Deputy Minister on Department of Health 2012 strategic plan

Meeting report

The Chairperson acknowledged the cordial relationship that existed between the Department and the Committee. The Committee appreciated the presence of the Deputy Minister and the Minister had indicated his unavailability for the meeting due to other commitments.

Dr Gwen Malegwale Ramokgopa, Deputy Minister, National Department of Health, thanked the Committee for the opportunity to participate in the meeting, adding it was her first time to do so. The Minister could not attend the meeting since he was involved in meetings on the pilot sites for the National Health Insurance scheme. The Department had been invited to present on the Annual Performance Plan in the context of the Medium Term Expenditure Framework (MTEF) and deliverables for this financial year as well as priorities over the next three years. The Minister had outlined strategic priority areas of focus during his presentation in the National Assembly on the budget vote. The Department presentation was going to reflect on the National Heath Insurance (NHI) plan and the additional NHI funding that had been created for that purpose. The Department’s focus was underpinned by the need to achieve four priorities which were: Increasing life expectancy, decreasing maternal and child mortality, combating HIV/AIDS and the burden of Tuberculosis and strengthening the effectiveness of the health system. Figures from Statistics South Africa (StatsSA) had shown that life expectancy was improving. The Department had achieved phenomenal progress in reducing the burden of HIV/AIDS nationally and globally as a result of a united effort against the challenge.

In a period of about 18 months, 15 million South Africans had availed themselves for testing and mother to child transmission of HIV had been reduced by half. The TB diagnostic period had been reduced from six weeks to two hours which helped patients to get appropriate attention earlier. On 7 May the Minister had launched the Campaign to Accelerate the Reduction of Maternal Mortality in Africa (CARMMA) which had been received well by other African governments’ Ministers. In the previous year a lot of work had been done in improving the effectiveness of the National Health System (NHS) and a National Research Committee had been established to link research to national objectives. A summit had been held on the essential equipment and technologies necessary in delivery. A Bill was being drafted to improve quality delivery. The Department had worked hard in this tier and she appreciated the leadership of the Minister and her predecessor in laying the foundation upon which they were building going forward.
 
Ms Precious Matsoso, Director General, National Department of Health, said the government had adopted an outcome based approach to service delivery and the health sector was responsible for the achievement of Outcome 2: A long and healthy life for all South Africans. Identified outputs were designed to increase life expectancy, decreasing maternal and mortality deaths, combating HIV/AIDS and strengthening the health system which was the thrust for the Department in this financial year. Strides had been made in health delivery but were being undermined by the weak performance of the health system.

For the Department to achieve life expectancy as stipulated in the Negotiated Service Delivery Agreement (NSDA), it had to reduce the burden of diseases, Mother to Child transmission, TB, mortality rate ratio, road accidents as well as violence and injury perpetrated against women. Areas that would be targeted would be primary health care oriented service delivery, quality of services, human resources for health, health infrastructure, financial management, health education among others. It would work with other departments in service delivery through inter-sectoral engagements. The preparation for the rolling out of the NHI had begun but its implementation would be preceded by the development of the Green Paper followed by a draft Bill that would be submitted to Parliament. During the process the Department would reflect on the original costing of the NHI as well as addressing financial management in the health sector. Reduction of new HIV infections would be scaled up and as of 31 March, over 20 million South Africans had been tested. It was hoped that the accelerated testing would contribute to behavior change.

The Department planned to increase Medical Male Circumcision from 600 000 in 2012/13 to 800 000 2014/15 at the same time encouraging the use of condoms, increase testing for HIV/AIDS from 18 million in 2012/13 to 20 million in 2013/14. It was important to make testing a norm, not only for HIV/AIDS but for Non-Communicable Diseases (NCD) as well. These efforts would be supplemented with health education messages. The number of patients initiated on Antiretroviral Therapy (ART) would be targeted at between 500 000 to 550 000 annually between 2012/13 and 2014/15. For South Africa to be able to sustain treatment there was a need to increase the capacity of local manufacturing companies which had been a problem over recent months. In the past few years the US had donated significant quantities of ARVs and local companies had produced about 200 000 which has been minimal. As of 1 January they had to up the production to 1 million tablets. Consistent with recent policy of the Minister of Trade and Industry that South Africa must promote local production with 70% of supplies being local, South Africa needed to increase its skills base and have competent people to produce this. SA must build capability to respond to this burden of disease.

