Department of Health Annual Report 2008/09: Department's responses to questions & Medical Research Council Annual Report 2008/09

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Health

10 November 2009
Chairperson: Mr S Suluman (ANC)
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Meeting Summary

The Department of Health tabled a document containing written responses and took the Committee through those responses, which related to the questions still outstanding from the last meeting in which the Department had presented its annual report. Members had questioned the performance, delivery and quality of primary health care. This was a problem, but the Department stressed that it was committed to revitalising and rejuvenating its approach with regard to all its functions. The most pressing issues were related to TB, its education, prevention and cure, and, after setting out some statistics, the Department said that it would adopt a more assertive approach. The two new vaccines were discussed and the measles outbreak in several districts was highlighted. The comprehensive plan and its monitoring and evaluation on the management of HIV was also discussed. The Department admitted that there were some pressing issues around human resources, and outlined the measures being taken for employment and retention of qualified, experienced and general skilled workers, which were causing backlogs within several functions within the Department and directly related to the quality of service the units could provide. It was noted that issues relating to clinic supervisors, the competencies of the CEOs and Managers was being looked at as a major issue relating to delivery of services. Other questions that were answered related to the national health insurance, what was being done to try to reintroduce legislation or sort out the conundrum around the definitions in regard to medical aid schemes, which should have been adopted in a Bill last year, but which lapsed. The South African National Aids Council and the takeover from the former South African Aids Trust were discussed. Members asked about the audit report and the reasons why bonuses were paid in the last financial year, in view of poor performance from the Department.

Medical Research Council (MRC) presented its Annual Report for 2008/09. It was stressed that the core function was research. This stretched over basic science, laboratory science, population and public health, to health systems research. A major problem was that the statistical information on mortality and cause of death were not reliable. The HIV new infection rates were also questioned. More information was given on the research into the use of UV light in TB cases, and the two new vaccines for influenza and pneumonia. The various projects around the links between alcohol and drug abuse, and causality for other diseases, were discussed. The two projects focusing on foetal alcohol syndrome were noted. Not all provinces had the same problems around nutrition and this must be recognised. The traditional medicines and indigenous knowledge system research was briefly discussed. Members raised questions around the statistics, the funding of the vaccine initiative, what was happening to clinical trials, and whether the MRC was attracting and retaining young black scientists. Further questions were asked around the vaccine initiative, foetal alcohol syndrome, which some Members felt was not receiving sufficient attention, the links between alcohol, death and disability, and the funding needs of MRC.

Meeting report

Election of Acting Chairperson
Due to the absence of Mr B Goqwana (ANC), and in accordance with the rules of Parliament, the Committee Secretary presided over the nomination and election of an acting Chairperson. Members unanimously proposed and elected Mr S Sulliman (ANC) as the Acting Chairperson.

Department of Health Annual Report 2008/09: Responses by Department of Health (DOH) to questions submitted by Members
The Department of Health had given its Annual Report presentation at a previous meeting, but there remained a number of questions outstanding. A list of questions and documented responses was tabled (see attached document) to facilitate discussions.

Dr Kamy Chetty, Acting Director General, Department of Health, was requested to take the Committee through the questions and responses.

Dr Chetty noted that questions had been asked on the implementation of the National Health Act 61 of 2003. She stated that certain sections of this Act had not promulgated, around the area of the certificate of need and classification on hospitals. In addition, the issue on blood transfusion services partly related to the tissue section, and in this regard legal issues had arisen, around having a single National Blood Transfusion Service, and this was causing delays. The other area relating to the implementation of the National Health Insurance and its promulgation was still under debate. A number of regulations had been gazetted recently to give effect on the other areas of the Act, and it was recommended that further sessions be held and notification be given to the Committee on regulations that had been passed.

Dr Chetty noted that questions were raised around the South African National Aids Council. This was being revised. There had formally been trustees of the South African National Aids Trust. The Trust document, however, stated that the Minister of Health, the Deputy President and other members would automatically become new trustees, and so the issue was being revisited.

Because of the uncertainty, the money in the Trust could not be allocated to Provinces for their Antiretroviral (ARV) roll out, but other mechanisms had been pursued to sort out the problem. Members were informed last week that the Minister of Finance had allocated R900 million, which was one of the largest sums allocated within the tight budget and was R300 million short of the requested R1.2 billion. Other strategies had been implemented through donor funding to accommodate the shortfall.

