Department of Health 2009/10 Annual Report: Further deliberations

Meeting report

National Department of Health (NDOH) 2009/10 Annual Report
Responses to Committee’s questions
Ms Precious Matsoso, Director-General, National Department of Health, led the discussion on outstanding questions asked of the Department of Health (NDOH or the Department) during a previous meeting with the Committee.

The Committee had asked how guidelines on the interpretation on the Choice of Termination of Pregnancy Act, and recommendations for the health facility managers, could be improved. It further noted that some health workers objected to implementing terminations of pregnancy. Ms Matsoso advised Members that the Department was taking legal advice so that it could appropriately advise the provinces.

The Committee had asked about female condoms. Ms Matsoso said that the Department was committed to increase the distribution of female condoms and had asked for an adjustment budget for this year. In the past year the focus had been on male condoms.

Ms Matsoso responded to the question when the cancer register would be reviewed, by indicating that the recent data released by the National Cancer Registry dated back from 2002. Because of lack of data, the next report would be produced in the next financial year, and would reflect the 2009 data. The registry would probably be ready in the next financial year.

The Committee had asked why radiation control was not specifically mentioned, specifically with regard to the vacant post, particularly for Durban, and had asked about the 236 missing radiation devices, what follow up had been done by the Department, and the data base information that had been created. Ms Matsoso said that in future this information would be reflected in the report. The Durban post had been advertised and the closing date was 18 October 2010. In respect of the missing radiation devices, the figure was not a reflection of what had been generated from the internal list. She acknowledged that there were inaccuracies and the information was outdated. The Directorate for Radiation Control was following up and would provide a detailed analysis and scrutinise the matter even further. An updated report would be provided. Although the Department had a limited number of inspectors, they would validate the information on missing devices with the authorities. In accordance with the update, the Department would be able to confiscate the unauthorised devices and find a safe location for their storage. All cases for missing sources would be communicated to SAPS Priority Crimes unit for investigation and prosecution.

In answer to the Committee’s questions on National Health Insurance (NHI) Ms Matsoso said that the matter was reported on by the Minister of Health to Cabinet, which then referred it to the Inter Ministerial Committee chaired by the Minister of Finance.  Costing work was done and this would be reported to the inter-ministerial committee.

The Committee had asked what was being done to address the Mpumalanga capacity problem with regard to implementation of Revitalisation. Mr M Shaker, Head: Infrastructure Unit, NDOH, reported that Mpumalanga’s capacity to deliver services was an ongoing problem, although there had been some improvements. He added that there were three major hospitals under construction, and each had several projects or contracts with their own challenges, but some progress had been made recently. He added that the approved budget of R331.6 million for the current financial year would be fully utilised for all these projects. The challenges experienced included capacity and contract management problems, but these were being addressed and the situation had improved.

The Committee had asked whether the Department had a complaints mechanism around the availability of infant formula. Ms Matsoso explained that visits by Portfolio Committee Members had made it clear that there was a lot of abuse in the provinces, and places where members of staff and mothers were selling baby formula. Provinces were responsible for monitoring, usage and safe custody of baby formula. It was noted that this also happened at district, sub-district and facility levels. Facilities should keep a register of formula received, recording the information about the infants and the products issued for each of these children. These registers were supposed to be given to the provincial nutrition units on a quarterly basis, and the provincial managers, together with the District Nutrition Coordinator, working in conjunction with Mother-child Women’s Health Unit, were supposed to verify this information on a regular basis. She said the Department needed to decide the level where the supplies would be kept. She said unethical practices were tantamount to theft and a complaints management system at provincial level would be considered.

The Committee expressed concern about child mortality rates and the lack of hospital infection control, and asked for the Department’s plans. Dr Carol Marshall, Deputy Director General: Health Planning and Monitoring, DoH, explained that although there were existing guidelines that had been developed in the past, and a policy on strategy and infection control, the Department still felt that it needed something more practical. The NDOH therefore commissioned academic institutions to write a comprehensive manual on infection control. The absence of concrete guidelines would thus be addressed within a few months. The Department was undertaking a comprehensive audit of the situation in all hospitals. It was aware of the presence of some infection control practitioners, though most of them lacked requisite training, and in other cases they were not allocated full time but were doing other tasks as well. The results of the audit would be available by the end of the year, to show what the situation was in the hospitals around infection control capacity. A standardised list for discussion had been developed on materials and products that were necessary for infection control, as guidelines to procurement sections around the country.

