Meeting SummaryThe National Department of Health presented its 2008/09 Annual Report. The achievements, challenges and some of the Department's priorities were listed. The Department had six programmes of action in this year. The statistics and challenges were set out across all the programmes in some depth. A general summary given at the end of the presentation listed progress against priorities. The Department had made some inroads into strengthening health programmes, but there was a long way to go, as indicated by some of the mortality data. The Department had nearly 400 public health hospitals, and had started improvements. It was on track with the development of an Integrated National Health Information System, and electronic patient records, and was in the process of finalising the National Indicator Data Set. Some work had been done to strengthen the Health Financing, outside the National Health Insurance (NHI), and the Minister would be making announcements on efforts to take that work forward in the next few days. There had been significant reduction in medicine prices. Although there were some improvement in strengthening human resources for health, there were still significant shortages in all medical professional categories. The new structure with six branches, and changes in the budget, would improve management and communication.
The Department had received a qualified audit, but the qualifications this year related to new issues, rather than those raised in previous years. There had been spending of about 98% of the appropriated amount, but the conditional grants made up 93% of total allocations, and here there had been only 95% spending. The qualifications related to the revenue management for the Medicines Control Council, and for fleet management. The Department had developed action plans to address these issues.
Members noted that it was perhaps time for a change of attitude, since the health budgets would clearly not match the needs, but stressed that the money that was made available should be properly used. Questions were raised on the reasons why so few institutions were conducting the monthly morbidity and mortality meetings, why there was so little being achieved at local levels in relation to HIV/AIDS, what the vacancy rates were for pharmacists, and how they were being deployed, and the need for more training of doctors in South Africa, which it was felt could be done by private institutions, rather than sending students to train in Cuba. Members also asked what had gone wrong in the provision of antiretrovirals in Free State, when the Committee would be addressed on the National Health Insurance system, what work had already been done on this, and what had been done in Limpopo to achieve the review on communicable diseases. Members asked for further details around the qualifications, commented that perhaps the Department was setting itself for failure by not setting realistic targets. They also cited instances of poor infrastructure and planning at Groote Schuur Hospital, the lack of mention of Foetal Alcohol Syndrome, the lack of focus on obesity, what plans were in place for immunisation of children, especially against measles, and whether foreign doctors were being taught to communicate in the local languages of the areas where they were working. It was noted that further issues would be addressed the following week.
Department of Health: Annual Report 2008/09
Mr Yogan Pillay, Deputy Director General, National Department of Health, presented the Annual Report for 2008/09 for the National Department of Health (the Department or NDOH). The Department's vision was to provide an accessible, caring and highly quality health system. That was not only a reflection on the public health system but on the private health system as well. The mission of the Department was to improve health status through prevention of illness and disease through the promotion of a healthy lifestyle and to consistently improve the health care delivery system by focusing on access, equity, efficiency, quality and sustainability. Several pieces of legislation informed the way in which the Department should function (see document).
There were eight priorities for 2008/09. NDOH was to strengthen Health Programmes, to develop and implement health facility improvement plans, to develop an integrated national health information system, to strengthen health financing, which included the introduction of National Health Insurance (NHI), to achieve further reduction in the prices of medicine and pharmaceutical products, to strengthen human resources for health, to strengthen international health relations and finally to improve management and communication.
Programme 1: Administration had focused on improving the administration of the Department in various ways. The Department had completed its 15-year review of the performance. A turnaround strategy was done to improve audit outcomes, which were an ongoing issue. Queries from the Auditor General were responded to within ten days. The South African National AIDS Council received an unqualified audit opinion for 2008/09. The Department had tried to address all the concerns of the Auditor General in the Annual Report of 2007/08.
Under this programme, NDOH had also sent all nine provinces the Health Sector Planning and Annual Performance Plans (APPs) that the provinces had to develop in terms of legislation. NDOH was able to analyse all of the APPs for the period 2008/09 through to 2010/11, and also to monitor the performance of the public health system in particular. A draft communication strategy for the Department was produced, to provide an avenue for interacting with from stakeholders and to inform the public on key health issues.
Despite the progress that the Department had made, there were still a number of challenges. There were certain weaknesses in the management and leadership of the health system at all levels of the system, weaknesses in the way the primary health care system and the district health care system had been functioning, and a less-than-optimal health information system.