It was stated that there were two 15-year review reports, one which was done by the South African Development Bank and the second was commissioned by the Department of Health (DOH) from an independent consultant. These copies were available at the Parliamentary Office.

Dr Chetty then referred to the questions on vaccination. The two new vaccines that had been introduced and the coverage were questioned. She noted that there was 85% coverage, but that the Department was aiming for 100% coverage.

Dr Chetty noted that questions were asked about the correctness of the information in the Annual Report for KwaZulu Natal (KZN). This information was correct. At the time of the National Health Laboratory Service (NHLS) Act, KZN was not immediately taken over. However, within the next five years this province would be included, in accordance with the Act.

Dr Chetty noted, in regard to the measles outbreak, that a major mop-up campaign in all of the districts was being done and over and above this, there was the measles and polio immunisation campaign planned for early next year, and there was a very detailed implementation plan to cover and strengthen this initiative for all districts.

Professor Freedman, Department of Health, added, with regard to the relation between the districts and the measles outbreak coverage, that there was in fact no correlation between the outbreak in an affected district and vaccine coverage in that district.

Dr Padyachee, Department of Health, responded to the food fortification question that implementation of the monitoring was already taking place.

Dr Chetty admitted that there was a time lag in the collection of data regarding the indicators for the number of fixed primary healthcare facilities offering prevention of mother-to-child HIV transmission, but that this was due to the clean-up of the data. She reassured members that all facilities offering antenatal care were offering prevention of mother to child transmission.

The reason for the slight delay of the release of the 2008 Antenatal Survey was partly due to the very thorough peer review process. An expert group, which included a number of the individuals who had previously commented on the survey, was consulted to ensure that, at its release, the review had such involvement. This was thought to be the best process to follow.

Professor Freedman said that Limpopo's strategic plan was in fact used to respond to the H1N1 outbreak.

In addition to the response already given to the question on Non Communicable Diseases, he then added that the difference between the disabled and indigent person was that all indigent persons were entitled to free primary health care, whereas people with disabilities were entitled to pre-health care at all levels rather than just primary health care.
Prof Freedman said, in regard to the wheelchair situation, that the demand for the range of services, especially for diseases with high mortality risks, had impacted on other prioritised services and consequently the wheelchair provision had suffered in terms of the timeframe issue, This was something that was being addressed.

Prof Freedman noted, in regard to the questions about the backlog in toxicology, that it was correct that there were backlogs in the forensic chemistry laboratories. There were renovations ongoing in the Johannesburg Laboratory to improve services. In addition, the human resource division had difficulties in trying to fill the posts for analysts. The training period for Analysts was two years and these persons would often get much better job offers, after training, from the private sector and/or Police Services, getting skills allowances and other additional incentives which were more attractive than those the Department of Health could offer. The Department was working on resolving these problems as there remained a large backlog that certainly was of great concern.

Dr Chetty wished to add to the response, by requesting an unpacking of what was being discussed, regarding toxicology and its results and if it involved hard metals or any other tests. Details of the tests could be provided and the Department was aware of delays in this regard as certain sections were very intricate and were difficult tests to do, quite apart from the difficulties around finding skilled staff to conduct these tests. The DOH could also provide details on how it had turned around the laboratories and reduced the time dramatically.

Prof Freedman spoke to the questions raised around the 72 hour assessment in mental health facilities, and the issue of Groote Schuur Hospital where there was an attempt to follow up on matters. He said that he was not sure whether the comments reflected the reality correctly. Some of the 72 hour assessment services were not in the desired condition but the Department was looking at improving the quality of all possible services and the psychiatric services were included in the revitalisation plan for all 9 provinces. There were draft guidelines to provide information on what exactly should be happening at these 72 hour assessment facilities regarding the infrastructural requirements, the risk management and the clinical management, which would be passed soon and ultimately lead to improvement.

Prof Freedman referred to the question on priorities, and said that although Foetal Alcohol Syndrome (FAS), was not mentioned, it had not been abandoned, and attempts and campaigns to reduce alcohol abuse as a whole were being conducted.

