Humana People to People briefing, Fee dispute between National Health Laboratory Services and KZN Provincial Department of Health

Meeting report

Private sector health issues: Humana People to People Briefing
Mr Lone Torbenson, Partnership Director and Vice-Chairperson. Humana People to People, gave a brief background about the organisation (Humana) and noted that this presentation arose out of a conversation he had had with the Chairperson, when he had requested the opportunity to present what the organisation was doing and how it might be able to assist government in the re-engineering of primary healthcare in South Africa. Humana had been involved in community mobilisation and the debate on private healthcare in South Africa for the last ten years and had been following the debate about private health care. It believed that primary healthcare must be made more efficient and clinics must be linked with communities, and also suggested that it had the ability to help with community mobilisation. Humana was formed with international donor aid funding, but as funding was becoming more scarce it was seeking closer partnerships with government in South Africa, to continue its work.

He added that Humana had been in operation since 1995, working with communities, and focusing on areas such as Child Aid, Hope Humana (an Aids prevention programme to reduce the spread of the virus), and the Total Control of the Epidemic programme, (TCE) reaching more than 3million people in door-to-door campaigns. In addition, the Humana Youth in Action included working with young people with regard to employment and other issues they were facing. It was working on a large scale in Gauteng, Limpopo, Mpumalanga, Eastern Cape and Kwazulu-Natal.

Mr Kilford Zimondi, National Coordinator: TCE Programme, Humana, reported that Humana’s staff saw themselves not so much as a non-government organisation (NGO) but as individuals who would stand shoulder to shoulder with the poor and assist them to improve their lives. The motivation behind the TCE programme was that only the people themselves could liberate themselves from the HIV and Aids epidemic, in much the same way as challenges for political liberation had been done. For this reason, Humana wanted to mobilise communities to stand up for themselves. From a national perspective it might seem impossible to control the epidemic, but if this was broken down to an individual approach, where people knew that they could be tested, and then, on receiving the results, would be able to decide what they could do to not become infected, if the test was negative, or how they should plan their lives, if the test was positive, so that they could stay productive citizens and would not spread the virus. Humana therefore was focusing on the individual. It moved from a house to house and person to person level, to try to empower individuals, with backup support on information, education, mobilisation and basic counselling.

Humana had also developed tools to determine the demands of the individual with regard to the epidemic, where step 1 was a basic level dealing with sex education and knowledge about the transfer of HIV. If there were any misconceptions, an information officer could assist with knowledge and advice on this. The second step looked at the fears and perceptions around testing. The third step included partner discussions and support from field officers, but again with responsibility from the individual.

It was intended that, from an area of about 100 000 people, 50 people would be recruited and trained as field officers, to mobilise and train another 2 000 per year per area to be certified as TCE compliant, and this would be followed up. However, he said that this could not be seen as a recruitment or job-creation opportunity, as only those passionate about HIV and making a change in their communities, on an ongoing basis, would be recruited, and it was not intended that they should leave and seek other jobs soon.

One of the current challenges was that people received so much information but were reacting differently to this information, and Humana was aware of a number of organisations with the same initiatives, who were often duplicating. Humana wanted to try to coordinate and work closely or jointly on existing projects within the communities. It worked with local government and councillors, presenting the programme to ensure buy-in from leaders. It would also work with health departments from whom information would emanate. Field officers were working with the Department of Education, and were giving training and seminars. House visits touched on a number of issues like abuse, including alcohol misuse. He added that field officers in door-to-door campaigns would join existing networks, where these existed, and would start support groups if there were no others.

The structures of TEC were highlighted (see attached presentation). The number and different kinds of field officers were discussed. He noted that about ten or twenty field offices would go into an area, ask questions and begin to educate both parties to a relationship immediately. On a weekly basis experts were invited from outside to address the field officers with regard to set-backs or problems arising from their community visits, and this also provided the opportunity for field officers to meet together and share and discuss their short comings. Every year a field officer conference was held.

In the future, Humana would like to be involved on the re-engineering of primary health care (PHC) and the rollout of the health worker programme, and wanted to partner with the government to train, empower and monitor community health workers in a strong provincial programme that would improve the country’s health overall. The Department of Health (DOH) would be recruiting six community health workers, to be stationed at each clinic, who would then work on an area of 250 households. Humana had much experience in this aspect already and had implemented similar  programmes in the Southern Africa Development Community (SADC), not just South Africa. It also believed it had the zeal and infrastructure to drive such a programme successfully.

