TB monitoring & evaluation: Biometrics briefing, Department of Health 2010/11 Annual Report

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18 October 2011
Chairperson: Mr B Goqwana (ANC)
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Meeting Summary

The company Biometrics had been asked to give a presentation to the Committee on its technology for monitoring TB treatment. Although some Members voiced their concern at the start of the presentation whether the Parliamentary structures were being used correctly, as this might be seen as the opportunity for companies to promote their products, other Members felt that it would be useful to be informed of what technology was available, and noted that the Department of Health had been notified of the product as well. The presentation continued, and noted that Biometrics had conceptualised and developed a mobile device that could assist in providing accountability in the monitoring of TB, was fully compatible with Department of Health (DOH) systems, and could help to address the challenges in a paper-based monitoring system, as well as the fact that many patients were required to attend clinics every day to ensure that they took their medication. It was possible that the device’s use could be extended to monitor adherence with treatment for other non-communicable diseases. Basically, it used fingerprinting of patient and carer to confirm that treatment was given, and could detect, more rapidly than paper-based recording, whether there were defaulters. It used several languages, recorded some socio-economic questions and would decline to accept inconsistent entries. Members asked if this had been implemented anywhere, what the challenges were, whether the device was locally manufactured and piloted, and if there was capacity to deliver on the new product, should it come into common use, how cost effective it would be and what areas might have been covered in any studies. They were also interested in details of maintenance and back-up.

The Department of Health presented its Annual Report 2010/11. At the outset, some Members expressed concern that the Director General was not in attendance, but the Chairperson noted that she was accompanying the Minister on an overseas trip and apologies had been given. The six budget programmes offered by the Department in this financial year were set out, and key achievements were noted for each. These included improving capacity in the offices of the Minister, the Deputy Minister and the Director General, the development of turnaround plans for provincial financial management, and support given to seven provinces to implement these plans. It was noted that the National DOH and seven of the provinces had received qualified audit certificates. In respect of HIV management, the DOH noted that 96.9% of pregnant women had agreed to be tested for HIV, and 80% of those who tested positive were put on highly active antiretroviral therapy. About 11.4 million South Africans were tested for HIV by the end of March 2011. As part of the campaigns, 8 million people were also screened for tuberculosis (TB) and more than one million were
referred for further investigation. The Department had not achieved its targets of distributing one billion male condoms, and six million female condoms. Although access to antiretroviral treatment was expanded, to 418 677 HIV positive people, this was still lower than the targets set. 42 756 Community Care-Givers were receiving stipends.  In respect of TB, there was a 7.9% defaulter rate in completing treatments, but the 71% cure rate target was achieved. There were now 19 Drug-resistant TB facilities, and 55% managed to get results within two days. The Department had a mini-masterplan with regard to non-communicable diseases. There were still challenges in improving maternal and child health, partially attributed to lack of personnel and inadequate clinic facilities. Fewer healthworkers than expected were trained, because many migrated as a result of Occupation Specific Dispensation. A chronic disease management register was implemented.  The Department still reported backlogs in laboratory services, especially at the three chemistry laboratories that the Department managed. A National Health Amendment Bill had been drafted, which sought to improve the quality of healthcare, and the NHI policy had been tabled to Cabinet and approved, although the NHI Fund was not yet established in this year. A draft workforce strategy had been created, but challenges were experienced with reduced intake of students by universities. Four hospitals were being constructed, and engineers had been appointed internally to strengthen project management.  The achievements in the international relations field were outlined. A full report was given on financial matters, noting that of the allocation of R21.6 billion, 19.8 billion related to the five conditional grants, and total expenditure was at R20,9 billion. The reasons for underspending were given.

Members criticised the Department for its failure to implement administration and control mechanisms, and noted that its achievements were overshadowed by the less positive aspects of its performance. Capacity constraints and lack of skills were its greatest weakness, although some Members noted their impression that the capacity was probably sufficient, if it was properly managed. Members questioned whether the approach to fighting HIV and Aids was correct, and whether the approach to contraception was sufficient to prevent the number of unwanted pregnancies and the high rate of terminations. There were also concerns about the inconsistency in the IT systems, which were hindering developments. Members asked about the cost implications of exceeding targets for caregivers, whether there were disaster management plans in place. They asked about plans to investigate misuse of funding, what actions were contemplated to recover money from individuals and contractors who failed to provide services, travelling costs and write-off of loans to departmental staff. They also felt that more flexibility was needed in redirecting services to where they were most needed, and asked if sufficient engineering expertise was available to assist with new hospitals. They further enquired about strike action by health workers, updates on the exchange programmes and OSD implementation. Members asked a number of questions about infrastructure projects, although a separate session would also address these later, and about contracts awarded to bidders who could not perform. They asked how the accounting officers in provinces were monitored and evaluated, and felt the DOH was falling short in correct monitoring, particularly of clinics. They also asked about the asset register, which had led to some audit qualifications, litigation against the Department, and its interaction with other departments and sectors. Members asked how far the Department had gone in implementation of the Office of Standards, and questioned why the reports given to the Auditor-General had been said to be inaccurate, as also commenting that a major shortcoming was the failure of the Minister or Director General to mention the R90 billion private medical scheme that the DOH regulated. More information was also requested about the Gene Xpert technology, and backlogs at the forensic laboratories. Some of the questions stood over for a written response.

