National Department of Health Annual Report 2008/09

Meeting report

Department of Health (NDoH) 2008/09 Annual Report briefing
Dr Kamy Chetty, Acting Director General, Department of Health, said that the President would be announcing government's efforts to strengthen healthcare later that day. She then tabled and presented her summary on the Annual Report 2008/09. The vision and mission were set out, which highlighted improvement of the health status through prevention of illness and disease, promotion of healthy lifestyles and improvement to the delivery of healthcare through access, equity, efficiency, quality and sustainability. There were 51 pieces of legislation that informed the mandate of the Department of Health. The priorities of the National Health Service for 2008/09 had included the strengthening of health programmes, health financing, including the introduction of the National Health Insurance Fund (NHI), the human resources situation, international relations, improving health facilities, as well as management and communications systems. The Department also aimed to set up  an Integrated National Health Information System, and lower the prices of medication.

Dr Chetty outlined the performance of the National Department of Health (NDoH or the Department) against the strategic plans for the year. Under Programme 1: Administration, she highlighted that the South African National Aids Council (SANAC) had received an unqualified audit opinion for 2008/09. A15-year review of the performance of the health sector was commissioned, completed and a report was submitted to the Department. A major challenge included the Department having received a Qualified Audit Opinion on the basis of two new matters. These were, firstly, the lack of a system to reconcile application forms from pharmaceutical companies to the fees received by the Medicines Control Council, and secondly, the lack of a system to enable the reconciliation of the payments for the use of vehicles under the National Fleet Public Private Partnership.

Programme 2: Strategic Health Programmes, including the immunisation programmes. The National full immunisation coverage increased from 85.2% in 2007/08, to 88.8% in 2008/09. 44 out of 52 districts implemented the Reach Every District Strategy, exceeding the 2008/09 target of 30 out of the 52 districts. No measles outbreak were reported in the financial year 2008/09 (that reported in Gauteng had occurred in the 2009/2010 financial year). There was a 29.5% decrease in malaria cases from 8 743 in 2007/08 to 6 167 in 2008/09. A TB cure rate of 64% was achieved nationally for 2007. The cure rate for 2008/09 would be reported in the Annual Report for 2009/10.

734 409 people living with debilitating conditions were given food supplements, which exceeded the target of 500 000. 93% of facilities offered Voluntary (HIV) Counselling and Testing (VCT) and 95% offered Prevention of Mother to Child Transmission facilities. 781 465 new patients started Antiretroviral Therapy by the end of April 2009, compared to 483 084 by the end of April 2007, thus showing a 38,2% increase. Just over 4 million female condoms were distributed, exceeding the target of 3,5 million. However, the targets for delivering male condoms was not reached, with only 283,4 million being distributed against the target of 450 million.

A National Antenatal and Syphilis Survey for 2008 reflected stability in HIV prevalence amongst the 15-24 year old group, with the prevalence being 22,4% in 2006, 22,1% in 2007, and 22,7% in 2008. It could mean that health promotion messages are getting through to young South Africans. However, she noted that the national HIV prevalence rate (including this group and older persons) showed a prevalence rate of 29, 3%.

Programme 3 dealt with Health Planning and monitoring. Core National Norms and standards for health facilities were produced. A National Infection Prevention and Control Manual was produced with support from the University of KwaZulu Natal (KZN). Technical work for the development of the National Health Insurance was completed. Relevant documentation for the Start-Up phase of the Electronic Health Record for South Africa (eHR.ZA) was finalised with the State Information Technology Agency (SITA). The NDoH also contributed to the development of the African Union (AU) Pharmaceutical Manufacturing Plan, with a view that to South Africa being one location where this would be run. A draft policy on African Traditional Medicine was produced.

Programme 4 dealt with Human Resources Management. Eight of the provinces produced Human Resources for Health plans.100 clinical Associate Students, exceeding the target of 36, were enrolled at University of Pretoria, WITS and Walter Sisulu..140 (against a target of 122) Hospital Managers were enrolled for a Hospital Management Training Programme. 23 Emergency Care Technicians (ECT) students graduated from the North West EMS College. The Community Health Worker (CHW) Policy was revised in collaboration with the Department of Social Development. Proposals for the Occupation Specific Dispensation (OSD) for doctors, dentists and pharmacists were developed. Challenges in this area were delays with funding for the OSD, the dispute declared by trade unions on the OSD for nurses, as well as the court interdict obtained by trade unions, stopping the implementation of OSD for nurses.

