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14 May 2002
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Meeting report

HEALTH PORTFOLIO COMMITTEE
15 May 2002
PROVINCIAL BUDGET HEARINGS: KWAZULU NATAL, GAUTENG AND MPUMALANGA

Relevant documents:
KwaZulu Natal input
Gauteng input
Mpumalanga input

Chairperson: Mr L Ngculu (ANC)

SUMMARY
KwaZulu Natal, Gauteng and Mpumalanga Department of Health gave briefings on their budget and programmes.

MINUTES
National Department on finance issues
Mr Ngculu, the chairperson, asked the representatives from the National Department for comments on progress. He also mentioned that in the news that morning had contained a story about SANTA in the Eastern Cape having to lay of workers due to payment problems. He said that this confirmed his sense that there were four provinces which the committee should continue to monitor.

Dr Luthuli said that in a later news report, it had been revealed that the staff would in fact not have to be laid off, because funds were available, they had just been transferred late.

In reply to Mr Ngculu asking them if the problem had been solved, Mr Muller said that the immediate problem had been solved.

Ms Chetty, the Deputy Director-General of the National Health Department said that it might be useful to schedule a meeting with SANTA. She said that an audit had been carried out, investigating cost efficiency and quality of care, and the Minister would be discussing this when she returned from Geneva. She also said that there were real problems with the equitable share and the conditional grants, and there was a need to address whether there had been any real growth in the provinces' budgets.

Mr Muller said that it might be possible to devote a morning's briefing to how allocations were made and what they end up being, as well as the modified formula which had been proposed to Treasury. He said that the committee could play a role in following up the early notification of roll-overs. He also said that tender boards had come across as another issue, and the Free State and KZN had abandoned the Tender Board system. Mr Muller also drew attention to the issue of the power of provincial treasuries, as this had been discussed as a major stumbling block in provinces accessing funds. He said for example that the Eastern Cape Treasury only accepted receipts and documentation until the 15th of each month, which meant that certain bills had to be paid out of the following year's budget. He also mentioned financial systems, saying that they were inadequate in some provinces, and this placed limits on the number of cost centres which could be established, which in turn made tracking expenditure more difficult. Mr Muller also spoke about the issue of inflation, saying that the department had made its briefing on the budget to Treasury on 12 September 2001. He added that in subsequent discussions with Treasury, they had indicated their willingness to entertain proposals for adjustments.

Mr Ngculu asked what were the proposals instead of Tender Boards.

Mr Muller indicated that Treasury recommended that the responsibility for tenders be transferred to the provincial departments. He added that KZN and the Free State had already done so.

Mr Ngculu asked for clarity on the issue of the financial systems.

Mr Muller explained that the old system, FMS, was still in use in some provinces, but National Treasury had recommended that all provinces move to BASS. He said that this would ultimately lead to consolidation of health accounts, which was lacking at the moment. He said that all provinces would be on the BASS system by the end of the next financial year.

Mr Ngculu thanked Mr Muller, and said that anything else could be dealt with later.

KwaZulu Natal
The briefing was delivered by Prof. Green-Thompson, the Superintendent-General. He started by tracing some general comments on the budgeting process. He said that budget hearings had been held in the province on the 15 March. He pointed out that health policy was informed by the ideal of transforming health in the provinces. He said that equity had still not been achieved, which he attributed partly to inter-provincial inequity. He said that the view taken was on the progressive implementation of the principles which informed health policy in the province. Prof Green-Thompson also said that there was a need to strengthen management. He also made mention of the fact that there was the problem of trying to shift resources, while maintaining services. Another problem that he identified as a major concern was the issue of human resources, in both the professional and management spheres. He said that nurses and doctors were leaving to go overseas, and that at a function at Edendale Hospital the previous day, he had been told that 21 professional nurses had left in the previous month alone, to go and work in the United Kingdom. He reiterated that management also needed to be strengthened.

He then went on to discuss some of the issues around the PMTCT program. He said that there was a need to strengthen capacity, and that this was being done. By the end of the month, all antenatal clinics would be equipped to deliver the PMTCT program, although there were problems at three of the hospitals, some community health care centres were also involved, and the goal was to have all of these centres involved by March 2003. The discussion moved to the Nkosi Albert Luthuli Hospital, which was to admit its first patients by 28 June, 2002. By August next year, it would be fully operational. This situation meant that Wentworth Hospital would now become a district hospital, and all tertiary and central functions for Durban were to be centred in the Albert Luthuli Hospital. Indeed, all such functions for the eastern half of the province were to be catered for by this hospital, with the same functions being carried out in Grey's Hospital in Pietermaritzburg for the rest of the province. Prof Green-Thompson indicated that this was sooner than anticipated i.e. by the end of 2003, not 2004, as there was an attempt to decrease the length of time during which there would be two hospitals with overlapping functions, in an attempt to bring down costs. He said that there was a significant attempt not to duplicate systems, particularly by strengthening first contact systems throughout the province, with a good referral system in place.

