Department of Health on its 2010/11 Annual Report

Meeting report

Overview of Department of Health Strategic Plan 2010/11-2012/13
Dr Aaron Matsoaledi, Minister of Health: Department of Health said that HIV/AIDS and Tuberculosis were affecting the life expectancy and maternal and child mortality rates of South Africans in a cruel way. Extraordinary measures were being implemented to combat this crisis. Health care was slanted toward curative medicine and the cost of it was currently unsustainable. Ordinary South Africans could not afford healthcare and they believed that the cause for this was inflation. However, DoH believed that costs were artificially increased and implementation of NHI, re-engineering of the primary health care system and revitalisation of infrastructure, through the National Health System’s Priorities 10-point plan (2009-2014), would arrest the cost. The Negotiated Service Delivery Agreement with the President (NSDA) 2010-2014 was in line with the 10-point plan and the international MDGs for health and was focused on: increasing life expectancy; decreasing maternal and child mortality rates; combating HIV/AIDs and Sexually Transmitted Infections (STIs); decreasing the burden of disease from Tuberculosis; and enhancing health system effectiveness. The 10-point plan also included improving Human Resource planning/development/management; and strengthening of research and development.

The revised organogram, which was aligned to the NSDA, had been finalised, approved by the Minister and submitted to the Department of Public Service and Administration (DPSA) for concurrence.

Highlights of Performance on the DoH Strategic Plan 2010/11-2012/13
Dr Gwen Ramokgopa, Deputy Minister, Department of Health presented the highlights and challenges of its six programmes according to Strategic Plan 2010/11-2012/13: administration; strategic health programmes; health planning and monitoring; human resource and management development; health service delivery; and international relations, health trade and health product regulation.

DoH received a qualified audit opinion for the Auditor-General South Africa (AGSA), the major reason for this being the delay in valuation of assets in the asset register. Only two provinces, the North West and Western Cape received unqualified audits. The target was that at least four provinces would obtain an unqualified audit opinion.

Quality Basic Antenatal Care (BANC) provided by public health facilities had exceeded the 2010/11 target of 60% by 12%. This included 96% of pregnant women being tested for HIV and 79.4% of HIV-positive pregnant women placed on highly active antiretroviral therapy (HAART).

Child health had improved significantly with 89.4% of children under the age of one year being fully immunised against vaccine preventable conditions. See handout for targets and achievements for the immunisations, Cotrimoxazole Prophylaxis Therapy (CPT) as well as results on TB and HIV prevention and treatment and DoH Laboratory Services challenges.

The Draft NHI Policy (issued as a Green Paper) was approved by Cabinet during 2010/11. Although the NHI fund was approved by Cabinet, establishment of the fund had not yet taken place.

Regarding human resource development, no progress had been made with the Management and Leadership Feasibility Study for the Management and Leadership Academy, which was planned to be completed by March 2011.

A revised and updated Primary Health Care model was produced and approved by the National Health Council to place emphasis on both the individual and family with focus on promotion and prevention, rehabilitative and referral services rather than exclusively on curative services and Health Technology Committees were created to guide Health Technology Planning at sub-national levels.

Four hospitals were constructed, namely: Cecilia Makiwane (EC), Ladybrand (FS), Trompsburg (NC) and De Aar (NC). Delays occurred in the approval of business cases for the following hospitals: Dr P ka Seme and Edendale Hospitals (KZN), Musina Hospital (LP), Bophelong Psychiatric Hospital (NW), Valkenburg Psychiatric Hospital (WC) and Tygerberg Tertiary Hospital (WC).

Six cross-border initiatives focused on malaria and HIV/AIDS were implemented to manage communicable diseases along border areas.

While DoH had set itself a target of 24 months for registration of Non-Chemical Entities (NCEs) and 18 months for registration of generics, and also aimed to eliminate the backlog of safety updates, it failed to meet its targets. The average time for registration of medicines was 32 months for NCEs and 30 months for generics. This was a result of delays by applicants in responding to the resolutions of the Medicines Control Council and shortage of evaluators.

Department of Health Budget and Expenditure
Mr Ian van der Merwe, Chief Financial Officer, Department of Health presented the background of the DoH budget and expenditure and a summary of the economic variances.