Programme 4 related to Special Programmes and Health Entities Management. 47 out of the 52 districts produced District Health Plans. Governance Committees were established in 60% of Provincial healthcare facilities (an increase from 33% in 2007/08).Hospital Boards were established in all nine provinces. A draft Disaster Management Policy was produced. Public Health Care utilisation rate increased from 2.2 visits per capita per annum, to 2.4, but was still lower than the target of 2.7. 22 hospitals were equipped to perform Benefit Medical Examinations, exceeding the target of 10.

The Medicines and Related Substances Bill, and Tobacco Products Control Amendment Bill, were passed. The Medical Schemes Amendment Bill and the national Health Amendment Bill were tabled in Parliament. Diverse public relations and marketing platforms like magazines, SABC, community radio stations, and church rallies were used to highlight health issues and promote sound health practices. 100% of public institutions were smoke free zones.

Under Programme 6: International Relations, South Africa signed bi-lateral Agreements on Health Matters with Namibia, Cameroon and Burundi. Agreements on Health with Guinea Bissau, Malawi, Mali, Sudan and Zambia were finalised and prepared for signature. A Memorandum of Understanding (MOU) between South Africa and China for Health Sector Co-operation in the area of traditional medicine was finalised. Programmes of action for Agreements with Algeria, Congo, Cameroon, Rwanda, Malawi, Nigeria and Zambia were also finalised and submitted to these countries for consideration. A surgical team from South Africa performed open heart surgery at the new Namibian Cardiac Unit, formally launched at Windhoek Central Hospital. The NDoH assisted with the establishment of the Congo Nursing Council. The NDoH provided technical assistance during a World Health Organisation (WHO) sponsored training programme for 13 developing countries on the inspection of clinical trial sites. 60 South African students left to pursue medical studies in Cuba in October 2008.

Dr Chetty presented the background to the National Department of Health Budget and Expenditure. The final appropriation for the National Department of Health for the year 2008/09 was R15 851 169. An amount of R14 362 786 was a provision for Conditional Grants. Actual total expenditure amounted to R15,464,470 , which was 97,6% of the appropriated amount. Under-expenditure was 2.4 % of the total appropriated. The conditional grants made up 93% of the total allocation. One table showed the National Department of Health appropriation excluding conditional grants, whilst another showed the summarised reasons for under spending, including Conditional Grants. Under the Administration programme, underspending was ascribed to delays experienced in the relocation to the newly upgraded Civitas Building. Reasons cited for underexpenditure on Programme 2 were the slow progress in the building of mortuaries and the payment of invoices for the Forensic Pathology Services Conditional grant at provincial level. Funds earmarked to NGOs could not be released in full before year-end. Programme 3 spent all its budget, and Programme 4’s underspending was related to the delay in finalising a tender for an audit of Nursing Colleges project. Programme 5 showed underspending that was ascribed to moneys from some provinces, in respect of Hospital Revitalisation and Forensic Pathology Services Conditional Grants due to delays with construction processes, as well as invoices not paid before year end.

The breakdown of expenditure showed R292 507 million spent on the compensation of employees,  R624 266 million spent on goods and services, and R14 868 billion appropriated for transfers and subsidies, including grants. Payments for capital assets amounted to R41 361 million out of R47 919 million. The provincial grants expenditure was also outlined.

Dr Chetty drew attention to the statements around remedial action to be taken in respect of the qualified report. From September 2009m a new plan was in place to monitor for compliance with the Public Finance Management Act (PFMA) and Treasury Regulations on a monthly basis.

The priorities for the period going forward were also set out.

Discussion
The Chairperson said that the Select Committee would like to have the minister or the Deputy Minister of Health present at a meeting, pointing out that they had never attended so far.

Mr W Faber (DA, Northern Cape) remarked that he had not seen anything on swine flu in the report. He felt it was a grave oversight, given the large numbers of soccer enthusiasts expected to descend on South Africa to attend the 2010 Soccer World Cup Tournament. He asked how prepared South Africa would be to contain an outbreak of H1N1 influenza at the World Cup. He said that he had found that OR Tambo Airport only had one hermometer (thermo scanner).

Ms Chetty answered that the Department was actively addressing the issue of H1N1. The Health Technical Task Team, NICD, developed an extensive plan, and there were ongoing discussions. NICD had concluded that inevitably there would be some visitors carrying the H1N1 virus. The Department was stocked up on medicine and vaccines. Thermometers at airports were not failsafe because a sick person could take medication to bring his temperature down, and this would not be detected by the thermometer.

Mr Faber asked how the National Health Insurance could be implemented if it had not been properly researched.

Mr S Plaatjie (COPE, Alt, North West) asked what kind of advocacy or popularisation was done to make ordinary people aware of the NHI and how it would benefit them.

