The Department of Health (the Department) had been asked to appear before the Committee to brief it on the updated plans, including comment on the new plans in respect of human resources and infrastructure, improvement of health services, Primary Health Care, infection control, HIV/Aids and communicable diseases programmes, and other issues as more fully set out in a letter to the Committee. The Department of Health failed to attend on time, claiming that there was a misunderstanding, and the Committee expressed its displeasure at the lateness and the fact that the required documentation had not been delivered two days in advance of the meeting. They agreed to allow the Department to proceed. A substantial presentation was given, covering a number of issues. The specific objectives of the Department were outlined, and these included phasing in National Health Insurance over the next five years, increasing institutional capacity to deliver health services, improving the management of health services at all levels, implementing and strengthening plans for HIV and Aids and TB, enhancing the management of non-communicable diseases and trauma, and introduction of new vaccines for children. Challenges included the lack of standardisation of care, and poor reliability and outcomes in certain places, along with lack of accountability and improper use of resources. The Department outlined the areas in which it planned to fast-track improvements, from cleanliness to reduced waiting times to better infection prevention and control.
The Department was focusing on reducing maternal deaths, since some of the findings over the years had not been properly implemented. Another area of focus was morbidity and mortality of children under five, and new targets were announced. There would also be an increased focus on Primary Health Care. The Department now had adopted a policy whereby it was no longer accrediting sites for Antiretroviral treatment, but was attempting to have all facilities available at all outlets. Another area quite fully outlined in the presentation was staffing, with reference made to community healthcare workers, doctors and nursing staff. Audits were being done on a number of aspects around the healthcare services to try to improve them generally, and this included studies around recruitment and retention.
Members asked a wide range of questions. At the outset, the Chairperson pointed out that the Committee expected honest answers so that the Committee could properly assess the position of the health sector and compare it to the desired outcomes. He also noted that although the presentation had not covered exactly what the Committee had wanted, it was nonetheless an indicator and that further engagement would be necessary. Members asked about budgets and spending, noting that there seemed to be underspending in some provinces, that stock-outs and insufficient budgets were raised in several provinces, and whether sufficient budgets had been allocated to some matters. A number of Members raised queries as to whether the Department of Health was intending to introduce legislation to try to curb the problems associated with alcohol use, including violence, road deaths, and medical implications of alcohol misuse. Members asked when the smoking regulations would be brought before the Committee. Several questions related to human resources issues, including the implementation of Occupation Specific Dispensation, the Department’s negotiations with the unions, the threatened strike action, the complaints submitted by the students being trained in Cuba, the plans to increase the numbers of doctors in the public sector and the retention strategies. They also asked about the Nursing Colleges and accreditation, saying that there seemed to be some confusion over who could accredit training institutions, and discussed whether it was appropriate for Sector Education and Training Authorities to be involved. Members asked about the courses for hospital managers, and why these were necessary. Members were concerned that there were insufficient staff to achieve the goals, and wondered if the targets were realistic. They were also concerned at poor staff attitudes. They asked exactly what would be different in the Department’s approach, as many of the plans had been put forward before. The position of the provinces and local government was also discussed, and the classification f hospitals was questioned. Members also asked about the costing for the National Health Insurance, stressed the need to look at patients’ rights, and preparedness of the Department for the 2010 World Cup.
Chairperson’s opening remarks
The Chairperson introduced the new Committee Researcher, Mr Zubair Rakim.
He announced that the Committee would be meeting on Fridays, with the exception of Friday 5 March. On the following day, the Department had invited the Committee to meet with a number of Africa’s former Presidents, who had championed the fight against HIV/Aids.
Department of Health (DOH) presentations
The Committee Secretary had informed the Chairperson that the Department was not ready, and was still working on the document to be presented.
Mr M Hoosen (ID) expressed extreme disappointment. If the highly-paid officials at the Department did not have the information at their disposal – which should in any event already have reached the Committee 24 hours in advance of the meeting - then there was a serious problem.
The Chairperson agreed and said the Department had been asked to send all documentation two days before the meeting.
Mr M Waters (DA) felt this was an insult to the Committee, and showed disrespect to Parliament, which was unacceptable. The Committee should take a firm stand.
The Departmental officials arrived, and said that they had understood that the meeting was to commence at 09:30. they were asked to leave while the Committee continued its discussions.
Ms A Luthuli (ANC) endorsed what the other Members had said, but noted that there seemed to have been some miscommunication between Parliament and the Department.
Ms M Segale-Diswai (ANC) added her support.
The Chairperson stressed the Committee wanted documents two days before the meeting.
The delegation from the Department were called back, and the Chairperson welcomed them but stated that .
the meeting was supposed to have started at 09:00.
Dr Kamy Chetty, Director General, Department of Health, apologised for lack of communication around the time.
The Chairperson reminded Dr Chetty that there was a specific reason why the letter had asked for an audit of infrastructure, and this same letter also stated that the meeting was at 09h00. The Committee’s concern was mainly around the audit of infrastructure and the under spending. People were complaining that hospitals were in bad shape, and so the Committee needed to understand why the Department of Health (the Department or DoH) had under spent. In preparation for the proposed National Health Insurance (NHI), public hospitals were to be upgraded to compete with the private hospitals and the Committee needed to know what was actually going on. He was surprised to hear that the audit of the infrastructure was still being done as the letter had been sent some time ago. He again stressed that members must have documents at least two days before the meeting.
