Health Budgetary Review and Recommendation Report 2012

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24 October 2012
Chairperson: Ms M Segale-Diswai (ANC) (Acting)
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Meeting Summary

The Committee considered its Budgetary Review and Recommendation Report (BRRR). Members were encouraged to make changes to the BRRR as necessary and make additional recommendations. Primary health care was of utmost importance to the Committee. Members were, however, perplexed as to why, in certain areas, primary health care was a provincial competency and, in others, a local government competency. It was agreed that this needed to be addressed. Related to primary health care was rural health. Funds and resources for rural health were lacking and Members felt a recommendation was needed. It was important to add a recommendation on the regulation of private hospitals as Members felt that private hospitals gave ordinary persons a raw deal. There was something amiss with medical aid schemes in general and the way they operated needed to be reviewed. People made payments but when they were in need of coverage they found that they were not adequately covered As only one province had obtained an unqualified audit report, Members added a recommendation on financial management. A further recommendation was that the Department of Health (DoH) should address issues which the Auditor-General had identified as recurring each year. The Committee furthermore recommended that the National Health Laboratory Service legislation needed to be amended as implementation was not taking place as it should. The BRRR was adopted with amendments. 

Meeting report


In the temporary absence of Dr B Goqwana (ANC), Chairperson, Ms Segale-Diswai was elected as Acting Chairperson. A little while after Ms Segale-Diswai’s election Dr Goqwana joined the meeting. He nevertheless asked Ms Segale-Diswai to continue in her capacity as Chairperson.

Budgetary Review and Recommendation Report (BRRR): consideration and adoption
The Chairperson at the outset stated that some Members had complained about receiving the current copy of the BRRR late.

Ms Vuyokazi Majalamba, Committee Secretary explained that the process had been on a tight schedule. The Department of Health had only the previous week briefed the Committee on its Annual Report. After the briefing she was able to compile the BRRR. The BRRR could only be circulated to the Committee after it had been edited. Unfortunately there was a delay in the editing. Members had been emailed the draft after it had been edited.

The Chairperson noted that much of the BRRR was a summary of the Department of Health’s (DoH) Strategic Plan and Annual Report. The most important and relevant section to the Committee was the recommendations that the Committee made in the BRRR. The BRRR would have to be adopted by the Committee in the present meeting.

Ms M Dube (ANC) suggested that the Chairperson guide the Committee through the BRRR page by page.

The Chairperson proceeded to take the Committee through the BRRR page by page requesting Members to propose changes where they deemed it necessary.  

Ms Dube referred to page 2 and made reference to the excerpts from Sections 27 and 28 of the Constitution contained on the page and asked how the provision of shelter, as was contained in the excerpts from the Constitution, was a health competency. Was the DoH providing shelter? The Sections also spoke about health being national and provincial competencies. She pointed out that there were health clinics falling under the control of municipalities so it was essentially a local government competency as well.

Ms T Kenye (ANC) remarked that the provision of shelter was relevant in the health environment.

The Chairperson confirmed that in some areas primary health care was provided by a province and in others was provided by local government. She felt that there should be a recommendation relating to the issue.

Ms Kenye referred to page 3, paragraph 2.2.2 and suggested that the DoH strengthen research and development on its Health Planning and Systems Enablement Programme. She added that it would be in line with one of the priorities on the Ten Point Plan. She also referred to paragraph 2.2.3 which spoke to the HIV & AIDS, tuberculosis (TB) and Maternal, Child and Women’s Health Programme and said that the Committee should recommend that the DoH should use its maximum budget for the Programme in keeping with Millennium Development Goals (MDGs) 4, 5 and 6 as they related to health. The Goals were to be achieved by 2015. The DoH should also refrain from underspending.

The Chairperson noted that government was moving away from its policy to focus on primary health care as opposed to hospice centres. The budget for primary health care was far too little.

Ms Majalamba pointed out that the second recommendation contained in the BRRR covered the issue of primary health care.

The Chairperson said that the Committee could leave it as that.

Ms Kenye said that she had seen the recommendation,  hence her mention of the MDGs. She referred to page 4, bullet four, and said that there was no recommendation with regards to National Health Insurance (NHI). She recommended that the DoH strengthen popularising the National Health Insurance Campaign. Many individuals were not aware of what the NHI was.