Dr Chetty referred to the response on the Monitoring of the Comprehensive Plan on the Management and Treatment of HIV, and recommended that Members read it. She added that there was a very detailed work plan that was developed during September 2008, which had timeframes on each stage, to try and ensure that problems did not occur again.

Dr Chetty, in response to the questions on the National Study on the Burden of Disease, stated that the study was completed and was circulated to heads of department. Once inputs and comments had been received, a final draft would be released.

Responding to the question on the National Incident Management System (NAIMS), she noted that there was intense research being conducted and once research had been completed there would at least be a framework as to what should be the indicators be for  the System.

Dr Chetty then responded to the question on the Health Financing and Economics, and the external work conducted. She drew attention to the importance of external consultation and said that the Ministerial Advisory Committee, which was looking at the development of the Green and White Paper on NHI and the extensive use of external consultation processes, had concluded the importance of having a proper framework as it created a base of knowledge on what the policies and principles were and their costing.

Dr Chetty noted that the court action relating to the pharmacists had been withdrawn and a new fee was published. Proposals were awaited on these fees. They would be open to public comment for three months.

Dr Chetty told Members, regarding the question on Human Resources and the establishment of the Forum of Statutory Health, that work was being done on to establish the Forum but that it was difficult to give a timeframe for completion.

Dr Chetty noted that two pieces of legislation were withdrawn before the recent elections, those being the National Health Amendment Bill and the Medical Schemes Amendment Bill.

Dr Nick Padyachee then turned to the question on municipalities. He noted that the Minister, in terms of the legislation, had the authority to deal with local authorities. However, in December 2000, the system of local government changed and the Minister had to re-authorize the various officials in the various new categories of local government. That process had taken some time. About 62% were now authorised, with the remaining 38% still to be done. This would be completed over the next few months. In the interim, the provincial administrations in the provinces were carrying out these functions.

The reasons why the two new qualifications were not covered during the 2007/08 financial year was due to them not being part of the audit plan at this stage.

Dr Padyachee also commented on the issues of clinic supervision. This was a serious priority as it entailed not just monitoring but also support, which made a very significant impact on the quality of services provided. Various reasons were provided on why 100% coverage had  not been achieved. A new policy was now in place that clearly defined the responsibilities and roles of the clinic supervisors.

He noted that transportation, in order to cover the 4 000 clinical centres, many of which were in deep rural areas, posed a huge challenge. This was made very clear in one of the outcomes, which would be measured.

Primary health care had been the fundamental core of services provided for the past fifteen years. There was a renewed emphasis and energy relating to this issue, and it related to a more comprehensive approach where there was uniform service. Primary health care and hospitals could not be separated and should function optimally, with each having their role to play.

Dr Padayachee stressed that the ten point plan for DOH was not new. A progress report had been compiled. There was much continuity between the ten point plan for 2004/2009 and the new plan for 2009 to 2014. The only priority in the previous plan not carried forward to the new was International Relations. A summary on progress was provided on each of the ten points.

Dr Chetty agreed that there would, in many instances, be similar issues to previous years. This ten-point plan now reflected was a well and long-thought out plan that had gone through intensive processes. DOH and the Development Bank of Southern Africa (DBSA) had picked out the key problems and challenges in a number of areas that had not been looked at before - for example the competencies and skills of CEOs – to make assessments and address leadership and management within the Department.

Dr Chetty pointed out that a question was asked on recruitment and retention of health professionals. Dr Percy Mahlati did respond previously. However, she wished to add that there were a number of strategies. These included the introduction of Occupation Specific Dispensation (OSD) for the health professionals, the vast improvement of salary scales, which was succeeding in attracting health professionals back into the sector, agreements with other countries to recruit professionals in under-serviced areas and the Department’s investigations into bursaries and training, as well as business and innovative ways to strengthen partnerships within the private sector.

Dr Chetty said the vision on District Health Systems (DHS) and Primary Health Care (PHC) remained intact, and had been the corner stone and foundation for the public health system. It was recognised that there should be a much stronger emphasis on revitalising and renewing the vision for primary health care. A comprehensive audit on primary health care facilities would be undertaken in order to start a similar programme to that that was done with the hospitals. It was agreed that the hospice-centric approach could not be taken and the Department was looking at a well balanced health system with primary health care as the foundation with a proper referral to the different levels of care.