Prof Green-Thompson went on to discuss the budget process. Priorities were set in line with the ideas set out by both the Provincial and National Cabinets. These were then devolved to the departments to develop programs, which linked the budget and the priorities. Prof Green-Thompson said that he felt that the objectives had been achieved in large part. There had been a seven year program to ensure the shift of resources from the over-resourced areas, particularly in the Uni-city and Metro to the rural areas. The balance of levels of services had also shifted between 1998 and 2002. In this regard, the targets for administration and district hospital care had been exceeded, the achievement for PHC was just short of the target and the ambulance service was improving. With regard to regional hospitals, the target had needed to be scaled back, but this was attributed to the regional hospitals handling a lot of PHC in outpatients. There was thus also an attempt to separate PHC functions from the regional hospital. With regard to specialised hospital services, the target had not been attained, and this was attributed to the fact that KZN had a large proportion of the population, but was not receiving the appropriate funds, which led to them using their equitable share to finance the shortfall. Maintenance was missing the target, but was still having to scale back expenditure. Prof Green-Thompson cautioned that this situation meant that there would be long term problems, as additional funds would be necessary to resuscitate the facilities at a later stage. In terms of priorities, he said that clinics and mobile clinics had been accorded the highest priority, with HIV being the second priority. He then moved on to a description of the budget programmes.

He said that the National Tertiary Services grant was inequitable. He then went on to discuss the HIV issue in some depth. He said that there were problems with the HIV grant. The 2000 antenatal clinic survey showed that KZN had the highest rate of infection. Prof Green-Thompson revealed that KZN had a new test which was able to measure the recency of the infection, which suggested that there was a lower incidence than the 2000 study indicated, but that prevalence rates were higher. The new test effectively revealed the incidence, rather than the prevalence, which was something which had been lacking. This meant that the number of new infections could be more successfully monitored. There was a worrying trend, which suggested that the incidence was increasing i.e. the rate of new infections was still climbing, despite the fact that national figures showed that prevalence was tailing off. The program was working, but was not successful in stopping new infections. According to data extrapolated from the MRC figures, KZN should have around 900 00 cases of HIV. Yet at King Edward Hospital in Durban, between 40 and 60% of the patients in both adult and children's wards were HIV positive, which led to a greater frequency of hospital visits overburdening the service. Effectively, 40 to 60% of the costs of the hospital are attributable to HIV. This was something which was not accounted for by the provisions of the grant, effectively indicating something of what were as yet hidden costs of HIV. The situation also existed where patients were being 'dumped' by their families into the hospitals. This created the need for HBC (Home Based Care) and community health workers, and there were plans to increase the number of community health workers by 1000 or more this year. There was also a Director of Community Health Workers who was due to be appointed, because there was the need for a person dedicated to this function. This would also be linked with the appointment of a director in charge of nutrition. Prof Green-Thompson revealed that the main cause of death in the province was TB, with HIV being the second. HIV was however the main cause of maternal death.

The PMTCT program had to be more rapidly rolled out. Prof Green-Thompson drew attention to the fact that the previous year, there had been R131 million of unbudgeted expenditure incurred for this. The cholera epidemic had also led to R170 million of unbudgeted expenditure, for which as yet the province remained uncompensated. The budget had been overspent by R285 million the previous year, but R170 million of this was due to cholera. The World Health Organisation had commended the response to the cholera problem, because the case fatality rate was the lowest ever, and as a team, the province had done very well. Yet it remained uncompensated. There was the concern that the PMTCT program would create a similar situation. In discussing the prevalence rate, it was indicated that the prevalence of HIV positive people in Durban was 48%, but only 19% in rural areas, as measured at the Church of Scotland Hospital. The PMTCT program needed committed and able leaders for it to be a success.

The issue of the Capital & Maintenance program was also addressed. It was suggested that some of the problems had been sorted out, but that some remained challenges. The Tender Board problem had been solved, by dissolving the Tender Board and creating a Central Procurement Committee which was working well. The speed of decisions was much quicker. The problems with the Department of Public Works had also been addressed, by removing funds from Works, and devoting them to Health, where the department was developing its own works capacity. However, bigger projects were still dealt with by the Works Department, although overall the working relationship had improved.

In terms of improving revenue collection, this was to be done by computerisation, by offering incentives to officials and developing capacity. The Albert Luthuli Hospital would help in terms of computerisation of services. The plan was to have a 'paperless' hospital. Prof Green-Thompson said that SETA was a disaster, which caused problems daily. It was inefficient and expensive, and he suggested that all provinces were likely to be experiencing the same problems. Training had now been taken over by the department, but the maintenance of the mainframes was still done by SETA. He felt that they were overcharging the province, as an example he said that they had charged R10 000 more than the market value for one piece of hardware. Prof Green-Thompson also briefly addressed the issue of cost centres, saying that there were problems of access, with people moving on as soon as they had been trained.

The briefing then shifted to the 2002/2003 budget. Prof Green-Thompson drew attention to one issue in particular, that of dental hospitals, where he said the province had the capacity to train dental technicians, but that this was being phased out nationally, and the province supported this. He concluded by saying that the budget had been approved by the provincial legislature.

Discussion

Dr Gous commended the professor on the report. He asked for more information on the new HIV test. He agreed that the hidden costs associated with HIV may mean that the budget for HIV needs to be re-examined. He asked whether the department was using its own capacity for works, or whether contracts were being used. He also asked what the difference was between a procurement commission and a tender board. His final question was whether the 'paperless hospital' also included the clinic nodes.

