The Department of Health presented their third quarter report to the Committee. The presentation noted some significant challenges in financial management that had been identified by the Auditor General. The Department was addressing these and other administrative challenges through their Financial Management Turn Around Plan. In Programme 2, the Department noted some very good efforts in their child immunization program, exceeding targets in both polio and measles vaccines. The Department noted a decline in Mother-to-Child transmission of HIV in all nine provinces. There were challenges with a lack of health care professionals specialising in child and maternal heath. Of particular concern was a lack of reliable statistics in reporting maternal and infant mortality rates. The Department ran a successful campaign to test people for HIV, which provided valuable confirmation of the prevalence of HIV in South Africa. The Department stressed the importance of prevention in the overall HIV/AIDS strategy. There was an increase in the TB cure rate, but it was still below the WHO goal of 85%. The Department spoke to the increased attention that should be paid to non-communicable diseases contributing significantly to the overall health outcomes of South Africans.
The Department noted challenges with health reporting and monitoring, especially due to the lack of available and reliable statistics. This presented problems with planning, monitoring and evaluating health facilities and health outcomes of individuals. The Department had introduced a set of Core Standards by which all health facilities would be monitored and evaluated. The Department had also addressed the lack of skilled doctors and nurses. They had been working with academic institutions and professional bodies to find solutions. Lastly, the Department spoke to the progress made in infrastructure revitalisation. They reviewed several major achievements, including a change in planning that would focus on the overall capacity of a health facility and not just on the building itself.
The Department's presentation of its fiscal position for the end of the third quarter demonstrated in most cases that they had under spent. However, figures for the end of January were also presented, which demonstrated a fiscal position closer to established targets.
The Committee questioned the Department's vacancies and the number of people that were in acting positions. They questioned if the highly successful immunization program was having any effect on adult outbreaks of these diseases and if additional counselling would be available if the HIV testing program was expanded. Members expressed concern about infrastructure revitalisation. It was felt that buildings were being renewed without significant concern for functioning equipment or staff for the facilities.
Members called for future quarterly reports to have comparative data from previous quarters; in addition, they requested additional information on plans such as the Financial Management Turn Around Plan and the Negotiated Service Delivery Agreement.
Members questioned the Department’s efforts on family planning, Choice of Termination on Pregnancy and the distribution challenges of male and female condoms.
In regards to monitoring and evaluation, members asked how Core Standards would be evaluated and what measures might be taken to correct poor performance. Lastly, members expressed concern about the under-spending and asked for strategies to ensure they spend their money.
The Department was not able to answer all the questions within the given time. They were asked to return the following week to continue to address the issues raised by members and also to give their presentation on the strategies on health technologies and medical devices.
The Chairperson welcomed the delegation from the Department of Health. The Chairperson noted that it was difficult to engage with the department without receiving any documents in advance of a briefing.
Ms M Matsoso, Director General, Department of Health introduced the delegation from the Department of Health and provided an explanation for not forwarding documents in advance of the meeting.
Presentation by the Department of Health
Ms M Matsoso outlined the purpose of the presentation as the highlights of the performance of the Department of Health against the target set in the medium-term Strategic Plan with a focus on the third quarter (Q3). She reviewed the vision and mission of the Department and outlined the National Health Systems Priorities 10 point plan for 2009-2014.
Ms M Matsoso stated that in May 2010, the Minister of Health entered into a performance agreement with the President that focused on four strategic outputs:
Output 1: Increasing Life Expectancy
Output 2: Decreasing Maternal and Child mortality
Output 3: Combating HIV and AIDS and decreasing the burden of diseases from Tuberculosis
Output 4: Strengthening Health System Effectiveness
This agreement was signed in October 2010 as the Negotiated Service Delivery Agreement (NDSA). Performance plans would now be based on the NDSA 2010-2014.
Ms Matsoso turned to highlights of performance for Q3 in Programme 1: Administration. The Department developed the Financial Management Turn Around Plan in response to assessments conducted by the Auditor General of South Africa, which highlighted the following challenges:
▪ Inadequate budget processes;
▪ Poor revenue generation and management;
▪ Expenditure management, including monitoring of Compensation of Employees;
▪ Ineffective Supply Chain Management;
▪ Poor Asset Management and Performance Information audit limitations.