In response to Committee requests about achievement of the Millennium Development Goals (MDG) by 2015, it was noted that the MDG report had been made available to all Members. Ms Matsoso noted that there were multiple sources of maternal mortality rates data from Statistics SA, Human Sciences research Council (HSRC), Medical Research Council (MRC), Demographical Survey & Unicef, and this made it difficult for the Department to plan around those figures, which in turn affected its interventions. This was an issue that required an urgent solution and all these institutions would be invited to come and discuss these figures.

Ms Matsoso then addressed the questions on under spending, noting that this had occurred because the office was not fully functional.

Dr Marshall added that the policy that governed quality in South Africa was out of date and a process of revising the policy and quality was under way. Inputs from the United Kingdom (UK) system would be considered, and, based on this revised policy, a draft amendment to the current National Health Act would be tabled to the National Health Council on Friday 22 October 2010. This would enable the establishment of the Independent Accreditation body that would accredit all facilities in the country, public and private, based on a set of agreed standards.

Dr Percy Mahlathi, Deputy Director General, National Department of Health, commented on the Committee’s complaint that it had never been provided with the Human Resources for Health Plan. He said that the plan that the Committee referred to emanated from 2006. It would be printed and made available to all Members by the beginning of next week. An electronic copy could also be made available, if requested.

Dr Mahlathi said the plan framework was currently under review and would be ready by March 2011. He noted that it was inaccurate to assume that the plan would be developed from scratch. He outlined programmes that were implemented from the 2006 plan. These included the remuneration policy that resulted in the Occupation Specific Dispensation (OSD), and noted that a policy document had been handed to the Committee. A nursing strategy was drawn and launched in 2008,  as set out in a CD also provided to the Committee. NDOH had also developed a programme and expansion of the training of clinical associates, the professionalisation of the emergency medical services, and the review of the policy on recruitment and employment of foreign health professionals. It had undertaken an audit of nursing education and training institutions, both in the public and private sector, as well as a mid-level worker policy and a health sciences education and training policy. Dr Mahlathi emphasised that these were some of the highlights that flowed from the 2006 plan, and illustrated that the work that had been done emanated from that plan.

Dr Mahlathi then turned to the Committee’s concerns whether the provinces had plans to recruit and attract health workers, particularly for rural areas. He said that there were many areas that the Department had addressed when considering the remuneration for health professionals. These included how to address incentives for some of the health professionals, a review of rural allowances,  introduction of OSD,  improving accommodation and facilities in line with the revitalisation programme for hospital infrastructure, improving management through training and development initiatives,  implementation of Community Service for Nurses, and recruitment of foreign healthcare professionals and their placement in rural facilities according to provincial requirements.

The Committee had also questioned whether the figures for the health workforce, indicating a rise from 243 000 to 271 000, were for the public or private sector, whether in fact there was an increase overall, and how the moratorium affected these numbers. The Committee also questioned the accuracy of the figure, given the lack of reliable data, and asked how PERSAL figures could be verified and validated. The Committee also asked for comment on any problems with the implementation of OSD.

Dr Mahlathi said the major challenge for the Department had been inaccurate data obtained from PERSAL. The Department had no dedicated health workforce information system and experienced challenges in getting variable data from the provinces. He noted that the introduction of OSD had improved the situation dramatically, because remuneration was recorded for this on an individual basis and not under a blanket category.

The baseline data was taken from the 2006 PERSAL system, which had under-counted nurses by 10 000 and led to a huge over expenditure, but this had since been resolved. Dr Mahlathi said the accuracy of figures would remain a challenge until the clean up of PERSAL was finalised.

Dr Mahlathi said the implementation of OSD was fraught with challenges, ranging from inaccurate data, to the preparedness of HR practitioners in the provinces to implement the OSD. He noted that this issue had been resolved over a period of time. The OSD would be implemented once an agreement with relevant Unions had been reached.

The Committee had further enquired about the audit of nursing colleges and inspection problems. Dr Mahlathi indicated that this was the mandate and responsibility of the South African Nursing Council and recently appointed Registrar of the Nursing Council, and indicated that the programme of inspection was under review, to bring it up to speed. The Nursing Council was also responsible for accreditation of colleges and standardisation.

Dr Mahlathi also addressed questions from the Committee on how the Department was reporting on the numbers, with regard to output, input, changing of behaviour as a result of training, and how all these linked together. Dr Mahlathi acknowledged that it was difficult to measure behavioural change when there were many variables that affected the desired change. However, programmes were put in place to improve the quality of care. Monitoring the effectiveness of those programmes was an important factor.