Dr Luthuli said that there was a real crisis of doctors and staff leaving the country. She asked what the province was doing to address this. She also said that the HIV test for incidence was a new test. She asked how the province was able to reach conclusions given the newness of the test. She went on to discuss the issue of patients being dumped in hospitals. She said that this could create the impression among health workers that patients do not deserve to be admitted, which led to people being turned away. She asked how the issue of deserving patients who were being turned away was going to be dealt with.

Ms Mnumzana followed up on the issue of the 'brain drain'. She said that PMTCT had been rolled out, and asked how this would be affected by the lack of staff. She also asked what had been done about the problems related the previous year relating to the distance between clinics and the lack of transport. In particular, she asked what the state of working relations was with other departments, such as Transport. She asked what effect cholera would have on this year's budget. She also asked what was the status on the provinces step-down programs, and what the status was of the DOTS program in the province, and whether referrals were working in relation to this program.

Prof Green-Thompson replied that the HIV test was being carried out and developed by provincial research workers, and that it was still too early to draw conclusions. He added that KZN was fortunate in that there was a strong resource of workers from the universities. He also said that until now, incidence had been an unknown factor, but that prevalence was tailing off. This could be attributed to people dying and infertility due to AIDS, which meant that people were not having babies, and hence that the antenatal clinics might be yielding skewed results.

In terms of the issue of expenditure on HIV/AIDS, he said that the HIV program had nothing to do with the treatment of patients, but was aimed at decreasing the pool of those who were HIV positive, by preventing the spread of the illness. He did however agree that there was an enormous expense associated with treating HIV positive patients, on a recurring basis.

The paperless hospital would include paperless clinical nodes, according to Prof Green-Thompson. The ideal was to have no written prescriptions and digital x-rays. He said that a meeting had been held with very senior stakeholders, and there was general approval for this. The one outstanding issue related to paperless prescriptions, which needed to be resolved. He did however indicate that the issue of signatures on the computer had been sorted out. However, regulations around prescriptions were still in effect. The groundwork had already been done for the Albert Luthuli Hospital, and it would be efficient and cost-effective, with off-site backup of the whole system.

In relation to the issue of doctors leaving, Prof Green-Thompson said that there was a need to train the right people, and that the demographics of the medical schools suggested that the wrong people were being trained.

In relation to the issue of dumping of patients, he said that this reinforced the need to bring the community in to give assistance. There was also a stronger need for home-based care, and community health workers. There was also a need to work with the staff to deal with attitudes, and the Nursing Council had approached the department to try and deal with this issue.

Prof Green-Thompson said that cholera was still present in the province, but it had been contained.

The DOTS program was being pushed in the province, following the results of a national study which found KZN was not doing well in regard to TB. Staff and resources were being allocated, and business plans had been drawn up.

Mr Conradie, the CFO for the province, addressed the issue of works and procurement. He said that there had been a negotiation, and the Health Department now handled day-to-day maintenance, and repairs up to R1 million. He said that they still made use of Works' expertise, and in remote areas, there was an agreement that Health contracted to use Works offices. The problem remained however in dealing with major contracts, where Works retained responsibility and hired outside contractors, who worked together with Health, but always through Works as an intermediary which was counter-productive. Overall, however, the problems had been managed. In terms of procurement, the department was in control of tenders now, which meant that the previous six and seven month delays had been removed. In terms of relationships with other departments, such as Transport, Mr Conradie said that the relationship was good, and Transport was involved when clinics were planned, for example. However, the topography of the province introduced significant difficulties, particularly for mobile clinics. This however had little to do with good working relations between departments. Sanitation and Water remain the area in which there is the most difficulty, and the relationship was not as good with the Department of Water Affairs, because Health was having to spend money to address this.

Mr Conradie said that the step-down facilities were in the planning phase, with the strategic positions having been drafted, but not finalised. Facilities had already been identified, and one issue which was being investigated was the 'transit bed' where patients travelled long distances for treatment, and were able to sleep over, where the treatment would usually be handled on a day-patient basis in the city.

Dr Katchalyar raised a question concerning the funding of home-based care.

In terms of HBC, Mr Conradie said that there was no dedicated budget for HBC, although there was the new HIV conditional grant. He said that the budget for community health workers was devoted to HBC, and funds were being provided in preparation for the roll-out of the HBC program.

Dr Luthuli asked whether moving funds from maintenance to other more pressing areas would impact negatively on future budgets, when there would be a need for more major maintenance work. She also asked how the new test for HIV compared with other tests in terms of price. She also raised the issue of breast-feeding, and the two competing problems of HIV and cholera. She asked for information on how this was being handled.

In relation to HIV and cholera, Prof. Green-Thompson said that the problem was that there was a need to ensure either complete breast-feeding, or complete formula feeding. He added that it was no use protecting a child from HIV transmission by advising the mother to use formula to feed her baby, when the child could catch cholera from infected water. In relation to the cost of the test, he replied that it did not cost much more than a normal ELISA test, although he was unsure of the exact figure.

Mr Conradie replied to the question of the shifting of funds. He said that in the past, funds had been shifted away from maintenance, but that now there was a dedicated budget for maintenance, which made shifting such funds more difficult. He said that the problem was that the funds for maintenance were inadequate. He also said that there were areas where maintenance would be more expensive, since coastal areas needed to take steps to combat rust etc.