Mr Hoosen added that clearly the Department was not ready to present. Dr Chetty had made it clear that the last audit was done ten years ago. Members often received complaints from people about the hospitals, the superintendents at the hospital would say they had raised those issues with the Department for years and nothing had happened. The Head of the Department should know all the details in order to plan and to provide an effective quality services to the people.
Dr Luthuli emphasised that the issue of getting documents beforehand was a very serious matter. It amounted to disrespect of the Committee and of Parliament.
Mr D Kganare (COPE) said the letter stated very clearly what was required but the Department had decided to give a standard presentation and the Committee would not receive the desired information, so the attitude was very disrespectful.
Dr Chetty wished to correct the impression of Members that not enough preparation was done. The Department had received the letter and had gone out of its way to capture every point, starting with the audit of the infrastructure, the Department’s understanding of the audit of infrastructure, being the state of repair or disrepair of the buildings of hospitals. The audit, in terms of the number of hospitals, the number of hospital beds, and the number of staff in those hospitals, was dealt with on a regular basis and that information was available. The presentation was not the standard presentation but was specially done according to that letter. She assured Members that the Department took the Committee very seriously and apologised again for the delegates’ late arrival.
The Chairperson responded that the letter, if read carefully, clearly indicated that the meeting was at 09h00; and if the presenters did not fully understand the contents of the letter they should have asked what was required.
Mr Waters pointed out that Dr Chetty was the Acting Director General, who had recently taken over, so the person at fault was actually the previous DG who was off to Malaysia. It was a serious concern of the committee that the audit was only done once every ten years, as it should be done annually.
Policy Mandates of the Health Sector: Medium Term Strategic Framework 2009-2014
Dr Chetty led the Committee through the first presentation. She noted that Strategic Priority 5 in the Medium Term Strategic Framework (MTSF) of government for 2009-2014 was entitled “Improving the Health Profile of all South Africans”. The specific objectives under this included:
- Phasing in National Health Insurance (NHI) over the next five years;
- Increasing institutional capacities to deliver health services and implementing structural reforms to improve the management of health services at all levels;
- Strengthening TB treatment management and combating Multi-Drug Resistance (MDR) and Extreme-Drug Resistance (XDR) TB;
- Implementation of the Comprehensive Plan for the Treatment, Management and Care of HIV and AIDS;
- Enhancing the ability of public health services to deal with non-communicable diseases, injuries and trauma;
- Introduction of new child vaccines to reduce diarrhoea and pneumonia.
Dr Chetty then outlined the 10 Point Plan of DoH, noting that improving the quality of Health Services was a central component of the 10-Point Plan. This was also highlighted in the Presidency’s Green Paper on Performance Monitoring and Evaluation.
Dr Chetty then gave an update on the National Health Insurance System. The progress to date included NHI policy proposals being presented to Cabinet. A dedicated NHI Technical Support Unit was established within the Department to steer the implementation of NHI, and a 27 member Ministerial Advisory Committee on NHI was established in terms of the National Health Act of 2003 in September 2009. Future plans included that during 2010/11 NHI policy would be finalised and public consultations conducted, while the proposed NHI policy legislation would be submitted to Cabinet, presented to Cabinet and subsequently submitted to Parliament.
Improving the quality of Health Services
Insofar as the legislative mandate and policy for improving the quality of Health Services was concerned, Dr Chetty noted that Chapter 10 of the National Health Act of 2003 established the Office of Standards Compliance. It also provided for designated Health Officers to inspect all health establishments and agencies (public and private) every three years. There was an Office of Standards Compliance empowered to recommend Certification of Health Facilities in case of compliance, and closure of facilities in case of violations. Inspectorates of Health Establishments at Provincial DoH level were also envisaged to conduct monitoring, inspections and recommendations. The Office of Standards must advise the Minister of prescribed standards, both for general service provision and specifically for quality, provide leadership and advice on strategies and mechanisms to improve quality across the system, and monitor and report to the Minister on system performance against standards.
She noted that particular concerns related to the lack of standardisation of care with poor reliability and poor outcomes, lack of accountability for delivery of care and use of resources, inadequate skills and a lack of responsiveness.
Dr Chetty noted that a booklet on the core standards was distributed, and this had established core standards for:
- Safety, Clinical Governance and Care
- Patient Rights
- Clinical Support Services
- Public Health
- Leadership and Corporate Services
- Operational Management
- Facilities and Infrastructure
Assessment tools would be piloted in all nine provinces in March 2010. This would be used as a basis for the audit of health facilities in 2010/11.
Dr Chetty said that the Deputy Minister announced that a Quality Management and Accreditation Body would be established to function independently of National, Provincial Departments, and the National Health Act of 2003 would be amended to facilitate the process. Accreditation was likely to be linked to funding through National Health Insurance (NHI). Licences might be required for all facilities (both private and public).
In regard to quality, the Department planned to fast-track improvements in the areas of positive and caring values and attitudes, reduced waiting times, improved cleanliness, improved patient safety, infection prevention and control, and availability of medicines and supplies. Future plans were for all Public Sector Facilities to comply with quality standards, beginning with 20% of facilities in 2010/11, increasing to 90% by 2012/13. Other areas for improvement in respect of supervision, programmes, hospitals and competencies were also described (see attached document).