Provincial specific plans had been developed to improve financial management in seven of nine provinces. She also outlined key cost drivers in health care delivery, which included: compensation of employees, cost of pharmaceuticals, medical inflation rate, increasing patient numbers, and an increase in fuel costs. The Department had made progress on their organogram, with a view to enhancing their service delivery capacity.
Ms Matsoso spoke to Programme 2: Strategic Health Programmes. In the area of Improving Maternal and Child Health she noted key interventions including a mass immunisation campaign to protect South African children, ensuring early diagnosis of HIV exposed infants, strengthening the Prevention of Mother-to-Child Transmission (PMTCT) of HIV programme and increasing the%age of mothers and babies who receive post-natal care within 6 days of delivery. With respect to immunizations, the Department was successful in 2010 for immunizing 101% of targeted children against polio and 95% of targeted children against measles up to the age of 179 months. Detailed statistics were available in the attached presentation. She noted that 73.7% of infants exposed to HIV had been initiated on prophylaxis from 6 years of age. The PMTCT saw a decline in transmission rates of HIV in all 9 provinces. She presented a slide that outlined the testing and % positive rate from 2008 – 2010, broken down by province. Also, 81% of mothers and newborn babies were reviewed within 6 days post-natally in the first two quarters of 2010/11. She noted that 40% of designated health facilities provided the Choice on Termination of Pregnancy (CToP) services, which was in line with targets. This intervention contributed to a decline in maternal deaths from unsafe induced terminations. She also stated that a decline in contraceptive use led to an increase in the use of CToP. The Department intended to scale up education in family planning to counteract this trend.
Ms Matsoso noted key challenges in the area of Maternal and Child Health including a shortage of health professionals experienced in newborn care. There were very diverse estimates of Maternal, Child and Infant Mortality Rates being produced by different data sources. These diverse estimates led to problems in planning and make it difficult for the Department to publish an accurate figure.
In the area of Combating HIV and AIDS and Tuberculosis (TB), Ms Matsoso noted that the HIV Counselling and Testing (HCT) campaign was launched in April 2010. By December 2010, the campaign had reached 6 021 330 South Africans, with 5 834 937 agreeing to be tested, of which 5.4 million were in the public sector and 369 000 were in the private sector. A total of 936 168 (18%) tested positive. She noted that the campaign would be heightened perhaps to include all public servants, parliamentarians, school children and teachers. A total of 1.3 million people with AIDS were on Anti-Retroviral therapy (ART), however, efforts should be on prevention. By the end of Q3, 403 million male condoms and 4.6 million female condoms had been distributed. The results of the National Antenatal Sentinel HIV and Syphilis Prevalence Survey indicated that HIV prevalence amongst pregnant women remained stable at 29.4%.
Ms Matsoso noted achievements in this area including an increase in the TB cure from 68% in 2008 to 70.4% in 2009. The HCT campaign also screened 2.7 million people for TB of which 441 486 were referred for further assessment. Challenges in this area included the TB cure rate, which should have a target of 85% and only 48% of TB/HIV co-infected patients were started on ART against a target of 70%. Department actions included increasing resources for access to ART and improvement in TB case identification through household outreach programmes.
Ms Matsoso turned to the area of Combating other Communicable Diseases and Non Communicable Diseases (NCDs). She noted achievements as the hosting of the Diabetes Leadership Forum Africa 2010 and producing the implementation plan for the Diabetes Declaration. In addition, a chronic diseases management register was introduced in all provinces in the first half of 2010. Challenges of this area was the fact that the HCT campaign was not as successful as planned in screening people for chronic conditions.
Turning to Programme 3: Health Planning and Monitoring, Ms Matsoso reiterated the lack of availability of good quality and reliable data on the health status indicators of South Africans. Moreover, there was a lack of consensus between local data sources and international agencies regarding health income indicators. The Department established a Health Advisory and Coordination Committee to improve the quality and integrity of data. This committee was expected to report in March 2011. Challenges noted in this Programme included an inability to conduct the South African Demographic and Health (SADHS) Survey 2010. However, elements of SADHS were incorporated into a national nutrition survey for 2011.
The Department developed and approved a set of Core Standards, in order to improve quality of care, to which managers would be held accountable. The Independent Office of Standards Compliance would be established to enforce national standards. The Department had laid a solid foundation for the introduction of the National Health Insurance (NHI) and the White Paper on the NHI would be published soon for public comment.