The final appropriation for the year was R21.6 billion, an increase of R3.2 billion compared to the previous financial year. R19.892 billion of the appropriation was for the provision of five Conditional Grants, of which R19.440 billion was transferred to Provinces and R18.867 billion spent. Actual total expenditure amounted to R20.9 billion (96.6%). The Conditional Grants under-expenditure accounted for 61% of the total under expenditure.

Under-expenditure on Compensation of Employees was influenced by a long recruitment process which commenced in September 2010 after the lifting of the moratorium on filling of posts. The amount involved was R30.7 million.

Some Goods and Services were committed late during the financial year and could not be delivered before year-end – there was a delay with the procurement of condoms through a tender by National Treasury resulting in under spending of R181.418 million.

Under expenditure for Transfer Payments included an amount of R452.5 million for the Revitalisation Grant which had to be withheld due to non-spending by Provinces.

Capital expenditure under-spending amounted to R27 million due to delays in the procurement processes.

Reasons for under spending on each of the six programmes were listed (see handout).

In summary, the DoH received a qualified audit opinion, the main reason for this relating to the valuation of assets. Matters of emphasis raised were comparative figures for the operating lease expenditure for buildings and other structures; irregular expenditure of R43 million, of which R30 million was for the supply chain process undertaken for travel, conferencing and accommodation (travel agencies); and reliability of reported performance information. These matters were currently being remedied.

Ms Precious Matsoso, Director General, Department of Health, concluded that major progress had been made in certain key priority areas of the Strategic Plan 2010/11-2012. Problem areas affected some areas of service delivery but DoH was currently addressing the challenges. DoH had set up an Advisory Committee to monitor the status of the infant and maternal mortality rates and the progress on the MDGs, the 10-point plan for 2009-2014 and the NSDA 2010-2014. In addition, the NHI Green paper was out for public comment and 20 Inspectors had been appointed to inspect the quality of facilities and would be trained by the Care Quality Commission. The assessment of CEOs had been completed and regulations for management of hospitals had been published and the HR Planning Strategy had also been published.

Discussion
Ms B Mncube (ANC; Gauteng) commented that on an oversight visit to a district hospital in Limpopo it was evident that the CEO’s leadership and management skills had filtered to the staff and that the CEO was ultimately responsible for the quality care that existed at the hospital. She suggested that such a person could assist with the training of management at hospitals and transference of skills as planned by DoH but which had not yet been successful.

The Minister was interested in the name of the hospital but the Member could not remember the name of it. She promised to forward the information to the Minister.

Ms Matsoso said that DoH would seriously follow up on the information shared by the Member on the Limpopo hospital. She added that it was impossible to workshop people who did not have basic skills. There were challenges with the Quality Programme and DoH would like to fast-track training of management in hospitals and ensure that managers were adequately qualified and competent. DoH had audited management programmes in all provinces and concluded that running of a hospital required managers with specific hospital management skills. The Minister had identified core quality elements to standardise compliance in provinces according to expectations. These were: attitude, drug stock, infection control, cleanliness and order in hospitals, safety of both the patients and health workers and long queues. Treasury had given DoH the responsibility of the Health Infrastructure Grant over and above the Revitalisation Grant. DoH had asked provinces to submit their infrastructure requirements so that DoH could match these grants.

The Minister added that ten Central hospitals had been identified which were attached to medical schools and which had criteria for management on a DDG level. Parliament would introduce policy to annually grade all hospitals according to standards of quality and safety compliance according to the UK Care Quality Commission.

Ms Mncube asked if there had been improvement in service delivery since Senior Management Performance Agreements had been implemented.

Ms Matsoso replied that DoH had taken the guidelines and recommendations of the DPSA for Senior Management Performance Agreements and for annual performance monitoring of managers. DoH had further requested DPSA to provide simpler performance agreements for all levels of staff between manager, supervisor and worker. These agreements had been converted to electronic documents and had been signed by all staff. DoH also wished to extend performance agreements to stakeholders, colleagues and peers.

Mr M De Villiers (DA; Western Cape) asked what the progress was on programmes for training of managers in hospitals and if senior managers complied with the Senior Management Performance Agreements.