Ms D Robinson (DA) agreed with the suggestions made by Ms Kenye to a certain extent. She suggested that primary health care be improved upon but that restructuring of hospitals also needed to take place. The idea of the NHI was all good and well but infrastructure and foundation was also needed.

Ms Dube agreed that the NHI needed to be popularised in haste.

Members briefly discussed the manner in which the process on the BRRR should continue,, as the pace was somewhat slowing down while Members were making recommendations and discussing them.

The Committee agreed to continue working through the BRRR page by page and that Members would note down recommendations which they wished to make and to present them to the Committee when the section dealing with recommendations was reached.

Ms Dube referred to paragraph 3.2 on page 6 where mention was made of four government priorities. She asked whether there were four or five government priorities.

Ms Majalamba answered that there were four priorities.

The Chairperson asked the Committee Secretary to confirm whether it was four or five government priorities.
Ms Dube referred to paragraph 8.3 on page 25 which related to findings of the Committee on fact finding visits and meetings held with provincial departments. She pointed out that issues like a shortage of medicines and the late payment for services rendered were not included in the paragraph.

Ms Majalamba asked whether the issues identified by Ms Dube had occurred during the 2011/12 reporting period. If it had occurred during the 2010/11 reporting period it could not be included.

Ms Dube responded that the problems at hospitals were all the same. There were no improvements in the state of affairs. She had identified the issues during the 2011/12 visit to hospitals.  It was a recurring problem.

The Chairperson said that Ms Majalamba should state in the BRRR that the issues identified were problems recurring over and over again.

Ms Majalamba referred to page 36, with reference to Programme 3 and recommendations made by the Committee but not implemented by the DoH, and said that the Committee had recommended better stock control measures for medicines. Unfortunately the recommendation had not been implemented. 

Mr D Kganare (COPE) referring to The Council for Medical Schemes and medical aid schemes in general said that the way they operated needed to be looked at. There was something amiss. People complained that they made payments but when they were in need of coverage they found out that they were not adequately covered. He could not pinpoint exactly what the problem was.

The Chairperson said that the Committee got the point he was trying to make.

Dr Goqwana said that whether it was with the Council for Medical Schemes or the DoH that there were tariffs that needed to be set by somebody. For example if a doctor charged a patient R300, the medical aid would only cover R200; the remaining R100 had to be covered by the patient. Private doctors’ tariffs had been set by the Health Professions Council of South Africa (HPCSA). The last time tariffs were set was in 2006. Doctors however felt that the HPCSA should not set doctors’ tariffs. The HPCSA disagreed and believed it was up to it to set tariffs. He saw the points that both parties made. The DoH had part involvement as the Minister of Health signed in tariffs.

The Chairperson noted the issue raised by Dr Goqwana, but where in the BRRR was it going to be included?
Dr Goqwana responded that tariffs affected the ordinary man on the street. The issue need not be included in the BRRR. The Committee could invite the respective parties to a discussion session and try to resolve the matter.

Ms Kenye agreed that the HPCSA should appear before the Committee. She had put it to the HPCSA that private doctors were using state facilities for private use. The HPCSA had denied this. She noted that the day before it had been confirmed in the House that private doctors were using state facilities for private use. She asked the research section of the Committee to obtain the statement made in the House the previous day.

Mr G Lekgetho (ANC) saw the issue as serious. A recommendation needed to be made.

Mr Kganare asked how the Committee was going to convince medical aids to treat people fairly.

The Chairperson noted that the issue was important and would be discussed by the Committee. The relevant institutions would be invited to address the Committee.

Ms Kopane pointed out that the BRRR did not speak about the complaints of doctors and nurses. It needed to be covered somewhere in the BRRR.

The Chairperson noted that the issue of nurses would be discussed with the South African Nursing Council (SANC).

Ms Kenye referred to the last paragraph on page 22 and said that the South African Nursing Council was covered.

Dr Goqwana observed that the Committee needed to check on how the sector was regulated. The Committee did oversight over the DoH which had set up regulatory bodies. He suggested that the issue be discussed by Members in a meeting and not be included in the BRRR as a recommendation.
On the issue of doctors using public facilities for private use he felt the issue to be a bit complicated. The meeting at present was not the forum for the issue to be discussed.