Ms Matsoso noted that the Department had awarded a tender for the procurement of ARVs worth R4.2 billion over two years. The Department also achieved a savings of 53% in this contract.
In Programme 4: Strengthening Human Resource Planning, Development and Management, the Department planned to revitalise 105 of the 126 public sector nursing colleges. A total of 183 Clinical Associates were enrolled in 2010/11 exceeding the target of 125. The Occupation Specific Dispensation (OSD) for Allied Health Professionals was signed in November 2010.
Ms Matsoso addressed Programme 5: Special Projects and Public Entities and spoke about the revitalised Primary Health Care (PHC) approach. She emphasised that the PHC model would provide a population oriented service delivery model, deployment of multi-disciplinary PHC teams, effective use of Community Health Workers, and greater community involvement in promoting health. Funding had been secured for the establishment of the PHC teams for 2011/12 - 2013/14 period.
Ms Matsoso noted that health facilities were being enhanced and that 41% of the 4,333 public health facilities in the country were build after 1994. In 2010, there were 2,299 infrastructure related projects in the country. There was also planning and design progress for 5 flagship tertiary hospital projects. There had been under spending of the health infrastructure budgets in several provinces despite the need for rehabilitation of buildings. The Department had implemented an infrastructure support model to assist provinces with technical expertise in managing projects. There were also other plans put in place to better plan and monitor infrastructure projects to reduce the amount of rollovers and unspent funds for infrastructure development.
Ms Matsoso noted that a diagnostic assessment of the competencies of CEOs and district managers had been completed, which would support the improvements in service delivery and in enhancing health outcomes.
Ms Matsoso spoke to Programme 6: Enhancing Health Care Delivery through International Relations. Specifically, she noted that 80 South African students were recruited into the SA-Cuba programme. Also, 45 Cuban health professionals were recruited to work in Rwanda under a trilateral agreement.
Ms Matsoso then reviewed a series of slides (see attached presentation) that showed a summary of expenditures by programme against a target expenditure of 75% of budget. Other data slides included summary expenditures by economic classification, progress on conditional grants including by provincial breakdown. All expenditures were based against a target of 75% of budget. She noted that the majority of areas, programmes and provinces were under spent as of the end of Q3.
Mr G Lekgetho (ANC) commended the Department for achieving a price reduction of 53% in ARV medication. He asked for clarity on the Department's vacancy rate and their plans to address it. He asked how many people within the Department were in acting positions, for how long had they been acting, and what the Department's plans were to address this.
Ms M Segale-Diswai (ANC) stated that persons filling acting posts for long periods was unacceptable. If there was a problem in filling these posts permanently, the Department should bring the problems to the Committee for assistance. She asked if the Department had examined the cause of an outbreak of adult measles from last year, and was it still ongoing. She asked if there was a decline in the HIV infection rate as a result of the awareness campaign. She queried the impact of the Occupation Specific Dispensation (OSD) and was the OSD yielding the results that it was intended to. She expressed concern that revitalised health centres were nice but there was no equipment or staff in these centres. She stressed that revitalisation should include everything, and not just infrastructure. Lastly, she expressed concern that the Department had hastened spending in the last few months. The Department should increase spending better throughout the year. She stated that under-spending could not be tolerated.
Ms M Dube (ANC) emphasised that one person could not fill two posts and acting positions should be finalised. She asked for clarity on where ambulances were located. She wanted to see that the Department was doing something in regards to non-communicable diseases. She asked if the reported figures on vaccinations included people who had given birth at home. She asked what message the Department could offer the members of the Committee to take to their constituents regarding teenage pregnancy. She stressed a need to balance infrastructure with human resources. She asked if the Department had a mechanism to monitor contractors and the purchase and transport of medications.
Mr M Hoosen (ID) requested that the Department provide comparative reports when presenting quarterly reports so that the Committee could review progress from past quarters. He requested information on the progress that the Department had made in these areas noted on slide 8 of the presentation regarding the Financial Management Turn Around Plan. He mentioned that the figures presented regarding termination of pregnancy were worrisome and he asked what plans were in place to address this. Similarly, he asked if there was a plan to increase the treatment of HIV to coincide with the increase in HIV testing. He asked what caused the disparity in the number of male versus female condoms being given out. Lastly, he noted the increase in the number of public health facilities as encouraging; however, the time had come to focus on the quality of care versus quantity.