The number of Primary Healthcare (PHC) facilities that implemented nutritional intervention for people living with HIV/AIDS as well as TB would be increased from 80% to 100% in 2014/15. Key strategic interventions for reducing infant and maternal mortality rate included maintaining the immunization of children under the age of one year at 90% throughout the MTEF, increase measles immunization by 90% and the Vitamin Supplementation in children between 12 to 59 months would be scaled from 40% to 55% in 2014/15. The Department of Social Development would be invited to help in the immunisation programme for young children as well as with school programmes.

An integrated School Health programme would be launched of which 80% of the programmes would be targeted at quintile 1 schools (schools with high levels of poverty). About 680 000 grade 1 and 2 learners would be targeted this year and the number would increase to 807 000 in the 2014/15 and grade 8 learners in the same category would be targeted especially because there were problems of alcohol and teenage pregnancy. They were engaging the Department of Basic Education (DBE) on how the programme would be implemented at high schools as there were school policy issues due to fears in some quarters that such a move could promote sexual activity. Learners in grade 1 and 2 would also be tested for sight and hearing problems, with the launch of the programme was earmarked for the month end. KwaZulu-Natal had bought 16 mobile clinics for the programme already.

The maternal mortality rate would be tackled through the launch of the Campaign to Accelerate the Reduction of Maternal Mortality in Africa (CARMMA) programme and currently the country was sitting at 310 maternal deaths per 100 000 live births. The report on maternal deaths revealed that of the 310 deaths, half took place within facilities, others along the way to facilities and the rest at home. To reduce the rate the Department would procure obstetric ambulances to have women who might not make it to facilities or are in remote areas. Maternity lodges would be built at facilities allowing women from remote areas to be accommodated for the last five days before giving birth to ensure safe delivery. They hope to increase antenatal visits and post-natal care within six days of delivery would be increased from 30% to 82% in 2014/15.

On sexual and reproductive health, the Department would increase cervical cancer screening from 52% to 58% as well as improving family planning programmes in conjunction with the Department of Basic Education (DBE). The targets for number of women tested for HIV would be increased to ensure zero transmission and the TB cure rate would be increased from 72% to 90% while the defaulter rate would be reduced to 5% from 7% currently.

The percentage of HIV positive patients screened for TB would be increased from 71% to 90% to reduce co-morbidity as well as improve early detection and treatment of diseases.

Pertaining to reengineering of PHC, Family Health Teams (FHT) would be established in communities and 5 000 health workers had received training on the programme. Districts specialists had been appointed to help in reducing mortality rates in communities and the initiative was informed by the recommendation of the Committee and well as the report on mortality rates. The specialists commenced duty this month and some would begin in June.

The Department’ efforts in improving infrastructure would be based on four approaches: improve the maintenance of facilities, preventative routine maintenance, construction of medical teaching schools and the construction or nursing colleges. The infrastructure plan for each province would be presented to the Committee. Infrastructure delivery in the form of doctors and nurses would be accelerated through Public Private Partnerships (PPPs). A health technology strategy had been developed and the implementation process would commence soon.

About 46 engineers had been employed, trained and deployed to provinces to help with maintenance of facility equipment. Medical schools had been encouraged to increase their intake levels and the Ministry had an agreement with Cuba on increasing intake. Community Health Workers had been trained and would be issued with formal certificates and 470 graduates had been recruited for a seven months training at the University of Pretoria to help the Department with laboratory forensics. Of the 470, 20 would be deployed to provinces to help with financial management and help provinces to prepare for auditing.

The DG mentioned upcoming legislation such as banning alcohol advertising, reducing salt in foodstuffs and the National Health Amendment Bill which dealt with establishing an Office of Health Standards to improve the quality of health care, was in Parliament and public hearings had been conducted. The country had 4 200 facilities and NDOH had audited about 3700 of them and they had teams working on rectifying the concerns raised in the audit. Five of the nine provinces had been attended to. For example, the team had gone to Sedibeng, Mangaung, Zululand, Vhembe and would go to Mpumalanga in June. The Western Cape had indicated that it had adequate resources to fix the problems themselves, as such it would not be part of the programme. A progress report would be presented to the Committee on how identified problems would be dealt with going forward.