Meeting report

Opening Remarks
The Chairperson said HIV/Aids and Tuberculosis impacted negatively on the economy because they were mismanaged. He said there was available information on the two diseases but he was not sure if it was correct. South Africans tended to migrate from one area to another, and if a person was diagnosed with HIV, it was not uncommon that a second opinion would be sought, in a different province and under a different name. This led to uncertainty in the statistics. The settlement structure of the country made it difficult for the two diseases to be closely monitored. In addition, HIV/Aids and Tuberculosis (TB) impacted negatively on the economy because they were mismanaged, and once again the information on them was subject to question. The Chairperson noted that the company Biometrics had requested to present its solution to some of the challenges that were faced by the sector. This company was based in Port Elizabeth and its vision was to be a leading provider of solutions that were locally-developed, and to contribute to the wellbeing of South Africans.

Biometrics presentation
Mr Gugu Nxiweni, Shareholder, Biometrics, said it was an honour to present an innovation which could assist in the monitoring of TB in SA. Biometrics innovation was based in Port Elizabeth and its vision was to be a leading solution provider, by focussing on contributing in the wellbeing of South Africans. Biometrics was a South African company that provided locally developed solutions that would leave a legacy that every citizen could be proud of. He noted that this company was responding to government’s call to assist. He was aware of the local and international focus on TB management, and the Millennium Development Goals (MDGs) had a specific goal that included the reduction of TB. TB was an integral part of the health strategy and was one of the priorities identified by the Department of Health. He noted that the combating of TB was one of the key outputs indicated in Government Outcome 2. He said millions of South Africa citizens had died from TB. The challenges presented by the Multi Drug Resistant (MDR) and Extremely Drug Resistant (XDR) disease, and HIV associated TB, were immense. TB was commonly identified as the most opportunistic disease that attacked 73% of HIV positive patients. This, coupled with the contagious nature of the disease, presented enormous challenges to South Africa’s United Stop TB campaign

Mr H Hoosen (ID) interjected at this point, questioning whether it was correct for a private company to promote its technology in front of a Parliamentary committee, saying that this seemed to set an unwise precedent.

Another Member asked if this presentation had been given to the Department of Health (DOH) prior to being delivered to the Committee. The Member said the Committee needed not know further than what had been presented already.

Ms J Segale-Diswai (ANC) suggested that the Chairperson motivate why Biometrics should give a presentation, before Members reached a decision on whether the presentation should continue.

The Chairperson said the reason for inviting Biometrics was to expose Members to innovations in the fight against TB. The work of Parliament included interacting on innovations to see where it could help. Members could inform the people of any worthwhile innovations that could help monitor TB, and he agreed that it was important that this information be shared in the presence of the DOH.

Mr Hoosen said he was uncomfortable with the fact that private companies might see Parliament as providing an opportunity to promote their products.

Another member expressed the view that those involved in combating disease should be able to be heard, and the presentation would help the Committee understand who the company was, and what services it offered.

Ms B Ngcobo (ANC) agreed that there was no reason why the presentation should not continue. TB had an impact similar to HIV/Aids in SA. The company was run by South Africans who had a vested interest in improving the lives of South Africans. She noted that this Portfolio Committee had listened to many non governmental and private organisations before.

Ms C Dudley (ACDP) agreed, and suggested the company needed to be heard.

The Chairperson ruled that the presentation should continue.

Mr Nxiweni said there were challenges associated with TB treatment adherence and monitoring. The challenges included the inability by patients to complete treatment, leading to the development of Drug Resistant TB which had been identified as expensive and more challenging to treat. He said the Department had repeated the call for mobilisation of support for TB patients to assist them to complete their treatment. Adherence had improved, but was still below the 85% that was the national target. There was difficulty in supervising the DOH’s treatment observers, who monitored patients who were home-based and needed visits. A number of clinics required patients to come in on a daily basis to receive treatment. However there was no conclusive evidence of patients actually taking their medication, except for the manual note on the patient card. Some patients took treatment at home without supervision. Nurses had to manually complete numerous TB registers to log patients who had been treated. He said nurses also had to calculate key statistics. This raised a significant risk around the identification of patients who had not taken their medication and potential errors in the reports. All this drove up the cost of management of TB.

Mr Nxiweni said Biometrics was a uniquely South African solution. Biometrics had conceptualised and developed a mobile device that was easy to use and could assist by providing greater accountability in the monitoring of TB. The device was fully functional with the current DOH system, and had already been loaded to that system. It used the patient’s and observer’s fingerprints to monitor adherence to the treatment programme. The software had been programmed in such a way that the fingerprints were not replicable. No one could use the device and the information it contained for any other purpose. He said the device easily provided information on the number of patients being treated for TB, those that took treatment, and the specific type of treatment they were on.

He explained that Biometrics’ device was not meant to actually reduce TB prevalence, but it would enhance government’s efforts to fight the disease. It was possible, by using this device, to confirm whether a particular patient was on treatment, and whether the correct health-care worker was observing that patient. Information on whether the carer had specified treatment to the patient would be automatically loaded. The device could also capture relevant socio-economic information, such as the patient’s diet, whether there was sufficient ventilation in the home, and substance use.