Humana believed and proposed that health workers should not become part of clinics in isolation, but should rather belong to groups where they could draw on the support and experience of the group.

Mr Zimondi tabled results from field officers, which included figures for monitoring and support and the number of people reached. These statistics and data were verifiable. He noted that there were existing programmes also running in schools and churches, and he indicated that anyone with a true interest from the community could do anything, from forming a club to providing condoms.

Discussion
Ms M Segale-Diswai (ANC) commented that there were a number of organisations working on HIV and Aids, and also noted that what Humana did seemed much in line with LoveLife’s activities. She asked how it would work to avoid duplication.

Ms Segale-Diswai asked if Humana was now approaching government only because it could not access other funding.

Ms Segale-Diswai noted that although Humana claimed to be involved in five provinces, the Department of Health had not mentioned this organisation in its Annual Report. Humana had also never been used previously to achieve the Department of Health objectives, and she wondered why they had not previously attracted attention, if they were doing such good work.

Ms Segale-Diswai asked what Humana was doing to address improvement in morals.

Ms E More (DA) commented that she had not heard of Humana in Gauteng, and asked where it was working in that province.

Ms More asked what stipend was paid to field workers, and wanted to know if Humana received any funding from government, and, if so, what percentage of its income this represented.

Ms More asked for more details as to how Humana saw its role in re-engineering PHC in South Africa.

Ms H Msweli (IFP) asked why Humana was not active in other provinces, and if it intended to do something about that. She asked if Humana really had time to visit everyone, how it would approach people like the indunas, and whether they were offering their support. She also enquired who was monitoring the field workers.

Mr M Waters (DA) wanted to know how Humana thought it would fit in to the re-engineering of PHC, and asked why government should use Humana, instead of community health workers, to visit the households.

Mr Waters asked how Humana intended to address cultural issues around use of condoms.

The Chairperson noted that the programmes had been implemented in a number of provinces and asked what impact this might have had on the spread of the HIV virus. If there was no impact, then the reasons should be given.

Mr Zimondi commented that an impact study had been done and was included in the information provided. One programme had been evaluated by the Health Research Council, and one in Bushbuckridge, that was currently running. Further documents could be provided.

He reported that Humana was working well with other NGOs. Some of the funding was emanating from USAid. In some cases, it had been found that government may be working in one area and USAid in another, not complementing each other. Humana had visited 3 million people in their homes and did not see this as at all a waste. It saw its role, in future, as coordinating what government would lead upon. He said again that several NGOs worked nationally and did do great work together.

The Chairperson commented that politicians tended to see things differently, and he said that sometimes the NGOs were not complying with what government thought they should be doing. He suggested that Humana should provide the information on the home visit to government, including the information on the numbers of homes visited, and its findings.

Mr Zondeli said that there were some misconceptions about NGOs that were doing commendable work, even without money.

The Chairperson asked how many NGOs there were.

Mr Zondeli said that Humana had been working in Soweto and West Rand, where it was working well with and had a good collaboration with the health authorities. It had given presentations to North West and other heads of provinces. In the West Rand alone, it had 150 field workers, although it was perhaps not as visible as it would like. It was very well known in areas like Namibia.

He added that Humana would produce a “PESCard” that asked seven to ten questions of an individual, and the individual would then compile his or her own health information, thereby gaining trust and confidence, which had been lacking to date. It was hoped that Humana could change the culture around using a condom by engaging with local leaders and discuss cultural and health issues and their inter-relation.

The Chairperson asked how Humana would approach the situation where a poor person, who lacked dignity in other respects, demanded that, as “man of the house”, no condom be used, and where his wife, who was dependent on him for support, must simply abide by his wishes.

Mr Zimondi responded that his experience as programme leader in Namibia, when the HIV epidemic was first brought to light, led him to believe that he would be able to influence that person to use a condom. He believed that the stigma around HIV had not yet been addressed.

Mr Torbensen commented that it took a lot of education and training to effect change.

Mr Torbensen said that Humana, in regard to its suggestions on re-engineering and working with government on the community health workers programme, would ensure that its targets were adhered to and work was done. He clarified that the current stipends formed part of the donation received from USAid but he was hoping that this would, over time, be paid by government as part of the health worker programme that Humana hoped to coordinate. Some funding was received from government in the early stage of implementation of certain projects.