NDOH had received a qualified audit report for this year. The qualifications related to a lack of reconciliation from pharmaceutical companies for the fees that were received by the Medicines Control Council. Secondly, the Department's national fleet showed some difficulty in respect to reconciliation of payments to the use of vehicles. The Department was also experiencing was the withdrawal and issuing of allocation letters for 2009/10 by the National Treasury, which affected the completion of Provincial APPs for 2009/10. The Department was trying to get the planning process to lead the budgeting process, so that it could become clearer firstly what was needed, and then the funding for that could be allocated. When allocation letters were not received early enough, plans could not be finalised. The Department did, however, finalise its plans before the end of the financial year.
With regard to Programme 2: Strategic Health Programmes, Mr Pillay noted that HIV/AIDS, TB, other communicable diseases and non-communicable diseases resided under the Strategic Health Programmes (SHPs) in terms of planning and budgeting. He listed some achievements. National full immunisation coverage increased from 85.2% in 2007/08 to 88.8% in 2008/09. The World Health Organisation (WHO) had a “Reach Every District” strategy which included a number of components. The Department had asked all provinces to include that strategy in all districts, and during the 2008/09 financial year had targeted at 30 out of 52 health districts in the country, and 42 districts had implemented that strategy.
There were no measles outbreaks in 2008/09, and no deaths from measles were experienced during that period. However, in 2009/10 there were reports of measles outbreaks in Gauteng and other isolated cases in a number of other provinces. Over 734 409 people living with debilitating conditions, including chronic diseases, had been provided with nutritional supplements, which exceeded targets. The South African National AIDS Council (SANAC) had been restructured and the Secretariat had been strengthened, and it would coordinate all sectors of government and civil society in their response and implementation of the National Strategic Plan for HIV/AIDS of 2007/11.
HIV prevention efforts had been strengthened with over 4 million condoms distributed. However, there had been less male condoms delivered than were targeted, due to significant delays in the awarding of tenders. The number of patients on antiretroviral (ARV) therapy had increased significantly, to more than 780 000 by end April 2009, compared to 483 000 patients in April 2007. By the end of 2009 the Department planned on having more than 990 000 patients on antiretroviral treatment.
The analysis of TB data always lagged behind the WHO recommendations. The TB data rate for 2007 was 64%, compared to the 2006 figure of 57.7%. Even though there had been improvements, the world's target for cure rate was 85%, which meant that South Africa was significantly low when compared to the international benchmark for cure rates. Three years ago the Department had identified four crisis districts for TB, being Amatole, Nelson Mandela Bay, Johannesburg, and eThekwini. Johannesburg had reached the closest to its target for cure rates, while the others were struggling. The TB defaulter rate had decreased from 10% in 2006 and to 7% in 2007.
The Department continued to do well with regard to malaria, and was likely to reach Millennium Development Goal (MDG) targets. The Department was now trying to eradicate, rather than control, malaria. There had been a decrease in malaria linked deaths, from 0.8% in 2007/08 to 0.6% in 2008/09.
The Department faced challenges under this programme in the number of districts with immunisation coverage rates of less than 80%. The target was to cover 90% of all districts. The Department had 27 out of 52 districts with measles coverage. 53% of its public health institutions, seen against a target of 70%, conducted monthly mortality and morbidity meetings
The Department still screened only 45% of HIV positive patients for TB, against a target of 60%. The Minister had released the antenatal and syphilis survey results for 2008 for HIV (see document). This indicated that the national HIV prevalence was still high at 29.3%, but it seemed it seemed to be showing a stabilisation. The Department was trying to establish what that meant, whether it was showing decrease in new infections, or people living longer with the disease.
The Department had guidelines for the management of non-communicable diseases at primary health care facilities, and noted that non-communicable diseases showed greater prevalence overall. These included hypertension, diabetes, cardiovascular diseases and there were a growing number of people who were being killed by interpersonal related violence.
The Department had a cataract surgery rate of 1 237 per million people for 2008/09, against a target of 1 600 per million people. There were insufficient optometric surgeons to perform cataract surgery. The Department had also set a target of six weeks wait for wheelchairs for those who qualified, reducing from the current eight-weeks wait. The Department needed to improve its capacity to respond to wheelchair requests.
Mr Pillay moved on to Programme 3: Health Planning and Monitoring, which included the comprehensive HIV/AIDS care and management and treatment plan, which was introduced in 2004, and which catered for ARV treatment. Together with the University of KwaZulu-Natal, the Department also produced a National Infection Prevention and Control Manual for youth by province and facilities.