Mr Nxiweni said due consideration needed to be given to the many factors that might adversely influence treatment outside of a clinic. The software automatically provided for information to be communicated to the patient. Because of the integration of software platforms, the device could identify a patient registering for treatment more than once. He agreed that in the past, many patients had tested but later moved to another location, and instead of informing the new clinic of their treatment already, they would merely say that they suspected they might have TB, which resulted in unnecessary tests and enrolment again on the programmes, which presented treatment difficulties. Ultimately, the device presented an opportunity to source information reports on the patient faster.

Mr Nxiweni said there was a backlog in healthcare infrastructure as a result of high numbers of TB patients visiting clinics, which were already limited in their resources, on a daily basis. This device would eliminate the challenges in paper-based monitoring, and would improve adherence, accountability and monitoring. It could assist in reaching remote communities and home based treatment, thus reducing overcrowding at the clinics, and enhance carer-patient accountability.

The device was interactive and could communicate in the language of choice of patient and carer. Certain socio-economic questions were in-built, which allowed for a more thorough analysis, and these required yes or no answers, to avoid ambiguity. The device would decline to accept misleading information or fingerprints of anyone other than the designated patient or carer.

He said the device provided for timeous interventions without waiting for month-end before detecting treatment non-adherence. The adherence information could be seen for all patients under a specific carer. The software could also provide information on the healthcare support system for a particular patient. The device could also be tailored to determine if HIV positive patients had taken treatment or not. It could be extremely useful in monitoring adherence to the mother-to-child programme.

Non-adherence to treatment of any other non-communicable diseases could be confirmed in the same manner. The device could be used in the proposed National Health Insurance (NHI) to provide accountability and proof of treatment, but also broader accountability to service delivery. All the information collected could be used to provide real time reporting.

Mr Nxiweni concluded that this was an exciting innovation that could be used to enhance government efforts in the monitoring of TB treatment in SA. Biometrics was excited to have conceptualised and developed the technology. He noted that prompt information was crucial in the fight against TB, as it could be beaten and cured.

The Chairperson cautioned the Biometrics delegation that it should not be discouraged by the Parliamentary debate and questions, which were not to suggest that the technology was not wanted, but to ensure that everything was done in a transparent way. He thought that the fingerprinting was important, because the health sector did have a challenge in many duplications. Nurses and doctors were overwhelmed by the amount of administrative work on top of seeing patients. This kind of innovations could help to reduce the workload of nurses.

Ms C Dudley (ACDP) asked if Biometrics had engaged the Department of Health on the new device, and, if so, what reaction the DOH had given. She enquired about capturing information on the device and wondered if it could be used on or by other sectors.

A Member asked if the device had been implemented elsewhere and what the challenges were. She asked if the device could help with getting in patients who simply did not come to complete their treatment. She also asked what Biometrics was expecting from the Committee, and why it had approached Parliament.

Ms C Dube (ANC) said the innovation was a move in the right direction. She asked for more details on the device and if it was manufactured and piloted locally. She asked if Biometrics had capacity to deliver successfully on the project if it was to be recommended and approved for use.

A Member said the whole concept was confusing and very technical. She asked what type of energy source the device would use. The Member also asked if the results of the initial piloting were positive.

Mr M Waters (DA) asked if analysis had been done on the cost effectiveness of the device and how it could be rolled out. He asked for the particulars and details of the patients who participated on the study, what areas the study had covered and when the study was done.

Ms Ngcobo asked if there was a maintenance strategy for the device. She asked if there were any built-in back ups in case of software crashes, pointing out that this had been a challenge in the past. She also enquired if the device would be available to all clinics, or whether there would be strategic access points.

Mr Nxiweni said the delegation had deliberately stayed away from giving a detailed presentation of the technical side of the device, as Biometrics wanted to introduce and inform Parliament about the concept, and share this effective method with the Committee. He confirmed that Biometrics had communicated and shared information with various stakeholders, including clinics, local government health departments and the provincial departments. At provincial level, Biometrics did not engage at depth about the innovation, but had focused its efforts more on garnering support for a clinical study. He said the study would be done in conjunction with the University of Stellenbosch, in December.

Mr Nxiweni said there were some challenges on the ground that could affect the outcome of the study. He said the device was very flexible and was able to create extra modules. There was only minimal capturing of information actually recorded into the device, mostly names and addresses. The bulk of the information was derived from the finger printing. He said there were currently limitations on updating the register and collecting information, but this would not be the case for long. He said it had been proved that the device worked. The defaulters could be monitored outside a clinic. He said the device would be given to a treatment observer who could see patients. Finally, he noted that the device was quite energy efficient.

Department of Health Annual Report 2010/11 briefing
The Chairperson said the Committee wanted to engage the Department of Health on its 2010/11 Annual Report and on how it had spent the R21 billion it received in the previous financial year. The Committee was aware that much of the work was done at the provincial level, and the Department needed to be ready to field questions that were province related. He said Members had received a briefing by the Auditor General (AG) and were fully aware of what was going on at provincial level.

The Chairperson asked the Department to give its briefing.

Mr Waters interjected and asked where the Director General was, noting that there were few members in the delegation, whereas in the past several senior officials had attended. He asked if the Director General had received the invitation, and, if so, when it was received.

Mr Yogan Pillay, Deputy Director General, Department of Health, replied that the Director General was not present, because of austerity measures instituted in the DOH. He noted that in fact only one of the Deputy Director Generals was absent. He reminded the Committee that the Department had a new staff organogram.

The Chairperson said invitations were sent early and the cycle of Parliament was known. It was possible that some officials may be attending to other engagements.