Ms Matsoso replied that DoH had created a repository of information that would be used for training at national and provincial level. DoH would share data and insights with the Committee at an appropriate time.

Mr W Faber (DA; Northern Cape) asked how much the training of hospital managers cost, including consideration of the time spent away from the hospital. Also, hospitals had received disclaimers since 2009 and he questioned whether CEOs and CFOs were in fact qualified for the job of managing hospitals. He asked what would be done about the situation. In the Northern Cape, it appeared that management training would not solve the problem.

Ms Matsoso agreed that the CEO and CFO capacity was important for performance audit outcomes. Indeed, training may not be the solution.

Mr De Villiers asked which programmes were in place to prevent under spending on the budget in future.

Ms Mncube asked what the reasons were for the under-spending of the provincial grants.

Ms Matsoso replied that the problem was that the Department of Public Works was the implementing agent at provincial level. In addition to the previous presentation by Dr Massoud Shaker to the Committee on the Appointment Strategy of Engineers, the Programme Management Unit had been created to oversee management of all projects. DoH had managed to support units in some provinces.

Dr Massoud Shaker, Minister’s Advisor on Infrastructure: Department of Health added that under-spending was an economic problem since 2007 and was not only a problem nationally, but a problem of the provinces and the Department of Public Works. Currently there were 636 unfinished projects to the value of R2.1 billion. The Infrastructure Unit Support System (IUSS) had been introduced as a mechanism to improve infrastructure service delivery.  The IUSS had five focus areas, one of which was a Project Management Support Unit for each province which involved packages to remedy the individual delivery needs of each province. Twenty three engineer experts on infrastructure planning, design, construction, maintenance, procurement fields, nursing colleges, public-private partnership projects, capacity building and strategic project management had been hired and began engaging with provinces in September 2011. DoH had also attracted IT advisors and technical assistance for each province. DoH was also endeavoring to attract the support and collaboration of DPW. Without this, DoH’s plan for infrastructure could not be fully realised.

Mr Van Der Merwe added that the CFO forum met quarterly at national and provincial level to analyse and improve on the provinces’ spending profiles. The Financial Management Recruitment Plan identified where funding was required and baselines were being established per province. Audit outcomes per province had been analysed and the AG was engaged to ensure consistency in terms of their findings. Conditional Grant Expenditure had been analysed and involved the National Accounting Authority in terms of withholding and reallocation of funds.

Ms Mncube asked how DoH ensured that communities were educated and that the distributed condoms were used for the intended purpose.

Ms Matsoso said that DoH had noted the problem with condoms. DoH spent a lot of money on NGOs and had many service level agreements with them. However education on condom use was lacking and should possibly be included on the service level agreement. Education to the public was still lacking. 

Ms Mncube asked if the 32% vacancy rate for human resources and skilled supervision was due to lack of available skills or lack of advertising.

Ms Matsoso replied that the DoH involved 27 occupational structures and the Human Resources Strategy had made a strong statement on filling of vacancies. In the past, funded and unfunded posts had not been clarified. Going forward, as a national as well as a provincial plan, each manager would be required to have an HR plan which spoke to the budget and reviewed vacant posts annually so that when projects were completed, positions would be closed.

Mr S Plaatjie (COPE; North West) commented that annually the cases of misconduct, corruption and fraud in the DoH had stemmed from irregular tenders and procurement processes. He asked what mechanism was in place to correct the anomaly. Also, he believed that expulsion for corruption was not a severe enough form of punishment. Officials who had been expelled from one department were placed in another department and continued to access opportunities involving corruption.

Ms Matsoso replied that DoH was aiming for a policy of zero tolerance on corruption and fraud. Suppliers that did not meet performance requirements were blacklisted. However, DoH also had the responsibility of putting in place mechanisms to ensure that suppliers were paid on time so that they could deliver.

Mr Plaatjie asked what the turn-around time was for registration of medications.

Ms Matsoso replied that there were three processes for registration of medicines. Fast-track should be a year; generics should be 18 months and nutritional entities should be 24 months. DoH would like to introduce the stop-clock system so as not to count the time that a company takes before responding to the DoH.