Ms Mnumzana asked how the referral system was working.

Prof Green-Thompson said that the referral system was working, but not as well as the department would like. The breakdowns were partly attributable to logistical factors such as the lack of public transport, and partly due to other factors, such as health workers' attitudes. He said that there was a need to work with the communities, but also to increase the number of clinics, because the absence of a clinic led to people going straight to the hospital.

Mr Ngculu said that he had the impression that there was a dedicated budget for HBC. He asked if the situation was different in KZN. He also said that the presentation on revenue had raised the issue of problems of payment. He asked what system was being used, and whether there was a uniform patient payment system.

Mr Conradie said that there was a conditional grant for HIV, which had as one component, funds for HBC in relation to AIDS. However, he pointed out that HBC catered to more than just AIDS. In relation to the payment system, Mr Conradie said that the province had not yet fully gone over to the nationally accepted system. He said that fees had been increased, using a scaling system. He also said that the national system (UPSS) was being implemented, with the Luthuli hospital being the first one to implement it. he added that part of the problem with payments was the difficulty in accessing outlying areas. KZN is still on the old accounting system, although they have asked to go over to the national system. As a province, there were few problems, and what problems there were relate less to the system, and more to the people making use of the system. Mr Conradie added that, nationally, there was a move to look at a newer, commercial system, and this meant that the province was waiting to see what happened. Such a system had been proposed by Treasury.

Mr Ngculu thanked the representatives from KZN.

Gauteng
Dr L Rispel introduced herself and delivered the briefing. She started by tracing the strategic goals of the Gauteng Health Department, linking each of these to specific priorities. The goal of improving health outcomes was linked to the priorities of women's health, child health, emerging and re-emerging communicable diseases (including HIV, TB and STIs), reducing the impact and incidence of injuries and promoting healthy lifestyles. Improving health care services, the next outcome, was linked to the priorities of strengthening PHC, ensuring rapid and effective emergency care, revitalising hospital services and developing effective and efficient clinical support systems such as laboratory and blood transfusion services. The improvement of health care services had a quality component, with the priorities of developing client-orientated services, developing a quality assurance programme, improving clinical outcomes, implementing the Patient's Charter and the Service Pledge, investigating and preventing complaints and developing incentive-based reward systems. The final goal, of ensuring value-for-money, had as priorities increasing revenue from 1,9% to 5% of the budget, reducing losses through theft and fraud, implementing functional electronic communication and implementing, monitoring and annually reviewing the planning and budgeting process at all levels. Other priorities in this regard included providing a conducive environment for staff, in terms of both security and an employee assistance programme (which included a workplace AIDS programme), reducing absenteeism and improving staff morale through a performance appraisal system and access for the disabled.

Dr Rispel then proceeded to trace some of the programmes and initiatives. She drew attention to some of the highlights of the HIV/AIDS programme. She said that the 2000 ante-natal clinic survey had revealed a 29,3% prevalence. This had resulted in four core areas being identified: social mobilisation and communication; prevention; care and programme organisation. The first area had been centred on World Aids Day, which reached 5 million people. The province had trained 7000 volunteers and conducted a door-to-door campaign, which resulted in over 20 000 referrals. This strategy was recommended, as it was relatively cost effective, particularly as it enabled penetration into the more rural areas. The prevention component involved life skills programmes in 85% of the schools in the province, the distribution of 7 million condoms per month, the PMTCT programme which presently covered 60% of hospitals, and 40% of the community centres, with the goal being full coverage by the end of the year and an HIV/AIDS programme in all the Local Authorities. The care component involved the delivery of basic services for HIV/AIDS in about 80% of all hospitals and clinics, involving the treatment of opportunistic infections. It also involved the delivery of HBC in all municipalities, which was delivered by NGOs, funded through the national allocation of R8,2 million. There are presently 14 Voluntary Counselling Treatment (VCT) sites in the province and 1000 lay counsellors had also been trained. The programme organisation component included the Premier's committee on AIDS which met once per quarter and the Gauteng AIDS Council.

The Quality of Care programme centred on creating an environment in which quality would be developed, and as such involved the implementation of the Patient Charter and Service Pledge, 100 % of which had been obtained. However, it was pointed out that, even though these were prominently displayed, it was accepted that this did not mean that this would be maintained. Name tags had been implemented, with 90% of staff now wearing name tags, which meant that good and bad staff could be identified by the clients. Service awards, had also been started in 1999, the Khanyisa Service Awards. Capital projects were also devoted to improving the aesthetics of the facilities. The programme also involved building capacity. Quality assurance teams had been developed, incorporating patient liaison teams as well as queue managers in central hospitals. Dr Rispel made mention of the personnel profiles, saying that 84,3% of the staff in Gauteng were black, which was further subdivided into 2,4% Asian, 79,1% African and 2,9% Coloured. 77,9% of staff were women, with 18% of those in management positions being female. This was felt to be a significant improvement, although it was still felt to not be good enough. Only 0,002% of staff had disabilities, and this was clearly an area where improvement was possible. Capacity-building mechanisms included the restructuring of the head office in line with the strategic goals, and the development of recruitment and retention strategies. This last aspect included the maintenance of basic health worker training, the reviewing of the bursary policy, the appointment of 347 graduate professional nurses, 100% of those trained having been offered posts and the contractual binding of graduate nurses and allied medical personnel, to prevent staff drain. There was also a process of management and skills development, with 5160 people (12,5% of staff) having received training in clinical, generic and management skills, with a special focus on financial management in line with the PFMA. A nursing exchange programme had been set up with King's College Hospital in the UK, in an attempt to control the number of nurses going overseas. This programme was subject to strict entrance criteria. Several HR challenges were identified, including the implementation of a personnel performance management system, the loss of highly skilled professionals to the private sector and overseas, inequity in HR distribution throughout the province and central bargaining agreements.

