Department of Health Strategic Plan & Budget 2009-2012: briefing

Meeting report

Department of Health (DoH or the Department): Strategic Plan and Budget 2009-2012 briefing
Mr Thami Mseleku, Director-General, National Department of Health, presented the Department’s Strategic Plan and Budget for 2009/10-2011/12. He briefly stated the Department's vision and mission and its legislative mandates. It was important for the Department to remain focused on its core objective of ensuring that South Africans were healthy, as opposed to merely combating disease. He provided a background to the planning process regarding the development of the strategic plan and budget, taking the Committee through the different steps of each process leading to the publication of Estimates of National Expenditure (ENE) by National Treasury. He highlighted the National Health System (NHS) priorities for 2009-2014, also known as the 10-point plan. Each of these priorities was expanded in a detailed outline.

Mr Mseleku said that Priority 1 was to provide strategic leadership and create a social compact for better health outcomes by ensuring coherence in the health sector through an integrated Annual National Health Plan (ANHP) and strengthening community based leadership structures in health through training of Hospital Boards, amongst other initiatives.

Priority 2 was to implement National Health Insurance (NHI). In this regard, the Department would produce a comprehensive policy document in the form of a White Paper, proposing a framework for an integrated NHI. The Department would publish the draft NHI legislation for public comment and would finalise the process of consultation by March 2010. It would then put in place the necessary institutional and organisational structures to prepare for implementation, in collaboration with all key stakeholders from within and outside government.

Priority 3 was to improve the quality of services in the NHS. A well-capacitated Office of Standards Compliance was to be established. There would then be implementation of an integrated plan for improving the quality of health services in 18 districts, through initiatives such as the design and implementation of a national adverse-event reporting and response system, to improve patient safety and reduce unintended harm to patients. Plans were also under way for the establishment of an Ombuds Office that would receive and investigate all complaints about the quality of health services and recommend appropriate interventions.

Priority 4 was to overhaul the NHS and its management by strengthening financial management systems and budget control, to improve audit outcomes, and to reduce over-expenditure and the number of concerns raised by the Auditor-General. The Department would strengthen hospital management by enrolling a total of 150 Chief Executive Officers (CEOs) of hospitals into the Hospital Management Programme by March 2010. Some of these issues were related to positioning for the implementation of the National Health Insurance (NHI) so that the NHS would be geared towards this new financing arrangement.

Priority 5, which was to improve human resources planning and development and management, entailed a review of the framework for Human Resources for Health Plan (HRH), implementation of the plan to develop a Nursing Strategy to address the country's need for various categories of nurses, finalisation of the audit of Nursing Colleges including costing of resources for recapitalisation and the mobilisation of resources for expanded production of nurses, and the finalisation and implementation of the Occupation Specific Dispensation (OSD) for medical doctors, dentists, pharmacists and Emergency Medical Services (EMS) personnel and all outstanding categories of health workers. OSD was a government initiative to address the problem whereby professionals could, in the past, only progress up to a certain ceiling by leaving the profession and going into  management positions.

Priority 6 concerned the revitalisation of infrastructure. This would be achieved by the production of a policy guideline on Planned and Preventative Maintenance (PPM) to assist Provinces in ensuring good maintenance of health infrastructure, by a complete evaluation of five tertiary hospitals so that they would render Tertiary (T1) services and serve as provincial referral hospitals, by exploring possibilities for the structured participation of the private sector in the Hospital Revitalisation Programme, and through an audit of infrastructure and services to assess the extent to which primary healthcare services were adequately equipped for community needs.

Priority 7 was for the accelerated implementation of the HIV and AIDS strategic plan and an increased focus on tuberculosis (TB) and other communicable diseases. It would strengthen the management of TB through training of health professionals and community care-givers to support TB patients and facilitate successful completion of treatment, through conducting a national survey of drug-resistant TB and use of the results to inform the TB control programme, by strengthening inter-country and cross border control initiatives; and, as part of the planning for the 2010 FIFA Soccer World Cup, by scaling up community awareness programmes on prevention and control of communicable disease.