Dr Mahlathi answered the questions whether provinces had the same organisational structure. The various provinces in fact had different organisational structures, because the provinces had latitude to develop structures that suited their service delivery needs. However, in terms of the Health Act, provinces were obliged to consult each other, so that the variation was not too great. Some provinces had Departments of Health and Social Development combined, whilst others had departments focusing on Health alone. This impacted on the organisational structures.

The Committee had expressed a wish to hear more about quality issues, and to get a report on training of Chief Executive Officers in hospitals, as well as clinic managers, and the expansion of priority districts beyond the number of eighteen. Dr Mahlathi said a number of strategies and programmes had been put together for the training of Chief Executive Officers (CEOs), human resources practitioners, and generally improving the performance of all staff. The Department synchronised the workplace provincial plans together with the training of HR practitioners.

Ms Matsoso added the report on the assessment of competences of CEOs would be made available on completion.

Dr Yogan Pillay, Deputy Director General: Strategic Health,  Department of Health, responded that a number of programmes had been established to train district managers. These included the Oliver Tambo Fellowship programme at UCT, Masters in Public Health and University of Pretoria had completed a programme for district managers, not only for South Africa but sub-Saharan Africa. He noted that the next step would be to review whether the programmes made a difference on the ground.

Dr Pillay said the eighteen districts had been selected on a range of indicators, largely maternal and child indicators, but also included TB and HIV indicators. These were then ranked on the basis of socio-economic factors developed by UCT’s Health Economics Unit. However, this was not a static number of eighteen. With respect to TB, there were three other priority districts that were not part of the eighteen mentioned. The Prevention of Mother To Child Transmission (PMTCT) programme had been expanded beyond the eighteen districts. The district PMTCT data for 2009 would be used to review the performance of all districts.

Dr Pillay said the PMTCT data had shown the reduction in transmission rates for Amajuba district in KwaZulu Natal (KZN) and Khanyokude had come down 5% and 7% respectively from 20% transmission rates. This was because of the additional effort that had been put in place with the Department’s development partners to engage with the district managing team, facility managers and service providers in those areas to strengthen service delivery.

Dr Pillay said Ukhahlamba in the Eastern Cape had experienced a number of child deaths in the past, due to diarrhoea, and there had been significant improvements in this district in the past year.

Ms Matsoso reiterated that the Department needed to improve its performance and had, in a systematic way, tried to move towards an integrated planning. She expressed concern that multiple audits in facilities disturbed staff from their duties and therefore an integrated approach was preferable, whereby there could be planning for all 52 districts, as it would reflect whether the human resources and facility infrastructure. Because of lack of an integrated approach in the past, some facilities had theatre equipment which had never been used, whilst another facility might be built without any electricity being provided, and another show poor workmanship, whilst yet another had not been handed over. There was a need for the Department to look at infrastructure technology audits in an integrated approach, and link them with the HR plan to ensure that the built facilities would be well resourced.

The Committee had enquired about a District Health Planning (DHP) Report that had not been produced. Mr R Mrewane, NDOH representative, explained that the area of District Health Planning (DHP) had not been successful because districts lacked capacity to plan, and relied on external support from the National Department of Health. This was despite the fact that the plans made provision for being signed off by the leadership of the municipalities, to show the relationship between Integrated Development Plans (IDPs) and the district health plans. The Department decided to align the DHP guidelines and the Annual Performance planning guidelines to ensure uniformity throughout the entire system, so that plans at the local level would inform plans at the district level.  The Department ensured that provincial planners, who were experts, provided support in the development of districts. Annual Performance plans would be informed by the DHPs, and provinces would see DHPs as important for planning purposes. The National Department of Health was working together with its colleagues from the development agencies and provincial planners, and visited provinces during their planning sessions to ensure that plans were aligned and fruitful.

Members of the Committee had asked for a report on how the Department was dealing with tuberculosis (TB) in the mines. Dr Pillay noted that TB in the mines had been a challenge for centuries. Three departments were responsible for handling TB on the mines. The Department of Mining (DoM), through the inspectorate of mines, was responsible for health and welfare, health and safety in mines, and the Department of Labour (DoL) and the Department of Health also bore responsibility. Part of the challenge was that the legal obligations for mines were based on the mining legislation and the reporting line was between the mine owners and the Department. Therefore NDoH received no reports from the mines. However, over the past eighteen months, the Department had some success in making the larger mines report through the electronic TB register within their districts. However a significant number of mines were not members of the Chamber of Mines. Dr Pillay added that the NDOH was working with Department of Mining to get the mines to screen all miners at least twice a year, and to have the treatment of patients who tested positive for HIV to be aligned with the same treatment used in the public sector. Although there had been some progress on both issues, it was uneven across the different mines.