Dr Chetty noted that the purpose and focus of overhauling the Health System was to improve its general management. It was also on revitalisation of Primary Health Care (PHC). 220 Chief Executive Officers (CEOs) of hospitals were enrolled in Hospital Management Training programmes at the Universities of Witwatersrand and KwaZulu-Natal. The programme was designed together with the French Government, the School of Hospital Management in France, conducted through Wits and KZN. Together with the Development Bank of Southern Africa, an assessment would be done to look at the skills and competencies of Hospital CEOs, Hospital Managers, and District Managers. Only one out of nine Provincial Health Department obtained an Unqualified Audit Opinion at the end of 2008/09.
Primary Health Care
Dr Chetty noted that a key priority of the Department and the improvement of the Health System was to look at the strengthening of Primary Health Care (PHC). The Minister had reiterated its importance. In 2008/09 there was a 10% increase in visits to primary level facilities, from those recorded in 2007/08.
Future plans included conducting an audit of PHC facilities and package of essential services. This audit would focus on the state of repair of the infrastructure, and would include clinics, to determine what needed to be built. It would also look at the delivery model of PHC, and what was needed. The intention was to improve and expand access to and coverage of PHC services, as well as incorporation of other priority programmes.
Human resources planning
Dr Chetty said that there were several initiatives with regard to Human Resources Planning. Firstly, a Ministerial Committee would be set up to guide the development of a new Human Resources for Health (HRH) Plan for South Africa and to look at strengthening of Mid Level Workers (including clinical associates) and including Emergency Care Technician programmes. There was ongoing work with regard to the Occupation Specific Dispensation (OSD) for diagnostic, therapeutic and related allied health professionals. There was also the Hospital Management Training Programme, referred to earlier. There would be finalisation of the Policy on Community Health Workers. The Nursing Strategy would be implemented in all Provinces.
Revitalisation of Infrastructure
DoH together with Treasury were conducting a comprehensive National Infrastructure Plan that entailed
reviewing the existing Hospital Revitalisation and Infrastructure Grant Plans to show the current financial backlog, and were looking at all the other facilities that would need to be revitalised.
Revitalisation included the physical restructuring of the building, modernisation of equipment, proper organisation and development, and quality of health services. A key challenge was to ensure that revitalisation was allocated 3% to 5% of the budget. There were eighteen hospitals in the revitalisation project, the intention being to add two per province per year.
Future plans were to focus on accelerating the delivery of health infrastructure through Public Private Partnerships (PPP), especially for the construction of Tertiary Hospitals, and agreements had been entered into with National Treasury and Development Bank of Southern Africa (DBSA) in this regard. DoH was targeting two per province and that would increase over time. Plans were also in place to revitalise primary level facilities and to accelerate the delivery of Health Technology and Information Communication Technology (ICT) infrastructure.
Accelerated Implementation of HIV & AIDS and Sexually Transmitted Infections National Strategic Plan 2007-2011 and focus on TB and Communicable diseases
Dr Chetty said that two pillars of the National Strategic Plan (NSP) on HIV/AIDS were to reduce the number of new infections by 50% by 2011, and to reduce the impact of HIV & AIDS by expanding access to treatment, care and support to 80% of people living with HIV and AIDS.
The four priorities of the NSP were prevention; treatment, care and support; ensuring respect for Human Rights and access to Justice; and Research, Monitoring and Surveillance.
By the end of March 2009 there were 493 accredited sites to provide Antiretroviral Therapy (ART) services, with 796 down referral sites. Accreditation was no longer a policy and a model of facility readiness was in place to speed up access to ART care at PHC level.
There was an increase of ART coverage and the number of patients that needed to be on treatment, including children. A target was set for reducing mother to child transmission from 30% to 10.6%. The Department believed that no child should ever be born HIV-positive.
Arising from the Presidential Announcements on World AIDS Day, in December 2009, the main aim was to improve ART access to special groups. These comprised pregnant women, TB/HIV co infected people, and children under the age of one.
Further aims of the NSP were to decrease the disease burden; to reduce maternal and child mortality and to improve life expectancy. This would be achieved through mobilisation of patients for ART, decentralisation of ART to PHC facilities, training and orientation of health workers and task sharing and nurse-initiated treatment.
The prevention of HIV was to be encouraged through behaviour change communication, targeting high risk groups, increasing distribution of condoms and focus on youth programmes.
The main challenges were late presentation of patients with low CD4 tests, shortage of human resources, inadequate infrastructure; and problems around Supply Chain and Financial Management.
There were problems around the shortages of Antiretroviral Treatment (ART) and TB drugs with problems of availability at provincial depots, problems around insufficient budget, logistical problems between the depots and the facilities.
Future plans over the next three years were to improve monitoring systems for drug supply management and ensure zero stock-out rate for essential medicines, including TB and Antiretroviral Treatment (ART).
The registration timelines for medicines would also be improved; the Electronic Document Management System (EDMS) would be implemented; and a new Medicines Regulatory Authority would be established to replace the current Medicines Control Council, and to improve efficiencies.
