The Department of Health presented its 2011 Annual Performance Plan. The presentation highlighted the vision and mission of the Department over the next three years, which centred on a long and healthy life for all South Africans. The mission of the Department was to improve the health status through the prevention of illness and the promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equality, efficiency, quality and sustainability. The briefing also highlighted the key strategic interventions. These interventions were to address the issues of HIV/AIDS treatment, funding models for the Department amongst many other issues. The Department further highlighted the programme of reintroducing school nurses and how the Department planned to accelerate service delivery through health facilities in districts and maintain health care infrastructure. The Department undertook a partnership with the Tshwane University of Technology to train junior engineers to service state hospital equipment. The Department mentioned its commitment to finalising the National Health Insurance (NHI) Policy and Legislative Framework. The report detailed budget allocations for the financial years 2011/12-2013/14. Over the Medium Term Expenditure Framework period, expenditure was expected to grow at an average at an annually increase rate of 19.2%.
Members raised concern in the issue of staffing within the department and asked what was being planned to address this critical issue. Members asked where the sites for the 41 hospitals currently under construction were. The delegation was asked how they planned to monitor spending patterns within the Department. The Chairperson stressed the need for more female condoms as 6 million was not sufficient enough compare to the billion male condoms. The Department responded swiftly to the concerns raised by members and committed to presenting quarterly reports to the Select Committee. The Chairperson thanked all stakeholders and adjourned the meeting.
The Chairperson opened the meeting and welcomed Members. In particular, she welcomed the Minister of Communications to the meeting and thanked him for his hands on approach. Thereafter, she asked the Director-General to present the Department of Health’s (DoH’s) 2011 Annual Performance Plan
Ms Malebona Precious Matsotso, Director-General, Department of Health, presented the Department’s 2011 Annual Performance Plan. The Director-General said that government had adopted an outcome-based approach to service delivery. The performance plan identified four outputs: 1) to increase life expectancy, 2) to decrease maternal and child mortality, 3) was to combat HIV and AIDS and to decrease the burden of disease from tuberculosis and 4) to strengthen health system effectiveness.
The question was raised as to whether the current infrastructure delivery model helped to put infrastructures near communities. This was what was meant by the term ‘health facility planning’. Universal access to care was based on a three-dimensional approach of ensuring that as coverage was improved there was a package of services that could be rendered.
The Director-General introduced the Key Strategic Interventions the Department of Health planned during the financial years of 2011/12-2013/14. These key interventions included the scaling up condom distribution to One billion for men and 600 million for women. The view was that the number of female condoms should be increased. In KwaZulu-Natal there had been an incredible success in male circumcision, this would need to be increased to 500,000 medical circumcisions in this fiscal year.
South Africa had been able to reduce the cost of Antiretroviral (ARV) drugs by 53%. This was significant because it meant that more people who needed treatment could be put on it. Child immunization remained an important intervention, financially the Department of Health was able to reach the target of 95% and they hoped to maintain this level in the coming year or even do better.
The Department hoped to initiate the School Health Services, in recognition of the fact that at school, children were “presented with ailments”. This programme needed to be disaggregated according to age groups, as the health challenges in secondary school are different from those in elementary schools. This programme addressed the activation of retired nurses to be used for the School Health Services.
Antenatal coverage was increased to before 20 weeks and increased deliveries took place in health facilities. As part of the programme, the Department of Health started visiting households and at the end of March, it had visited 20 000 households- this was done in recognition that there were many women who did not attend antenatal screenings. This was used in conjunction with the Tuberculosis (TB) strategy. There were 400 000 households with Tuberculosis. It was important to know what the status of the family was and to know associated problems, like children who had not been immunised and pregnant women who had not attended antenatal care. They had started contact tracing and active surveillance to increase the 20 000 number and to ensure that once babies were born, the mothers and babies received postnatal care where vital signs were picked up.
On reproductive health, HIV/AIDS was “driving cervical cancer” and there needed to be an aggressive screening program. There was recognition that reproductive health services, particularly family planning, were not working as well as they should have-hence an increased number in termination of pregnancies (TOPs). Since the passing of the law on TOPs, there have been more then 700 000 TOPs performed. A functioning family planning service is a priority.
On Prevention of Mother to Child Transmission (PMTCT), transmission rates had been reduced from 10% to 3.7% according to the latest research data. There needed to be a push for the significant reduction of all other communicable diseases such as malaria. South Africa had done well in the reduction of malaria in provinces where malaria was prevalent, through the widespread use of DDT. There was a need for an aggressive screening program for “silent killers” such as diabetes and hypertension.