Professor Freedman said that UV light was just one method of mitigating the transfer of TB. It was not reliable as an assessment on its effectiveness had  not been clinically proven.

Dr Chetty added that TB was one of the Department's biggest problems and that it was an area that would receive special focus.

Dr Chetty continued to comment on the questions posed. The only norms and standards not yet finalised were the infrastructure norm, and what services should be provided at the district levels, the various levels of the clinics, and the definition of what were level one and level two drugs, and if they were to be provided at these clinics.

There were numerous norms and standards and the Department would like to present the core standard and norms that had now been developed on the accreditation and appraisals of facilities.

Dr Chetty noted that concern was expressed regarding the response on primary health care and that it still was following a hospice centric approach, because doctors had to be employed at the hospitals, did outreach to the district clinics, and served at the hospitals for follow up.

With regard to TB, the issue of the Department having to be much more aggressive in its approach, before TB became a pandemic, and the policy on how infected people should be isolated, treated, and the rights of other people with whom they may come into contact, had to be addressed.

Discussion
Dr S Pillay (ANC) posed a question on the two pieces on legislation that were withdrawn, saying that the withdrawal of the amendment on the Medical Schemes Act had the potential of curbing the huge monetary losses in money and dealing with a definition of what was the business of a medical aid. In terms of the Supreme Court's decision, every medical aid in the country was illegal , a decision which the Department had to appeal, alternatively a change to the legislation must be made.

Dr Chetty responded that the Department would look at the definition around insurance as opposed to medical schemes.

Dr Pillay then raised the issue on the tightening of the legislation around the definition of cost, and referred to the cost of the prescribed benefits that should be paid in full. He questioned how this was defined.

Dr Chetty said that the issue of the cost , the fact that funders had to pay in full, and the tendency of certain providers to charge rates way above the national health sector’s prices would be addressed.

Mr M Waters (DA) then requested clarity with regard to the question on the adjustment process (set out on page 109 of the Annual Report) the previous year. He noted that the Free State did not receive any adjustments for the ARV programme, and asked why this was the case.

Dr Chetty confirmed that there was a request for funding, and a response given for the Free State. During the adjustment budget of 2008/09 the Department received a further R300 million from National Treasury, but the split was done by National Treasury, despite inputs from the Department, which created a slight dispute. The R900 million for the current year relied on the Department's initiative on splitting in line with the provincial needs.

Ms M Segale-Diswai (ANC) requested clarity on certain facilities that did not provide antenatal care, irrespective of a clinic's operational time of five days a week, and eight hours per day. If a pregnant woman arrived at the clinic she should get antenatal care. Some clinics were not offering this, nor doing baby deliveries, especially not after hours. She asked if this was correct.

Dr Chetty said that the lack of antenatal care applied only to the very small clinics. As part of the revitalising programme on primary health care, the Minister had requested that the prevention of mother to child transmission and antenatal care be integrated as part of the comprehensive approach to health care services.
 
Ms Segale-Diswai referred to the vision on district health systems, which she thought had been lost. Nothing had  been done regarding the district health plan and its principles. Most of the attention and money were being given to the curative aspects, as opposed to the primary issues of prevention. In addition, there was not sufficient focus on education and promotion.  This confirmed the hospice centric approach.

Ms Segale-Diswai asked that the issues about Human Resource development and the concentration on the CEOs of the hospitals, and not on the Deputy Directors or District Managers of the primary health care, should be explained. Ms Segale-Diswai felt that the Department was not on top of issues. It was discovering and facing challenges without winning any of them. She believed that if the primary health care was mastered there would be no problems with hospitals.

Ms M Dube (ANC) referred to the Auditor-General's Report. This had highlighted issues around funds not accounted for, and noted that the Department did not have a system to enable the reconciliation of the payments nor use of the vehicles under the national fleet of a Public Private Partnership Project, and the supporting documentation was questionable.

In regard to the departmental revenue and its inclusion of the financial statement, and the issue of an amount of R29.7 million relating to the revenue from the Medicines Control Council (MCC), she noted that there were doubts as to the accuracy of the figures.

Dr Chetty said that the R29.7 million for the MCC was accounted for. This money had been in the Department’s system. The revenue collected from industry and what was pending during the time of audit was found in the reconciliation documentation, and the same was true for goods and services. She said that the Department would put the lack of systems into context. Although two new issues were raised, the Department already had a plan to rectify the issues. The Department was confident that a clean audit would be achieved in the following year.