The issue of TB on the mines was a major issue that came up at the Stop TB Partnership board meeting and the Minister of Health undertook to facilitate a coordinated approach to TB on the mines, not only with the South African Ministers but also those from Lesotho and Swaziland. The Minister would build on the Southern African Development Community (SADC) draft document on TB in the mines, which was yet to be approved by the Ministers. The document detailed five issues of standardised treatment protocol of SADC, surveillance system across SADC,  a health passport that could be used across the region,  monitoring and evaluation, and resource allocation. The meeting had been scheduled for February 2011.

Dr Pillay added that the level of dust in both the coal and gold mines presented a major challenge and contributed significantly to the transmission of the bacteria. Some empirical work had been done by the Department and the National Institute of Occupational Health to assess what was happening in the mines. A review of 60 mines had been done and a report was prepared for the Department of Mining.

The Committee had questioned the turnaround times in the Compensation Commissioner’s office. Dr N Padayachee, NDOH, responded that the Compensation Commission (CC) had experienced leadership challenges. The Compensation Commissioner position was at Deputy Director level, which was inappropriate for an organisation that was disbursing R1 billion a year. The Department had been unable to attract a suitable person at that level, and finally upgraded the post to Chief Director level, and it had just been filled. At the same time the Department appointed Sizwe Consultancy Group to do an assessment of the Compensation Commissioner, with a view to doing a business process review and improving the processes in the Compensation Commission’s offices.

The Department noted that the Commissioner for Occupational Injuries and Diseases and the Compensation Commission worked essentially on similar issues, but operated individually. A single Deputy Director General was now assigned to deal with all issues arising and working relationships attempted to coordinate the work of the organisations better. There had been some problems but systems were put in place to improve the throughput of individuals, which resulted in an increase of cases referred to the Compensation Commission. There was a large number of vacancies in both organisations, and measures had been taken to ensure the filling of the vacancies.

The Committee had asked whether the Environmental Health Officers in the Department were fully utilised and what had happened to municipalities that had no environmental health services. Dr Padayache said the environmental health officers who were still in the Department were fully utilised to strengthen port health services, handling of hazardous substances and control of malaria. The changes in the Health Act made environmental health the main function of the local government, instead of provincial and national government. The legislation would be changed to allow local government to employ environmental health officers. He added that at the moment there were 588 environmental health officers employed by the provinces and 1 479 by the local government, with 96 vacancies in provinces and 109 in local government at 109. This meant that the environmental health officers employed by the local government were approximately three times as many as those employed by the provinces. There was a very low level of vacancies in the local government, so contrary to the belief that there was actually a huge shortage of staff and that district health was not functioning, the vacancy rate for local government was less than 10%, while that of the provinces was less than 20%.

Dr Padayachee dismissed the question of whether environmental health officers were fully deployed to carry out port health services, hazardous substance and malaria, adding that the majority were deployed in KZN, Limpopo and Mpumalanga, where malaria was prevalent.

The Committee had asked how the Department would address the issue of long queues of patients at health facilities. Ms Matsoso confirmed that the Department started a programme where National Department of Health officials visited facilities, as part of the performance agreement of health workers at national level. She added that members of public who visited those facilities spent the whole waiting for medical attention. At Thembisa Hospital there was no numbering system to ensure that patients did not spend the whole day at the facility. A check at the hospital’s feeder clinics revealed that some were not busy. Most patients preferred the hospital, possibly because of lack of adequate medical care at the peripheral facilities.

Dr Marshall said two approaches would be taken to address this issue. The first was to document the problem of queues, through software developed by the University of the Western Cape. Negotiations for technical support were in progress. Secondly a methodology called LEAN would be employed, that was already used widely in industry to work out where time was being wasted, thus reducing dead time. Workshops would be held in 18 hospitals throughout the country, which would train hospital management teams to identify five critical priorities and to develop a problem solving approach to reducing the waiting time.

The Committee had asked about the students who were sent to study in Cuba, the cost implications of this, whether this programme was necessary, and had called for a detailed report. Ms Nthari Matsau, Deputy Director General: International Relations, DoH, addressed the political and cost aspects of the programme. This programme was started in 1995, after an accord had been signed between South Africa and Cuba to cooperate in the health field, with direct sponsorship by Cuba for South African training in medical health. As part of that accord, Cuban doctors were brought to South Africa to serve the underserved rural areas where it was difficult to employ local professionals. In addition, engineers and research scientists were also trained in Cuba. This latter programme had to be terminated, because it was very expensive.