Public Private Partnerships (PPP) were briefly addressed. A feasibility study tender had been drawn up, to look at the revitalisation of Chris Hani Baragwanath Hospital. It was also revealed that the province had opted to lease its renal dialysis machines, which shifted the maintenance risk to the owning company. An equipment PPP had been entered into in Sebokeng Hospital. PPPs in relation to services included the leasing of beds in Bronkhorstspruit hospital, which had been running for one year, IT hardware and maintenance and chronic psychiatric and inpatient TB care. This issue of local government was also addressed. A general agreement had been reached on the core vision for an integrated District Health System (DHS). PHC had also been integrated into evolving local government. Dr Rispel indicated that they had entered the final phase of the provincial evaluation and review of the first municipal IDPs (Integrated Development Plan). Structure existed to facilitate ongoing consultation with municipalities. These included the PHA, where the MEC meets health councillors from category A (large metros) and C (district councils) municipalities every 2-3 months; the technical committee, where the HOD and senior managers meet the Heads of Health of metropolitan and district council areas and participation in the DPLG process of cross boundary municipalities. There had been growth in PHC utilisation as well as in access to PHC. An increased number of patients had been seen over the years, with improved quality of the priority TB services and the maintenance of IT hardware. However, several challenges remain, including the need for clarity on the issue of devolution versus delegation. It was revealed that Johannesburg was piloting the delegating of certain functions to local municipalities, although certain technical issues remained to be resolved. Other challenges included the lack of capacity at the planning and policy level, weaknesses in management systems, and delays in progress. Delays were likely due to the anticipated difficulty in transferring provincial staff to municipalities when delegation to local municipalities took place, as well as the liability for costs of transferring staff as well as the ongoing risk. This last aspect included the cost of closing the parity gap between staff salaries, meeting the hidden costs and accepting responsibility for future growth in costs and demand.

The last year's expenditure was discussed in terms of the various budget programmes, seven in total. The management/head office and public health programmes were the first programme. This included the EMS Bill had been approved by the Cabinet, which reflected a goal achieved. In terms of the implementation of a management information system, the target had been for 40% of institutions to have such a system, and this had been achieved. Increasing revenue had been targeted for R10 million, but R 60 million had in fact been collected. Dr Rispel traced several specific examples in programme one. one of these was the implementation of an intersectoral HIV programme involving all departments. The target had been for six line department to be reached, but all 11 line departments now had such programmes.

Programme 2 involved PHC services, EMS, nutrition and district hospitals. The target of 70& of sub-districts ad been set for districts offering the core package of primary services, and this had been achieved at the district level. The target of 244 580 needy primary school children receiving a morning snack had been achieved, and the target number of crèches with feeding schemes had been considerably exceeded.

Programme 3 (regional hospitals) had achieved the target of reducing the number of beds for mentally ill patients cared for by private institutions, with the goal being exceeded. The target number of TB patients maintained by private institutions, set at 600, had also been achieved.

Programme 4 (academic hospitals) had the target of attending to 70% of the priority one patients in casualty departments within 15 minutes, and these results were due in June. The target of 3 outreach programmes being implemented from academic hospitals to regional hospitals had been achieved, as had the goal of implementing cost centres in four hospitals. The re-organisation of highly specialised units had the goal of reorganising two units, however, only the audit of the cardio-thoracic unit had been completed, with the audit of ICU beds underway. The specialised oral services had the goal of seeing 375 000 patients, and this target was exceeded.

Programme 5 (health sciences) had the target of maintaining 2260 students, and this was achieved. There was the need to rationalise the number of ambulance training colleges, and this had been done, with their numbers being reduced to a single college.

Programme 6 (health Care support services) had achieved 100% of supply deliveries on time. The target for reducing the percentage of hospitals experiencing difficulties with linen supplies to 5% had not yet been achieved, although linen budgets were decentralised to hospitals, and the restructuring of the laundries had commenced.

Programme 7 (health facilities development and maintenance) had achieved its target of developing master plans for 31 hospitals to address the backlog in relation to the Health facilities Audit. The goal of decentralising day-to-day maintenance functions to institutions had had the goal of reaching 30% of institutions, although 100% of hospitals had been reached during the year.