Mr Waters insisted on knowing the whereabouts of the Director General and said that if she was overseas, he wanted to know whom she was accompanying. Again, he asked when the invitation was sent.

The Chairperson replied that the Director General and the Minister were in Rio de Janeiro, attending a meeting of the World Health Organisation. He said it was not necessary to relate those details. The invitation was sent when the time for annual reports came, but the Committee had not specified who should attend. The Committee would like to have the Director General present, but the work of Parliament had to go ahead even if she was not available. He had received an apology and that was enough.

Ms Segale-Diswai said the Department had sent senior personnel, and even if the Director General was present, those officials would still have done the presentation.

Ms C Dube (ANC) said Members needed to deal with the issues, and suggested that the meeting must proceed. She noted that apologies had been received and there were sufficient people present to present. She noted that in the past departments had formed the “habit” of sending large delegations.

Ms Ngcobo noted that the Deputy Director General was delegated by the Director General to give the presentation.

Mr Hoosen said the issue was not about the competencies of the individuals; whilst he was pleased that the Director General was attending an important meeting, it was equally important to engage with her as the head of department. He also noted that she had not attended a meeting in the previous week.

Mr D Kganare (COPE) voiced unhappiness at this discussion, and noted that the Director General would not be able to attend, so there was little point in continuing the discussion. Members should simply be interrogating the Annual Report, and he requested that the presentation should continue.

Mr Pillay continued with the presentation.

He noted that the DOH had many achievements in the 2010/11 financial year. He outlined a ten point plan that focussed on areas such as implementation of the NHI, revitalisation of infrastructure, and mass mobilisation for better health. This was aligned with Government’s Outcome 2, which focused on a long and healthy life for South Africans. He said the four major outputs for this Department were to increase life expectancy, decrease child mortality, combat HIV and Aids, and strengthen effectiveness of the health service.

Mr Pillay said the Department ran six programmes in the 2010/11 financial year. The Administration programme sought to improve capacity in the offices of the Minister, the Deputy Minister and the Director General, and to provide effective leadership. This was consistent with the new organisational structure of the national Department, as approved and submitted to the Department of Public Service and Administration (DPSA). The DOH had convened a National Consultative Health Forum and also launched an AID effectiveness framework, to harmonise the way the DOH worked with donors. Turn-around plans had been developed on provincial finance management. Seven provinces had been supported in implementing the plans, and KwaZulu Natal (KZN) and Western Cape were in the process of developing their plans. The public sector strike was a challenge and had affected the health service delivery.

He said the Department had received a qualified audit opinion. The major reason was the asset register. Only two provinces, North West and Western Cape, received an unqualified audit opinion, below the target of four provinces to be unqualified.

Programme 2: Strategic Health, developed policies and funded key health programmes. He said 72% of public health care facilities implemented the Basic Antenatal Care programme, which enhanced the quality of antenatal care. 96.9% of pregnant women had agreed to be tested for HIV, and 80% of those who tested positive were put on highly active antiretroviral therapy (HAART). A Medical Research Council study found that cases of mother to child transmissions had decreased from 8.5% to 3.5%. Services were provided to 46% of the designated facilities for termination of pregnancy. He said 90% of children were successfully immunised, and the Department expected a lesser number of children dying from pneumonia and diarrhoea.

In respect of HIV/Aids and TB, 11.4 million South Africans had responded, and were tested for HIV by the end of March. He said this figure needed to be maintained. The Department had not achieved its targets of distributing one billion male condoms, and six million female condoms. Delays in the distribution of female condoms were largely due to tender processes. There were 418 677 HIV positive people on treatment. Although access to antiretroviral treatment was expanded, numbers were still lower than the targets set. Another reason why fewer people were initiated on anti retroviral treatment (ARVs or ART) last year had been the public sector strike. However the Department ensured there was no interruption of the service to those who already were on treatment. He said 42 756 Community Care-Givers were receiving stipends.

TB treatment outcomes were recorded with a one-year time lag, and there was a 7,9% defaulter rate of TB patients. However, the targeted TB cure rate of 71% was achieved, exceeding the target of 70%. As part of the HCT campaign, 8 million people were screened for TB and more than 1 million were referred for further investigation. There were 19 Drug Resistant TB facilities. 74% of TB patients completed treatment here, and 55% of health facilities had a turn-around time of only two days to confirm tests. The introduction of the Gene Xpert machines would improve the turn-around times even further. About 69% of HIV positive MDR, and 84% of XDR patients were initiated on ART.

The Department had adopted a mini-draft master plan with regards to non-communicable diseases. He said effective implementation would contribute to curbing drug abuse. There were still challenges around improving maternal and child health. The numbers of mothers and babies receiving post-partum treatment were lower, and maternity facilities conducted fewer peri-natal review meetings. He said personnel shortages and inadequate clinical facilitation skills contributed to this.

Mr Pillay said the Department trained fewer people, due to health workers migrating as a result of Occupation Specific Dispensation (OSD), and migration towards pediatric ART services. The re-engineering of primary health care would make significant inroads in addressing some of the challenges.

He said the Department did not have a register that recorded the quality of care for diabetic patients. The Department piloted a new tool – the chronic disease management register – but this had indicated challenges in poor use and analysis. He said there were 1 061 cataract operations done per one million people, which was way short of the target, because of lack of skills in this field.

