received an award two months ago from the World Health Organisation recognising the achievements in malaria control made in this country. The department was currently engaged in identifying the patterns of increasing numbers of malaria cases as well as conducting research into issues around resistance to medication. Cholera was the other major communicable disease discussed. Ms Chetty made reference to the link between cholera and socio-economic conditions, as well as saying that the cholera issue had been handled very well, citing the very low case fatality rate in support of this. She also said that the department had put systems in place in preparation for the coming rainy season.

HIV/AIDS and TB were the final item to fall under the domain of reducing mortality and morbidity. Ms Chetty stated that the reduction of morbidity and mortality rates were intimately linked to these issues. The key priority this year for the department in dealing with HIV/AIDS was the provision of home based care models. Mention was also made of the implementation of an integrated plan for children, the expansion of pilot programs addressing HIV and TB together and the need to strengthen and roll out the DOTS (Directly Observed Treatment System). The department was also going to engage in attempts to reduce the impact of HIV through capacity-building, as well as prevention, through the establishment of two pilot programs per province researching mother-to-child transmission and increasing condom distribution. Legislation was also being investigated dealing with the issues of testing, public awareness and support for vaccine research, with the National Institute for Virology and the MRC. The department is also aiming to expand on treatment programs for sexually transmitted infections, strengthen the implementation of guidelines for the treatment of opportunistic infections and develop guidelines for the use of anti-retrovirals in the private sector.

At this point, Dr Baloyi (IFP) suggested that Ms Chetty rather give an overview of the ten-point plan. There was a request that the committee be provided with her notes, so that certain issues could be engaged with at a later date. This was accepted and Ms Chetty proceeded, making reference to only certain points on the transparencies.

Ms Chetty drew attention to oral health, particularly the development of policy and the need to investigate fluoridation of the water services.

Pharmaceutical services
Attention was on the National Drug Policy as a way of ensuring affordable drugs. This was linked to the need for a reliable, constant supply of drugs.

Maternal, child and women’s health
Particular reference was made to the need for an engagement in the department around the issue of genetics, and the development of youth-friendly services, including those for teenage pregnancies.

Nutrition was identified as another key concern, with Ms Chetty suggesting that food fortification, the development of a nutrition strategy for children aged 0 - 18 years, poverty alleviation programmes and the launch of guidelines for persons with debilitating diseases were the priorities in this area.

She also made reference to the issue of acute flaccid polio, the dramatic decrease in the number of cases of measles and the need for an integrated approach to the care of orphans.

Improving the quality of care
Ms Chetty outlined the main aims of the department, saying that they were: defining packages for the four different levels of care; developing norms and standards, strengthening health rights and establishing call centres and help desks in facilities across the country.

District health system
The need for speeding up delivery through the district health system was highlighted. Ms Chetty suggested that this point be discussed when the National Health Bill was proposed to the committee, although she did point out that broadly speaking the aim was to focus on clinical management and training to strengthen the district health system.

Revitalisation of the hospital services
The aim was to finalise the Integrated National Planning Framework, which would lead to the development of strategic positions in the provinces, which would encompass costing and identifying the available resources. In terms of this, Ms Chetty pointed out that hospital revitalisation was about more than refurbishing the buildings. She said that it included management and equipment, for example. Consequently, effective management was identified as one of the priorities under the revitalisation of hospital services. The development of policy on organ transplants was another objective. She also pointed out that the governance and guidelines for Hospital Boards would be examined. The last issue raised in this regard was that of step-down facilities. In order to make the best utilisation of hospital beds, the strengthening and development of such facilities was identified as a priority.

Improving resource mobility and management, while keeping to the goals of equitable resource allocation was another aspect of the national strategy. Issues highlighted here were those concerning health technology, mention being made of pilot projects investigating the regulation of medical devices; management; the restructuring of conditional grants, in collaboration with the National Treasury to look at effective utilisation; revenue retention; effective public-private partnership and the issue of Social Health Insurance.

Improve human resource delivery and management
Collective bargaining, industrial relations and compliance with the various regulations and pieces of legislation, such as SETA, were identified as areas for attention. In terms of human resources development, post-graduate studies, mid-level development, the revision of the scopes of practice as well as community service and intern allocation were all being examined.

At this point, Dr. Nkomo suggested that the best way to make use of the remaining time was to stop the presentation and have questions, since this would hopefully allow other issues to be touched upon as well.

Discussion
Dr Jassat (ANC) raised the issue of blindness, the provision of spectacles and the related costs. He said that an NGO in the United States was prepared to provide spectacles but the problem was that the tests were expensive. RAU had developed a cheaper version of the spectroscope which the Ophthalmic Society was providing. He asked if the department would be prepared to investigate ways to develop these ideas into a fully-fledged project.

A member of the ANC raised a question about the home-based care for people with HIV/AIDS. She asked what kinds of models were being investigated and how soon they were to be implemented.

Ms Njobe (ANC) asked whether there were other projects similar to the one involving the Tunisian doctors, and if so, where they were based and what criteria were used to determine where they should be based. She also pointed out that many programs seemed to be in the process of finalising issues. She asked whether the department had guidelines for this finalisation, so that the committee could monitor their progress.