Dr Chetty noted that a draft National Integrated Health Promotion Strategy was produced in 2009, together with National Implementation Guidelines for promoting Healthy Lifestyles Programmes. These identified five priority lifestyle programmes of tobacco control; physical activity, nutrition; and the prevention of alcohol and substance abuse.
Dr Chetty noted that another major focus area for the Department was reducing maternal deaths. Despite Ministerial Committees and research over the years, DoH was concerned that some of the recommendations were not adequately implemented. There would now be increased focus on implementation, especially with regard to preventable deaths, and a task team was addressing those issues.
The other area was morbidity and mortality of children under five. In this regard, DoH was strengthening the Community Health Worker Programme, areas around the Integrated Nutrition Programme, and implementing a standard programme on immunisation. The Department was very concerned around the outbreak of measles in Gauteng and the Western Cape and a major immunisation campaign around that, and polio, was planned for March/April. South Africa was the first country in the world to include in its immunisation programmes the vaccine for pneumococcal disease and also for the rotavirus that caused diarrhoea.
Another critical area for the Department was emergency transferral and transport between hospitals and facilities. DoH was also looking at the training of doctors in emergency obstetric interventions and acceleration of the Mother to Child Transmission programme, post natal care and follow up care was also a challenge.
The Minister had mentioned that family planning must be strengthened. The Department was also concerned at the number of illegal abortions still being carried out, and there was a need to look again at the legislation to try to reduce these.
School health programmes, targeting youth, would also be announced by the Minister.
The first draft Review of the Drug Policy was completed in 2009/10 and would be presented to the Committee as soon as it was available.
Dr Chetty noted that, in regard to research and development, the South African Demographic and Health Survey (SADHS) was not completed in 2009/10.
Finally, Dr Chetty tabled the Revised Outcomes-Based MTSF 2010-2014. She noted that the key outcomes would be reducing ill-health, increasing life expectancy, combating HIV/AIDS, decreasing the burden of disease from Tuberculosis, and improving health systems’ effectiveness. There were twenty outputs and the targets and implementation plans for each one were outlined.
The Chairperson said the Committee wanted to hear honestly from the DoH what was happening, so that they were able to assess the position of health and the Department at the moment, and compare it with the desired outcomes.
Mr M Waters (DA) noted that the stock-outs of ARV and insufficient budgets seemed to be an ongoing problem for all provinces. DoH had apparently stopped paying suppliers and was waiting for the new budget on 1 April. In the meantime it seemed to be paying for the current financial year’s supplies from the next financial year’s budget. The problem would escalate. He enquired what was being done to ensure the provinces were allocated more money so that suppliers were paid and did not have stock-outs of drugs.
Mr Waters asked when there would be legislation, similar to that on smoking, for alcohol. Alcohol was contributing to the huge problem of deaths on the roads and the cost to the Health system.
Mr Hoosen supported Mr Waters. A study by UCT showed that on average every month three hundred people died in the Western Cape because of violence linked to alcohol abuse. He was disappointed that more effort was not put into preventative measures. The country was spending billions of rands on cases of alcohol related violence and abuse. He wondered why the Department did not recover costs related to injuries inflicted on patients as a result of crime and violence from the perpetrators.
Dr Luthuli believed that where prevention of HIV/AIDS was not succeeding, this was largely related to alcohol and drug abuse, as people under the influence would not use protection and contribute to perpetuating those infections. Violence against women was also largely related to alcohol and drug abuse, as well as the violence shown on TV. She appealed to the DoH to tackle alcohol and drug abuse r.
Mr Waters asked for clarity on the smoking regulations. During the Third Parliament, the DoH had promised to bring these before the Committee. There still appeared to be confusion in the community, particularly in regard to smoking sections in restaurants.
Mr Waters said that the DA supported the PPP initiative for revitalisation. However, he queried how often hospitals and clinics were assessed for compliance with the Health and Safety Act.
Mr Waters noted the threat of another doctors’ strike because OSD had not been paid, and asked the DoH to advise how the negotiations were going.
Mr Waters wanted to hear more about the reopening of nursing colleges and what was being done to increase the pool of nurses coming into the system, as well as doctors. The private sector was a huge resource that could be used to train doctors. Students in Cuba were complaining about their living conditions.
Mr Waters noted that the Nursing Council said it was expected to accredit all nursing training facilities, schools and colleges, but had to stop doing that five years ago due to lack of finance. He asked who was currently doing accreditation, and if nobody was doing it, why this was so.
Mr D Kganare (COPE) asked for clarity in respect of improving the qualifications of hospital CEOs to provide leadership and ensure that hospitals were run efficiently and effectively. The issue was whether patients were satisfied, and whether there had been any assessments of the current situation, particularly in the Provincial departments.
Mr Kganare asked for the role and contribution of the Health Sector Education and Training Authority (SETA) to updating the National Human Resources development.
Mr Kganare asked what provinces were involved in the planned strike by medical workers, which provinces were involved, the reasons and why the Department was not able to implement the agreement.
Mr Kganare cautioned against PPPs, saying that in the past these had resulted in benefits to the private sector, and asked what lessons had been learnt to ensure that, in future, Government would benefit.
Mr Hoosen asked for clarity on the issue of supply of female condoms as he understood that the tender had been cancelled and there was no existing supply.