Mr Pillay confirmed that there was also a backlog in laboratory services, especially at the three chemistry laboratories that the Department managed. This was due to lack of staff and refurbishment of the Johannesburg laboratory, but most of these challenges had since been resolved.

Mr Pillay described the Health Planning and Monitoring Programme, which conducted planning and monitored service delivery, as well as coordinating health research. He said the Department had compiled and submitted a report on HIV/Aids to the United Nations (UN) Special Session on the disease. The Department developed a web-based disease notification system during the 2010 World Cup.

Mr Pillay reported that a National Health Amendment Bill had been drafted, which sought to improve the quality of healthcare. The Department had drafted the National Health Insurance (NHI) policy and this was tabled before Cabinet, which had approved both the draft NHI policy and the establishment of the NHI Fund. He said challenges included facilities not accredited, conducting external audits of facilities and the establishment of the Ombud’s Office. These would be in place once the legislative framework was completed. The NHI Fund was not established in the previous financial year, but approval had been obtained from Cabinet.

In respect of Human Resource (HR) development, Mr Pillay noted that a technical advisory committee of the National Health Council (NHC) was presented with a draft workforce strategy. 183 clinical associates were enrolled on a degree programme. Two universities had increased their annual intake. Two OSD agreements were signed, in line with the targets the Department had set for itself. National implementation workshops were held with provinces and trade unions. Challenges on this programme included the reduction of student intake by the Universities of KZN and Witwatersrand (Wits). He said no progress was made with the management and leadership feasibility study for the leadership Academy.

The Programme on Health Service Delivery had managed to produce an updated primary healthcare (PHC) package, with support from the University of Witwatersrand to guide service delivery. He noted that the construction of four hospitals had begun in East London, Ladybrand and Trompsburg, and De Aar). Feasibility studies had been undertaken for two out of the five flagship tertiary hospitals at Chris Hani Baragwanath and Limpopo Academic.

The appointment of transactional advisors was finalised for three out of the five flagship tertiary hospitals, namely Nelson Mandela Academy, Dr G Mukhari and King Edward VIII. The Department and the three provinces of Eastern Cape, KZN and Western Cape had appointed engineers to strengthen internal capacity. This would ensure cost-effectiveness in awarding contracts, fast tracking completion of projects, and improving quality of health care facilities. There were still challenges around the non-meeting of targets for district health systems and the delay in approval of business plans for a number of hospitals
Mr Pillay then outlined the Programme on International relations, health trade and health product regulation, which coordinated bilateral and multilateral health relations, including donor support. The Department continued to contribute towards improving health systems in Rwanda and Sierra Leone. 32 Cuban health care workers were recruited and had started working in Rwanda. 80 South Africa students were retained in the SA-Cuba programme. Six cross- border initiatives were implemented to manage diseases as malaria and HIV/Aids around the border areas. There were delays in the Tri-lateral project with Cuba and Sierra Leone, as a result of sufficient healthcare workers not being recruited. The Department aimed to eliminate the backlog of safety updates.

Financial report
Mr Ian van der Merwe, Chief Financial Officer, DoH, said the Department had received R21,6 billion in 2010, of which R19,8 billion related to the five conditional grants. Its total expenditure was R20,9 billion. He said under-expenditure on compensation of employees was as a result of long recruitment process. Another reason for the underspending was the delay with the procurement of condoms. An amount of R452 million was withheld, due to non-expenditure by provinces. The reasons for under spending on most of the programmes included vacancies that were not filled but were budgeted for. He said this was coupled with the late commitment of roll-overs. These were attended to under the administration programme.

He said the Strategic Health Programme under spent by R160 million mainly due to the finalisation of the condom tender by National Treasury. The Health Planning and Monitoring programme under spent by R31 million, also as a result of vacancies. He identified a number of areas of emphasis and said the qualified audit opinion was as a result of the asset register.

Mr Hoosen acknowledged the achievements of the Department but said it had failed largely on administration and control mechanisms. Capacity constraints and skills were its greatest weakness. It was unfortunate that the Department had, once again, received a qualified audit opinion. He said he was interested in the reasons given for this. The irregular expenditure in the amount of R43 million was extremely worrying. Tender irregularities around the distribution of female condoms were another challenge for the Department. He asked when the issue with female condoms would be sorted out.

Mr Hoosen said the entire approach of the fight against HIV/Aids had failed, despite the fact that it was multi-pronged. He pointed out that when one of these programmes failed, it impacted on the overall strategy. He asked if there was any study done to determine if the one billion male condoms released annually reached the end-user.

Mr Hoosen wanted to know more about the IT systems, which did not seem to be working consistently. He asked why nothing seemed to be done at the Department towards reaching gender equity. The figure quoted on the report on termination of pregnancies was still shockingly high. He asked about the money that was spent on this aspect of healthcare. In the last two years, the Department spent R35 million and R65 million on programmes related to termination of pregnancies, a substantial amount, and felt that there were still many instances in which young girls deliberately engaged in unprotected sex, knowing they could terminate pregnancy, so the Department should rather be promoting use of contraceptives.

Mr Hoosen asked for an indication of the cost incurred by caregivers being given stipends. He said the Department did not have a disaster management plan in place and had also failed to enhance the existing one. He asked for the details of the investigation into the misuse of R5.2 million. He asked what actions were contemplated to recover the money from the individuals and contractors who had failed to provide the services. He also asked about the amount of R23 million that was spent on travelling. He wanted to know about an amount owed by departmental staff that was written-off, and enquired if it was not possible to deduct the money from salaries.