Dr Chetty answered that a document would be drafted for public consultation and this would be discussed extensively with all the stakeholders. The information would be gathered and only then would the cost be determined. The public would be the consumers of the NHI, and they had to be consulted.

Mr M de Villiers (DA, Western Cape) asked why the Department was using outdated Information Technology equipment.

Ms V Rennie, Acting Deputy Director-General: Corporate Services (and Chief Financial Officer), NDoH, said that new IT equipment was being installed in the Civitas Building where the Department would be moving in the near future. A team was monitoring progress with Department of Public Works.

Mr de Villiers asked why Performance Management Agreements could not happen faster.

Dr Chetty said that the numbers in the Annual Report came from the Human Resources Department. In the Annual Report for the financial year 2009/10 there would be full submission of these agreements.

Mr de Villiers asked the delegation to elaborate on the restructuring of SANAC.

Ms Rennie explained that according to the financial report, SANAC was dormant, because there was no financial activity through the administration of SANAC for the financial year 2008/09.The previous signatories were in the process of being replaced by the current members. The Department was paying SANAC's accounts during this period.

Mr Plaatjie asked why the Collective Bargaining Agreement for Doctors and pharmacists had not been signed.

Dr Percy Mahlathi, Deputy Director General, National Department of Health, answered that the Annual Report addressed the period 2008/09. Since then, the issues of doctors, dentists and pharmacists had been resolved. There was an agreement with labour to look after the outstanding issues. The agreements had been reached and were awaiting signature by the unions.

Ms B Mncube (Gauteng, ANC) asked a question about provincialisation. She said that nurses employed by municipalities in most instances earned much higher salaries and had better working conditions that those working in provincial hospitals. The salaries also depended on what the municipalities could afford, with the result that nurses would migrate to the municipalities where the earnings were highest, leaving many vacant posts in poorer municipalities.

Dr Mahlathi answered that there were disparities between what municipalities and provinces paid nurses. Most nurses were part of public bargaining councils and many different agreements were reached within these. The differences needed to be addressed. He said that two provinces were already provincialised. Others were in the process of being provincialised.. There was resistance to the process, because nurses working for local authorities earned more than nurses working for the province. Some of the resistance came from South African Nursing Association (SANA), which obtained a court interdict to stop the process, and this was complicating matters.

Ms Mncube said that, according to the report, 63% of hospitals nationally were listed and equipped as 72 hour assessment facilities for Mental Health in terms of the Mental Health Care Act. She asked for a list of these hospitals.

Prof Melvyn Freeman, Acting Deputy Director General, NdoH, reiterated that there was a 72 hour mental health assessment service available at Provincial Hospitals. The clinics would have the list of centres available, because they knew where to refer patients.

Ms Mncube commented on the fact that the waiting period for a wheel chair was 8 weeks, instead of 6 weeks. She said that the disabled thought that they were not prioritised.

Prof Freeman said that there were dwindling numbers of wheelchairs, because the high mortality areas like TB and HIV usurped more finances and attention.

Ms Mncube asked where to obtain details of the 10 point plan.

The Chairperson asked how the Department planned to address weakness in leadership.

Mr Thulani Masilela, Chief Director: Strategic Planning, NdoH, said that two reviews were done, the first by the Department itself, and another by an independent agency. There were several key findings. The reviews found that mistakes were made in the management of HIV and AIDS, such as the delay in commencing treatment with anti-retroviral medication. Secondly, health outcomes were not consistent with the resources that went into healthcare, and the results did not justify the expenditure. The new ten point plan was a plan to respond to the challenges exposed by the reviews. The first priority was to mobilise society to address the issues. Hospital managers, for example, would be trained and assessed. If inadequate skills to fulfil the roles were found, then the managers would be re-trained or re-deployed.

Ms D Rantho (ANC, Eastern Cape) wanted to know why so much of the budget for Programme 5 remained unspent. She questioned whether the money could not be moved and spent on anti retroviral treatment for AIDS patients in the Eastern Cape.

Dr Mahlathi clarified that in fact 96% of the budget was spent and only 4% was unspent.

Ms Rennie said that the issue of under expenditure was confused. That money was not necessarily meant for HIV and AIDS. The R10 million was earmarked for nursing colleges and could not be redirected. She also said that the National Health Department could not intervene in the Provincial Treasury’s allocations as they were not linked.

The Chairperson referred to under spending that was reported to be due to delays in the progress of projects, where funds were already committed. She wanted to know what the Department were doing to avoid similar situations in the future, to bring its finances in order.

Dr Chetty said that the Minister was actively monitoring finance and expenditure. One province that was found to be spending enormous amounts of money on consultants was stopped from doing so.