Page 38 of the BRRR contained the Committee’s recommendations and the Chairperson invited Members to make additions if they were so inclined.

Mr Kganare pointed out that there were serious financing problems in the Eastern Cape and Limpopo. He said that there was no recommendation in this regard. He noted that hospital infrastructure was a mess and in Port Elizabeth, at Livingstone Hospital, patients had to bring their own blankets and the hospital was dirty. The Member of the Executive Committee (MEC) of Health in Limpopo complained that there was a lack of equipment. The national Department of Health on the other hand said that there were enough funds. He felt it time for the DoH to start resolving real issues. The Committee needed to formulate a recommendation in this regard.  

Ms Dube thought that the BRRR did have a recommendation that National Treasury should allocate more funds to the DoH. She, however, referred to the conclusion on page 39, the last line in the second paragraph where it stated that the DoH was underspending its funds. The issue was hence how more funds could be requested for the DoH if it was not spending the funds it had.

The Chairperson said that Ms Dube was correct. The underspending was explained by the DoH to have been on goods and services. Even though underspending took place there were accruals.

Dr Goqwana noted that the issue should be reviewed. The conclusion should reflect what the Committee had picked up. Even though the Committee did oversight over the DoH the actual work took place in the provinces.  He felt that the underspending by the DoH should not be reflected in the BRRR. The DoH had emphasised that it was underfunded across the board. The DoH had received an unqualified audit report from the Auditor General’s Office. He suggested that the conclusion be reviewed.

Ms Majalamba suggested that the issues raised by Members not be included in the conclusion. The issue of underfunding would be included in the recommendations.

Mr Kganare said that the Minister of Health had made a statement that persons with medical backgrounds should be managing hospitals. How far was the process? The problems in the Eastern Cape could not be laid at the feet of the MEC on Health and his staff alone. There were many external factors which contributed towards the problems.

Dr Goqwana confirmed that there were many external factors which contributed towards the problems in health in the Eastern Cape and Limpopo. Most of the external factors were political in nature. All that the Committee could recommend was that the DoH should look at the two provinces.

Ms Kenye referred to the last paragraph on page 22 which made reference to the State of the Nation Address which had called for the training of doctors and nurses and the revitalisation of 105 nursing colleges. She suggested that the Committee call on the South African Nursing Council to account on what progress had been made. If it was not to be a recommendation; the Committee should ask them to brief the Committee.

Dr Goqwana said that there were two things. The first was that the South African Nursing Council was a regulator of the nursing profession. The second was that the DoH was in charge of building nursing colleges. It was best for the Committee to call on both parties to brief the Committee.

Ms Dube pointed out that the attitude of staff at hospitals was terrible. She was not sure whether a recommendation in this regard could be captured.

Mr Lekgetho informed the Committee about a strike that had taken place at Mmabatho Nursing College. The issue was about some students receiving better benefits than others. He added that this was the trend throughout the country.  He recommended that the DoH look into the matter.

The Chairperson, addressing Mr Lekgetho, said that perhaps the issue was perhaps best suited to be dealt with by the Committee at another time. It should not be included in the BRRR. The Committee needed to schedule a meeting where Members could simply raise issues. Meetings of the Committee usually had a specific agenda. She spoke about page two of the BRRR which contained the sources of information that had been used to compile the BRRR and said that Committee meetings were also a source of information. It should be added to the list.  She asked Ms Majalamba to include the recommendations made by Members into the BRRR.

Ms Majalamba responded that she would draft the recommendations made by Members. The issue was that most of the recommendations made were general in nature. Recommendations need to be clear and time-framed. She would forward the recommendations to Dr Goqwana, the Committee Chairperson.

Dr Goqwana said that it would be better if the Committee as a whole could deal with the recommendations in the present meeting.

Mr Lekgetho proceeded to read the recommendations out to the Committee.

The Chairperson said that Members could comment on the recommendations.

BRRR recommendations
The Department of Health should make sure that traditional leaders and communities were well educated about the importance of medical male circumcision.

Ms Robinson noted that the recommendation only dealt with adult circumcision. What about circumcised babies?

Dr Goqwana said that the recommendation was specifically related to traditional leaders.