Ms Dudley asked for an explanation of what the Department was doing with regard to doctors who were moved to outlying areas, although a greater need for their services existed in the congested urban communities. She said there should be flexibility in redirecting resources to where the need was greatest. She wanted to know if the channelling the grant money meant for forensic services to provinces would help improve public health.

Ms Dudley enquired if there were sufficient engineers and people with technical skills available to assist with construction of new hospitals. The Committee understood that these were scarce skills, but wanted to know what was being done to source these skills.

Ms Dudley asked if under-spending by provinces could be prevented.

Ms Dudley also wanted to know what was being done to ensure that violence associated with strikes did not occur in the future.

Ms Dudley also asked for an update on the exchange programme of medical students with Cuba.

Ms Segale-Diswai said the Department needed to account for the infrastructure projects that were done in conjunction with the Department of Public Works (DPW) and other implementing agencies. The awarding of tenders on the projects was unsatisfactory, and she cited instances where it had taken up to 13 years to award a tender, after the need was identified. This contributed to increases in costs because it meant the scope of projects would also change.

Mr Waters asked whether Members could also interact with the DOH on the infrastructure projects.

The Chairperson replied that both the Annual Report and the infrastructure report would be interrogated, but a separate session had been scheduled to discuss infrastructure project reports with provinces later in the financial year.

Ms Segale-Diswai enquired about contracts that were awarded to bidders who were not recommended on evaluation.

Ms Segale Diswai asked when the Occupation Specific Dispensation (OSD) programme would be implemented to curb strikes in the sector.

She agreed with other Members that the pregnancy termination rate was unbelievably high.

Ms Segale Diswai was pleased with the success of the mother-to-child programme in KZN, but wanted to know how that success could be extended to other provinces.

Ms Segale-Diswai was also interested in the number of caregivers that received stipends, asking if this did not lead to over spending, if the Department targeted a smaller number than those it employed.

Ms Segale-Diswai asked which provinces were experiencing challenges with TB treatment and cure rates. She said she was unhappy with the progress of district health provision and primary healthcare in the lead-up to the pending National Health Insurance (NHI). Good primary health care would lessen the burden on hospitals and on the Department.

Ms Segale-Diswai asked how accounting officers were evaluated and monitored in provinces that had not submitted their district health plans, such as Western Cape.

Ms E Kenye (ANC) wanted to know about the engagements between the Department and public sector unions in so far as strikes were concerned, so as to prevent future disruptions at health centres. She asked if there were mechanisms to monitor expenditure in the provinces that had unqualified audit opinions. She wanted to know why the Western Cape and KZN were allowed to draw their own provincial financial management plans. Those two provinces also had to be monitored by the Department.

Ms Kenye asked if the challenges encountered in the chronic diseases register were due to negligence. Noting that the Department wanted to champion primary healthcare, she asked who monitored the clinics, noting that some were closing at 15h00.
Ms Ngcobo wanted to know if there were any interventions to improve on the Department’s ICT challenges. She asked what measures were put in place to avoid another qualified audit opinion.

Ms Ngcobo enquired about the relationship with neighbouring countries in the fight against TB and malaria. She wanted to know how far the Department had gone in implementing the 18 pilot projects on primary healthcare.

Ms Ngcobo said it was interesting to note how the strike had impacted on HIV treatment. She asked if the Department had followed up on patients whose treatment was interrupted during the public sector strike. She also asked for the rationale behind putting TB patients on antiretroviral drugs (ARVs). She wanted to know how men were responding to the HTC campaign.

Ms Ngcobo enquired about litigation against the national department, noting that the provincial departments were subject to much litigation.

Mr Kganare felt that the Annual Report itself was confusing. He noted that the Department of Health should not be restricting its activities only to addressing Government Outcome 2, as there were other outcomes that spoke to the mandate of DOH.

Mr Kganare said that the DOH needed to interact with provinces on spending patterns. He also asked if the Department was involved in talks with other departments like Sport and Basic Education, and the fast food outlets, on improving child health. He asked if the Department had engaged with the Department of Social Development (DSD) on the impact of HIV on parents, and the possibility that it presented of potential orphans. The Department could not talk of child health if the parents of those children were dying. He wanted to know if the Department was conducting research on the number of condoms supplied by the private sector companies. He said it was important to compare the statistics of those buying condoms and those relying on government. The numbers of people using government condoms might appear low, because they could afford to buy them, and the chances were that if they bought condoms, they would use them.

Mr Kganare said it was a good thing to enrol larger numbers of people on the ARV treatment, but asked if it was sustainable. There was danger in initiating a large scale HIV treatment for many people, if it was not continued.  

Mr Kganare asked if there were any programmes to accommodate volunteer care-givers as full-time employees of the Department, and asked how they could be used, given that there was a shortage of healthcare workers.

Mr Kganare also enquired into the progress made by the Department in consulting communities on the NHI, noting that in Free State there had been no indication of any hearings on the programme.

Mr Kganare asked if the Department followed any specific processes when implementing its programmes, commenting that if there had been, the Department should not have missed the accreditation of health facilities and external audit of health facilities, and also asked if the Department took steps when provinces failed to spend, especially on the revitalisation grant.