The presentation then proceeded to trace some of the 2002/2003 budget highlights. Among these were the improvement of the participation process. This had incorporated a senior management lekgotla, briefing meetings with the institutions, budget workshops, institutional submissions and hearings and public hearings. It was stressed that this process was not a once-off event. The budget had been better linked to the outputs, and there had been a focus on strengthening primary and secondary health services. There had also bee a focus on shifting funds to the point of service, for example in linen and maintenance. In terms of equity, it was indicated that steps were being taken to address intra-provincial equity. In terms of inter-provincial equity, Gauteng indicated their acceptance of the need to address the problem, and said that the province was committed to this goal. However, it was suggested that there was a need for better information on patient origin as well as that the changes be phased in to prevent problems. Various dimensions of the conditional grants were discussed. The highlights of the AIDS grant (R 95 million) were to extend the VCT programme to 25% of the population, and extend the Lifeskills programme to 85% of primary schools. Key features of the allocation to the various programmes outlined above included R 25 million being devoted to developing financial management capacity (programme 1) the shifting of the AIDS allocation of R97 million from programme 1 to programme 2, the above average increases for EMS (12,66%), community hospitals (9,9%) and clinics and community health centres (9,84%) in programme 2, the shifting of Kalafong, Helen Joseph and Coronation Hospitals from programme 4 to programme 3, the approximately 4% increase in the budget for Programme 4, which also benefited from the Hospital Management and Revitalisation Grant and the increase in funds for day-to-day management (programme 4). Programme 5 saw a R 5 million increase in bursary allocation, to R 10 million and the provision for an additional 200 student nurses.. in programme 6, R 26 million of the linen budget had been shifted to hospitals, laundry management was to be strengthened, stock management systems were to be implemented and the process of starting trading accounts was to be established. Programme 7 saw R 70 million allocated to the new Pretoria Academic Hospital, R 105 million for HR & R, the revitalisation of Chris Hani Baragwanath and an increase in the day-to-day allocations to institutions for maintenance.

Discussion
Ms Mnumzana asked what strategies were in lace to increase revenue. She also asked whether the department had any supernumerary staff, and what was being done to address this.

Ms Rispel said that there were already incentive schemes in place for the generation of revenue. She said that 80% of the surplus went back to the hospital, and 20% was redistributed. She also indicated that a share debt management system was being implemented. The tender for this was about to be awarded. The need for this was felt to stem from the finding that the greatest chance for recouping a debt was within the first thirty days, which meant that invoices had to be processed within that time. A central invoicing system would introduce efficiencies of scope and scale. It was also felt that this would facilitate quicker recovery from medical aid accounts.

In terms of supernumerary staff, she said that there was a shared service centre, with routine functions located in one unit, such as IT or HR. she said that what also happened was that, where services were being increased, staff could be re-assigned. For example, establishing cost centres meant that there was a need for data capturers.

Dr Luthuli asked what costs were involved in the exchange program. She also pointed out that this program had been developed to try and curb the loss of staff overseas, and asked how this program made this likely. She asked what was being done to improve salaries and working conditions.

Dr Rispel replied that part of the agreement was that the costs of the ticket and the salary would be borne by King's College. She did however admit that the administrative costs, such as processing applications and replacing staff were carried by the province. She also said that it was a small program, and agreed that there was a need to address working conditions and salaries, in collaboration with the public service department. Non-monetary steps were being taken, such as improving management and decreasing non-functional equipment etc. She said that in two years, it would be possible to assess the impact of the programme. She indicated that the argument in favour of the programme was that people were going to go anyway, and these people could be targeted, and given the opportunity, in the hope that they would be more inclined to stay after having been given the opportunity.

Mr Ncgulu asked what the reason was for the shortage in the expenditure on VCT. He also asked why treatment seemed absent from the program on HIV.

Dr Rispel replied that the staff co-ordinator had left in August, which meant that there had been no-one to do the recruiting until the start of this year. This also meant that there had been a lag in the implementation of the VCT program. There was a new VCT co-ordinator that had been appointed at the start of the year, and the department was investigating various ways of strengthening the program. It had also been realised that the programs had been conceptualised vertically, but in fact they could be integrated, as they overlapped in various ways. In relation to the issue of treatment, Dr Rispel said that the care component of the program referred to treatment as well, although she had not gone into detail.

Mr Ngculu thanked the Gauteng department.

Mpumalanga
Ms Charles, the Mpumalanga HOD delivered the briefing. She traced some of the provinces successes and challenges over the previous year.

In relation to HIV/AIDS, she said that health promotion practitioners in the province had been trained as master trainers in VCT, to train other health workers, and this was underway. Life skills programs had been delivered to primary and secondary schools, and provincial and district AIDS councils had been implemented. HBC and pilot programmes for PMTCT had been started. This had meant that hospital rooms had needed to be converted, and nurses needed to be reassigned. It was indicated that many challenges remained, particularly in terms of infrastructure. This was most evident in the areas of counselling and the training of health workers.

The child health programme had seen 90% coverage for its immunisation programme, reaching all the districts. There had also been enhanced measles surveillance and nil return on the polio cases. IMCI had also been implemented, and three hospitals had received awards for being 'baby-friendly'. However, there was still an unacceptably high infant mortality rate, attributed to HIV and malnutrition.

The women's health programme had launched guidelines on the management of the causes of maternal death, and developed management protocols for labour and hyperintensive disorders in pregnancy. Pilot sites had also been identified for cervical cancer screening. The abortion care programme still had only a limited implementation, although demand had increased.

In terms of managing rehabilitation, Ms Charles indicated that many assistive devices had been delivered, a community-based peer counselling programme had been established in all municipalities and an integrated disability service program had been developed.