Priority 8 was for the mass mobilisation for better health. The DoH sought to intensify health promotion programmes and the Healthy Lifestyle Strategy (HLS) would be finalised in 2009/10. This consisted of 5 pillars, namely, nutrition, physical activity, tobacco control, alcohol and substance abuse control and safer sexual practices. DoH would be supporting provinces to implement and report on the HLS in all 52 districts, implementing of a set of key interventions for reducing alcohol abuse, and implementing a long-term care model to address non-communicable diseases and conditions such as hypertension and diabetes.

Priority 9 was a review of drug policy to improve drug supply and management and the implementation of a drug supply management information system to improve the monitoring of drug availability.

Priority 10 was on research and development. The DoH would commission research studies and surveys to generate key information for health planning, health service delivery and monitoring. The types of surveys included gathering reliable data on the health status of South Africans, including the extent of infant and maternal mortality, and conducting an Annual HIV and Syphilis Prevalence Survey. The DoH would also commission and fund research studies to assess the outcomes and impact of the implementation of the comprehensive HIV and AIDS plan.

V Rennie, Acting Chief Financial Officer, DoH, presented the Department's budget and expenditure. In total the budget for the Department was R15 billion. She highlighted certain discussion points in the figures tabled before the Committee. The under-expenditure of 4% was mainly attributed to withholding of conditional grants, and also to the setting aside of capital funds for the intended move to newly upgraded premises. The Department had requested National Treasury for a roll over of this under-expenditure. The Department had funding needs and pressures for which there had been no funding in the 2008/09 financial year. Ms Rennie provided the Committee with the Department's budget spending by economic classification, showing categories such as administration, strategic health programmes and health human resources management. She illustrated how the budget and expenditure estimates reflected priorities such as a comprehensive HIV and AIDS programme, the South African Health Products Regulatory Authority and the Office of Standards Compliance. These priority areas had been submitted to National Treasury.

Ms Rennie showed the Committee the disparity between the funds requested from National Treasury for these priorities and the actual allocation that the Department had received for the three financial years of the Medium  Term Expenditure Framework (MTEF) cycle. The Department was insufficiently funded with regard to its HIV and AIDS grant. The public health sector was experiencing pressure, particularly at provincial level, where through successive over-expenditure and accruals. Most provinces withheld payments when they saw that they were over-spending towards the end of the year, resulting in accruals and, in some cases, failure to pay creditors. They therefore went into the next financial year with a deficit, creating a vicious cycle year in and year out. Other factors creating pressure on funding were issues of compensation as a result of OSD, inflation as a result of rising fuel prices, rand depreciation and rising food prices.

Ms Rennie pointed out the particular areas of the Department's programmes that came under pressure. There was insufficient funding for the HIV and AIDS programmes and programmes for the TB epidemic, the Expanded Vaccine programme and initiatives for addressing the deterioration of health infrastructure. Provincial health expenditure had consumed 101% of what had been allocated, and there were a number of other high over-expenditures at the provincial level. The Department had limitations when it came to capital expenditure. The trend over the years had been that the full allocations for capital expenditure had not been spent, either due to delayed tender processes or poor performance by contractors.

Ms Rennie provided highlights of the bids submitted to National Treasury for 2009/10, and commented on the adverse implications of under funding with regard to the Department's comprehensive HIV and AIDS Plan, particularly at provincial level, where the Department had requested R1.4 billion but received only R200 million rand. These plans would now have to be rolled out at a slower pace, and in phases. Drugs would become a major cost driver for patients already in the system as their treatment could not be stopped. This affected the Department's desire to focus on preventative health programmes, forcing it instead to focus more on treatment. The bulk of the expenditure was therefore confined to acquiring drugs. She also outlined the budget cuts that had been effected throughout the provinces as a result of under funding of the Hospital Revitalisation plans. The National Tertiary Services Grant aimed to minimise the pressure caused by the migration of patients from rural areas and provinces without central hospitals, to the Western Cape and Gauteng, by ensuring that services would be decentralised.  The Department was not able to achieve this objective as a result of under funding. Provinces would have to use their provincial equitable share to fund the gap.