Dr Luthuli referred to the issues emanating from the President’s State of the Nation Address, one of which was to reduce the pandemic of HIV/AIDS, and asked whether the HR component of the DoH was sufficient to allow this to happen. In general, she was concerned that there was inadequate HR to carry out the plans.
Dr Luthuli cautioned that perhaps the targets set for improving the quality of health services were too high. She thought it was better to under promise and over deliver.
Dr Luthuli said that the attitude of staff at hospitals and clinics discouraged people who were hoping to have a safe abortion. It was very important to deal with the attitude of caregivers.
Ms T Kenye (ANC) noted that patients’ rights should have been one of the National Core Standards
Ms Kenye said that the Policy on Community Health Workers needed to be finalised urgently, since Health Care Workers had no policy, no benefits, and no facilities.
Ms Kenye said that the number of accredited sites to provide ART services must be increased, as currently people had to travel long distances and that deterred them from checking their ARVs.
Ms Kenye wondered if the reduction in the number of female condoms being used could be because people did not know how to use them.
Ms Kenye was concerned about under-spending, and questioned that while the provinces were under-spending, they were also claiming that their budgets for ART and TB drugs were insufficient. She believed that there must be improved healthcare financing and better monitoring of spending.
Ms E More (DA) asked how the Department was intending to reduce the time patients must wait. This related to the issues of resources and staffing, and corruption also played a part.
Ms More asked exactly what type of training was envisaged for Hospital CEOs. Whilst she noted that two courses were being offered for Hospital CEOs, nothing was said about the Primary Health Care Management Course that was also being offered.
Ms More asked which province had obtained an unqualified audit opinion.
Ms More asked whether the 10% in visits cited by the Department related to oversight, or visits by patients. She asked what the implications of both would be, and whether an increase in patient visits was positive because it showed improved services, or heralded an increase in disease.
Ms More thought the HRH plans seemed to be geared towards attracting staff, but she wanted to hear about retention of existing staff.
Ms More asked when the signature of the Allied OSD would happen and what the agreement meant.
Ms More noted that training seemed to have increased, but wanted to know about monitoring and evaluation.
Ms More asked if there were any plans in place to tackle the challenges to the accelerated implementation of HIV/AIDS and sexually transmitted infections, and increase focus on TB and other communicable diseases.
Ms M Segale-Diswai (ANC) wanted to know exactly how things were going to be done differently by DoH. She pointed out that all these issues had been on the strategic plans over many years.
Ms Segale-Diswai noted that the President had announced 2010 as the Year of Action. If the Department was still going to pilot an assessment tool, she asked how those not within the pilot were going to deal with the issues.
Ms Segale-Diswai asked how supervision was to be improved, particularly if there were no resources, no equipment, and no transport.
Ms Segale-Diswai asked what the impact of the CEOs being enrolled in the Hospital Management Training Programmes would be, in terms of improving the functionality and management of the Health System
Ms Segale-Diswai referred to the municipal clinics operating for hours and said that there should be functional integration between provincial and municipal clinics.
Ms Segale-Diswai noted that the DoH had announced a plan to reduce the number of new HIV infections by 50% by 2011. The targets set by Southern African Development Community (SADC) were for 2015.
Ms Segale-Diswai said that women had been complaining that the female condoms were uncomfortable and also noisy, which meant their husbands did not like them, which seemed to be the reason they were being used less.
Ms Segale-Diswai noted that the DoH’s readiness for the 2010 World Cup was not mentioned in the presentation. Members would need that information when doing oversight.
Ms M Dube (ANC) said that, as an “experienced” hospital patient, she was very concerned about the attitude of health care officials in South Africa. Her concerns extended from staff attitudes, to waiting times, cleanliness, infection prevention and control and availability of medicines and supplies, and the problems were rampant from cleaning staff through to specialists. Often, elderly people waited in queues from 5am to 7pm and nobody thought if they even needed food. She asked how attitudes would be improved.
Ms Dube asked who had the mandate of changing a District Hospital to a Regional Hospital.
Ms Dube was also concerned at the under spending, noting that there was much that was not being done in the hospitals.
Ms Dube asked whether the DoH was currently employing people who were not qualified for the positions of CEOs and was essentially paying them whilst retraining them.
Ms Dube wondered if hospital cleaners should be government employees, or if this function should be outsourced.
The Chairperson said a lot of money went into Health, increasing annually, but still the rate of infant and maternal mortality was on the increase.
The Chairperson made the point that many of the questions might seem harsh or critical, but the Committee was concerned that it must ensure that matters improved. Many of the questions related to what must be done in the provinces. Service delivery was often a problem. Referring to questions by Members, he said that Parliament could make laws – for instance for tobacco and alcohol – but a lot of funding was being put in to hospitals where the outcomes were not good. There were problems of under spending. Huge resources were also spend on matters like Nursing Colleges, which had not been sorted out. He was concerned that matters were not going well in the Department of Health. Members must get the information for their constituencies. He asked the Department to try to categorise its responses.
Dr Chetty responded to the Chairperson’s question on what the current situation was, the outcomes based approach, the current base line value and what the desired outcome was. Details were in the Strategic Plan.