With regard to health delivery infrastructure, community primary health care had under performed relative to the budget. Technical capacity to monitor projects in provinces was an important element of service delivery. There had been lots of waste in the area of healthcare technology, mainly because there were not enough people trained to maintain the equipment; therefore the replacement cost of equipment is quite high. The Department had taken 36 junior engineers trained by Tshwane University of Technology to be deployed to the provinces to fix broken equipment.
The Minister of Health had announced the Public Private Partnership flagships: these were the academic hospitals. A process of consultation had been established in the provinces. The reason these institutions were chosen was because they were the academic institutions that produced South African medical students and health workers. It was an important investment for service delivery and production of the workforce.
An audit of the norms and standards of nursing qualities revealed that 105 nursing qualities have to be revitalized. With regard to healthcare financing, National Health Insurance (NHI) policies were to be presented to cabinet in the near future, to identify pilot sites demonstrating how NHI would be rolled out. Also, an audit of the readiness of all the facilities would be performed to establish such readiness when the bill is implemented.
The Chief Financial Officer (CFO) briefed the Committee on the Department’s financial plans. She said that the Department had requested additional funding for both national and provincial departments in the amount of R19.9 billion during the Medium Term Expenditure Framework (MTEF) budget process. The provinces had been given R1.2 billion for quality standards and to meet the Millennium Development Goals (MDGs).
Of the R19.9 billion, the National Treasury had approved R18.1 billion. Of that R18.1 billion, R3.4 billion was at the national level; the rest was at the provincial level, which amounted to R14.6 billion. Within the R3.4 billion at the national level, the trend had been an average increase at an annual rate of 19.4% since 2007/08. Over the MTEF period, expenditure was expected to grow to R30.1 billion, at an average at an annually increase rate of 19.2%. The increase was largely driven by transfers to the provinces in terms of conditional grants and the main increases were in the HIV and AIDS grants, the Hospital Revitalisation Grant and the National Tertiary Service Grant (NTSG). The Forensic Pathologies Services Grant would be phased out during the 2012/13 financial year. Going forward it will be allocated to the provinces and it will form part of the equitable share.
For the MTEF period, the budget allocations included R442 million in 2011/12 and R692 million in 2012/13. Allocations at the national level, quality assurance for the Office of Standards, were R10 million in 2011/12, R20 million in 2012/13 and R10 million in 2013/14. For the infrastructure management at national level, in preparation for the NHI to build the capacity, there were allocations of R21 million in 2011/12, R17 million in 2012/13 and R15 million in 2013/14. Health technology and National Insurance Support had allocations of R5 million in 2011/2012, R7 million in 2012/13 and R9million in 2013/14. There were allocations for the improvement of hospital tariff schedules R4 million in 2011/12, R5 million in 2011/13 and R5 million in 2013/14. The improved hospital tariff schedules would be used by provinces in the road accident fund. This fund included improved uniform patient fee structure, road accident fund re-imbursement.
The Department also received R5 million per year for the health information systems to support national work group investigations. R2 million for 2011/12, R3 million in 2012/13 and R4 million in 2013/14 to monitor and support provinces in order to stabilise provincial finances. There were allocation increases for the national tertiary services conditional grant of R250 million in 2011/12, R500 million in 2012/13 and $750 million in 2013/14. These grants were largely at the provincial level to achieve norms and standards in preparation for the NHI and the Office of Standards and Compliance.
Over and above the baseline, the Department received an additional R30 million per financial year for the increased distribution of condoms, R13 million in 2011/12, R15 million in 2012/13 and 16 million in 2013/14 for the improved conditions of service, R10 million in 2011/12, 20 million in 2012/13 and 10 million in 2013/14 for quality of standards, R10 million per year for forensic chemistry laboratories for procurement of equipment, R10 million per year for oversight of hospital revitalisation projects for capacity building together with the provinces, R5 million, 7 million and 9 million for health technology and the Public Private Partnership project are R11 million , R7 million and R3 million.
