Follow-up Deliberations on Third Quarterly Report; Department of Health briefing on Health Technology & Medical Devices; Policy on rural, community & remunerated work outside the public service doctors

Meeting report

The Chairperson welcomed the delegation from the Department of Health (DoH).  The Chairperson noted that this meeting was supposed to start with the follow-up from the Third-Quarter Report.  He noted that the Department had submitted written replies to the Committees questions and that if there was any further follow-up, it would be addressed at the end of the meeting, time permitting. 

The Chairperson asked the Department to continue with both of their presentations and the Committee would engage the department following the presentations. 

Presentation by the Department of Health
Ms Malebona Matsoso, Director-General, Department of Health asked Ms Molai to present on Health Technology.

Ms Nonkonzo Molai, Deputy Director-General, Department of Health noted that her presentation emphasised the Department's strategy and did not address 'work-in-progress' issues. The main purpose of the Department's strategy was to ensure that health technology (HT) was available when and where required, that HT was fully functional, that it posed minimal risk to patients, while reducing the systematic inefficiencies and associated wastage. The Department's HT strategy had 5 strategic objectives (SO), defined as:
•SO1:  Promoting Equity In Access & Distribution Of HT (HT Planning);
•SO2:  Reduction Of The Unnecessarily High Cost Of HT (HT Acquisition);
•SO3:  Ensure Safety and Efficacy of HT (HT Asset Management);
•SO4:  Ensure Appropriate Introduction, Adoption and Continued Use Of HT (HT Assessment, Evidence Based); and
•SO5: Development of Relevant Legislation (HT Regulations).

Ms Molai presented a detailed definition of HT.  However, she noted that this strategy focused on medical devices only. Turning to SO1, she noted the challenges as poor planning, no rational basis for HT procurement and replacement, lack of skilled operators for HT equipment, and a mismatch between the need and available technologies. The strategic goals to address these challenges were to develop a technology planning mechanism, including acceptable norms and standards and the adoption of a national HT Plan. Other goals included building a planning capacity, including experts and establishing a national HT inventory. The Department was currently planning an HT audit to determine what equipment was available, what equipment worked, and when it should be life-cycled.  A Ministerial Advisory Committee on HT had just been appointed to oversee the multi-disciplinary HT planning committees (not yet established).

Addressing SO2, HT acquisition, Ms Molai noted the challenges as an inability to determine HT cost drivers.  The department would like to perform a value chain analysis to determine where the costs are.  The Department had poor controls on device acquisition and without having an HT asset register, it was impossible to control.  The Department was looking to restructure the procurement process by introducing central procurement and bulk buying to achieve cost reduction.  Ms Molai also noted that there were possible price variations between provinces.  The Department planned to address this challenge through an HT pricing review and introducing an HT budget item in the Standard Charts of Accounts (SCOA).  There were also opportunities to develop local manufacturing capabilities and strengthen Black Economic Empowerment (BEE). 

Ms Molai presented a slide that showed exports decreasing and imports increasing in health care materials.  It demonstrated a lack of support for the local industry in this area. 

Turning to SO3, HT management, Ms Molai noted that this SO applied to HT that was already in place in hospitals.  There were very low maintenance rates and the maintenance budget was usually the first to be reduced when funding was not available.  The Department had a tendency to fix equipment only when it broke.  A lack of internal capacity to fix equipment meant that the Department outsourced repairs.  Ms Molai stated that equipment was not functional approximately 25 percent of the time.  She noted deterioration in the clinical engineering capacity in the country.  There was no investment in HT human resource development.  Ms Molai jumped ahead to the next slide which showed the exceptionally high vacancy rates in the health technician sector.  The Department would be meeting with universities that educated biomedical engineers to increase production.  She noted that the Department planned to optimize in-house maintenance capacity.  A set of standards of usage would be established that would include maintenance.