The first issue was to increase life expectancy, which was at 45 years, to 60 years over the next five years. In regard to child mortality, the target was to halve the current base line rates of mortality. Maternal mortality was at 178 deaths per 100 000 women; the target here was to reduce it to under 100 per 100 000.
Dr Chetty replied to the comment that perhaps the targets were unrealistic. The Department did not wish to be unambitious. It welcomed the interaction from the Committee, which it saw as enhancing the work of the Department and ensuring that all had the same objectives.
Dr Chetty said that the Department would answer for the provinces because it claimed the leadership and stewardship role at National level as one country. The stock-outs of ARVs and the question of the provinces being millions of rands in the red also related to the question asked about the under spending in the document. The National DoH was actively engaging on budget with the provincial DoHs, and also engaging with them on their particular problems. It was working together with National and Provincial Treasury, particularly around payments to suppliers, to ensure that the suppliers were paid and there were no stock-outs.
The Chairperson interjected that in the Eastern Cape certain companies were not getting paid, and had said they would only be paid after April.
Mr Waters added that even the Blood Bank was not being paid by the provinces, and the Gauteng Department of Health was asking financial institutions to be lenient with the Blood Bank and give them a bigger overdraft.
Dr Chetty replied that the Department was in contact with the Blood Bank, Gauteng had paid the Blood Bank and the Department was actively managing that, and had also recognised the crises in several of the provinces, and was trying to prioritise them. The Department had informed the provinces that in the adjustment budget, money was given for the Comprehensive Plan for HIV/AIDS. It was a conditional grant and had to be used for that purpose.
Dr Chetty said that the 79% spending referred to in her presentation was not under spending, but was a currently adjusted budget towards the end of the financial year and there were still payments to be made.
Dr Chetty said that the DoH agreed that, in respect of alcohol, a lot more needed to be done. It was also concerned with Alcohol Dependence Syndrome, which was a major problem in the Northern Cape. Some regulations had been done around counter-advertising on the labels, but that was not enough. No legislation would be going through this year. However, the Minister was supportive of more being done and the DoH would see how to deal with it. Dr Chetty commented, however, that recovering costs of treatment from perpetrators was not really the core business of DoH.
Dr Chetty noted that Smoking Regulations had just been published for comment and would be brought to the Committee before being published in final form.
Dr Chetty assured the Members that Occupational Health and Safety Act assessments did get done, and all hospitals had to comply.
Dr Chetty noted that OSD was being implemented in all provinces, and the instruction was that it had to be done before December. An extension of time was to be given to produce the registration certificate, so there was a delay in the process. The problem was that some doctors were getting less money than before, because they fell into a new tax bracket, and there were complaints about the Scarce Skills Allowances being taken away. There were some issues that Medical Officers and Production Specialists that would be sorted out in April. The Department had been working actively with the unions and were committed to sorting out the problems. It was therefore surprised at the media reports. OSD was positive and the DoH wanted to ensure that positive consequences ensued and that everyone would benefit.
Ms Carol Nuga-Deliwe, Chief Director, Human Resources, DoH, was doing an audit of the nursing colleges and would give the details around that.
Ms Nuga-Deliwe said that a combined committee consisting of representatives from Education, Health and National Treasury was looking into training and production of health professionals, including doctors.
Dr Chetty said a recruitment and retention strategy had been drafted by the DoH and was being updated.
Ms Nuga-Deliwe expanded further on the HRH Retention Strategies for the Health workforce. The Health Systems strategy looked at a multitude of interventions, to address different aspects of retention, recruitment, development, particularly in relation to conditions of employment, equality issues and management and leadership of facilities. All of these considerations affected how a lot of health professionals felt about their work. Remuneration was another issue. People were opting out and the Department had to set up projects where they wanted to assess the success or otherwise of the OSD. A monitoring and evaluation framework was being set up for that. In addition, there was a retention strategy for staff of the Department itself.
Dr Chetty noted that, in regard to those students studying in Cuba, a delegation from DoH would visit them at the end of the month to investigate their complaints around conditions. The trainers in Cuba, on the other hand, claimed that the South African trainees were complaining unfairly as they were getting paid more than the other students, and they were living in better accommodation. The names of those lodging complaints were requested.
Ms Nuga-Deliwe said that the accreditation was supposed to be done by the Nursing Colleges, as part of a statutory obligation, and she would look into that.
Ms Nuga-Deliwe commented on the questions around qualifications of Hospital Managers. The DoH had a system for auditing their competencies and performance, and these formed part of the Core Standards, so the DoH was not just assessing individuals but the general performance of the hospitals. The reasons why hospital managers needed to be trained differed across the country; in some provinces they were already highly trained, but in others, not. The course was a specially designed course in Hospital Management, to enhance skills specifically in the hospital area. In other countries such as the UK and France the hospital managers tended to have Masters degree qualifications. Both CEO courses had been developed by the Department, with Wits University, starting with a diploma and in the final year a thesis and research for Masters. The Department did not develop the Primary Health Care Management Course.
Ms Nuga-Deliwe said that patient satisfaction surveys were part of the Quality Improvement Programme and were done regularly.
The Chairperson said the target was to reach an unqualified audit report, which really did not help the patient, who would be looking for something else.
Dr Chetty responded that for a hospital to get an unqualified audit, it must be properly managed, and therefore that included the patient management.