The area of mental health had been addressed through the training of PHC nurses and medical officers in mental health issues, the establishment of the Othadweni Violence Referral Centre, which provided counselling and support to about 80 clients per month in connection with rape and sexual and domestic violence and the establishment of a database of mentally ill patients, to provide information on their illness, its duration and their medication. It was also pointed out that there remained a lack of any facilities for treating chronic patients within the province, which meant that they had to be referred to Gauteng.

Steps had been taken to reduce infectious and parasitic disease. In relation to TB, the availability of drugs had been increased, the turnaround time for test had been decreased, the DOTS programme had been implemented and a referral system with SANTA had been established. It was pointed out that the incidence of TB reflected the maturing of the HIV epidemic in the province. The malaria programme had received an award for its success, and field research in the province had also revealed that the fever tree plant provided protection from malaria. Cholera had been the focus of many health promotion initiatives, and personnel had been trained in this regard.

In relation to managing chronic conditions, the province had developed standard treatment guidelines, established essential drug lists at primary and secondary level, conducted eye care awareness programmes and developed a primary eye care network in all hospitals and some clinics.

The improvement of PHC in the province had the objective of developing capacity in local communities, but patients still bypassed the facilities and went straight to the hospitals. There was a need to improve the availability of drugs and develop a comprehensive PHC package.

In relation to the development of a quality assurance framework, there was ongoing monitoring of the implementation of the patient's charter and the province had received awards for good performance.

The improvement of EMS was identified as one of the biggest challenges facing Mpumalanga, because the decentralisation of management to hospitals had led to problems in the area of management. A director for EMS had been appointed, and thirty ambulances had been purchased, but the drivers still needed extensive training. It was revealed that the Barberton training facilities were still inadequate, and there were no funds to develop these facilities.

In terms of developing the workforce, a plan had been developed, and training programmes were to be conducted. The plan was still being finalised. Performance management had been improved, but a major constraint on workforce development in general was the variety of problems related to organisational structure, which led to skewed staffing.

There was a need to improve hospital services, particularly as it was felt that referrals from level 1 institutions were inadequate and there was a need to strengthen level 2 services.

The improvement of pharmacy services was another important area. It was revealed that there had been shortages initially, due to cash flow problems, but that these had hopefully been resolved. Ongoing problems were the inadequate training received by staff and the theft of drugs.

The final area dealt with was the improvement and maintenance of facilities, which included an ongoing program to upgrade facilities as well as expand the number of clinics.

In terms of the budget for the coming year, certain comments were made on the allocations. There were felt to be problems related to equity. The budget had increased from R1,350 billion in 2001/2002 to R 1,65 billion in 2002/2003. however, Mpumalanga experienced additional demands due to cross-border migration, both between provinces and from other countries. There was a need to expand PHC. Another factor which affected the budget were the impact of HIV, where the 2000 antenatal clinic survey had revealed 29,7% prevalence in the province, which led to opportunistic infections, bed occupancies and medical costs. The issue of bed occupancies could be addressed by HBC, but this needed improvement. There was also a need to expand the number of VCT sites, implement programmes aimed at behavioural change among the youth, train personnel, distribute specialised services throughout the province and establish tertiary level services and address problems related to human resources through the retention of staff in rural parts of the province.

The inequity in budgetary allocations was addressed. It was revealed that the province allocated 17,1% of its budget to health, whereas Gauteng allocated 32%. The per capita average in the province was below the national average as well.

Discussion
Ms Mnumzana said that the previous year the committee had been told that the Chief Nursing Officer was unsure about her position. She asked if this had been clarified. She also said that the previous year, the committee had been told that staff were working for Social Development, but being paid by Health. She asked if this had been sorted out. She also pointed out that VCT had spent 64% of its budget, which was good, but that there ad been gross underspending on PMTCT and community-based programmes, and that, as a whole, the HIV programme had only managed to spend 30% of its budget. she finished by asking how the underspending was going to be addressed.

Dr Katchalyar asked why patients were bypassing the level 1 services. He asked if there were insufficient services, or problems with access. He also raised a question related to the funding sources for malaria and the community-based services.

Ms Matibele asked what was being done to address the issue of training pharmacists to monitor and supply medicines. She also asked what had happened with regard to the revising of the essential drug list.

Ms Sithole responded that the review of the essential drug list was being conducted in collaboration with the national department.

Dr Luthuli (ANC) asked what was done to officials who were implicated in corruption. She also said that the Rob Ferreira hospital was experiencing chronic shortages of doctors and nurses, and asked what was being done to address this. She raised the issue of the staffing in the Head Office, asking if the problems related to staff had been sorted out. With regard to the immunisation programme in the province, Dr Luthuli asked what impact it had had on mortality, saying that the committee needed figures on this as well as on maternal deaths.

Ms Sithole said that those found stealing were referred straight to the police.

With regard to the issue of the staff establishments at the Head Office, the positions of staff members had been clarified through the development of an organogram.