The Department identified SO4 as HT assessment.  Ms Molai stated that there was a rapid rate of technology influx.  For example, in past years, the FDA registered approximately 28,000 new devices per annum.  The concern was then deciding how to choose what devices to purchase.  Ms Molai presented the next slide, which demonstrated the multitude of products currently on the market.  She noted that there were often perverse incentives in the servicing and use of medical technology.  The Department did not a comprehensive mechanism to determine trends in HT.  In this case, they risked being sold obsolete technology.  She noted that the Department's priority was to finalise the HT assessment model and establish an HT assessment structure within the Department.

Ms Molai presented slides that demonstrated the outcomes resulting from poor maintenance, poor user training and poor equipment selection. Therefore, the Department needed to pursue Regulations in three areas.  The first area of regulations focused on the market availability, safety and performance and post-market obligations.  The second area of regulations focused on selection criteria, needs assessments and HT assessment.  The last area of regulations focused on qualified users and good management practices.  The priority was to address issues of safety in each of these areas first. 

Ms Molai concluded by noting that the Health Technology Strategy was approved by the National Health Council and it would be published soon.

The Chairperson reminded the Committee that that the Department dealt with strategy and policy, whereas the work was conducted by the Provinces.  He asked the Committee to engage them on this level.  He confirmed that the Department had recognised the challenges that they faced and that they had a strategy to address these challenges.  He commented that the Department makes the regulations, but parliament was not always aware of what the regulations contained.  He suggested that there may be regulations that conflicted with the law, and therefore the Committee should see the regulations.  The Chairperson handed the floor over to Dr Percy Mahlathi for his presentation.

Dr Percy Mahlathi, Deputy Director General, Department of Health noted that this presentation answered questions that were posed by the Committee relating to the health workforce only.   He stated that issues regarding the human resources (HR) plan would be addressed near the end of this presentation.  However, it must be considered that there were a number of initiatives that were implemented late last year that would go a long way towards addressing elements of the HR plan. 

Dr Mahlathi noted that the impact of the Occupational Specific Dispensation (OSD) in the Free State was positive and that it should not be judged in financial terms only.  Vacancy rates in the Free State varied between seven – ten percent for nurses and nine - 34 percent for doctors; with higher vacancy rates for senior and specialist positions.  OSD was commencing now for Allied and Medical Therapeutic groups.  The Department was about to do a comprehensive assessment of OSD for all groups.  He noted that the Free State was lacking doctors while experiencing severe financial strain.  As a result, the Provincial Department of Health was being managed by the Premier's Office for the prioritisation and filling of vacant posts.  He noted that doctors were not in abundant supply globally.  Recruitment of foreign doctors was an open option but this was not easy to achieve.

Dr Mahlathi turned to the issue of student nurses.  He noted that all proper nursing schools were registered with the South African Nursing Council (SANC).  The Department encourages potential students to check with SANC and the Department of Higher Education to ensure they enrol in registered schools. 

Going back to the issue of OSD sustainability, Dr Mahlathi reviewed the problem for which OSD was created to solve.  In particular, before 1994, doctors and dentists were migrating in and out of the country in large numbers.  He noted that doctors were willing to move for short periods to countries with extreme climates simply for the remuneration.  After 1994, nurses began the same migratory trend.  Reasons for this migration included remuneration and favourable working conditions.  Nurses in South Africa had no career paths in place and were capped at level 8.  Nurses also moved out of nursing into administration for the higher pay.  The Department therefore looked at how South Africa could retain clinicians in clinical roles within the country.  Experience showed that remuneration alone did not solve the problem.  The Department decided to combine four elements into OSD:  salary, career paths, career progression, and performance management, noting that career progression was linked to performance.  He noted that OSD severely limited the power of provinces to violate regulations relating to remuneration and promotion.