In terms of conditional grant allocations, the Health Infrastructure Grants were R1.7 billion in 2011/12, R1.8 billion in 2012/13 and R1.9 billion in 2013/14. This Grant had previously been at the provincial level and 2011/12 was the first year that there had been a transfer to the national level. The provinces used to receive this money as a conditional grant from their Treasuries. Now the money wouldl be allocated to the provinces directly from the National Department. The Health Professions and Development Training Grant allocations were R1.9 billion in 2011/12, R2 billion in 2012/13 and R2.1 billion in 2013/14. The National Tertiary Services Grant assisted the provinces to develop tertiary services and not depend on other programs such as academic hospitals. It had allocations of R8 billion in 2011/12, R8.6billion in 2012/13 and R9.3billion in 2013/14. The comprehensive HIV and AIDS Grant is one of the grants where allocation had largely increased from R6 billion in 2010/11 to: R7.4 billion in 2011/12, R8.8 billion in 2012/13 and R10.6 billion in 2013/14. The Forensic Pathology Services Grant terminated this financial year for 2012/13 and 2013/14 it would fall under equitable share. The Hospital Revitalisation Grant had an allocation of R4.1 billion in 2011/12, R4.3 billion in 2012/13 and R4 billion in 2013/14. The drop in the final year is a result of projects to be completed for the 12/13 financial year. The totals for conditional grant allocations were R23.9 billion in 2011/12, R25.7 billion in 2012/13 and 28.1 billion in 2013/14 this was close to 92% of the allocation of the national department.
Funds allocated directly to the provinces from the National Treasury top priority focus areas included funds for Health Technology, Nursing college upgrades and maintenance, Occupation Specific Dispensation (OSD) for doctors, OSD for therapeutic, Maternal and child health, personal goods stabilisation and the ARV 350 threshold.
On the whole the status of the baseline for the past financial year shows improvements in accruals. In Limpopo, Mpumalanga and Western Cape there were significant improvements in the reduction of accruals. The Northern Cape and North Western province and Free State showed slight improvements in the reduction of accruals. The Eastern Cape had a significant increase in accruals Guateng had a slight increase in accruals. There were implications on the manner in which the funds requested would be allocated.
In total over the three years, there was a variance R4.7 billion in the money received at national level to be allocated to the provinces. The Department believed (but did not have any evidence) that it was sitting at Provincial Treasury. The matter was brought up at National Treasury. The Department was not happy with the manner in which the money that had been received on behalf of provinces had been allocated. Not happy with the manner in which there was cultivation at National Treasury. They used the equitable share formula. The CFO asked how was this used to allocate OSD, registrar and other specific bids for specific provinces? The Department wanted to take up this matter with National at the next 10x10 meeting. In provinces with academic institutions, with an end to prepare those institutions to have more specialists for training, the equitable share formula would not work in that instance.
This annual performance plan reflected interventions, which were hoped to improve service delivery and the health outcomes. A sector wide plan would be provided by the end of May, which would reflect the contribution of the entire health sector including the national and the nine provincial Departments of Health.
The Chairperson asked Members to engage with the strategic report.
Ms B Ncube (ANC; Gauteng) referred to key strategic interventions for 2011/12-2013/14and the said 41 hospitals the department planned to build and the 25 hospitals still in the planning phases. She asked where the planned sites of the hospitals were as the performance plan did not indicate. In regard to the revitalization of nursing, she asked how many grants per province would be allocated. She acknowledged the distress between the government and public service union, and asked if there was a possibility of centralising the procurement of medicine.
Ms D Rantho (ANC; Eastern Cape) commented on the call made by the minister for staffing hospitals especially managers. She asked how the department planned to address the issue of non performing mangers. She remarked that in her area, the supply of condoms is sufficient, but they are not being used. Thus, she felt that the outreach of local health officials was not adequate, while acknowledging the logistical problems associated with outreach efforts. She suggested that departments should allocate budget resources make rural and hard-to-reach areas more accessible to health services. Finally, she asked if by 2014 there will be enough nurses in hospitals, noting the current shortages.
A Member asked what plans the Department had to address the issue of training auxiliary nurses.
Mr M De Villiers (DA; Western Cape) noted that there was no program promoting abstinence in the presentation and asked if one existed. In regard to ART, he inquired about what the distribution of the plan will be over the provinces. He asked if there was pre-birth assistance from the department for mothers, indicating the importance of aiding those with low incomes and food shortages. He further asked how the hospital staff can visit post-birth mothers, particularly those in rural areas. He also commented that there was a need for better cervical cancer screening advocacy, stating it was important for women to do it once a year or every two years. On the subject of tuberculosis, he advised identifying the areas where food shortages are greatest to curb the disease. He also noted the danger of DDT, and asked what else can be done to prevent malaria-carrying mosquitoes.