The Department had started a process of doing an audit on all health systems, which included all pieces of software in the country. That was being done through a consortium and was being public managed by the State Information and Technology Agency(SITA). The intention was to create an electronic health network,. The Department also developed an electronic White Paper jointly with the Presidential National Commission on Information. The Department continuously reviewed its annual refining of health statistics in the National Indicator Data System.
There was an ongoing attempt to decrease the prices of medicine. NDOH estimated that the efforts had resulted in a 30% decrease, translated into a net saving of R3 billion. The media had recently picked up on prices for antiretroviral medication, and there was ongoing work on the benchmarking of antiretroviral issues.
Ongoing challenges with Programme 3 mainly related to the quality of data. There were problems in reaching agreement on the infant mortality rate and the maternal mortality rate. The Department had been trying to get consensus on those by doing demographic and health surveys. The first was done in 1998 and the second one in 2003, with another, scheduled for 2008, that had to be cancelled due to resource constraints. In addition, the tracking system for the distribution of pharmaceuticals, to ensure that those products reached the intended patient level, had not gone as planned. The Department still had drug stock shortages at facility level, perhaps due to suppliers being unable to supply to the medical depots, or facilities not ordering supplies on time. The Department had also advised all doctors to keep a two month supply of stock at all facilities. A further challenge related to the shortage of licensed dispensers inspected in the financial year due to chronic shortages of pharmacists.
There was also limited progress made with the review of the hospital level of standard treatment guidelines and essential drug lists, again due to the shortage of pharmacists. The Occupation Specific Dispensation (OSD) for pharmacists would help at a provincial level and the Department hoped that some of the challenges related to the shortage of pharmacists would stabilise over the years. The recommendations of the Medicine Pricing Committee had been challenged by the pharmaceutical industry.
Programme 4 related to Human Resource Management. Eight provinces produced Provincial Human Resources for Health (HRH) plans. The South African Dental Technicians Council was inaugurated on 27 June 2008, and a new South African Nursing Council was inaugurated in July of 2008, which was in keeping with the national target. The Department was still completing its review of the HRH planning framework, which could not be completed owing to funding constraints.
Programme 5 covered Special Programmes and Health Entities Management. Here the planning process at district level had been strengthened, with 47 out of the 52 districts producing district health plans. The Department would have liked to have seen district health plans link closely with the Municipalities’ Integrated Development Plans (IDPs), to get the inspectoral collaboration which was key for primary health care. Only 37 out of the 52 health districts showed clear integrated development plans. The clinic supervisor rate was defined by the number of primary health care clinics visited by a supervisor from the district at least once a month. This should have risen to 100%, but instead it declined from 69% to 61%, most often because of lack of transport to visit facilities. 22 hospitals had been equipped to perform the benefit medical exam for occupational health miners.
The Department also experienced challenges under Programme 5 with the limited progress on development of health technology relations, due to a lack of certainty about the exact legislation to govern those regulations. The Department's Emergency Centre Regulations had not been finalised.
Two pieces of legislation were passed by Parliament; the Medicine and Related Substances Bill and Tobacco Products Control Amendment Bill. The Medical Schemes Amendment Bill and the National Health Amendment Bill were tabled as planned. 100% of public institutions were now smoke free areas.
Programme six was the International Relations, Health Trade and Health Product Regulations programme. A number of bi-lateral and multi-lateral agreements had been signed, including those with Namibia, Cameroon and Burundi, while others were put into action. 60 students had been sent to Cuba for training as medical doctors from October 2008. 41 final year medical students passed their exams in December 2008, who were now doing rotations in the South African Military.
The summary of progress against priorities was then tabled and discussed. The Department had made some inroads into strengthening health programmes, but there was a long way to go. Some of the mortality data substantiated the extent to which South Africa must still go. The Department had nearly 400 public health hospitals, and had started improvements in after doing a vigorous assessment in 2010, which showed that the Department needed to upscale dramatically. It was on track with the development of an Integrated National Health Information System, and electronic patient records, and was in the process of finalising the National Indicator Data Set. Some work had been done to strengthen the Health Financing, outside the National Health Insurance (NHI), and the Minister would be making announcements on efforts to take that work forward in the next few days. There had been significant reduction in medicine prices. Although there were some improvement in strengthening human resources for health, there were still significant shortages in all medical professional categories, and servicing the agreements with other countries with the capacity that the Department had would be an initiative for the future. The new structure with six branches, and changes in the budget, would improve management and communication.
The final appropriation for the NDOH, for the Department alone, not the whole health system, was R15 billion (not R15 million as indicated in the document). R14 billion of that was in conditional grants. The amount allocated for the functioning of the NDOH was R1 billion. Actual total expenditure amounted to R15.4 billion which was almost 98% of the appropriated amount. There was under-expenditure of R386 million (2.4% of total expenditure). The conditional grants expenditure made up 93%.