A Member said that the good work of the Department was unfortunately overshadowed by the poor performance. The AG had noted that the Department of Health was the worst performing sector. This Department alone accounted for 25% of irregular expenditure across all departments together, which was excessive. Previously, the Department had assured the Committee that the asset register was in place, but it was clear from today’s presentation that this was not so. The Department needed to be consistent. She was also worried by the irregular and unauthorised expenditure, which was raised as a problem in every financial year. She wondered if the Department would ever achieve a clean audit.

The Member noted that it was her view that although the Department had policies, it struggled with implementation. The Department needed to get this right, and stop quoting lack of capacity, since she believed that the resources and personnel were already sufficient. The Department needed to look more closely into tender awards for companies, particularly multiple tenders, and their ability to deliver, and suggested that a policy be drafted to prevent simultaneous awards of projects. The Member said that empowerment impacted negatively on the development of project managers. The Department had a right to sanction contractors and could therefore impose penalties including withholding funds. She said it was surprising to note, from the infrastructure reports, that contractors were paid without completing projects. The Department must examine how it would get the money back, since blacklisting took a long time. She said empowerment companies needed to be linked to big construction companies, with conditions imposed on skills transfer. There was a need for the DOH to change its policies, as people could not be expected to keep waiting for infrastructure.

The Member also felt that the DOH needed to review its human resource strategy. The current approach might be suitable to the provinces, but there had to be a turn-around time. There also needed to be programmes and procedures in place that would ensure staff were retained.

The Member was not sure if the Department’s reports were entirely accurate, noting that the DOH’s audit committee claimed that the Department was doing good work, but this report seemed to indicate something different. Even the audit committee did not seem to be effective. The Committee expected honest reports.

The Members asked how far the Department had gone in implementation of the Office of Standards. She also asked for details on maternal and child mortality, and if the Department had a plan to change the situation. She finally sought clarity on whether the engineers that would monitor infrastructure projects were already employed.

Mr Waters asked for the details of the four major outputs to which the Department had made reference. He wanted to know why the AG was not given accurate information when he requested for it, as stated in his report.

Mr Waters commented that the failure to mention the R90 billion private medical scheme was a major failure on the part of the Minister and Director General. Their responsibility included looking after the industry, by regulating it and making sure it was functioning optimally. The fact that it was not mentioned at all called into question whether the Department should be tasked with this responsibility.

Mr Waters asked for more information on the Gene Xpert technology that was faced with huge financial difficulties, due to provinces’ lack of funding to the chemistry laboratories in Johannesburg and the Western Cape. He added that there was an increasing backlog caused by financial difficulties, and asked what the Department was doing to rectify this problem.

Mr Waters asked what other programmes there were at the Department, other than the nursing summit, that would ensure improvements in the quality of care.

Mr Waters said that when the Director General assumed office there were assurances that vacancies would be filled and the condition of the Johannesburg forensic chemistry laboratory would be improved. He asked why, despite this, there remained unfilled posts, and nothing had been done with the laboratories.

Mr Waters wanted to know the processes in place to follow-up people who were getting TB treatment, and how the Department ensured that they completed the course of treatment.

Mr Waters asked whether there had been any changes to the process of appointing the Chief Executive Officers, to ensure that competent people were hired. He wanted to know if the process of deducting monies from those who went on strike last year was completed, and if any nurses were fired as a result.

A Member wanted to know which provinces and hospitals were responsible for the under expenditure, and the reasons.

The same Member asked what contributed to the improved rate of TB cure and how that would be sustained. She also called for more details on the new TB grant.

The Member enquired if the delays in paying suppliers resulted from lack of financial planning.

Mr Pillay responded to the questions by grouping them in broad categories. Firstly, he said that the department had tried to give a very general idea of how it had spent the R21 billion that if had been allocated in the 2010/11 financial year.

Mr Pillay stated that the methodology used by the Auditor-General to get information was very contentious. The DOH had asked for a meeting with the AG, following his report, and requested also that it be delivered to the National Health Council. A workshop was being arranged with the AG to see if there could be a workable methodology decided upon and used for the 2011/12 financial year. The Department needed a verifiable flow of information. He said that for the AG to rely on the information received in respect of 20 facilities, out of a possible 4 000, as a sample was not ideal, and raised the difficulty of generalised assumptions. He conceded that there were some difficult issues, but repeated that the DOH was contesting the methodology that was used.

A representative from the Auditor-General South Africa commented at this point that the methodology used in evaluating the 20 facilities followed internationally-accepted auditing guidelines. However, the AG would be more than happy to engage with the DOH to clarify the findings and report.

The Chairperson said the Committee was not interested in the methodology but the report, and said that the methodology must be discussed between the AG and Department, in regard to the collection of data.  

Mr Pillay conceded that whilst the information system in the DOH was not fully accurate, the electronic TB register was working well, and in fact was able to give information on a selected patient that would include data on where that patient had first been given TB treatment. The same was unfortunately not true for HIV. In respect of the HIV programme, the Department had adopted a three tier system of paper, electronic and patient information registers. The Minister had already been promised that by March 2012 each facility would implement the electronic register for the ARV treatment.

Mr Pillay noted that the reason why a higher number of caregivers had been reported than were targeted was that the DOH had received additional funding from the Department of Public Works, through the Expanded Public Works Programme. The Department of Health had therefore been able to hire a larger number than initially targeted, without affecting the original budget. DOH had also engaged with provincial departments and Department of Social Development to ensure that there was no duplication in the caregivers’ programmes.