Ms Matsau indicated that a detailed report had been compiled and would be given to members for their information. A total of 731 people had been recruited since the inception of the programme in 1997. Of the 731, 261 had qualified and were now employed in various public health facilities, and 400 were in Cuba in different levels of training. All local medical schools participated on the integration programme, except the University of Free State. Ms Matsau said the cost and admission criteria were reasons for students training in Cuba.

Dr Mahlathi added that one of the challenges of the local institutions was their capacity to expand and admit more students. She confirmed that a report had been drafted for the Minister and would be made available to the Committee at a later stage. A joint academic meeting was held in March 2010, in Cuba, to close the gap in training of students who returned with few skills related to surgical procedures and infectious diseases, because they hardly saw TB patients or diseases like cholera and some other childhood diseases. It was important that students familiarised themselves with disease patterns in South Africa.

The Committee noted that a report on Vitamin A had been reported under International Relations. Ms Matsoso confirmed that this had been a mistake.

The Committee had asked how the Department reviewed and monitored work done by provinces. Ms Matsoso said a recent development had seen managers visit facilities and this would be expanded further with senior managers as part of their performance agreement. She said that an overall government project established by the Department of Public Service and Administration linked performance management of senior management teams and also had a developmental component, and the Department wanted senior managers to “adopt” facilities, so that they could be monitored, to ensure that things were done on a regular basis. Reports would be prepared for the Members to inform them fully about the Department’s activities to improve services. Ms Matsoso added that the Department also received reports from the provinces, particularly on infrastructure-related projects, as part of the conditional grants.

The Committee enquired about the quarterly reviews. Ms Matsoso said the performance contracts of different managers was an issue that had been discussed in management meetings. Every manager should have a performance agreement, in which individual performance was linked to the overall performance of the Department. She admitted that while this had not been done on a regular basis, a proposal had been tabled, linking performance and development plans, as also with the DPSA project. This would then be linked with the service agreement which the Minister had signed with the President, and this would also provide a link between performance agreements between the Minister and the MECs of the Provinces. This whole integrated plan would inform the activities of the Department. There would be clear indicators for MDGs. The Department would like to move from just developing tools to having an approach that ensured service delivery. The DPSA project was seen as a vehicle for further enquiry and expansion.

The Committee had raised questions on data management. Ms Matsoso acknowledged the Department had problems with data management. The role of the auditor was to assess reliability of the information given by the Department, as well as its source. The District Health Information system’s data was recorded sometimes manually, sometimes electronically, but this needed to be standardised. Ms Matsoso confirmed that the R3 billion allocated to the Department was not for conditional grants, but for services and activities that it had to perform, while the balance was for conditional grants. The performance of province would  establish whether the Department was making a difference in each of the provinces.

The Committee had questioned the need to focus on Primary Health Care (PHC). Ms Matsoso acknowledged the importance of PHC and said that the basic principles needed to be reinforced to reduce some of the maternal or infant mortality rates. She added that institutions needed to be strengthened so that they could produce the nurses and the doctors that were required.

Discussion
The Acting Chairperson noted that, for future Annual Report presentations, the Auditor-General (AG) should be invited to attend the meeting, to confirm or challenge what was said.

She commended Ms Matsoso on the report, and reiterated that if  PHC was handled properly then everything would flow smoothly. She also commented on the past mismatched planning that had resulted in infrastructure being built, which had ended up as white elephants, with no equipment nor human resources capacity to operate them.

Ms M Dube (ANC) commended the Department for the detailed responses to issues raised in the previous meeting. She asked whether proper handover  or takeover was done in the Department. Ms Dube asked whether it was the trend that every new management team introduced different programmes and wondered why there was no continuity between the programmes that were introduced 15 years ago to those currently in place. She wondered whether the past fifteen years had been chaotic.

Ms Matsoso everything that had been said reflected the Department’s planning and implementation process. She said that historically the National Department of Health had developed policies, but the question had been its ability to implement. It was not so much a question of new management doing new things. The Department had to show why health services had not performed for the past 16 years, and should change the way it worked. What was needed was not mere oversight done through remote control, writing reports sending emails to provinces, or organising workshops. Instead, management needed to walk around and actually enable things to happen locally, whilst it also led and supported at the national level. If the NDOH was enabling locally this meant provinces would be able to perform, while the oversight role continued. She acknowledged that in order for provinces to perform, the Department had to support them, and said that where the NDOH had set up systems, there had been significant improvements.