The Chairperson stressed that the DoH was not a Department of Finance or a Department of Public Administration, and that the main outcome must be patient satisfaction.
Dr Chetty supported that, but also believed that hospitals must have health professionals.
Dr Chetty said that there were both pros and cons to PPPs. One issue was contractual obligation and commitments, because contractual obligations could take up a large portion of the budget. It was of key importance to have effective contract management.
The Chairperson asked what was the experience in the past. The private sector was looking at profits, whereas Government was looking at making the lives of people better.
Dr Chetty replied that the development of PPP was a Government priority, and her function was to implement that. She offered to do an evaluation and do a presentation on PPPs.
Dr Chetty said that the Department wanted to focus on youth, so the Youth Health Strategy, and School Health Services were a major priority of the Minister, and included teenage pregnancy, drug abuse, suicide and depression and also alcohol abuse. These also had to do with perception of life style habits, and were issues on which the Department needed to target the youth, so as to promote health lifestyles.
Dr Chetty said that the Department was trying to find out why people were not coming to the clinics for abortions, but it seemed there was an active drive by unqualified individuals to target pregnant women. Part of the problem was the DoH itself was unable to do anything about that because those people were not registered as doctors.
Dr Chetty agreed on the problem of attitude, saying that poor attitudes were unacceptable for any health care professionals. The issue around Patients Rights, the Batho Pele principles were entrenched in the Patient’s Rights and were in the Core Standards. Reducing waiting times involved benchmarking best practices, and here, the Department was looking at key areas and at partnerships with some pharmacies in order to reduce waiting times at pharmacies. A Johannesburg hospital separated children from adults and that had a huge impact.
Dr Chetty said that task teams were working on DoH backlogs.
Dr Chetty said that the Minister had instructed that the policy on healthcare workers must be finalised.
Dr Chetty noted that the Department thought that the label “ARV sites” should be done away with, since all facilities should be making ART available, as well as other treatments.
Dr Chetty noted that finances were monitored through a cluster.
Dr Chetty said that the increase in patients was considered to be positive, as more people had access and were using Primary Health Care.
Dr Chetty agreed with the sentiment about targets but it would not matter if the Department did all of those things and the life expectancy went down. In regard to the question around the pilot course, she said that this had already been revised and it was now a matter of testing whether the questionnaire worked, when it would be spread further.
Dr Chetty noted that the functional integration of clinics was a key issue of provincialisation. The mandate to change regional hospitals to district hospitals could only be done by the Minister of Health according to the National Health Act.
Dr Chetty said that the Department was ready for 2010 and could give a detailed presentation. After the Confederations Cup and the assessment done by FIFA, DoH was singled out as one of the better organised sectors.
Ms V (Tiny) Rennie, Acting Chief Financial Officer & Deputy Director General: Corporate Services, DOH, confirmed that the apparent under expenditure was not actually under-expenditure, but resulted from the figures being shown only up to end December 2009, so most of the spending was on target.
Dr Toby Mbengashe, Chief Director, HIV/AIDS, DOH, explained this further, saying that the Division of Revenue Act required specific Schedule 5 funding on conditional grants. A challenge around delayed payment arose because provinces were out of funds, so the actual budget levels were negative. All provinces had now been made aware that monies under the grants were dedicated for specific purposes and could only be spent there.
Dr Mbengashe agreed that the complaints about the FC1 female condom had been reported. It was bulky and difficult to insert, and was also noisy. The manufacturers had now designed a new condom, FC2, which would be better. Although the male condom was still the most efficient condom use, the female condom was designed to improve the empowerment of women. The plan was to distribute 4.5 million condoms. A female tender was on line, but had been cancelled as some components were not judged satisfactory by the South African Bureau of Standards. It was possible to proceed with another tender.
Dr Mbengashe responded to questions around the ART sites and readiness. Accrediting certain sites was no longer the policy of government. Sites were devolved to provinces, and 1200 Primary Health Care facilities must be tested and supported to initiate treatment and to provide services. In respect of World Aids Day, the Minister would probably be making an announcement soon, and had set a very tight process to ensure readiness. There were two major components. One would ensure that people were aware of the testing and the campaign, and the second would ensure that people designated by the President (namely, pregnant women who were HIV positive and with a certain CD count, people who had TB and HIV/AIDS with CD4, and children who were born to mothers exposed and were TCR positive) would be provided with services as of 1 April. Last year National Treasury increased the budget by R900 million and there were subsequent increases for the next financial years up to 2013. These would cover the additional designations, and were all above baseline figures.
Dr Mbengashe said that the National Strategic Plan that made a commitment that new infections would be reduced by 50%, by 2011. This was based on specific preventative strategies. The figure of 50% might not be reached by 2011, but probably by 2013/14. Currently, the new infection rate translated to up to 1.3 million people being newly infected per year. It was hoped to reduce this. Key strategies included targeting the youth, especially those in their early twenties, HIV Counselling and Testing, which would help people to take responsibility and get treatment early to get access to treatment if necessary. STI interventions also encouraged people to be tested and treated for sexually transmitted infections, to provide a service for family planning and to be tested for pregnancies. He appealed to Members to assist, since prevention was largely driven by social intervention in the communities. Prevention was the priority of Government, and treatment was supplementary. DoH hoped that over time, people would come for treatment early, so as to prevent secondary infections.