The Chairperson noted that Humana was to be commended on its work. He noted that national departments made policy to be implemented at the provinces, and any suggestions would be conveyed to provincial departments

National Health Laboratory Services: Problems in respect of outstanding payments: MEC and Provincial Department of Health KZN briefing
The Chairperson commented that Parliament had received a complaint from National Health Laboratory Services (NHLS) about non-payment for its services by the provinces. One of the provinces in default was KwaZulu Natal (KZN). The problem had already been raised with the Office of the Member of the Executive Council for Health, but apparently still persisted. According to the information received, about R800 million was owned. Two other provinces, who were also in default, were not able to be present at this meeting. Although NHLS had not been invited to this meeting, it would be present at a meeting on 9 November.

The Chairperson said that this also begged the question of other problems, and their causes, in this province. It had been said, however, on the positive side, that Albert Luthuli Hospital was good, and that the KwaZulu Natal overdraft, which had previously run into billions, had been addressed. Members wanted to hear about this, what was happening in the province, and how its activities affected health services.

Dr Sebongiseni Dhlomo, MEC for Health, KwaZulu Natal, said the reluctance of the Department of Health to pay the amount demanded was supported also by the Premier for KZN, the Executive Council, and the Director General of the National Department of Health.

Dr Dhlomo said that in the past there were inefficiencies and high costs in the province, but the ARV tender had been obtained at a cheaper rate than anticipated, decreasing the size of the overdraft to R4 billion instead of R8 billion. 25% of Antiretroviral drugs (ARVs) in the world were consumed in South Africa, and of 500 000 of the 1.5 million people on ARVs were in KZN. NHLS was undertaking far more investigations in the KZN province than any other province.

During 2000, an agreement was signed with NHLS, but this agreement had excluded KZN. It was intended that the concerns that prevented KZN being included in that agreements should be discussed later and separately, but this was not done. The MEC and Head of Department at the time moved away from their positions in health, and an interim agreement was then signed by NHLS in 2006, for a flat rate. In 2008, a new interim agreement came into effect, again for a flat fee for services, but there was again agreement that this would not affect the facilities used by the NHLS. In 2010 the NHLS unilaterally decided that the KZN Department of Health must pay a fee for services, and must use KZN facilities, although other work would be done at no cost for the Department of Health. KZN was of the view that in fact NHLS had been paid, and paid on time, although it was of the view that NHLS was using the KZN facilities without paying.

Dr Dhlomo added that the tuberculosis (TB) infections were the highest in the world per capita, and constituted about 7% of the total epidemic. One of the initiatives that the Department of Health lost to NHLS was the power to use matriculants and train them as microscope specialists, as well as using them to administer TB treatments, which would reduce the turnaround time for treatment of TB. Another contributor to costs was the cost of pick-up and delivery of specimens from far-off areas. All other specialists in the country, apart from KZN, were trained using a subsidy from the Department of Higher Education and Training (DHET), except microbiologists and pathologists who were trained using own resources.

Dr Dhlomo suggested that the Laboratory Services Act should be utilised fully. The fee for services posed a number of challenges for KZN. It was reiterated that NHLS was using facilities, without paying for them, of the provincial Department of Health. There were some irregularities in the payments and services charged. If the KZN provincial department was forced to pay the fee demanded, of R820 million, then it would be unable to continue its operations. It was suggested that the position in other provinces should be examined.

Discussion
The Chairperson commented that KZN provincial department must surely be aware that it should pay for services that it received. The complaint from the NHLS had said that if it was not paid for these services, it would have to close down. It had been alleged that NHLS was in fact doing more than it was supposed to do – for instance, charging for a full range of services, even if the doctor had requested only a white-bloodcell count. He noted that NHLS would be questioned on 9 November. He also suggested that the Committee should ask the National Department of Health to report on its findings on this issue.

Ms Segale-Diswai wanted clarity on the agreement, and asked if there was a Memorandum of Understanding that could be sent to Members. She asked if the provincial department had thought what consequences might follow should NHLS be unable to do any further investigations, both in the province and nationally.

The Chairperson commented that in terms of the legislation, the NHLS was to be used for testing, even if KZN provincial department was not part of the agreement. He pointed out that KZN had said that a flat rate was being levied, and that it was unknown where the fee for services emanated.

Ms T Kenye (ANC) asked if there were any other services or products being rendered.