A member of the Committee re-emphasized that revitalisation of infrastructure could not occur without revitalisation of equipment and hiring staff. Security of patients and staff must be addressed. She asked what action had been taken in regards to under spending in several provinces, which was noted in the presentation. She asked the Department how resolutions from former summits were to be implemented, or if they were implemented at all. She asked what would be the role of private doctors in providing information for the Chronic Disease Management Register. She also asked if the Department had a checklist or other means to follow-up on health facilities' ability to meet the core standards noted in the presentation. She asked the Department to elaborate on their statement that a solid foundation for the National Health Insurance (NHI) had been laid (slide 33 of presentation). The presentation noted project approvals for hospitals in the Free State, but she asked what had happened between the approval date and the present. She asked what South Africa's responsibilities would be towards the Cuban health professionals recruited to work in Rwanda, and who would be paying these health professionals.
A member of the Committee noted that according to the National Treasury, the Department had not spent any money on loveLife and she asked the Department to explain this position. She asked if the Department had an asset register. In addressing the issue of teenage abortion and teenage pregnancy she asked what role the Department had with the Department of Education or the Department of Social Development. Lastly, she asked if the Department would spend their full funding allocation by the end of the fourth quarter.
The Chairperson noted that the National Treasury was invited to attend, but was unavailable. He accepted their apology.
Ms L Makhubele-Mashele (ANC) stated that, in 2009, the Department failed to conduct the Demographic and Health Survey. The Department presented that it was again planned for 2010. She asked when the Department planned to start this survey, especially given that the Department now relied on Statistics South Africa and they had no information of their own. She noted that the Department planned to roll out the HIV testing programme to schools. She expressed an interest in the Department's plan to roll this programme out and manage all of the repercussions of positive tests given the shortage of councillors and health care workers in the country. Lastly, she commended the good work of the department in reducing the procurement costs of HIV medications by 53%.
Ms T Keyne (ANC) asked how the Department planned to integrate the various data sources on maternal health and infant mortality rates in order to report accurately on Millennium Development Goals (MDGs). She asked for clarity on the disparity of distribution between male and female condoms and how the Department intended to increase availability of female condoms. She noted with concern that although there was a significant increase in the number of health facilities in South Africa, in many regions people still had to travel great distances to get to one. She asked if the Department was monitoring vaccinations in rural areas.
Mr M Waters (DA) stated that he would like to have the Department present figures on the Financial Management Turn Around Plan and he asked for the turn-around strategy. He asked if plans such as the Occupation Specific Dispensation (OSD) were sustainable and he asked the Department to explain what measures were in place to ensure that provinces received money to fund OSD. South Africa was 11 years into the MDG process and he expressed concern that there was no standardised measurement tool. He asked the Department to explain the statistic that was given for the infant mortality rate, and to provide a date when the Committee would have a reliable report with accurate information. In enforcing standards within health facilities, he asked what the consequences were of failing to meet published standards. He asked the Department how they intended to hold people accountable within the health system. He then asked for clarity on how HIV testing would be conducted in schools. In particular, he asked if there would be pre and post testing counselling, would those who tested positive be separated from those who tested negative. For those who tested positive, what counselling would be offered to the parents. The Department had not provided any figures regarding human resources. He expressed a desire to be briefed on the Department’s plan to increase the number of doctors and nurses in the country.
Ms E More (DA) asked for the details on the Negotiated Service Delivery Agreement (NDSA). She asked for further details on the Financial Management Turn Around Plan, including when it was developed and what was the progress thus far. She asked for clarity on the term ‘inadequate’ that the department used on slide 8 of their presentation. The Committee should have input into the Department's plan for a revised top level structure. She also noted examples of service delivery failures and that it would be advantageous to link the Department’s achievements to service delivery at the operational level. Health promotion should be conducted in a way to encompass the entire spectrum of health versus focusing on one specific disease. She asked the Department if information from their proposed disease register would be reliable and who would monitor this register. She shared the desire to see the Department’s human resource plan.
The Chairperson noted that when the Department provided services and gathered data in areas that they have not previously been to, there would be a significant possibility of actually having worse statistics than they had now. Given that the Department made plans based on statistics, and that current statistics may not be accurate, he implied that the Department's plans may be inaccurate. He asked the Director General to respond to the questions.
