National Health Amendment Bill: Final mandates & adoption, Department of Health & Deputy Minister 2012 Annual Report briefing

NCOP Health and Social Services

27 November 2012
Chairperson: Ms M Boroto (ANC, Mpumalnaga)
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Meeting Summary

The Committee met to finalise the National Health Amendments Bill [B24B-2011]. There had been much confusion at a previous meeting about the version of the Bill on which the provincial legislatures were expected to give their mandates, and opinions were sought from the Parliamentary Legal Advisors, the Procedural Advisor to the NCOP and the State Law Advisors. It was ultimately noted that the correct description of the Bill sent to provinces, and the one on which they should have voted, was “B24B, with amendments”, that the amendments effected by the NCOP were contained in a C-list, and the final Bill, as adopted by the House, would be called the D-version. Although only three of the provinces actually referred, in their mandates to “B24B” it was clear that they had considered both this Bill and the amendments already proposed by the Committee, and the legal advisors agreed that there would be nothing wrong in voting on the Bill now, and explaining the confusion in the Committee’s Report. All provinces indicated their support for the Bill, except Gauteng, which had not sent a mandate. The Committee voted to adopt the Bill.

The Deputy Minister of Health, Dr Gwen Ramokgopa, and the Department of Health (DOH) presented the Annual Report for 2011/12. The main achievement in this year was the impact that the DOH had had on HIV/AIDS, where the epidemic had been stabilised, as reflected both in the reduced number of new infections and Statistics SA report that life expectancy had risen by two years. 617 147 new patients were put on anti-retroviral (ARV) treatment in 2011/12, compared to 418 677 in 2010, and 9.6 million South Africans accepted HIV testing in this year. Over the last 24 months there had been a reduction in mother-to-child transmission, from 8% down to 2.7%. 6.3 million female condoms were distributed, although the male condom distribution was way short of the target, due to worldwide shortages of latex that led suppliers to default on their commitments. South Africa had managed to lessen the cost of ARVs substantially, making savings of R4 billion that in turn enabled more people to be put on treatment. The Deputy Minister noted that although the DOH was criticised for its substantial focus on HIV/AIDS, this had an offshoot of alleviating other diseases and conditions. A TB cure rate of 73.1% was achieved, below the 75% target, but still an improvement on the previous year. The steps to improving child health, reducing mother-to-child transmission, improving access to antenatal care and increasing cervical screening were outlined. All expectant mothers receiving antenatal care were tested for HIV/Aids. The distinction between the number of new cases – expected to decline – and the numbers of people receiving ARVs – expected to increase, was explained. The achievements in Primary Health Care were outlined, including numbers of visits, vitamin supplementation for children, revision of the Health Services to take account of non-communicable disease and chronic disease, and prevention of injury. The performance of district hospitals was being monitored. Although the supervision rate in the primary health care facilities was below target, steps were being taken to address this, and 3 780 hospitals had undergone a baseline audit. On the pharmaceutical side, there were attempts to reduce backlogs and there had been 386 generics registered. Ten pilot sites were identified for the National Health Insurance (NHI), and the NHI Conditional Grant Framework was approved by National Treasury. Eighty students had been recruited to study medicine in Cuba, to address the shortfall that could not currently be filled by the schools of medicine, although there was good cooperation with the medical schools.

The financial statements indicated that the national DOH had received an unqualified audit, although four of the provinces showed incorrect spending. DOH had spent 99% of the allocation, with the underspending on personnel and in goods and services, where procurement problems had hampered spending. The DOH was trying to address the concerns of the Auditor-General, had managed to solve various problems cited in the previous audit, and was holding weekly meetings to resolve others. A future possible audit risk was identified, with the inventory, but the DOH was monitoring this. It was also monitoring the spending on conditional grants, since several provinces underspent on the HIV/Aids grant. The pathology grant was to be phased out. Funding to the entities was briefly explained.

Members asked no students from the Western Cape and Free State had participated in the Cuban training, asked whether the Department of Higher Education and Training was involved in discussions on doctor numbers, and how the DOH was addressing its own staffing difficulties. Members asked why the Eastern Cape had exceeded its grant allocations, and how it had funded the work. Several Members asked about the vacancy rates, stressed the need to ensure service delivery, the importance of asset management, and the need for the national Department to inspect conditions in all state facilities, as well as ensure that senior personnel were supervising adequately. Questions were also raised about male circumcision, the NHI pilot sites and how they were selected, and concerns expressed about the huge cost escalations at the new psychiatric hospital in Kimberley, as well as the transfer of funding from De Aar hospital to complete it, whether the DOH was ready for implementation of the NHI, and who would be monitoring the non-negotiables. Overall, they felt that staff needed to be motivated to perform better and this was linked to reporting lines in the Department. However, Members did express their appreciation for the good work being done.

Meeting report

Nomination of Acting ChairpersonMs Marcelle Williams, Committee Secretary, asked Members to nominate an Acting Chairperson, and Ms M Boroto (ANC, Mpumalanga) was duly chosen.

She welcomed the Deputy Minister of the Department of Health, Ms Gwen Ramokgopa, and officials from the Department of Health (DOH or the Department).

National Health Amendments Bill B24B – 2011: Consideration of Final Mandates & Adoption
The Acting Chairperson reminded Members of the confusion at the last meeting as to which version of the National Health Amendment Bill (the Bill) should be voted upon. The Parliamentary Legal Advisors had now confirmed that the final mandates should be given on the B-version of the Bill, and she hoped that Members could now reach agreement.