Ms Kopane said that the DoH should be involved in monitoring circumcision in schools. The sterility of equipment was a key challenge.

The Department should concentrate more on primary health care with the aim of increasing funding and increasing human resources to reduce hospital overcrowding and focus on hospital 'centralism'.

Dr Goqwana emphasised that the DoH should move away from 'hospicentricism'. He felt that the recommendation could be worded better.

Ms Kenye added that the focus of primary health care should be in rural areas.

Dr Goqwana said that the Premier of Gauteng had stated that Chris Hani Baragwanath Hospital was overcrowded because people from rural areas flocked to it. Rural health should be promoted with a focus on the allocation of resources. Primary health care clinics in rural areas were not properly resourced.

Mr Lekgetho observed that most of the funds were allocated to urban areas. He noted that equitable share funding was skewed. Rural development needed to be emphasised.  

Dr Goqwana suggested that rural health be a separate recommendation.

The Committee agreed.

Dr Goqwana said the problem was that primary health care was sometimes under local government and at other times under provinces.

The Chairperson suggested that it be captured as a recommendation.

Dr Goqwana said that it needed to be captured in good English.

Ms Kopane pointed out that the Committee did not have statistics on primary health care and hence it was difficult to take a decision.

The Chairperson noted that the Committee needed to consider the district health system.

Ms Dube suggested that perhaps the policy on primary health care needed to be changed.

The Chairperson explained that devolution of power took place after 1994. The situation arose where municipalities could not handle health which led to the 'provincialisation' of the delivery of health. There was apparently legislation in place for the 'provincialisation'. All funding for health, however, came from the DoE.

Ms Dube said that primary health care needed to be done nationally. At delivery it should either be the provinces or local government but not both.

Ms Robinson pointed out that the BRRR could not deal with issues of a constitutional nature. What the Committee could make a recommendation on was the state of health care, whether delivery was in the hands of provinces or local government.  

The Department should allocate additional funds for hospital revitalisation in preparation for the Office of Health Standards Compliance (OHSC).

Ms Majalamba said that the recommendation needed to go further.

Dr Goqwana agreed and stated that the OHSC should accredit institutions.

The Department needed to have oversight function on private health care industry.

Dr Goqwana said that something needed to be added to the recommendation. The problem was that the Committee did not have statistics on primary health care facilities.

Ms Kenye said that public-private partnerships could help.

Ms Kopane added that norms and standards needed to be checked on. Ordinary persons were being abused by the private sector.

Dr Goqwana noted that private hospitals were the only institutions that were not regulated.

The Chairperson said that it could be a recommendation to be added to the BRRR.

The Department should make sure that the cancer registry was updated.

Ms Kopane asked how often the cancer registry was updated.

Ms Robinson asked whether funding was available for it to be updated.

Dr Goqwana suggested that the Committee recommend that the cancer registry be updated annually.
As far as funding was concerned it would be allocated once the task was taken on.

The Committee had dealt with the recommendations as contained in the BRRR.

The Chairperson noted that there was only one province which had obtained an unqualified audit report. Perhaps the Committee should have a recommendation on financial management?

Ms Kopane pointed out that the Auditor General had stated that the same issues recurred each year. The DoH was not doing anything. Perhaps a recommendation in this regard should be included in the BRRR?

Dr Goqwana said that the recommendation could state that there were things noted about the provinces and there were no consequences. The DoH should look into the issue and add consequences.
He also said that the Committee should recommend that the National Health Laboratory Service be looked at and that parts of its legislation needed to be amended.

Ms Majalamba responded that a recommendation in the BRRR could not introduce new government policies.
Dr Goqwana answered that it was legislation which Parliament had set up and it was not working as it should in terms of implementation. The Committee could therefore amend the legislation so that it could be implemented as it should.

The Chairperson suggested that the budget of the Medical Research Council should be looked at by the DoH.

Ms Kopane noted that the Medical Research Council should assist the DoH to meet its targets. This was according to the Annual Report of the DoH. Was there perhaps a duplication of services? Perhaps their functions should be looked at?

The Chairperson placed the BRRR before the Committee for adoption.

The BRRR was adopted as amended.

The Chairperson concluded that the inputs made by Members would be incorporated into the BRRR.

The meeting was adjourned.


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