Dr Mahlathi explained that the current framework to increase the number of doctors and nurses was created in 2006.  The framework was challenged by the capacity of universities to train additional students resulting from lack of financial support, infrastructure and educators.  There had been a reform of the Health Professions Training and Development Grant, which had made it possible to increase the training of registrars by approximately 1000.  For nurses, revitalisation of public nursing colleges was announced in the 2011/12 budget to increase capacity.  Other elements of the 2006 framework that were implemented include:  the OSD system, nursing strategy, clinical associates, revised policy on the recruitment of foreign health professionals, and policy harmonization across provinces. 

Dr Mahlathi turned to the issue of remunerative work outside Public Service (RWOPS).  This policy was engrained in the Public Service Act, Section 30(1) and 30(2).  See attached presentation for sections.  The Public Service Act provides that RWOPS may be performed after approval by the relevant Executing Authority.  Normally this function was delegated to CEOs at facility level.  Dr Mahlathi noted that management of RWOPS was critical.  RWOPS could only be approved after the standard 40 hour work week plus commuted overtime was completed, but this was not always happening.  In light of the high remuneration packages of OSD, he stated that there should be consideration of scrapping RWOPS. 

Discussion
The Chairperson asked members of the Committee to engage the Department.  The Chairperson noted that this was a summary presentation because of the time limits, but more documents could be made available if requested.  He noted that previously, the Committee recommended that tertiary services should be managed at the national level.  He questioned where this policy stood. 

Ms M Segale-Diswai (ANC) enquired how involved the nursing colleges and medical universities would be in ensuring that graduates could operate medical devices upon graduation.  How would the Department achieve a reasonable level of Health Technology devices when there was a history of being under-funded? With most doctors being remunerated at the same level, how was the Department planning to retain doctors in rural areas.  She felt that RWOPS was not a good programme and that allowing people to work so many hours was not conducive to effective work.

Mr M Waters (DA) stated that there should be a meeting scheduled to address the Financial Management Turn Around Plan.  Following up on questions from the previous week, he asked how the Department arrived at an infant mortality figure of 400 deaths per 100 000.  He noted a previous response from the Department that the South African Demographic Survey was the tool for tracking progress towards the Millennium Development Goals (MDGs).  He reasoned that if the survey was such an important tool, why had it not been conducted in the last several years.  He was astonished to note that there was no asset register of health technology. He asked when it might be completed.  Mr Waters noted that bulk procurement might save money, but he asked how the Department would ensure that bulk procurement did not cause undue delays in the process. 

Mr Waters asked how accurate the human resource figures were that were presented.  Furthermore, he asked for clarification if these figures represented funded posts or both funded and unfunded posts.  He asked if OSD for Allied and Medical Therapeutic was backed up by funding, or would this add to the already strained finances of some provinces.  Mr Waters noted that he had not seen the 2006 plan that was referenced in the presentation.  He stated that it was difficult to hold the Department to account and he suggested that the Committee get a detailed copy of the plan.  In regards to nursing school accreditation by the SANC, he noted that in a presentation last year that SANC stated that the last time they accredited any facility was 5 years ago. 

In regards to RWOPS, Mr Waters agreed that, in principle, a person could not hold down two jobs indefinitely.  He provided the context that doctors were not just 'moonlighting' in the private sector, but that they were also working a second job in another facility of the public sector.  He asked how the Department would ensure that there would be enough staff to fill all their facilities then if they removed the RWOPS entitlements.

Mr D Kganare (COPE) asked what mechanisms the Department had to monitor developments in Health Technology.  He asked what role the institutions had in managing a record of maintenance for health technology devices within their organisations.  He asked what the contribution of health centres was in providing assistance in the development of health technicians and engineers.  He reiterated the fact that central procurement may be introduced in good faith; however, there may be unintended consequences through bureaucratic delays.  Mr Kganare was not pleased to hear that the appointment of posts in the Free State was controlled at the Premier's office.  He believed that the issue with OSD was the communication strategy.  People believed that it was about money, but there were other benefits that were not being communicated well.  In regards to foreign doctors, he asked if the Department was looking at doctors from Zimbabwe who were already in South Africa, who were skilled and could work.