Department Financials over the MTEF
Mr Ian van der Merwe, NDOH Chief Financial Officer, presented on the financial allocations to provinces with emphasis on funding of priority programmes and new allocations in the MTEF. The total allocation for the 2011/12 financial year was R25.7 billion, R28 billion in 2012/13 and R30 billion in 2014/15. The biggest contributor was transfer payment of grants and allocations to NGOs. Department expenditure grew from R16.4 billion in 2008/09 to R25 billion in 2011/12, at an annual average rate of 16.5% and it was expected to grow to R33.9 billion by the end of 2014/15 at an annual rate of 9.25%. The increase was driven by transfers to provinces for conditional grants with the main areas of absorption being the HIV/AIDs grant, the new NHI grant and the nursing grant.

The forensic pathology grant was discontinued, as such the Department will have a total of seven conditional grants to manage. The budget included new allocations of R97. 6 million for 2012/13, R618 million for 2013/14 and R1.9 billion for 2014/15. From the new allocations, R10 million had been allocated for the Forensic Chemistry Laboratories (FCLs) to purchase equipment and appoint new staff and interns to help clear backlogs. About R20 million would be used for higher accommodation cost of the renovations at the Department Head Office, R3 million per annum for costs associated with increases for the Medical Research Council (MRC), R100 million for nursing colleges to plan and coordinate upgrading, recapitalisation and maintenance nursing colleges infrastructure.

Over the MTEF, the conditional grant for HIV/AIDS would be R834 million, R128 million under the revitalization of PPP programmes, R150 million in 2012/13 for NHI pilot projects, R636 million until 2014/15 financial year for wage increase in National Tertiary Service Grant (NTSG). Pages 31-34 of the presentation showed funds allocated for specific policy priorities including R210 million for the purchase of FCL equipment from this 2012/13 to 2014/15.

Three grants had been earmarked for the health infrastructure: Hospital Revitalization, Health Infrastructure and Nursing College Grant. The Hospital Revitalisation Grant was R12.9 billion from 2012/13 to 2014, The Health Infrastructure Grant was R5.6 billion from 2112/13 to 2014/15 and the Nursing Grant totaled R450 million for the same period. The Department had seven grants, four Schedule 5 Grants and three Schedule 4 Grants and the total allocation for 2012/13 was R25.6 billion, R28.7 billion in 2013/14 and R31.7 billion in 2014/15. Schedule 4 Grants were grants allocated to provinces to supplement functions funded from provincial budgets. In terms of the Division of Revenue Act (DoRA), 5% could be withheld from provinces allowing for necessary interventions to be put in place. Grants that fell under this category included the National Tertiary Services, Health Profession Training and Development and Health Infrastructure Grant. Schedule 5 Grants were allocated for specific purposes and the Director General had the power to withhold funds based on non performance or compliance. The grants included the HIV/AIDS Grant, Hospital Revitilisation Grant, National Health Insurance Grant and the Nursing College Grant. The National Tertiary Services Grant (NTSG) allocation to province’ growth over the three years was 7.7%, the Heath Profession Training and Development Grant (HPTD Grant average growth 5.75% over the MTEF, Health Infrastructure Grant growth was 6.4% over the MTEF, the Hospital Revitalisation Grant growth was 5.4%, the Comprehensive HIV/AIDS budget increase over the MTEF was 18%, National Health Insurance would increase by 88% and the Nursing Colleges Grant would increase by 41.6% over the MTEF. Total allocations to provinces per grant were indicated from page 39-45 of the presentation.

The Director General included a brief presentation on the progress and time frames for Phase 1 deliverables for the Green Paper on NHI. The Green Paper had been released for public consultation and the inputs were being evaluated and reviewed. The regulations on the designation of hospitals and policy management of hospitals had been released for comment. The posts for Chief Financial Officers had been advertised; a total of 3 600 applicants had responded and short listing was underway. A proper reimbursement scheme and revenue collection was necessary. An audit of the amount of money owed to provinces by emergency services had revealed that the Road Accident Fund (RAF) owed all provinces R700 million.

The tabled National Health Amendment Bill would establish the Office of Health Standards Compliance (OHSC) and 20 inspectors had been trained last December, who would do inspections in hospitals. About 3 370 facility audits were achieved against a target of 3 900 and four facility improvement teams had been dispatched to four provinces already. District specialists had been appointed and would be deployed at the end of this month. To improve ward-based PHC about 5 000 agents had received training and would be deployed to provinces and 390 retired nurses had been appointed to oversee the implementation of the School-based PHC services; the service of other specialists would be solicited as well. Profiles of all districts had been done based on social amenities, demographic factors as well as the assessment of service delivery output to guide intervention strategies. Other efforts included the collection of population data working together with the Department of Home Affairs (DHA), revamping of Information and Communication Technologies (ICT) systems and accreditation of service providers.