Mr T Mashamaite (ANC; Limpopo) asked why schedule 5 grants were withheld and how the department of Health planned to monitor spending patterns. He further commented on how there were still problems in the rural areas where the closest hospital was many kilometers away.
A female Member thanked the Director-General for her presentation. She remarked on the problem of intergovernmental relations. She assured the Director-General that programs and services were not reaching the poorest of the poor. She recommended making sure that MMCs visit local clinics to provide oversight, because they do not know how to operate. She called for stricter policies to be enforced. She noted that there is still an understaffing problem in rural clinics and expressed hope that the plan to reopen nursing colleges will be successful. She said this was imperative to the overall success and added that it could lure young unemployed people into the profession.
The Chairperson supported the idea of increasing female condom distribution, as females must be able to protect themselves without relying solely on the male. She said the presentation was unclear on the issue of medicine shortages in health facilities. She noted the problematic issue of ambulance shortages and said there needed to be an increase. She asked if tertiary academic hospitals would be built in other provinces not listed in the presentation. She further inquired how the inclusion of nurses from the auxiliary level upwards would be reconciled with the reopening of colleges. She concluded by asking if there were any plans for additional building of nursing colleges to mitigate the shortage problem.
The Director-General expanded on the issue of staffing within the department and said that the department had started a program to increase the number of medical students enrolled. She specifically advocated increasing the number of students from disadvantaged communities. She also said that the department had 9000 retired nurses which were to assist in the school nursing program, and that nurses returning from abroad would be put back into the program. She made specific remarks on the situation in Gauteng regarding budget allocation and equitable share. She recommended that each province create a post of registrar. Responding to the question on abstinence, the Director-General that the department was still promoting the message of “ABC” Abstain be faithful and Condomise, but it needed to be effectively packaged. She agreed that she was disturbed and worried by reports on condom usage, as well as by the attitude of nurses. The Director-General conceded that department was not delivering healthcare properly and the model needed reconfiguring, but she said that the department was delivering infrastructure. She said that the DOH will make sure that facilities will be adequately equipped and staffed. The Director-General noted the case of Mpumalanga, where there have been instances of facilities operating at 50% of the adequate level. She also said that interventions should also identify social determinants of health. Responding to the question on auxiliary nurses she said that the department changed the nursing program into an academic stream. She said that there were too many senior nurses and less of enrolled and auxiliary nurses. She said the DOH planned to increase the training of both auxiliary and enrolled nurses. She acknowledged the need to prioritize rural areas and agreed on the importance of intergovernmental relations.
The Chief Financial Officer elaborated on the schedule 4 and 5 grants, explaining the differences. She articulated that schedule 4 grants were based on an equitable share allocation plan, while schedule 5 grants were based on a specific business plan. If the recipient was not meeting its respective plan’s target, funs could be withheld. She said funds were monitored with regard if they were spent where they were intended to be. She acknowledged that rural allowances had fallen away.
The Director General responded to the CFO’s final point and stated that these programmes were well-intended but had negative outcomes, and they were not getting OSD. She stated that it would be effective to meet with the different stakeholders to ask about rural incentives. As examples, she mentioned accommodation needs, access to schools, and transport.
The Chairperson allowed each Member to ask one question before closing the discussion, and commented on the need to speed up the Department’s information system integration.
Ms Rantho requested the Department to invite at least one member to the upcoming health summit as a means of keeping up with new developments and resolutions in the sector.
Mr Mashamaite referred to a programme by Parliament (Taking Parliament to the People). He asked whether the concerns raised by community had been accommodated.
Ms Ncube asked whether the Department had planned efficiently for addressing the issue of referrals, especially in rural areas.
The Director-General invited Members to the unveiling of the Departments Information System on 1 June 2011. She highlighted the success of the “iKapa” system developed in the Western Cape, and said it would be a model for a national system. Responding to the comment of referrals she said that the department planned to take specialists to the people in rural areas where people do not have to travel long distances. The question at the moment was whether there were enough specialists to be effective, but the long-term plan would be to increase the number. She thanked the Committee for the opportunity. She closed by admitting that the department had not used the “Taking Parliament to the People” date because it was not centrally presented.
The Chairperson thanked Members and the delegation from the Department.
Meeting was adjourned.
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