Ms E More (DA) asked how far along the planning was in the Departmental re-engineering project. She asked if the Department was adopting the Brazilian model.  She expressed her disappointment with the Department's plan to adopt a new model without fixing the problems that existed in the current model.  She noted that under a new model, the same problems would continue to exist.  Ms More noted that OSD was designed to attract people.  She asked that if it was successful, why we could not see a difference at the service delivery level.  She suggested that the Department should look at research into OSD that could provide a solid baseline against which to evaluate future plans and programs.  Ms More felt that if RWOPS were to be scrapped, it should be scrapped for all and not just for senior people.  She also noted that before it was scrapped, working conditions should be conducive to a productive workforce.  She requested that any national human resources plan include the Allied and Therapeutic groups and not just doctors and nurses.  She noted that service delivery was a value chain and everyone in the chain must be considered. 

Ms M Dube (ANC) noted that there were no guiding timelines raised in the health technology presentation.  She asked for clarity on funding issues with regards to some of the interventions mentioned in the presentation.  She asked if there were asset registers for health devices in the provinces or in individual hospitals.  Lastly, she asked how the national Department was linked with the provinces and local governments. 

A member of the Committee noted that most hospitals would state that they were overstretched.  She appealed to the Department to prioritise an increase to medical staff at all levels.  In additions, she stated that poor working conditions contribute to a demoralised workforce.  Together these points raised questions of service delivery quality and also contributed to doctor migration.  She also stated that some foreign doctors were professionally discriminated against, which causes them to leave. 

Ms Matsoso noted that she had detailed presentations available for the Committee on human resource strategies and on finance plans.  She asked the Chairperson if he wished these to be presented at this meeting.

Following a tea break, the Chairperson asked the Committee if they wanted to hear additional presentations at this time.  Members of the Committee stated their viewpoints and the Chairperson recommended that they receive the documents and call the Department back at another time.

Ms Matsoso noted that some elements of the Department's presentations contained very detailed answers to some of the questions raised.  The presentations contained figures and projections for human resources.  Financially, the Department could show where the over expenditures were and what improvements had been made.  She noted that there was an integrated approach to the Departments plans that focused on promotion of health and prevention of disease.  She spoke to health indicators and noted that experts from all agencies that have been gathering data should meet to discuss methodologies and assumptions. 

The Chairperson welcomed the enthusiasm of the Department to share information, but he noted that the problem was availability of time.  He asked the Director General to answer the questions already posed and that they would schedule another meeting to go over the other presentations in detail.

Ms Matsoso addressed the questions regarding the Demographic Health Survey (DHS) and figures on maternal health.  She noted that the 2003 report had not been formally published as a result of methodology problems.  There were many agencies that were conducting similar surveys and she wanted to avoid duplication of work.  She noted that the DHS was still important for comparative purposes and for analysing trends over time.

Ms Matsoso noted that provinces and hospitals should and do have asset registers.  She noted that the Department was still questioning if there should be a national register, given that the items purchased change throughout the year.  Regardless, provinces and institutions should have a register that could be called upon for review.   Definition of roles at the national, provincial, and local levels needed to be defined to track and maintain assets.

She noted that the Department had been working with higher education and various partners to maintain their data on health human resources. She noted that the Department had made projections for investments that may be required in future years. She also stated that the Department had reviewed the National Health Act, noting that there were provisions of the Act that needed to be adhered to.  The Department would share a copy of the nursing college audit with the Committee.

Dr Mahlathi stated that the Department was reviewing the rural allowance policy in order to address the migration of professionals away from these areas.  He noted that RWOPS was not new.  It was implemented in order to allow people to supplement their income without leaving the Public Service.  The new OSD system had addressed the issue of remuneration.  However, he noted that people would not suddenly stop receiving money from outside of the Public Service unless there was tighter management of the system.  He stated that management must be done at the facility level, overseen by the province.  To achieve this, hospital CEOs had been receiving further training in this area. 