The Deputy Minister invited the Committee and the Portfolio Committee to help in combating diseases and finding solutions to the challenges confronting the health sector. The Department would ensure that programmes would be implemented and the effects of disease would be reduced through ensuring early detection of infection among other ways. If the Department succeeded in passing the legislation on reduction of salt in foodstuffs, about 6 000 lives could be saved annually.

Discussion
The Chairperson applauded the Department for its innovativeness and research abilities. She was happy that the Department had taken into account the recommendations of the Committee. What were the plans and the Department’s budget for emergency services. What was the target for the distribution of male and female condoms?

The DG said some of the statistics on programmes were still being compiled but once the audit process was over, a report would be presented to the Committee. A few people had been accredited to access the information because it could be used for the wrong reasons by the media, especially now that the audit was still in process. The emergency service issue was controversial. The Health Professionals Council (HPC) had came up with a standard for paramedics which had resulted in some of the people being unemployed.
The Minister had set up a Task Team to look at various forms of paramedics and a report would be presented on the matter. The Department was also doing data analysis of all emergency services provided in provinces so as to do a cost analysis. During the World Cup ambulances were bought and had since been donated to province and some had been converted for obstetrics, but care was being taken to make sure that some were reserved for the other services. The initial target for male condoms was 1 billion and 600 million for females but the information had been omitted because the Department was studying the usage patterns. In the past two years the country had been consuming between 465 million to 500 million condoms. The other issue was that condoms were misused. There was no thought out clear strategy on distribution but the Department wanted to engage among other stakeholders such as the hotel industry to see if condoms could distributed in hotels and lodges.

Ms B Mncube (Gauteng) appreciated the presentation which took into account the recommendations that had been made by the Committee, adding that the rollout of the hospital infrastructure programme would restore patient dignity. What criterion was used by the Department in budget allocations because the Western Cape and Gauteng had bigger amounts compared to other provinces? What measure were being put into place to prevent the recurrence of the problems that resulted in Limpopo province being put under administration and the problems faced by Gauteng.

The DG explained that the allocation of funds for medical schools was guided by the number of medical schools a province had. Gauteng, KZN and Western Cape were prioritized but other provinces would be catered for once infrastructure had been put in place. The Department would try to prevent the recurrence of the problems in Limpopo and Gauteng. With a Section 100 intervention, one had to ensure sustainable systems were in place before withdrawing. They had taken 400 unemployed graduates (60 would be deployed per province). About 20 would sort out the finances to improve the negative audit outcomes. The second group would deal with vacancies. Another 20 would do PERSAL clean-up. The main problem that explained the situation in Limpopo and Gauteng was that invoices were sitting unprocessed and the graduates would be deployed to do account payments lying around at the facilities. The same would be for collecting reliable information about facilities. The interns would be trained but would not leave as usual and join the unemployed. Instead, they would be absorbed by the Department and attached to the Office of provincial Head of Department (HoDs) to ensure the province delivers. It was going to be a little bit forceful because NDOH had committed the provinces to doing this but one could no longer be casual about these things. To prevent activities such as inflating prices, Project Management Support Units had been set up in each province to monitor programmes and a steering committee chaired by the DG would do follow ups.

Ms D Rantho (Eastern Cape) commended the excellent work being done by the Department. She asked the Department to invite the Committee to any summits that were of interest to members. Youths in her province needed health education as they were complaining about the high death rate and what efforts were being done to educate adults on family planning. What efforts were being made by the Department to redress the unpaid doctors who had appeared in the media as that was affecting their performance? What was the Department doing to deal with the attitude of young doctors who went onto the internet while examining patients? Had the clinical engineers that had received training been deployed to all provinces?

The DG replied that 46 engineers had been trained and KZN had indicated that it was taking all of them because other provinces were reluctant to do so and some were facing financial constraints. The Department would continue advertising for new engineers.

The non-payment of doctors was a major problem but the Department was communicating with affected provinces. At the last National Health Council (NHC) the Minister and MECs had agreed on non-negotiable items that every province would be required to budget for and that included payment of medical staff. Provinces that had under allocated to the sector would be asked to reprioritise and Treasury would be involved.

Ms Matsoso said there was a problem with the country’s family planning system and no guidance was being offered on the programmes. Despite statistics that the fertility rate of South Africa was dropping, there were still big families.