Ms Baloyi (ANC) asked Ms Chetty to elaborate on the ‘provincialisation’ mentioned in her discussion of the emergency medical service and disaster management. She also asked whether health promotion was solely being focussed on the area of tobacco. She asked whether there were guidelines for dealing with medical waste in private practices. She also asked whether the priority to ensure quality of care made any provision for the retraining of staff. She also said that she would like more time to make a fuller interrogation of the various issues.

Ms Njobe said that there had been arguments over the funding of HIV/AIDS initiatives, with suggestions that there was an insufficient budget being devoted to this issue. However, she pointed out that various departments were allocating funds to their own projects dealing with the subject. She asked whether the department had a figure for the overall budget that was being devoted to awareness programs, not just from the health department.

In relation to the earlier question concerning the provincialisation of services, Ms Mnumzana (ANC) asked which one of the nine provinces were not involved.

Dr. Baloyi (IFP) asked what were the functions of the health department and the department of social development respectively, in dealing with the problem of elder abuse. Along a similar line, he asked why the department was still responsible for poverty alleviation as part of its attempt at nutritional development. He also asked whether this was working and if not, what were some of the probleMs In relation to human resource development and the hospital services review, Dr Baloyi asked how the national plan related to the provincial plan and why some of these strategies were still in the process of being developed, seven years after the new government was elected.

Ms Baloyi raised a question concerning a possible announcement by Prof. Magoba from the MRC in relation to an AIDS vaccine which had been reported in the media. She asked that the committee be informed of developments in this regard.

Ms Chetty suggested in response to this that Ms Katzenberg could report back to Ms Baloyi on this issue as she was the person most likely to have information on this. In terms of home-based care, Ms Chetty suggested that this warranted a complete discussion, but that it was a joint initiative with the department of social development. She went on to say that various models were being investigated, with varying levels of public sector and NGO involvement and that the strengths and feasibility of each were being discussed in the provinces. She also stressed that they were not just home-based, but community-based strategies as well, and consequently it was envisaged that they would be decentralised  and quite extensive, requiring NGO assistance. She drew attention to the fact that home-based care recognised the important role played by communities in addressing the impact of HIV/AIDS.

Ms Chetty then addressed the question of the Tunisian doctors, saying that the initiative was the result of an agreement reached during the minister’s visit to Tunisia. She said that groups of doctors came from Tunisia and went throughout the provinces, addressing the areas where there was the most need, particularly in the rural areas. She also suggested that she could furnish the committee with a list if desired.

Dr. Baloyi asked if the doctors imparted their knowledge to the communities.

Ms Chetty confirmed that capacity-building was built in as a key aspect of the agreement. She also discussed similar projects such as the Zanzile project in which US doctors with a range of specialities, facilitated by some measure of sponsorship, travelled to South Africa to work in hospitals and assist with strategic backlogs identified by the department as well as to help with capacity-building. She identified the arrangement with Cuban doctor as another example. She said that such arrangements were made possible by country-to-country agreements.

With regard to the issue of the deadlines for finalisation of issues raised in the strategic plan, Ms Chetty explained that the ten point plan was a 5 year strategic framework, with one year plans developed for each point. Every year, these were reviewed and recommendations made, including new projects. She also stated that the department worked very strictly to deadlines and performance management, including appraisals with incentives and bonuses as well as investigations into why deadlines were not met. The deadlines are specified in the organisational plan attached to the strategic plan.

The Chairperson asked what mechanisms were in place for the national department to ensure that the norms and standards set nationally, and disseminated to the provinces by the various directorates, were being implemented.

Ms Chetty agreed that this was somewhat problematic, given that ultimately this was agreed upon by the heads of department, since there was no statutory way of doing this. Consequently, each province was responsible for its own deadlines, although Ms Chetty qualified this by saying that the health department has been described as one of the more effective departments.

Ms Chetty then addressed Dr. Baloyi’s question about the relationship between national and provincial planning. She stated that the strategic plans of the provinces were meant to conform to the national ten-point plan. Twice a year, the national department and each province reports to Minmec? On how they have approached each of the points.

With regard to the funding for HIV/AIDS, Ms Chetty indicated that she would seek feedback, but that this was likely to be an underestimation due to the hidden costs, such as the treatments offered in hospitals for opportunistic infections which were incorporated into the daily running costs.

In terms of the issue around the provincialisation of emergency services, Ms Chetty stated that this did not concern disaster management, but was solely in regard to emergency medical services. She said that it had been found that, constitutionally, EMS was the responsibility of the provincial, and not the local government. Steps were taken as a result of this in all provinces except Gauteng. This was because in Gauteng, the EMS was linked to the emergency fire service and there were significant difficulties in separating them.

The Chairperson illustrated this by referring to the fact that in Tshwane, the mayor was attempting to deal with problems related to the shortage of ambulances.

Ms Chetty moved on to the question of health promotion, saying that tobacco control was not the only issue, citing life skills training and initiatives to control cholera as examples.