In regard to the handover reports, she said that if things were done at a certain level, then this would improve health in South Africa. The Department of Health provided a safety net where other sectors had failed. For example, if the trade and industry sector failed, people could become depressed, which was a health issue, and Department of Social Development would also have to intervene. It was important that NDOH should be able to make interventions in all spheres, which would only be possible if it structured itself to handle the challenges.

Ms Dube asked whether the Department had qualified people to deal with money, in light of the reports of  under spending, unauthorised expenditure and fraud. She asked what the job description of the national structure was vis a vis the provinces,  and whether it was not the National structure’s responsibility to oversee provinces.

Ms Matsoso acknowledged that the Department’s mandate was to take responsibility of the funds allocated to it by Parliament. The Department would present a report to the National Health Council, outlining improvement measures to help provinces to perform financially. She undertook to share the reports with members as a basis to measure the Department’s performance. She said the Department had technical support units, to support provinces to move towards sound financial management.

Ms Dube asked whether there were people who managed assets and whether data was available on equipment in hospitals. She expressed concern that an asset report had never been made available.

Ms Matsoso said the Department aimed for a clean audit because the management reports of the AG reflected that there were still problems that required major improvements. Although the Department had achieved some improvements in certain areas, there was still a lot of work needed for it to achieve the clean audit.

Mr M Waters (DA) commended Ms Matsoso and her team for the quality of responses given to the questions, noting that this was refreshing after answers in previous years. He asked why the Medical Control Council (MCC) had not been mentioned in the Annual Report, and whether it was an oversight. He commented that the Office of Standards Compliance should have been established seven years ago, and it was inexcusable that it had a small staff compliment, which accounted for the fact that standards in public and even some private health facilities were appalling.

Ms Matsoso said significant improvement had been achieved in MCC, and a separate report would be provided. Parliament had approved funding of MCC operations. However, there was an area that required clarity and policy guidance. Firstly, MCC needed to be headed by a Chief Executive Officer, but normally that would require that a Board be in place, whereas MCC had only an advisory committee. This would require a policy decision, and might also require that the legislation be amended to provide for a board.  

Mr Waters commended the achievements of the HR plan in the last four years but expressed concern that it was not comprehensive, as it did not set targets and time frames. He hoped these would be reflected in the revised plan. He noted that, since the 2006 plan, the Department had not filled the vacancies and the condition had actually worsened. The audit of nursing colleges had just been completed but no new colleges had been opened, which reflected that the plan had not considered the needs of the country.

Ms Matsoso said the HR plan was in place, but had to be improved to show projections. She indicated that Eastern Cape had more vacancies for professional nurses than student nurses, which meant that it would be top-heavy.

Dr Mahlathi added that some of the challenges of the Department in regard to the HR plan included recruitment and retention. Another element was the vacancy rate, which related to production. In its 2006 plan, the Department had set target and dates, as provided by the Deans of nursing colleges. Funding was another challenge. The audit of the nursing colleges revealed that part of the problem was the scarcity of nurse educators, without whom there could be no production of trained nurses.

Dr Mahlathi observed that another challenge was the differentiation according to type of employer or sub-sector.  In KZN, consultants employed under University conditions earned less than those employed by the provincial departments, and demanded OSD as education-sector employees. OSD had had some unintended consequences.

Mr Waters commented on the maternal health issue and the five different sources of maternal mortality rates. He was astonished that, ten years into the programme, there was no standardised method for analysing and evaluating the information. This was an international embarrassment, especially given the resources available. He pointed out that in any event, the maternal mortal mortality rate was increasing, irrespective of the figures used.  

Ms Matsoso acknowledged that there was a need for a sound demographic profiles, and data should emanate from NDOH. Statistics SA was mainly a confirmatory body, and data used from the Census could not be used as the basis for planning. Another study had been conducted, annually, while the demographic survey was conducted every five years. The Department needed both sets of data for comparative purposes, and South Africa must benchmark itself against other countries.

Mr Waters noted discrepancy between the Department’s Annual Report and the Auditor General’s report, which granted unqualified audits for some provinces. The AG had also raised a few concerns about the HIV/Aids grant spending, projects completed under the hospital revitalisation grant of R1.76 billion, and irregular expenditure by provinces. Mr Waters asked why there was no correlation between the 99.9% HIV/Aids grants allocation and the 53% target achieved in the year under review, and what the Department would do to improve the situation in the next financial year.