Mr M De Villiers (Western Cape) appreciated the presentation. How was the Department going to deal with underperforming hospitals that invited bad publicity from the media? What were the figures on male circumcision per province and what obstacles was the Department facing in implementing the Vitamin supplementation programme. Apart from quintile 1 and 2 category of schools, what other quintiles were there? How would the Department be able to increase post natal care to people in the remote rural areas which were inaccessible? Nothing had been mentioned about the tertiary hospital grant in the Western Cape and what was the need that justified the revitilisation and upgrading of hospitals? How many nursing colleges would be built and how many needed to be revamped?

The DG said the data on under performing facilities in the Western Cape was available and would be given to members once the audit report was finalised and members would be trained on how to access the information on the Department’ website. This would assist them with their oversight. On male circumcision, KZN had linked the programme with promotion of social values as part of the campaign against violence on women but other provinces had not started yet. Obstacles that affected supplementation programme were similar to those on immunisation; the problems could be avoided by introducing the programme when children were still young. Work would be done in all the quintiles. On increasing post natal care, a plan for each province had been set and a report would be submitted to the Committee. The Western Cape had indicated that it was not in need of support services, as such funds were allocated where they were needed most. However there were under performing facilities that would be capacitated. About 122 colleges needed revitalisation and work had been started in 49 and the target for this financial year would be 50 colleges.

Mr S Plaatjie (North West) wanted the Department to capacitate district clinics to improve service delivery. What level of training would community health workers be trained at? What was the Department doing to ensure that the functions of health care NGOs such as the Catholic Welfare Development (CWD) agencies were re-energised and realigned with Department strategies.

Ms Matsoso replied that there were a total of 78 000 community health workers and despite assistance from the Department of Labour (DoL) to employ all of them, it had no capacity. There was a need for a comprehensive integrated strategy to make sure that agencies worked as one force without getting into each other’s way or conflicting with department programmes. A standard definition of a community health worker would be developed in conjunction with the Department of Social Development (DSD) and there was need for better regulation of the sector.

Ms M Makgate (North West) was positive that the banning of alcohol advertising would be successful. The health facilities maintenance plan was excellent but did the Department have a budget for that? Was the Department getting value for money in funds transferred to provinces? This was after she received a report that a private hospital had been allocated R16.6 million but only R1. 2 million was spent for the year 2011/12 and Moses Kotane Hospital had received R49.8 million and managed to spend only R29.9 million. What were the unspent funds used for and how could provinces be assisted to budget? Was the Department conducting skills audits on infrastructure in hospitals because Western Cape had indicated that it did not need support services while people were suffering in its rural areas.

Ms M Boroto (Mpumalanga) said the presentation was good but she was worried about the successful implementation of the programmes especially in rural areas. Did the Department involve local municipalities in its planning programmes and were there enough personnel to carry out programmes. Was it possible for the Department not to outsource delivering of medication because contracted companies had no capacity? Was the Department addressing poor conditions at some of the training colleges such as Elijah Mango? She asked for the reports on district and hospital surveys and how would community health workers be assigned?

The DG answered that KZN had bought 16 mobile clinics to be used to reach rural areas and the Department would buy 30 and these would be availed in June. The Minister had raised concern on tendering for medical transportation and plans were underway to centralise the procurement system.

Ms Rantho asked what was the Department doing to address lack of security that had led to abolishing the school health scheme and how would long queues in hospitals and the bad attitude of workers be managed?

The DG said the Minister had come up with core standards of delivery which encompassed addressing the bad attitude of workers and the introduction of queue marshals in some provinces had reduced the problem. Attitude was a cross cutting problem in hospitals from nurses to doctors and something had to be done. The results of the audit had shown that some hospitals were dirty and security was relaxed. The results would be included in the report to the Committee.

The Deputy Minister reminded members that the country was in the middle of the UN decade of reducing casualties from accidents and the Department was working together with the Department of Transport on this. Training of community members was therefore focused on high risk areas and a comprehensive report would be presented on the matter. Gauteng province was complaining about underfunding and the Committee should help in interfacing with the Financial and Fiscal Commission to address matters of equity in budget allocation. The other intention was to redress the historical imbalances as no urban area would develop by overlooking the matter, especially in former disadvantaged rural communities. To encourage quality delivery the Department had initiated National Service Excellence Awards (NSE) to reward best performing provinces. Success of programmes would be achieved by partnering with other stakeholders.

The Chairperson thanked the Department and encouraged it to ensure that programmes were implemented.

The meeting was adjourned.