Mr De Villiers asked if the ICT problems experienced by DoH in the past where currently under control.

Ms Matsoso replied that the ICT Health Strategy was under review. It was clear that investment on competent employees was the solution to the problem.

Mr De Villiers asked in which hospitals there was stock-out of TB (5%) and Antiretroviral (2.6%) medications and what DoH was doing to prevent the occurrence of stock outs in future.

Ms Matsoso said that the idea was not to have stock-outs. Since DoH had increased monitoring of stock in the provinces, the situation had subsequently improved.
 
Dr Anban Pillay, Acting Deputy-Director General: Department of Health, added that DoH monitored stock-out at depot level and that the stock-outs reported related to the stock-outs at the depot. This did not mean that patients did not have access to drugs. Where there may be a problem with delivery to the depot, DoH attempted to access the drugs from alternate suppliers before there was a shortage of access to patients. This took an average of six weeks. The problem was when provinces did not pay suppliers on time and suppliers were reluctant to supply drugs.

Ms M Makgate (ANC; North West) commented that her experience (and that of the media) was that service delivery and monitoring at the depot was clearly not adequate. She argued that drugs were at depots but not in the clinics where they were required and where people were suffering.

Ms Matsoso added that she would follow up with Dr Pillay on whether officials who were monitoring depots also had the responsibility of monitoring stock at facilities and what the situation was in that regard.

Mr Faber asked if DoH was winning the race to reduce maternal and child mortality.

Ms Matsoso agreed that maternal and child mortality rates were still a problem. DoH had not conducted longitudinal demographic health studies and it was difficult to know exactly what the target should be. Stats SA was compiling a national database and benchmarking it internationally and these findings would soon be released to the Committee.

The Minister added that a child that was HIV positive was 16 fold more likely to die in the first six months than a child that was born HIV negative. There were 70 000 children born with HIV but it was expected that the rate of HIV transmission from mother to child would be reduced by half since the President’s call on 1 December 2010 for antiretroviral therapy to be administered to mothers with HIV during pregnancy and breastfeeding and to children born with HIV. Apart from HIV, diarrhea and other viruses contributed to the mortality rate. With the introduction of immunisations against viruses, measurable effects were expected to show within a year.

Mr Faber commented that it was of great concern that the AG Report had stated that information given by the DoH was questionable and that many of the indicators in Programmes 2 and 5 could not be established. He asked how the DoH was responding to these findings.

Ms Matsoso replied that the DoH had engaged with the AG and Stats SA on how to improve the quality of data capture.

Ms Makgate commented that while the North West province finances looked good, the reality was that hospitals did not have blankets or medications. She asked if the AG Report was based on funds spent or on service delivery.

Ms Matsoso replied that the report related to financial performance and in response to similar concerns by other oversight Committees, DoH had prepared an Implementation Protocol to be signed by the HODs as a contract to ensure service delivery.

Ms Makgate asked what plan was in place to ensure that provinces implemented the Disaster Management Plan.

Ms Matsoso replied that the document on Disaster Management Plan was still in draft form. Once finalised, the Inter-Ministerial Committee would design a Disaster Management Strategy for implementation. DoH would align its strategy with COGTA.

Ms Makgate asked how DoH ensured that the Community Care Givers were consistently paid their monthly stipend by the Provinces.

Ms Matsoso replied that DoH had developed a code of conduct to ensure that provinces paid the NGO community workers.

The Minister added that to improve the situation of inconsistent stipends paid to specific groups, each of the 4000 municipal wards would have ten primary health care workers, coordinated in the provincial premier’s office. This would eliminate the problem with NGO, Social Development and COGTA stipends and salaries. Currently there were 78 000 community workers but the positive results of their work were not evident. Only 40 000 primary health care workers were actually needed. With a proper structure, the issue of stipends and provinces not being able to pay NGOs would not be an issue.

The Chairperson commented that the work performed nationally should be reflected in the provinces. In the Eastern Cape, 95% of complaints were being addressed by the MEC and team. She asked if the problem of shortage of doctors at hospitals and clinics in the Eastern Cape should be addressed by the DoH or by the provinces. She also commented that although the TB hospital in Aliwal North was performing well medically and the personal care was excellent, the structure and conditions were in collapse. She asked if the Revitalisation of Infrastructure Project would address this problem.