Discussion
The Chairperson commented that the Department's strategic plan and budget was people-centred. She requested clarity on the establishment of Clinic Committees and Hospital Boards to ensure good governance of hospitals. She wanted to know how this initiative would reach out to communities in rural areas.

Mr Mseleku responded that in terms of priority 1, the Department intended to have a partnership with communities to ensure that structures were revived everywhere, including rural areas. This could not be done simply by Government, and it would be important to include political parties and civil society in order to mobilise communities to participate.

Ms B Mncube (ANC, Gauteng) commended the Department for prioritising all the areas that had been discussed and agreed to at the ANC's Polokwane conference. However, the hopes that these resolutions had raised appeared to have been dashed by budget estimates and expenditure.  The issue of under funding and budget cuts would have a major impact on the electorate whose hopes had been raised during the ANC's door to door campaigning and promises in the party's manifesto.

Mr Mseleku responded that although the Department was accountable, it could not be expected to fulfil its responsibilities without the necessary resources. He pointed out that as a result of the budget cuts, the health budget had now returned to its 1996 levels, and did not match the current challenges. The fiscus alone would not be able to cope, which was the reason why the Department had embarked on an approach of pooling its resources to combat the challenges facing the health sector. DoH would also embark on initiatives that would give access to funding in the private sector, so that it would not be totally reliant on the fiscus alone. The relationship between social services, particularly health services, and the equitable share was not always recognised by some of the provinces. This meant that the health sector did not always receive what was due to it in terms of the equitable share. If it did receive all amounts, then perhaps there would be an improvement in the provinces. The issue of budget cuts was not therefore a simple and straightforward issue arising from the recession alone, but incorporated several other factors.

Ms Mncube told the Committee of an incident concerning a domestic worker who had been run over by a car in Sandton, close to a private hospital. Paramedics attending to the scene had made calls to government hospitals further away from the accident, since the victim did not have health insurance. The accident victim had subsequently died. She asked how the NHI would curb such practices by paramedics, which were surely unconstitutional, and whether there was any action that could be taken.

Mr Mseleku responded that three issues arose from this incident, if indeed there was evidence to prove the allegations. If so, then the paramedics did not follow the rules as they should have, and it was necessary to ensure that their behaviour attracted the due consequences. The private sector wanted to be assured of payment for their services, leading to the third issue, namely the financing of health care using the NHI.

Ms Mncube asked about HIV and AIDS patients who received temporary disability grants, yet subsequently had these withdrawn after their CD4 cell count went above 200. Such people were often not employed and living in poverty. Without assistance they could not buy food and therefore could not sustain their treatment programme.

Ms Boroto asked whether it was acceptable and safe for HIV and AIDS patients to have to travel to hospitals to receive grants, when in some cases they were bedridden or too frail to walk on their own. She asked if there was anything that could be done to make it possible for these grants to be disbursed in a different way.

Mr Mseleku responded that the grants were given on the basis that the recipients suffered a temporary disability. Once that disability was gone, then the reason for the grant fell away. This grant was the responsibility of the Department of Social Development and not the Department of Health. The discontinuation of the temporary disability grant was related to the definition of temporary disability. The problem lay with using an inappropriate mechanism to address this problem. It was now the responsibility of the Social Protection and Community Development Cluster to work out the problems associated with the disbursement of grants to HIV and AIDS patients, working in consultation with the Department of Health.

Ms Mncube asked what action was contemplated by the Department to curb the proliferation of fly by night “nursing colleges”.