The Chairperson asked, in respect of the measles outbreak in Gauteng, what measures were in place.

Mr de Villiers asked about vaccinations against measles. According to the Annual Report, only 27 out of 52 districts had a measles1 vaccine coverage of 80% and above. He enquired which districts these were and what the Department was doing to roll it out further.

Dr Chetty answered that there was an extensive plan to contain the measles epidemic in Gauteng. There was a massive immunisation campaign under way against smallpox and measles. Prisons and other institutions were also targeted. She said that the information concerning vaccine coverage per districts would be provided, as well as the details of the 10 point plan. She said that divulging too much at this stage would be pre-empting the announcements that the President and the Minister of Health would be making later that day.

Mr T Mashamaite (ANC, Limpopo) quoted the vision of the Health Department as including accessibility. However, he questioned why the Department had not publicised its tracking system that would ensure that medication was issued to the correct patients for whom it was meant, and asked how the drug management problems had impacted on hospitals, and what measures were instituted to alleviate the situation.

Dr Chetty explained that the Drug Management Supply System was Oracle-based, and there were weaknesses in the Supply Chain Process. The Department had now changed to a new system, but had had to revert to the old system at a stage, due to problems with the new system. The Department was aiming for a situation where the system would keep track of all stocks and would alert the stock controller which stocks were running low and had to be replenished

Mr Mashamaite enquired about the reasons in the delay in rollout of the Electronic Health Record.

Dr Chetty answered that the Department was in phase 0 of the Electronic Health Record process. It was a very expensive process.

Mr Mashamaite wanted to know what were the challenges associated with pharmacists.

Dr Mahlathi said that there was no large pool of health professionals in South Africa. It was a global problem. It was the reason why countries poached each other's trained professionals. India and the Philippines were producing large numbers of doctors, but their own health systems were rated very low internationally, because these doctors were mainly going out of the country to earn revenue. The WHO was looking into the problem. South Africa had agreements with other Southern African countries like Lesotho and Namibia, to help develop their health systems. If South Africa allowed doctors and pharmacists from these countries in to work in South Africa, this would amount to poaching skills from another country with an even bigger skills crisis. He said that the challenge that faced South Africa lay in producing the skills and sufficient numbers of skilled individuals. South Africa had a scarcity of nursing educators. The Occupation Specific Dispensation (OSD) was conceived to give everybody who was performing a specific task the same deal, so that skilled professionals did not have to gravitate towards situations or geographical areas where there were more rewards for the same function.

Ms Mncube asked about any Memorandums of Understanding, and the working relationship with the Department of Public Works. She cited, as an example, an instance of water leakage in the operating theatres Baragwanath Chris Hani Hospital, which had been reported to the Department of Public Works (DPW), who had not yet done anything. Crucial and expensive imported machines were being damaged due to the leakage. She complained about the slow response of the DPW.

Dr Chetty said that the relationship with DPW was one fraught with difficulties across all areas of government, due to slow response times. She said that there was a need to consider whether it was really necessary to call the DPW to do routine maintenance. In her opinion, it was not. Independent contractors could be employed to do routine maintenance and repair work. She stated her intention to investigate the Baragwanath case in person.

Ms Mncube asked for clarity on the strategic plan to increase the hours that primary health care clinics would be open.

Dr Mahlathi answered that issues around human resources and safety had to be considered when extending clinic hours. The HR aspect was a big challenge. A few resignations of doctors would result in increases in workloads for other doctors, which would then trigger more resignations. To keep doctors reasonably comfortable and settled, many other issues such as accommodation and living conditions also had to be considered.

Mr Nick Padyachee, Deputy Director General: Special Programmes, NdoH, addressed the issue of extended hours in primary health care. He said that there was a policy to extend the hours incrementally over time, firstly to 19h00 and then to 22h00. In the longer term the plan was to make community healthcare available 24 hours a day. There was a study under way, which would be completed in three years, and this study would inform the way forward for this programme.

Dr Mahlathi said that there was a project under way to revamp old nursing colleges in the public health sector. A service provider would assist provinces to develop business plans, which would be funded. In some areas where facilities existed, these would be upgraded. In areas where none existed, for example in the Northern Cape, new colleges would have to be built.

Mr Faber said that he would hold Mr Mahlathi to his promise of a nursing college for the Northern Cape.

Mr Plaatjie wanted to know what the impact was in the provinces, of the financial situation.

Ms Rennie said that in financial year 2008/09 only one province received an unqualified audit report. In the financial year 2007/08, two provinces had received unqualified reports. Qualified audit opinions in the provinces impacted negatively on the national financial situation.

The meeting was adjourned.