Dr Baloyi asked whether the national department had managed to integrate te various programs, saying that in terms of the district health system, there should be seamless integration. He asked how the department made sure that at the primary health care level, there was integration in the provinces.

Ms Chetty answered by saying that health promotion was a small unit which played a supportive role and this enabled integration. She said that the method employed was that of inter-sectoral and interdepartmental task teaMs Using the example of cholera, she explained how health promotion, environmental issues and disaster management were dealt with on a project management level. Another example she referred to was that of the anti-rape strategy which involved a number of departments. She did however point out that the primary ‘driver’ of each initiative was identified, to facilitate smoother and more effective management. Returning to the issue of elder abuse, she said that health was not the sole focus, but that it was related to mental health, and identifying causes so there was prevention as well as treatment.

Dr. Nkomo raised a question related to the trickle down from the planning level to the level of actual intervention. He said that up to 1994, many services were offered at the district surgeon level, with a community nurse and home visits to all but the former black areas and townships. He asked whether this had been addressed.

Dr. Baloyi attempted to clarify this point, saying it was a good example of how policy failed in implementation because of finances. The service was designed for a small cluster of people and an ‘all or none’ rule was applied. It was felt that if it was not available to someone in Umlazi, it should not be available to someone in Durban. As a result, it had been scrapped. Dr Baloyi suggested that there was a need for national guidelines for phasing this in. He also stated that the situation got worse at the level of primary care owing to the difficulties associated with integrating all levels of government. He recommended that there was a need for national guidance and that the gaps in existing legislation needed to be addressed. He said that seven years down the line, there was still not enough attention given to the “nitty-gritty” of funding shifts. He felt that there was a need for the three levels of government to get together to flesh out the issue and then propose legislation.

The chairperson thanked Dr. Baloyi for his input.

Ms Chetty indicated that there had been costing and an integrated strategy. She suggested that these issues could be dealt with during the discussion of the National Health Bill. In response to Ms Baloyi’s question concerning the retraining of staff, Ms Chetty indicated that this was a key focus of the improvement of the quality of care, and that there had been a number of meetings dealing with this issue.

Ms Baloyi asked if any input had been made at the Denosa’s Conference on quality of care.

Ms Chetty stated that there had been meetings with Denosa and NEHAWU and that the issue would be addressed in the health summit. She also indicated that the department had started discussions with DONOSA on a strategy around health staff migration.

Ms Baloyi requested that the committee be kept informed of any progress.

Ms Chetty said that with regard to the vaccine, the MRC had been involved

Ms Baloyi explained that her question had been motivated by reports that Professor Magoba had just come back from overseas and had said that it would be four or five years before a vaccine was made available.

At this point Ms Chetty offered her apologies saying she was not well enough informed on this issue and would have to report back to the committee.

Dr. Nkomo said that the MRC reported back through the Department of Arts, Science and Technology and that this was the reason the committee was not informed. He said from his understanding that the first human trials were due in January 2002. He also indicated that he’d like the committee to be informed, so that as community representatives, they could report back something other than the information gleaned from newspapers. He also said that the technical nature of medical information made journalists unreliable sources at times, underlining the need for committee members to be informed directly.

Ms Chetty asked if she had covered all the questions.

At this point the Chairperson returned to the issue of poverty alleviation programmes.

Ms Chetty said that in this regard there had been ongoing discussions with all the department sin the social sector. For the case of nutrition, it was viewed as a health matter, but that discussions with Education had been undertaken, since the nutrition programs were largely part of primary school prograMs There were also discussions with the Department of Agriculture on this issue. Despite these discussions, she indicated that there was no finality, and as a result, Health retained the responsibility.

Dr. Baloyi indicated that he was satisfied with the response, but reiterated the need for co-ordination. He raised the example of cholera, which had placed a significant burden on the health budget, which was unfunded, unless there was some success in attaining transfers from other departments who were meant to be responsible for the establishment of infrastructure, but which had been established as a result of the health department’s handling of the situation. He asked what strategies had emerged, for example were they (members of the department) sitting with Minister Kastrils and the army etc. dealing with the issue. Drawing from his experience in KwaZulu- Natal, he stated that the provincial government had spent R11-million, which was unbudgeted, and the situation had only been resolved when the national government had ‘bailed out’ the province. Dr Baloyi returned to the point that there was a need for strategies to prevent the situation whereby the Department of Health was providing toilets in an emergency.

Ms Chetty replied that, while Health initially drove the response, it came to fall under the domain of the Department of Provincial and Local Government, and it was now a joint initiative. She said that while it was difficult, there was some sense that it was being done.

Ms Chetty raised the point that she had not touched on the upcoming legislative reforMs The bills to be tabled this year (2001) include the Medical Schemes amendment Bill and the Mental Health Care Bill. She also said that the National Health Bill was due to be resubmitted to Cabinet, and the Traditional Healers Bill and the Nursing Bill were due next year.

The Chairperson thanked Ms Chetty, and said that certain issue would need to be addressed in further meetings, such as the issue of home-based care.