Ms Matsoso responded that for the CFO position, hiring was complicated by policy that required the Minister and two Deputy Ministers to be part of the hiring board. In regards to other positions, in 2004 and prior, the Department had two Deputy Directors General (DDG), 33 Chief Directors (CD), and 29 Directors. Now the Department had six DDGs, 33 CDs and 110 Directors. The Minister's plan was to move as many people as possible from the national offices to the provinces and into positions related to service delivery. The numbers of deputy and assistant directors had decreased, which the Department was also trying to correct. The current vacancy rate was 15%. The Department had filled more administrative and management positions than technical positions. The Department had requested funds specifically for increasing the number of doctors and for OSD.
In regards to revitalisation of infrastructure, Ms Matsoso noted that the Department had changed its concept towards health facility planning, not infrastructure construction. These facilities were based on an access model of ensuring that no person should have to walk more than 5 km to a health facility. There were other dimensions that would also be considered before erecting other facilities.
Ms Matsoso stated that the Department had improved their spending patterns from the third quarter until present. The Department had introduced measures of fiscal discipline. This included the Department no longer funding events, cutting down on travel, and reducing workshops. The emphasis of the Department would be on service delivery. The ambulances used in 2010 had been donated to the provinces. The Department had embarked on a national disaster management plan. However, emergency services and ambulances were controlled in the municipalities, which therefore required a reconfiguration to align services with the disaster management plan.
Ms Matsoso agreed that the Department's response to non-communicable diseases needed to be scaled-up. The outreach programs conducted by the Department that visit households reported on issues other than just TB. They also reported on mental health, enrolment in school, and access to social grants. The Department would unveil these results when complete.
Ms Matsoso stated that the youth and adolescent services were not that strong. loveLife was instrumental over the years in raising awareness of HIV and AIDS in teenagers. However, the coverage was only 50% so the Department had asked them to review their program. There were different departments that funded loveLife: Department of Social Development (R30 million), Department of Health (R70 million), Department of Basic Education (ceased funding). She noted several concerns with loveLife including audit problems. The Department of Health threatened to cease funding if the audit problems continued. Second, loveLife only produced one financial report for all departments. The Department had asked them for a complete review.
Ms Matsoso stated that the National Health Council agreed that there should be a central procurement agency for the procurement of medications and vaccines. South Africa had secured funding from the Global Fund, and that central procurement was a condition of this funding. A central procurement authority provided good supply management and oversight in the provinces. The Western Cape and Gauteng provinces had implemented a chronic medication plan whereby chronic medications were either delivered to people or there would be a central place to collect such medication. This would avoid the problems of people reporting to facilities that did not have any stock to give out.
Ms Matsoso agreed that future reports to the Committee would be a comparative report so that progress could be monitored over several quarters. She would ask the Acting CFO to speak about the Financial Management Turn Around Plan in a few moments.
She noted that currently, the Department's school health program had only targeted learners in primary school. However, the Department recognised the need to target younger children. The Department would like to work with the Early Childhood Development (ECD) programme to identify problems at an early age.
Ms Matsoso agreed that the use of female condoms must be increased, but also that increased use must go hand-in-hand with education and empowerment. She proposed an audit of health facilities to determine their responsiveness to female health issues and victims of violence. This audit would occur in conjunction with the UNFPA and UNICEF.
She said that equipment problems within the revitalisation programme were being looked at. In particular, grant usage would be examined to see how grants were addressing equipment problems especially in the facilities noted by the Committee.
Ms Matsoso stated that the delegation of authority to CEOs of hospitals was a problem. Few CEOs had authority to buy even basic consumables. She linked this to security of staff and patients through examples such as improper lighting, which CEOs did not have the authority to fix even though it exposed people to risk. She had asked the Heads of Departments to give CEOs the proper delegation of authorities to conduct their work effectively.
Ms Matsoso agreed that the Department must present their human resource plan to the Committee. There was a shortage of clinical technicians. The Department now replaced broken equipment instead of fixing it. The Department had signed an agreement with schools to train clinical engineers and clinical technicians. The first group should be working in the provinces within four months.
The Chairperson proposed that due to the time, the Department should be called back next week to finish their responses to questions and give their presentation on strategies on health technology and medical devices.
The Committee agreed and the Chairperson adjourned the meeting.
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