Dr Pillay explained that HIV was a conditional grant, for which 75% related to the antiretroviral (ARV) drugs, which included three components, including human resources (doctors, nurses, pharmacists and community health workers), the cost of purchasing the drugs, and laboratory diagnostics. That component of the grant was easy to manage. The outcomes were tested as the new patients initiated for ARVs and the number of former patients carried through to the new financial year. Each year the targets on antiretrovirals had been exceeded. The balance of the grant focused on preventative measures and NGO support, and the impact of this 25% was more difficult to quantify. This was an area that required more work. NDOH had engaged with National Treasury  had engaged the Treasury on changes to the grant, in terms of its funding, indicators to monitor it and how monitoring should be done. Other targets, including distribution of condoms, were not funded from the grant, but from money from the NDOH.

Dr Pillay accepted that the way in which provinces had developed their business plans, with the assistance of NDOH, was similar to issues around the district health plans. The capacity to plan at provincial and sub-district level was still evolving. That affected the business plans for the conditional grants. An external review for the 2010/11 business plan had been done by the Department’s development partner. Provinces had given their feedback. It was hoped that the next set of business plans, which included the set targets and indicators used, would improve.

Dr Toby Mbengashe, Chief Director, HIV/AIDS, DOH, added that the assessment of performance of programmes like HIV/Aids was defined within the Division of Revenue Act (DORA) and was the basis on which indicators were monitored. The focus had initially been on access to treatment, and these targets had been consistently achieved over the years. However, it was thought that the indicators should change to show the clinical outcomes of the interventions done and the difference they had made to the patients. The component that dealt with prevention had to look at successful prevention, which included not only number of condoms distributed, but also medical male circumcision, PMTCT use by pregnant mothers, and the structural component dealing with prevention.

Dr Mbengashe noted that most of the people who became infected were partly responsible for this themselves, although studies also showed that some people’s setting exposed them to more infection than others, which then brought in social determinants for health. These indicators were not presently included in DORA.

Three provinces would be used for a study to understand the patterns for usage of money of conditional grants, and what monitoring was effective in ensuring accountability. Recommendations would then be made and changes implemented, to provide quality information. These were people in particular settings that exposed them to more infections than others – which brought about a social determinant of health. He confirmed that these indicators were not there in the present DORA.

Mr Waters noted that the report had not mentioned projects that had been completed or were in use within the budget.

Mr Waters noted that both the Department and the AG had raised the problem of irregular expenditure of R3.8 billion across all the provinces and asked what steps were taken to address this. The same question applied to the unauthorised expenditure, which amounted to R6 billion in one financial year. Mr Waters opined that the three main culprits, Gauteng, KwaZulu Natal and Eastern Cape should be placed under curatorship in terms of Section 100 of the Constitution, as they had shown their inability to handle their finances.

The Acting Chairperson reiterated the need for the AG to be present when the Department presented its Annual Report in future. The two entities should be working more closely together to influence the preparation of the next Annual Report.

The Acting Chairperson noted that the report on the PHC facilities offering Voluntary Counselling and Testing (VCT) said that the targets had been achieved. The AG’s report on the same indicator said that there were no supporting source documents. She questioned the discrepancy in reporting, and asked about the authenticity of the Annual Report, especially in light of the NDOH’s challenges in collecting information.

Dr Mbengashe confirmed that he had not seen the AG’s full report on this. However, of the 4 300 health facilities, 3 800 were fixed, and 500 provided voluntary counselling testing for about two to three years. The method of verification by the AG could be different, and it was important to understand the expectations. Whether the money spent, and its impact, could be tested, spoke to an epidemiological assessment whether the resources were related to perceived outcomes. If people were provided with good quality treatment, then the results could easily be seen. Population-based surveys done by Stats SA showed the reduction in deaths related to HIV/Aids, which was a function of good quality treatment. There was a definite correlation between the billions of rand put to treatment and the impact achieved.

Mr T Masilela, NDOH, explained about the problem of source documents. All the health facilities provided VCT, and the Department had discussions with the AG in preparation for the 2009/10 audit. However, the bone of contention between the Department and the AG was the District Health Information System (DHIS) as a statistical routine health information system. The Department had explained to the AG that the DHIS was not a patient-based information system. He explained that if the TB cure rate was given as 64% this meant that the Department had been given aggregated data, from lowest to highest levels of the health system. However, it was not possible, using the DHIS, to see which individuals had been cured, unless the AG was prepared to call for and review individual records. Mr Masilela added that the 2008/09 data reflected 96%, and the 2009/10 report mentioned 100%. The AG, however, asked for disaggregation at the lowest level of patients. The Department was still building a system that would enable it to get that patient information.  