Mr Pillay noted, in regard to condom distribution and use, that the Department concentrated on trying to ensure that people would use condoms. The contraception programme had not been dismantled. In terms of the Act, contraception must be available. The Department tried to avoid unwanted pregnancies.

Mr Pillay assured Members that the Department did have a disaster management plan.

Mr Pillay then commented on the Occupation Specific Dispensation (OSD) and vacancies, and said that the OSD had resulted in a lot of unintended consequences. These were being addressed but he was not sure where the process was. The OSD had been finalised with doctors and other allied health workers. That did not mean those workers were happy with what they received. A service level agreement had been entered into with both the unions and employees. However, there were difficulties in reaching agreement on what would be permissible. The DOH believed that every facet of work at a health facility could be classed as an essential service, and therefore health workers should not be allowed to strike. This view had led to an impasse with the unions. Essentially, the Department wanted to make sure that health workers would not go on strike.

Mr Pillay was of the opinion that the conditional grant had made a meaningful difference to people’s lives. The infrastructure grant had improved a lot of facilities, and the quality of the service. The Department could not have run an effective hospital management programme without donor funding, but it had halted this particular programme until the audit of the CEOs was finalised. Discussions were presently ongoing in relation to the salaries and qualifications of the respective CEOs. He said where there was a match of the individual and the qualification required, the person would be retained, but it this was not found, then that employee would be retrained or moved to other responsibilities commensurate with his or her abilities.

Mr Pillay said Mpumalanga returned the worst Mother-To-Child HIV transmission programme results. The Department was introducing new targets for the programme. The plan was to eliminate the mother-to-child transmission altogether.

Mr Pillay conceded that TB was a problem everywhere in the country, and the Western Cape and KwaZulu Natal had the highest rate of infections. The fight had to be won at district level as opposed to relying on the provincial departments. The DOH was going around the country, screening people, and about 100 000 households had been visited. He said there was a gap between diagnosing and putting patients on treatment. HIV was contributing in the high rate of new infections of TB, and as a result the Department was putting all HIV people who were not already infected with TB on a special treatment.

The Chairperson interjected at this point to suggest that it might be useful, if the Department could not answer all questions, for written replies to be submitted.

In relation to staffing questions, Mr Pillay said the Department had made progress in recruiting new staff. All vacant posts had been advertised and 16 new appointments were made. He said the 24 vacant specialised positions in the Department would be filled by the end of the year. Interviews had been conducted and the process was still ongoing.

Mr Pillay assured the Committee that there was a turn-around plan for the forensic chemistry laboratories and this could be sent to the Committee on request. The plan involved the three areas of specialisation – toxicology, food and blood alcohol. The Department had asked all analysts to increase their throughput. Additional analysts would be employed from universities, and further training for them would be provided. He said this should be easy work, considering the robustness of the programme. As a result backlogs would be dealt with in a space of 18 month to two years.

Mr Pillay then addressed the various questions on HIV. He said that the number of males undergoing tests was very low, and was currently at 30% of the total number of people who had tested. The Department needed to do a lot of work to improve on this statistic. Most of those who approached the HCT campaign were women. He said there was a team that worked with the Department of Social Development, to match programmes that aimed at addressing challenges faced by those orphaned by HIV. The Department of Health hoped to have 3 million patients on ARV treatment by 2015. However, more emphasis had to be put on prevention. The Department had no choice other than to initiate more people on treatment. He said the Department had a model that projected the number and cost of ARV treatment, and this was evaluated annually. All those initiated on treatment had to be retained on treatment. Again, however, the emphasis would be on reducing new infections.

Mr Pillay noted that the Bill on the Office of Standards had not been returned to Parliament. The Department had prepared for the implementation of the Act by appointing ten inspectors, who had left already for training in the UK. In the last year, the Department issued a tender for external evaluations of all health facilities, on areas like human resources, facilities, quality of care and infrastructure. He said 2 000 facilities had been evaluated.

Mr van der Merwe commented on the questions in relation to the audit report. The R30 million irregular expenditure resulted from the DOH putting out a tender, for which eight companies applied. Two of them were awarded the tender to supply travel services, but the AG and National Treasury found that the companies were not suitable to provide the service.

Mr van der Merwe agreed that other provinces should be encouraged to follow the example set by the Western Cape and North West, who had returned clean audits. The National DOH was moving closer to getting a clean audit, and had introduced a peer learning programme where other provinces were encouraged monitor finances.

Mr van der Merwe assured the Committee that there was a register for assets, but it needed to be audited.

Ms Tiny Rennie, Deputy Chief Financial Officer, DOH, said the issue regarding the World Aids Day was not payment for a contractor, but just a matter of supply chain management procedures that were not followed correctly. She noted that the utilisation of a helicopter was irregular at the time it was used. The Department had issues of old irregular expenditure but was processing them now.

A representative from the DOH noted that lack of planning and management capacity led to the under expenditure of infrastructure grants. It was noted that the Department of Public Works also needed to improve in its capacity and management. Other challenges related to land acquisition in urban municipalities. There were problems with using the DPW as an implementing agent. One solution might be for the DOH to employ a managing engineer and managing architect. In five provinces, the provincial Departments had already employed engineers.

The Chairperson noted that any unanswered questions must be responded to in writing.

The Chairperson also noted that the Committee would consider the matter and draw a report.

The meeting was adjourned.


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