The budget allocations and spending for each of the programmes was set out (see attached document). 95% of the conditional grants – described as the comprehensive HIV and AIDS grants, forensic pathology services, health professions training and development grants, hospital revitalisation grant and the national tertiary services grants – was spent.
The Department received a qualified audit opinion. The previous year’s qualifications had been addressed to the satisfaction of the Auditor-General (AG). The qualifications this year lay in new qualification areas. These related to the revenue management for the Medicine Control Council, and the travel and subsistence related to the use of vehicles for the Department's fleet management in the National Department. Action plans were developed in September 2009 to address the two weaknesses. Monthly monitoring and reporting systems were now in place to ensure that those negative audit opinions did not recur.
Mr Pillay outlined the ten new NDOH priorities for 2009/14. These were the provision of strategic leadership and creation of a social compact for better health outcomes, the implementation of a national health insurance plan, improving quality of care of health services, overhauling the health care system and improving its management. NDOH would further improve human resources management, attend to revitalisation of physical infrastructure, accelerate implementation of HIV and AIDS plans and reduction of mortality due to TB and associated diseases, undertake mass mobilisation for better health for the population, undertake the review of the drug policy and strengthen research and development. Despite many challenges, it would continue to work for achievement of these targets.
Ms M Segale-Diswai (ANC) said that she believed it was time for a change of attitudes towards health issues. The health budget was clearly not where it should be, but the money available should be used to the best of the Department's ability.
Ms Segale-Diswai referred to page 10, where mention was made of the 53% of health institutions which conducted monthly morbidity and mortality meetings, which was clearly not sufficient, since these meetings were important in addressing what was happening at facility levels.
Ms Segale-Diswai then referred to page 11, and queried what SANAC’s leadership meant to the local AIDS councils, where in some areas nothing was happening, although people were being hired and resources were being made available.
Ms Segale-Diswai said that the manual data capturing, especially HIV capturing, was working well and enquired why the two systems of manual and electronic could not be used to capture cure rates.
Ms Segale-Diswai wanted to know what the vacancy rate was and how the pharmacists were being utilised.
Mr M Waters (DA) commented on the students that went to Cuba to train to become doctors, and enquired why DOH was not increasing its own capacity to recruit and train doctors. The universities had been static for the last 10 to 15 years, with enrolment figures not increasing, and he commented that it made no sense to prevent the private sector from training doctors while allowing a foreign government to do so.
Mr Waters commented that Free State had had some evaluation on its ARV system, yet had stopped the roll out of antiretrovirals for a while. He enquired what had gone wrong, and whether Free State had applied for emergency funding.
Mr Waters noted that the Minister was yet to address Members on the NHI, yet pointed out that it was listed as a priority. He asked what work had been done on this, outside of the Department, and whether there was yet any costing or funding for this scheme.
Mr Waters commented that it was most disappointing that the NDOH had received qualified audit reports for nine years in a row.
Mr Waters said that he was aware that the provinces were generally underfunded. However, if targets were set knowing that it was unlikely that more funding would be given, then the Department was only setting itself up for failure against those targets.
Mr Waters asked how many of the millennium goals did the Department think it was going to achieve.
Mr Waters noted that in the previous year all provinces, with the exception of Limpopo, had a strategic plan for the review on communicable diseases He wanted to know whether Limpopo had finalised its report yet.
Mr Waters said that it was mentioned that nationally 63% of hospitals were equipped. However, he knew that at Groote Schuur Hospital men and women were put into one room, and some of them were forced to sit on the floors due to there being insufficient beds. He said that that was unacceptable.
Mr Waters said noted that no mention was made, under substance abuse, no mention was made of Foetal Alcohol Syndrome (FAS), and wanted to know what was being done about it in light of South Africa’s highest world-rate for this system.
Ms C Dudley (ACDP) asked what the plans were to speed up the nursing children's project.
Ms Dudley referred to the NHI plans and also enquired when the public was going to be brought on board.
Ms Dudley asked whether special measures were being put into plan for the immunisation of children with measles.
Ms A Luthuli (ANC) said that not enough emphasis had been placed on the fact that there were serious weaknesses of management and leadership across all levels of the health system. She noted the comment that the vision had in some areas been lost, and that there was not a functional infrastructure, and asked for more information on these comments.