On the issue of vacancy rates, the statistics presented were funded posts.  Also, Dr Mahlathi noted that OSD for Allied health professions was fully funded. 

He noted that the capacity of the Nursing Council to accredit institutions was a broader issue of funding for all strategic councils.  These councils existed as a result of an act of parliament, and they were required to be self-funded through registration fees. 

Moving back to OSD, Dr Mahlathi noted that the Department planned thoroughly before implementing the programme.  He noted a few challenges, but OSD was working better now.  He noted that it was difficult to control the quest to make more money.  Employment agencies in a province were employing public sector health care workers from another province back in the first province.  He also noted that RWOPS should not be confused with 'moonlighting'.  RWOPS was a regulated activity that required approval.  He stated that it was fair to state that communication for OSD was not the best, and often presented conflicting views. 

Dr Mahlathi noted that the question of employing Zimbabwean doctors was a foreign policy issue.  The Immigration Act allowed for refugees and asylum seekers to be employed in the public health sector.  But, if one did not fit into these categories, there was no basis for employment.  He also suggested there was an obligation to consider neighbouring countries when South Africa created immigration policies that may deplete them of their human resources.  In accepting qualifications of foreign professionals, he noted that standards were different and some lack certain skills based on their country of origin. 

Ms Molai noted that the rate of development of medical devices was so great that no institution could possible keep up with training.  The Department agenda was to create Health Training Units in Provinces to provide workshops that would enhance skills on new devices.  Procurement should not only consider the cheapest equipment, but it should consider what was the easiest to use.  Health professionals, especially clinical engineers should always be involved in the decisions of procurement. 

Ms Molai noted that medical devices amounted to approximately 80 percent of items on the asset registers.  She stated that the registers must not just list the devices, but they should also monitor issues of maintenance.  The National Treasury implemented a system of integrated financial management that contains a module for asset management that could be applied to medical asset management.  The Department was looking at this program for the health sector.  She noted that each level of government requires different levels of information.  For example, nationally the Department did not need the level of maintenance details that the hospital might need.  In regards to time frames, this strategy presentation was a road map.  The Department would be limited by capacity issues over the next few years. 

Ms Matsoso added that there was an advisory committee to look at types of equipment that should be procured.  There was also a task team that was looking at operational issues.  Lastly, there were trouble-shooting teams that were responsive to immediate issues and specific problems.

Ms Molai stated that the Department was dealing directly with schools to create opportunities for biomedical engineers to be trained.  They were attempting to flood the market with technical skills. The shortage was significant, and many more would still move out of the public sector, thus the Department was attempting to train as many technicians as possible.

Ms Matsoso noted that the Department was also looking at recruiting and bursary programs.  They had signed an MOU with a university to increase the number of student positions available at the school.  More formal agreements would be made in the future.

Dr Thobile Mbengashe spoke to the school health programme.  The school campaign was intended to reach about 12 million secondary students.  The focus on secondary schools was a result of evidence of high-risk sexual activity at this level.  A task-team had been assigned to work on the preparations for this campaign.  The task-team had members from the Departments of Health, Basic Education, Social Development, and Public Administration. They would work with the Provinces and Premier's offices to complete preparations.  Preparations were strict to ensure that young people received counselling in a confidential and safe environment, proper psychosocial support and long term support for those who tested positive.  The Minister stated that this program must be implemented with a long-term view and all elements of the program should be implemented from the start, otherwise it would not be started. 

Ms Matsoso added that there had been recognition that school health services had to be improved.  One size did not fit all, and programs for primary students were not suitable for secondary students. 

The Chairperson accepted their strategy on health technology.  He renewed his call for copies of the Financial Management Turn Around Plan (FMTAP) and human resources plan and he stated that the Committee would call the Department at a later date to discuss them. 

The meeting was adjourned.