The Chairperson expected Dr Mbengashe to have mentioned circumcision.
Dr Mbengashe responded that circumcision was a policy of Government in two ways: firstly, traditional circumcision rituals must be respected, and DoH must provide circumcision as part of health care facilities.
The Chairperson said there were a lot of problems regarding circumcision. Lesotho was one area where traditional circumcision was done, and HIV was a problem there, as also in the Eastern Cape. The problem lay with how these were being performed.
Mr Masilela reported on the classification of hospitals. Section 35 of the National Health Act, as well as the definition section, said the National Minister had the authority to classify any health facility, be it a Primary or Tertiary Health facility, and a hospital was a facility defined as such by the Minister. The request was made to provinces that they must produce long term plans of fifteen to twenty years, outlining where they were taking Health Services. One facility might be classified in a particular way, and a province would want to elevate or decrease the level of services provided in a particular hospital. It would apply to National DoH to reclassify, and, once the DoH had looked at this, the request would be conveyed to National Treasury. The DoH would prefer that the classification of facilities remained constant.
Ms Nuga-Deliwe responded on the issue relating to supervision insofar as it dealt with the Health workforce. The Department had held conversations with the health professions’councils, relating to their Codes of Practice and the supervision requirements. It had also collaborated with the Office of Standard Compliance on their tools for Quality Standards at Facilities, including supervision. The Councils were asking all newly-established mid level worker categories to spell out the supervision requirements very specifically, so that in future mid-level categories would not be created without also knowing how supervision would occur.
Ms Nuga-Deliwe said that National Treasury and the Department of Education were able to provide R800 million, over and above the existing allocation to Clinical Training Institutions in the Higher Education Sector, for strengthening clinical training. This was based on business plans, and a conditional grant from the Ministry of Higher Education and Training for building capacity and assets related to clinical training. The Department was also in discussions with the College of Medicine and others, relating to research and building capacity for research, particularly in the Health profession. She said that the Department, whilst recognising the need for diversity of education and training, nonetheless realised that in respect of health professionals, there was a limit to what the SETAs would be able to do. There were particularly rigorous requirements for clinical training, which the Department felt were best placed within the Education and Training sphere.
Ms Nuga-Deliwe said that the Department had been working on the planning aspect and empirical evidence for revitalising the Nursing Sector. Dr Chetty had spoken about the audit that would assess the kind of capacity, in the broadest sense, that was needed for professional training and what assets there were at public and private colleges that could be mobilised for expansion of production. Accreditation of nursing programmes was also under discussion, and was related to the National Qualifications Framework, and the Nursing Council accreditation processes.
Ms M Mafolo (ANC) said the six priority areas for Quality Improvement were the things the Committee wanted to see on the ground. She was pleased to see the time frames 2010/2011 and would like to know how they were going to be implemented. She asked whether there was any way of preventing the measles outbreak from reaching the other provinces.
Dr Chetty responded that the Department did not want to have any clean up operation because it should have a high measles vaccine coverage for a number of years, which should minimise the risk of further outbreaks.
Ms More asked the Department to give the specifics on the OSD for the allied medical workers unions for at least a month.
Dr Chetty said she would have to send on this information.
Mr Waters said the issue of the Nursing Council accreditation was contradictory to what he had been informed in another meeting.
The Chairperson interjected to say he did not fully agree with Mr Waters. When the Committee met the Nursing Council he did not think they really understood what he was asking, so maybe the Committee should ask the Nursing Council and the Department to attend a meeting together to explain the issue.
Ms Nuga-Deliwe understood that the Nursing Council was no longer accrediting private providers for the four-year qualification; however, they had been accrediting providers for other qualifications.
Mr Waters noted that National Health Insurance was not raised in terms. Although the document mentioned the implementation of NHI, there was no costing on it, and so the Committee could not find out if it was feasible, or affordable or sustainable.
Dr Chetty responded that NHI had been put out for consultation and this would include a full comprehensive proposal.
Ms Kenye followed up on her question on Patient’s Rights, saying that there were problems when patients were moved from one facility to another. She asked where the pilots were being done.
Dr Chetty recommended doing a detailed presentation around Patient’s Rights and policy on another occasion.
The Chairperson said another issue that should have been addressed, together with the attitude and quality of care and waiting times, was corruption at Tertiary Hospitals. The Tertiary Hospitals should belong to the National Department of Health and not to the Provinces.
Dr Chetty said that the Department was still in the process as to which hospitals would be piloted; the Minister would want to announce that.
The Chairperson asked the Department how it was preparing for emergencies or disasters such as chemical warfare that could arise at the 2010 World Cup.
Dr Chetty assured the Committee that the DoH had a very robust plan for 2010 around biological warfare, terrorism, disaster management and every single stadium had been designated. The Department was working with Disaster Management.
The Chairperson noted that although this presentation had not done exactly as the Committee had asked, it had been useful, and the Committee and Department would need to meet often. He urged the DoH, if it did not understand exactly what the Committee was asking, please to clarify it. The Committee had wanted to hear about the strategy on HI/NI infections, but that could be given at another time. There was a need for the Committee and Department to work together, and the Committee wished to know exactly in what state Health Services were, and what could be done.
The meeting was adjourned.
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