Ms Dube asked about the UV light not having been proven to have any effectiveness on TB transmission, and why it was not being installed in any case.

Dr Chetty replied that the technical issues around the effectiveness of the UV light could not be finalised until scientific results could be presented on its advantages and disadvantages.

Dr A Luthuli (ANC) also expressed her concern regarding primary health care and its delivery. She appealed to the Department to get health care delivery systems working properly and to re-look at the implementation around  district health, prevention, promotion, drug supply and availability, rehabilitation centres, HR and education.

Dr Chetty confirmed that the Department was in agreement on all the points made on primary health care, fully endorsed Members’ views and was committed to strengthening primary health care.

In addition, the Department agreed that there should be a more aggressive approach to the TB issue.

Dr Luthuli raised a question on bonuses. There was inevitably misunderstanding, and discontent by the public on this, and it was dangerous. She asked why the CEO had received a bonus in the last financial year, when the Department had gone so horribly wrong.

Dr Chetty noted that the bonus did not relate to the whole health system, nor for all senior managers. It applied to all workers. It applied to those who had performed well, below director level. More details could be provided on the 511 workers that had received the bonuses.

A Member stressed that in regard to the mission statement and the primary healthcare function, hospital revitalisation and infrastructure, it would be preferable to address exactly how many facilities had been built, instead of making general statements about how all the systems that made up primary health care were functioning.

The Member also pointed out that it seemed, each year, that more priorities were being set yet there did not seem to be continuity from one year to the next.

Dr Chetty said that yearly monitoring and evaluation was being done, by the creation of matrixes, which did determine actual delivery and performance.

Ms T Kenye (ANC) requested the Department to consider sending mobile clinics to the rural areas for chronic cases who had problems with the far distance to access health services. This was probably one of the reasons why there were defaulters in treatment.

The Chairperson asked that further questions and responses should be done in writing.

Medical Research Council (MRC) Annual Report 2008/09 presentation
Dr Ali Dhansy, Vice President: Research, Medical Research Council, opened the presentation by explaining the mandate of the Medical Research Council (MRC) and its functions. It was mandated, through research development and technology transfer, to aim for improvement of the health and quality of life for the public and building a healthy nation, through promotion and conducting of relevant and responsible health research. He stressed that the operative word was “research”.

The organogram was set out. MRC's focal research areas stretched over basic science, laboratory science, population and public health, to health systems research.

Dr Debbie Bradshaw, Director, MRC, explained to the Committee that the statistical information on mortality and the cause of death statistics were not reliable due to under-registration and mis-classification of causes (Slide 16).


Dr Dhansy added to the issue of the vaccine production in South Africa. If South Africa could get to the stage where it was doing this, it would not only manufacture vaccines for HIV/Aids but so too could deal with various other vaccines, especially for TB.

With regard to the UV Light and its effectiveness (Slide 29 and page 22 in the Annual Report) it was reported that one of TB units in Mpumalanga was currently conducting research at the airborne infectious research facility, which was a unique attached as a research facility at the Department of Health's facility treating TB. The infectious air was transferred from the Department's unit to the research unit and thus tested the effectiveness of the UV lights. There were technical issues regarding this light, which involved airflow systems, and the servicing of such units. The definitive answer was thus not known as yet.

The two vaccines vaccines, discussed earlier by the Department, for pneumococcal and rotavirus vaccine were described on Slide 30. MRC had contributed to the research, and, through a recent study had shown that the intake of drugs, such as panado had an effect on the vaccine. It was important to realise that evidence and outcomes could still change as research was still being conducted.

It was noted that burning mosquito coils also had harmful effects, with similar damage caused as the smoking of 400 cigarettes, which had  a serious effect regarding the issues on personal and environmental health (Slide 35)

Prof C Parry, Director: Alcohol and Drug Abuse Research Unit, MRC, discussed the numerous projects ranging from surveillance and monitoring on what was happening with alcohol and drug abuse, and understanding causality, especially the link between alcohol and HIV, improving assistance delivery, provision of treatment services to drug and alcohol abusers and intervention research. There were two projects focusing on Foetal Alcohol Syndrome and a number of projects involving alcohol-related sexually risky behavior, which were putting people at risk of contracting HIV. There were also projects looking at alcohol and the antiretroviral medication.