Mr Mseleku responded that the re-opening of Nursing Colleges would increase training capacity and prevent the prevalence of nursing colleges opened up by former lecturers of the Department.

Mr T Mashamaite (ANC, Limpopo) asked for clarity on the time frames covered by this Strategic Plan.

Mr Mseleku responded that the 5 year strategic plan would be produced in October 2009.

Mr Mashamaite commented that the strategic plan was silent on adherence to the Batho Pele principles.

Mr Mseleku responded that the Department of Health differed from, for instance, Department of Home Affairs, where service delivery could be measured by the number of documents issued to people. In the DoH, the Batho Pele principles were integrated and intertwined with the issue of patient safety and patient welfare. Although implementation of Batho Pele principles was not highlighted as a specific goal in itself, they were integrated, in a number of ways, in all aspects of patient safety, handling all cases in the proper manner and with accountability.

Mr Mashamaite asked for clarity regarding the opening hours at clinics in the provinces. He wanted to know why they did not operate on a 24 hour basis.

Mr Mseleku responded that this was an ongoing saga. Problems ranged from budgetary to human resources to safety issues. The Department emphasised that, wherever possible, clinics had to remain open for 24 hours. If this was not possible then it was important to ensure that transportation was available to take patients to the nearest health facility.

Mr M De Villiers (DA, Western Cape) asked how the Department was dealing with the issue of unnecessary deaths at initiation schools, pointing out that 33 young men had died so far during 2009. 

Mr Mseleku responded that there was no proper legislation to ensure that people who performed circumcision rituals were trained and linked to hospitals who could deal with any medical emergencies or complications. It was important for the Department of Cooperative Governance and Traditional Affairs and the South African Police Service to monitor and enforce the necessary standards, to prevent a proliferation of “fly by night” circumcision schools. These illegal initiation schools were directly responsible for the high number of deaths because they did not work together with hospitals and did not have the sanction of institutions of traditional leadership. If this area was regulated and criminal sanctions imposed, it would deter people from taking chances and significantly reduce deaths resulting from initiation ceremonies. The Department had a partnership with all formalised traditional initiators, and was actually involved in their training which included identification of some of the symptoms that could lead to complications.

Mr De Villiers asked whether the budget concerns would affect the delivery of medicines.

Mr Mseleku responded that the budget constraints would affect the Provinces. The Department was working very hard to deal with those challenges, especially since the current budget had already been depleted by accruals in the Provinces, meaning that they were already operating from a deficit. There was already a problem in some provinces regarding their over expenditure and there would be implications from that over spending.

Mr De Villiers asked whether the Department was involved in advocacy regarding the H1N1 flu virus with communities in South Africa.

Mr Mseleku responded that H1N1 advocacy was mainly focused on potential areas such as ports of entry and airports. However, when it came to community advocacy, there was a need to strike a balance between creating unnecessary panic and dealing effectively with the virus. The Department was satisfied that existing awareness initiatives such as the “cough ethic” would sufficiently educate communities without raising unnecessary public alarm and panic.

Mr De Villiers asked what the Department was doing about dirt and overcrowding in hospitals.

Mr Mseleku responded that it was important, from the point of view of addressing shortage of capacity, to involve communities in cleaning up the hospitals  as opposed to leaving this responsibility solely to hospital employees.  This was therefore a partnership issue. The Department was focusing on issues of patients lying, apparently abandoned, on the floor in hospitals, and aiming to eradicate the problems.

Mr S Plaatjie (COPE, North West) asked whether the budget was contextually valid if it had a deficit upfront. He commented that government hospitals had little potential to compete with the private hospitals, both in terms of resources and personnel.

Mr Mseleku responded that every budget was contextually valid, but the surrounding circumstances would need to be examined. If this was seen as a needs based budget, then the current budget did not meet the needs and could be said to be invalid. However, if it was related to the availability of resources, then it could be seen as valid against the available resources.

The meeting was adjourned.