Ms Charles responded to the issue of the staff working for other departments, saying that the confusion had developed after the previously unified department had been split into Health and Social Development. The staff had been transferred to Health this year, and those who had not wanted to be transferred were now working for Social Development, so this issue had been resolved. In relation to the issue of underspending, Ms Charles said that no director had been appointed for the programme, and that previously, the head of the unit had been carrying out other activities for an NGO, which meant that the unit's functions were not being carried out. This matter had been investigated, and the head of the unit had subsequently left the unit. A new director has now been appointed, and business plans had been drawn up, with timeframes, for PMTCT and HBC. She added that much money had been spent on social awareness programs since January. In terms of the general underspending in the province, Ms Charles revealed that programme 2 had benefited from savings obtained through the rationalisation of the number of districts in the province. In programme 3 (regional and specialised services), there had been an audit conducted, which had produced a delay in the ordering of equipment and the advertising of posts. In order to improve capacity, strategic planning was to be carried out early in the year, to renew the priorities for the year. There was also a requirement that quarterly and monthly financial reports be submitted to the provincial treasury, which was a measure to improve monitoring and spending. Programme managers were also required to submit business plans, and the province was receiving technical and liaison support from the national department. Ms Charles also said that service level agreements had been entered into for all tertiary services, and were subject to quarterly reports. She added that she would forward information on the training that had been conducted and required. She also said that the provincial Cabinet monitored the department's compliance with its priorities.

Dr Baloyi asked for clarification of the meaning of the terms 'inventories' and 'professional and specialised services'. He also said that the report referred to PHC clinics being bypassed which imposed a burden on hospitals. He said that, with this in mind, what strategies were there to deal with this. He said that a general feature of the report and the presentation was that there were many problems which it identified, but there were very few solutions which seemed to have been identified.

Mr Mmisi said that inventories referred to what was previously known as stocks and livestock, i.e. medicine etc. professional and specialised services referred to audit fees, engineers consulted for upgrading facilities, and laboratory services which were bought from the national department.

In terms of the second issue that Dr Baloyi raised, Ms Charles said that the availability of drugs was adversely affected by cash flow problems, and this was a problem, because patients expected a comprehensive package of care, but nurses were untrained in PHC. This issue was being addressed this year. In the rural areas, mobile clinics were not always available. There was also the problem of retaining staff in the remote rural areas. In the most remote areas, there was a desire to make 24 hour services available, and in other areas, steps were being taken to establish twelve hour clinics using funds from the revitalisation program. The province was beginning to improve its recruitment of student nurses, with contracts to prevent them leaving the province. Their training also now involved primary health care. The province was trying to build its capacity to combat its problems.

Ms Mnumzana asked what happened to the funds from PMTCT that were unspent, in particular whether these were to be rolled over. She also asked whether the staff in the province were able to administer Difluconazol.

Ms Charles replied that almost all clinic nurses had been trained in the use of various treatment for STIs, including Difluconazol, as well as in the use of the register, because this was a schedule 7 drug. All nurses and doctors were being trained in this. A referral system also existed between clinics and hospitals. The PMTCT program was being addressed through a task team which was evaluating the institutions for roll-out. The aim was to first consolidate the existing sites, and feeder areas. After the evaluation, it would be possible to improve capacity.

In further comments on the issue of PMTCT, Ms Sithole said that there was 90% coverage, and the department linked up with social services to provide an integrated programme, focussing on mother and child. This also involved the issue of nutrition. In the antenatal clinics, social workers were involved, and health education was being carried out. The school nutrition program was closely monitored, with nurses visiting schools and starting to develop statistics to assess the impact.

Mr Ngculu said that the province spent R600/capita, and that its health budget was only 17,1% of the provincial budget. There seemed to be a clear indication that there was underfunding, but there remain the fact that the province consistently underspent its budget. He asked what the problem was. He also raised the issue of late transfers from provincial treasuries, saying that it was not unique to Mpumalanga, and asked what the reason for this might be.

Ms Charles said that they received 17,1%, and had not moved to the 85:15 principle in the province. She also said that, in the wider context, the province received less. The reasons for the under-expenditure were attributed in part to the delays caused by provincial treasury discretion in relation to transfers, with late payments causing projects to only be finalised at the end of the financial year. Ms Charles also said that the relief funds from national only came through in June.

Mr Ngculu said that increases in budget allocations were only possible when there was evidence of increased capacity to spend. He thanked the presenters, and said that it had become clear that there were certain anomalies such as poorer provinces which had the need to be more sensitive to health actually underspending. Part of the reason did seem to be the provincial treasuries, and there was the danger that autonomous republics were developing. This political question needed to be addressed. He asked for input from the Treasury representative.

Dr Blecher said that budgets had increased significantly, and there were opportunities to deliver and upscale. He added that the Treasury would be watching the extent to which strategic goals were integrated with the budget. He also thanked the committee for their invitation to attend.

Dr Chetty, the deputy director-general, offered her thanks on behalf of the national department for the opportunity to attend the hearings. She said that the chairperson had summarised the issues accurately, and suggested that in future it might be necessary to bring provincial treasuries into these hearings, to get clarity and sort out some of the issues. Other areas which might benefit from more detailed discussion which Dr Chetty identified included the migration of staff and the issue of SANTA and the TB hospitals.

Prof Gumbi, from the national department, said that the next round would also benefit from having figures available on the numbers of staff trained, and the migration of staff.

Mr Muller picked up on two issues, the need to look at the impact of PMTCT, and the Gauteng PPPs which might be investigated more thoroughly. He emphasised his earlier point, that the issue of provincial treasuries seemed a recurring problem, in the Eastern Cape and Mpumalanga, and this needed to be addressed.

The meeting was adjourned.

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