Ms Matsoso said that officials had been deployed to provinces to tend to the needs of the provinces based on the audit outcomes. Progress would be presented to the Committee.

Dr Yogan Pillay, Deputy-Director General: Department of Health added that TB hospitals, along with psychiatric hospitals, were part of the Revitalisation Programme. In the past three years, nine new TB units had been built in seven provinces to treat drug-resistant TB.

The Chairperson asked if in addition to the new organogram of the DoH to meet the needs of the DoH objectives, there was a change in the provincial, district and local structures to align with the changes made on a national level.

The Minister replied that in the past the problem was that the Health sector was run as 10 different departments. Currently, the DoH controlled the nine provinces and the national organogram now had a DDG dealing specifically with HIV/AIDS. A national engineer would establish a team of engineers and the CFO would meet with CFOs of provinces. Each provincial organogram would be aligned consistently with the national organogram and would be expected to be compliant with national requirements.

Mr De Villiers asked how many of the 80 students who went for medical training in Cuba were still in Cuba and what the success rate was of the training.

Ms Matsoso replied that to date 257 students had graduated from Cuban medical training and were working in South African facilities. The problem was that South Africa continued to be short of doctors and the question currently being addressed was whether to send more students to Cuba or to increase capacity at institutions in South Africa.
 
Ms Mncube warned that there was a great risk in overlooking Disaster Management. She cited the incident whereby the electricity tripped after flooding in the new state of the art hospital in Mthatha.

Ms Matsoso agreed that Disaster Management was a key problem even without the recent health sector strikes. DoH was eagerly waiting finalisation of the Disaster Management Strategy with the provinces before the Disaster Management Plan could be implemented.

Ms Mncube said that on an oversight visit to the rural Umzinyathi District, it was evident that there were no role models, FET colleges or career opportunities for students completing school. These youth were inclined to marry and not further their studies despite the presence of many hospitals in the area. Ms Mncube suggested that DoH recruit students or offer alternate opportunities for the youth in this vastly rural area.

Ms Matsoso said that the Umzinyathi district would be revisited.

The Chairperson asked if the DoH was responsible for public education on cancer or if this work would be left to the NGOs.

Ms Matsoso said that the National Institute of Occupational Health was still finalising the Cancer Registry. Cervical, breast, prostrate, lung and colon cancer as well as cancer in children were prioritised as key cancer programmes. DoH was not waiting on the registry to identify backlogs but had moved to drive initiatives for cervical and breast cancer screening as part of the Non-Communicable Disease Prevention plan.

Ms Makgate asked for a strategy to ensure that the smaller rural areas were monitored for safety and quality of service on a more regular basis as the rural communities tended not to complain about lack of service delivery and it appeared that health care workers in those areas tended not to comply with the service delivery requirements.

Ms Matsoso agreed that there had been little oversight support at some facilities for many years. However, problems at small and large facilities had been identified in the audit. DoH had set up a task team of medico-legal experts to respond to correspondence received from patients due to negligence at facilities. Through the National Health Services Litigation Authority, it was clear to DoH that litigation translated into money to lawyers and little compensation to the victims. DoH had identified that obstetrics & gynaecology, spinal surgery, orthopaedic and neo natal cases were the most common criteria for litigation.

Ms Mncube noted that Gauteng had made great progress with regard to curbing theft and she asked how the other provinces were faring in that regard.

Ms Matsoso replied that detailed audits on safety aspects were being performed at all the facilities in the country. The primary problem was that security services were outsourced and the hospital could not hold the security company accountable as it did not hold the contract with the security company. Theft included intellectual property, information and equipment theft and there was also the problem of litigation whereby nurses were partnering lawyers in making money through lawsuits. DoH was formulating its security plan based on its safety audit and with the assistance of the Minimum Information Security Standards (MISS) guidelines.

Adoption of Committee Minutes of Proceedings: 18 October 2011
Mr De Villiers moved to adopt the Minutes with amendments and was seconded by Mr Plaatjie.

The meeting was adjourned.