Dr Dhansy added to the issue of nutrition on Slide 37, and said that not all provinces had the same problems, which needed to be recognized. The national vitamin A campaign had to be stopped in order to complete this research. There was emphasis on monitoring and evaluation on these differences. This unit was involved in producing the Community Nutrition text book.

Dr Motlalepula Matsabisa, Director: Indigenous Knowledge Systems, MRC, discussed the mandate of the lead programme on traditional medicines and indigenous knowledge systems , on Slide 39, to do basic research and clinical research. The core activities entailed research and developing new methodologies to validate the heath claims and the use of the medicines to discover new lead molecules. Secondly, MRC was involved in knowledge management and development and the creation of databases. Thirdly he discussed the social impact and how science could be translated in having impact on daily lives of the community.

Discussion
Ms T Kenye questioned the percentage statistics on HIV/Aids and the accuracy of the 2.2% decline, as she felt that HIV/Aids was still prevalent and the rates were alarming.

Dr Dhansy commented that the statistical information was not optimally correct The HIV mortality statistics currently were showing about  2% each year, despite the fact that the number of deaths had risen every year since 1998 largely due to AIDS. Dr Bradshaw noted that there were nine conditions related to HIV that had increased and that there was an attempt to reconcile the figures. The fact was that HIV related mortality was not as low as 2%.
 
Mr M Waters (DA) questioned the HIV/Aids vaccine initiative regarding funding. He noted that the Department of Science and Technology had not renewed the contract, nor had Eskom, and noted also that the DOH had not signed off some funding for 2009/2012. He asked if there were other means of financing. He asked what was happening to the clinical trials, what funding they had, and if MRC was able to source from anywhere else.

Dr Dhansy said that Eskom was contributing R112 million from 1999 to March 2008. To date, R264 million had been paid. South African A,,,,, ( SAAVI) was a Cabinet initiative and not a MRC programme was clearly pointed out. He said that a business plan had  been sent to the Department. There was a strong advisory committee of 22 specialists in vaccine research and development, who advised on priorities. There were serious concerns regarding the trial sites, and 150 monkeys to maintain who were used for research.

Ms L Makhubele-Mashele (ANC) questioned the attraction of young black scientists as there was no indication of transformation, and asked what strategies MRC was using.

Dr Dhansy said that young black scientists usually only stayed for a couple of years before moving on to government or public sectors, due to more attractive salaries and incentives. There was a struggle to draw skills. MRC was fully aware that transformation was required.

A Member asked a question on the vaccine initiative of 36 people on clinical trial, what their ages were and where they were situated.

Ms E Levendal stated that SAAVI funded this. The first part of was run by Wits and situated in Soweto. The other parts were run by UCT and at Crossroads, by the University of Limpopo in Klerksdorp, Northwest Province. Other parts were being run by Medunsa and Walter Sisulu University. There was a site at the Umtata General Hospital that had been connected to the Italian collaboration but had not been activated. The age group for people on trial ranges from 18 to 45 years.

Mr Waters questioned the silent disease of foetal alcohol syndrome, and said it was not receiving enough attention.

MRC responded that the programmes were active and many initiatives were taking place, but were more focused on programmes and the testing of intervention.

Prof Charles Parry, MRC, stated that alcohol was the third greatest contributor to death and disability, according to 2000 data, which had been underestimated. It would require immense political will from government to create interventions. It might need to include a new global initiative on rectification, excise taxes, coherent liquor outlet policy, drink and drive counter measures. Two initiatives that had proven to be effective were brief treatments for heavy drinkers, and addressing alcohol advertising with active counter advertising.

Mr M Waters requested information regarding the shortfall and the funding required for the vaccine and SAAVI.

Ms Elise Levendal, MRC, discussed the ideal business plan, for which MRC would require R31.5 million for basic laboratory sciences, R24.5 million for the clinical trials, R9.1 million for community involvement, social sciences and ethics plus legal aspects, R1.4 for ongoing South African Aids Vaccine Initiative activities and documentation, R3.5 million for business and operational structure, giving a total of R79.8 million for 2009/2010. Then it would like to have an annual 10% escalation. The shortfall was 68 million

The meeting was adjourned.

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