Ms Luthuli also commented on the 53% of health institutions who conducted monthly morbidity and mortality meetings, against a target of 70%, and enquired what the current targets were.
Ms Luthuli asked what was being done to try to address obesity.
Ms Luthuli also asked why there were so few imbizos as she believed they were critical.
Ms Luthuli asked whether the foreign doctors were being taught to communicate in the languages of the areas in which they were based.
Ms E More (DA) said that certain projects and programmes were not done, due to a lack of funding, and she wanted to know what the Department was doing to address this..
Ms Kamy Chetty, Acting Director General, National Department of Health, answered some of the questions in broad terms. In regard to the questions around the NHI, she noted that the NHI was seen as one point that was divorced, at present, from all other aspects of the public health system. The Minister had stressed that the implementation of NHI was intended to strengthen the public health system, improve the quality of health care and overhaul the total health system in order to ensure that there was effective implementation. At the moment, the framework of the NHI was going through a Cabinet process, and the Minister would be briefing the Committee on the progress. Whilst the Annual Report contained a comment that implementation had started, this referred to the strengthening of the health system, which was one of the key points of the implementation of the NHI.
Ms Chetty referred to the under spend on programmes. She was grateful that the Committee had categorically stated that the health system was under-funded. The Foreword to the Annual Report, by the Director General, had made that very same point. She understood the argument that it was difficult to argue for more funding in the light of under spending, but felt that this must be put in context. The under-spending had happened in specific programmes, where the funding was earmarked for certain functions, as conditional grants, meaning that they could not be shifted to other areas where there was pressure. The Department generally did try to monitor these issues and would often ask National Treasury for permission to move funds.
Mr Percy Mahlathi, Deputy Director General, National Department of Health, answered the human resources related questions. He commented on the morbidity and mortality meetings and the target. In order for the meetings to be effective, there was a need to have senior professionals present, and over the last few years there had not been sufficient available to hold the meetings, due to the general shortage of professionals.
With regard to pharmacists, there were several reasons for the shortage, but he noted that the Department was trying to address the issues. It was currently reviewing the strategic planning framework, and one of the priorities was to work with the training institutions, the Department of Education and National Treasury. There had been a challenge in lack of funding for the institutions, and lack of trainers. This was not related to salaries alone, so the Department was also looking at career progression and performance management. The pharmacists were being utilised appropriately, but the more work they had, the less time was available for them to travel. The Department had been in discussion with the South African Pharmaceutical Council around the training of pharmacists. That intervention had produced good results already.
Mr Mahlathi explained that the agreement at the Bargaining Council was that if someone held a qualification then they he/she must be registered for Occupation Specific Dispensation.
Mr Mahlathi noted that the different institutions were working together on the issue of training. There was not a shortage of demand of those wanting to study medicine, but there was a shortage of lecturing staff. The University of Cape Town had lost a number of its lecturers over the years. The medical schools had to adhere to an educational ratio of teachers to students, but at that had to be financed. Insofar as the suggestions in regard to private hospitals training were concerned, the mandate for higher education in all fields lay with the Department of Education, not of Health, and there was a committee on Higher Education and Training.
Mr Mahlathi noted that the nursing college projects should have commenced last year. There had been under-expenditure reported of R10.8 million, but R10 million of that money was actually related to the tender, and some meetings had been held to solve the problem.
Mr Mahlathi clarified that the examinations were for South African, not Cuban students. South African students were sent to Cuba for training, would graduate in Cuba and would then return to work in South Africa. In respect of foreign professionals, he noted that there were challenges in regard to languages. There were some universities, such as Wits, that were trying to bridge the gap.
Mr Mahlathi said one again, the challenge with shortages of technical skills, related to the difficulty in attracting and retaining technical trainers across the sector. it was one of the issues which government needed to review.
Mr Pillay then addressed other general health issues. He noted that the most common cause of death as recorded in the death certificates was TB, which was ranked first for both 2006 and 2007. The second most common cause was influenza and pneumonia.
Mr Pillay noted that maternal and child health started with immunisation and NDOH had targeted having 90% immunisation coverage nationally. There were still a number of districts where this was at less than 80%, where the Department was concentrating its efforts.
Mr Pillay noted that obesity was a national phenomenon which rested on diet, level of inactivity and other lifestyle issues. The Department could only do a certain amount, but the WHO had suggested a new strategy, called Health in Every Policy, so every policy that the government passed would have to include a review of linked health systems.
The Chairperson noted that further issues arising from the Annual Report would be addressed in the following week.
The meeting was adjourned.
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