Mr M Hoosen (ID) asked if there was any way that the provincial department and NHLS could resolve this issue without the National Department of Health having to mediate. He also asked if there was a way in which the possibility of double-investigations, where a specimen might be sent from multiple doctors, could be isolated and eliminated

The Chairperson said that if there was anything in the agreement through which government was “being held to ransom” then it was necessary to address this and amend the legislation.

Mr Waters asked how much the arrear payments were. He asked why, when the payment structure was apparently changed in 2010, additional funding was not requested, and commented that this seemed to indicate poor management of the provincial department’s finances.

The Chairperson commented that other provinces would need to confirm overpayments.

Dr Sibongile Zungu, Head of Provincial Department of Health, KZN, responded that the turnaround and savings made under the general financial provisions did not affect the NHLS services. She explained that in the first place, there had been under-spending of infrastructure of about R223 million. Secondly, some payments were not made on time, although committed, amounting to about R900 million. There was about R106 million worth of savings on certain security measures.

She explained that in the Umsonari District, much good work was being done, and this was the only district where the aggregate of HIV prevalence was under 30%. Due to the changes in the running of the health system and community-based services, the outbreaks of Extremely Drug-Resistant (XDR) and Multi-Drug Resistant (MDR) TB were contained successfully. Albert Luthuli Hospital was indeed an impressive one. It was a public-private partnership. A whole block of this facility had been allocated to the NHLS, at no cost, for its use. A non-clinical and equipment refurbishment contract would be done every five years, paid for by the provincial Department of Health.

There was a Service Level Agreement (SLA), extended from 2008 to 2010, which said that a flat rate would be charged for NHLS services and there would be no charge for use of facilities. Research into alternatives had shown that the NHLS costs were cheaper than private services, but when the costs were examined, it was found that the costs were in fact greater than they would have been, if contracted privately. There were also various “hidden costs”, where NHLS was not rendering the service, although it was charged. NHLS demanded payment. However, the Department did not believe it should pay other than on the flat rate, and the demand was far higher than the flat fee. KZN was working according to a cost recovery model. Many of the tests could have been performed by the training of mid-level workers, although this training had been abandoned. There was no single system to monitor the movement of patients from one doctor to another.

An amount of R839 million was claimed by NHLS as outstanding up to August. The Department had not applied for additional funding because it did not believe that there was a necessity to do so unless the case for payment was proved by the NHLS.

Dr Zungu said that other provinces were also refusing to pay NHLS accounts, with some indicating that the accounts were incorrect, whilst others said that they did not have the money to pay. Only KZN was excluded from paying for services, since it had opted to follow the flat-fee structure.

Dr Dhlomo added that the reports from other provinces seemed to support the substance of the KZN complaint about the service level agreement. KZN was adamant that if should only pay a flat-rate fee as long as the NHLS was using the Albert Luthuli facility at no cost.

Ms More  asked how the fee was structured, and whether it used a percentage calculation.

Ms Kenye commented that there was a high rate of HIV in KZN, and asked if trained laboratory technicians were used, to ensure that the results were correct.

Ms Segale-Diswai said that it was common practice in healthcare facilities for the incorrect forms to be used when calling for specimen results, and asked if this had been corrected.

The Chairperson asked if the main issue was one of mismanagement, not having money available to pay, or not wanting to pay.

Dr Zungu responded that KZN had different cost structures in relation to the shared facilities and there was a need to take account of percentage use of services such as water and electricity. In relation to the forms compiled, she noted that the same forms were used, no matter whether the claims were to be made under the Provincial Equitable Share or the grants, and the reconciliations were done at a later stage, although the billing was done separately, identifying where the patients came from, and which tests were done. She noted that those who had been doing the microscope work were not trained as laboratory technicians or assistants but were in the past trained on malaria or TB specifically; they had matric, were able to express themselves clearly, and could do the pathology readings, and were employed as assistants, and this course of action had been followed to improve    the recording and turnaround time.

Dr Dhlomo noted that “an army” of staff would be needed to deal with the problems of HIV and TB. It was not necessary to use people with highly sophisticated skills to do the blood tests, as this would be a waste of government money.

The Chairperson said that although the comment had been made that the NHLS services were expensive, they were nonetheless mandated by law, and the matter had to be dealt with in terms of the law. Another meeting would be held, at which the NHLS would be asked to present its case, as well as input being sought from other provinces.

The meeting was adjourned.