There were a few areas where the Department had agreed with the AG’s requirements to log data for ease of verification, and the systems included adapting the DHI system to include this function, reduction of the turnaround time for information flow, and restriction of access control to the DHIS, which was presently not strong enough.

Mr Mrewane said processes were being put in place for the DHIS to ensure quality data from the sources.

The Acting Chairperson asked whether the Department had evaluated the impact of OSD. She said that in Free State, management complained that although it had done well, it had also created some problems around incentives, especially for people in remote rural areas. She urged the Department to revisit its determination of rural areas.

Dr Mahlathi said that when OSD was conceptualised for the health sector, the Department was quite clear that, since it was solving chronic problems of the sector, new challenges would arise. This was designed in a manner that the challenges would be minimal, compared to what happened in the past. The nursing field had been one of the major problems. However, within a year of implementation, the public health sector gained about 6 000 nurses, while Baragwanath Hospital declared that it no longer had challenges of ICU and theatre nurses.

Dr Mahlathi acknowledged that it was difficult to define a rural area as some, like Cinsa in Eastern Cape, might be rural in situation yet have a high level of affluence, whilst pockets of Johannesburg reflected the deepest poverty and lack of access to health facilities. Social dynamics around urbanisation provided challenges, which had led to the development of guidelines by World Health Organisation (WHO), in which South Africa also participated, geared to the retention of health workers in remote and rural areas, and increasing access to them.

Dr Mahlathi said that when evaluating OSD, the Department was aware that it had to develop a tool not to measure salaries only, but to deal with issues of career pathing and progression, disruption of family lives and other challenges. HR staff at each facility were expected to understand and implement correctly.

The Acting Chairperson asked about the environmental health officers’ role in areas where there was no port health facility, hazardous substances and malaria. Although the Department had said these officers had gone to municipalities, many Municipalities had their own officers. She wondered if more officers were trained than could be absorbed into employment.

Ms Matsoso confirmed that the Department struggled to have trained environmental service practitioners utilised in the municipalities. One recommendation from the Department had been the amendment of the law that enabled them to be employed across the board, for instance, to help inspect facilities where food was produced, implementation of food control, and other facilities, to ensure compliance with legal provisions.

Mr Mrewane explained that when devolution started, many environmental health practitioners felt insecure and resigned, so that many municipalities had considerable less in 2010 than in 2006. They had been attracted to other government institutions, like Department of Labour or Water Affairs, into abbatoirs, agriculture or health or private facilities. He added that Eastern Cape provincial department employed 94, whilst 152 were at the municipalities, and those in the provincial offices were performing the same functions, because these still resided with the province. Municipalities had been unable to recruit them, so there were service level agreements allowing for the functions to be carried out in this way.

The Acting Chairperson linked this issue with provincialisation and devolution of powers, noting that there were, in some sub-districts, clinics with the Department and Local Government. She asked what the NDOH was doing to address this, and whether it had the AG’s report.

Ms Matsoso everything that had been said reflected the Department’s planning and implementation processes. She reiterated that historically the National Department of Health had developed policies, but there had been questions around implementation.

Mr Mrewane said that when the decisions were made, the municipalities that, in 2005, were rendering PHC should release these to the provinces. That exempted metropolitan municipalities from the whole exercise. The IMATU Union then took government to court, challenging the legality of the definition of health services or primary health care services. Despite that, significant progress had been registered in Limpopo, Free State and Western Cape. Limpopo, however, lacked funds to maintain the infrastructure, and some services were rendered from offices shared with general municipal service administration. In other provinces, larger towns had tended to be resistant, but smaller towns, who were cash-strapped, cooperated, and some provinces relented after they started losing nurses because of the OSD. No progress was made in Gauteng, KZN and Eastern Cape. These issues would be solved once a meeting was held with South African Local Government Association (SALGA).

The Acting Chairperson raised three issues, and called on the Department to respond in writing. She emphasised that the Department spoke on behalf of all the provinces. She asked that the NDOH address issues of staff migration from one province to another, to get promotions. She also wanted the issue of transport for clinic supervisors be addressed as a matter of urgency. In outlying areas like Mose Skothane, the supervisors had initially used their own cars and were reimbursed, but had stopped doing even that because of the state of the roads, so that supervision had declined to becoming the odd clinic visit, not in accordance with the requirements. She also queried the relationship of the South African National Aids Council (SANAC), what it was doing, who it reported to, its source of funding and its expenditure patterns.

The meeting was adjourned.