Ms Shahida Bowers, Procedural Advisor, NCOP, noted that she had been asked to attend the meeting to advise Members of the procedures. She noted that final mandates were given in terms of the Mandating Procedures of Provinces Act, at the Committee stage and before plenary stage. The mandates would be used as voting mandates if there was any change in the provinces’ position at the plenary session. She stressed that there was no negotiation at final mandates stage. The final mandates related to the Bill as presented by the National Assembly (NA) to the Select Committee (the B-version) read together with the amendments proposed and accepted by the Committee at the negotiating stage. It would be confusing and legally incorrect for the provinces to provide a mandate on the B-version of the Bill only, as this would in effect be saying that the provinces were disregarding the amendments made by the Select Committee, and were in favour of the Bill as sent by the NA only. She therefore summarised that the vote would generally be made in favour of, or against, “B24B with amendments”. The Committee could also vote on the D-version, but these were the only acceptable versions for the purposes of voting. If the Members simply voted on “B24B” this would be incorrect.

Mr M De Villiers (DA, Western Cape) said he understood fully, but when the Western Cape Provincial Legislature had considered the Bill, there was a problem, because the wording of ‘with amendments’ was not used. Either the wording had been incorrect, or the Western Cape had given him a mandate to vote on the B-version without amendments.

Mr W Faber (DA, Northern Cape) stated that perhaps he had been misinformed, but he believed that the Bill would only be called a ‘D’ version once it had been passed in the NCOP. Before this, it was still a B-version with amendments. He questioned whether it was correct to state that a D-version was now acceptable.

The Acting Chairperson had hoped the confusion would be alleviated. As she understood it, from Ms Bowers, if the B-version was used, it must be “B version with amendments”. She asked for comment from the Parliamentary Legal Advisor.

Mr Gary Rhoda, Parliamentary Legal Advisor, said that Mr Faber was correct, and the Bill only became a D-version once voted upon in the House. The correct terminology and Bill to be used were the B-version with amendments.

The Acting Chairperson bemoaned the fact there were differing opinions from the different legal advisors.

Mr S Plaatjie (Cope, North West) expressed concern that the same difficulties were apparent during the last meeting. He thought, however, that there had been agreement on the process. The Bill should stand as B24B with amendments, to be converted to the D version after voting in the House. He confirmed that the mandate from his Province had not changed.

The Acting Chairperson sought the input of the legal advisor from the Office of the Chief State Law Advisor.

Mr Gideon Hoon, Principal State Law Advisor, Office of the Chief State Law Advisor, stated that technically there was no D-version before the Committee, but he thought that the Committee should not become bogged down in technicalities, as it was quite clear what the intention was, and there would be no difficulty in passing the Bill. It was clear, whatever it had been called, that the version sent to the Provinces was in fact the “B-version with amendments”.

The Acting Chairperson sought an opinion from the Department of Health.

Mr Lufuno Makhoshi, Acting-Director: Legal Services, Department of Health, said that the process was with the NCOP, and the Department did not want to express a view on Parliamentary processes.

The Acting Chairperson asked the Committee Secretary to clarify how many provinces had made corrections.

Mr Faber disputed that the intention was enough, saying that the Committee could not pass something called a “D-version” of the Bill. In his view there were no grey areas. He pointed out that only five provinces had submitted proper mandates.

The Committee Secretary said only three mandates had specified “B-version with amendments”.

Ms Bowers clarified that when amendments were made to a B-version, it became a B-version with a C-list. The C-list could not be read on its own, and thus could not be sent, independent of the B-version, to the provinces. The B-version, together with the C-list, if not amended any further, then because the D-version and she believed that it was not incorrect therefore for the Provinces to vote on something referred to as the D-version. The negotiations had already been done, and voting was the last stage of the procedure.

The Acting Chairperson asked the Parliamentary Legal Advisor if it would correct to pass the Bill, and simply minute the fact that there had been confusion. The provinces were in favour of the Bill.

Mr Rhoda confirmed that this could be done. The Committee Secretary could minute it and it would form part of the Report to the House.

The Acting Chairperson then asked the Members to read their mandates, and the representatives read out the mandates as follows: .
- The Eastern Cape supported the Bill and mandated the Member to vote in favour of it.
- Free State had voted in favour of the Bill and mandated its representative to do likewise at the NCOP.
- It was noted that Gauteng did not send a mandate.
- The KwaZulu Natal representative was mandated to support the Bill.
- Limpopo was in favour of the Bill
- The Mpumalanga representative was mandated to vote in favour of the Bill
- Northern Cape indicated that it supported the Bill
- The Western Cape representative was mandated to support the Bill.
- North West indicated that its legislature was in favour of the Bill.

The Acting Chairperson therefore confirmed that all provinces, except Gauteng, had indicated that they were in favour of the Bill. She announced the adoption of the Bill, version B24B with amendments.

Department Of Health 2011/12 Annual Report briefing
Ms Gwen Ramokgopa, Deputy Minister of Health, said that without the inputs of provinces, the achievements of the Department of Health would not have been possible. She said that the greatest achievement of the Department, and the one that had the most impact in the lives and health of citizens, was combating HIV/Aids. The epidemic had been stabilised. According to Statistics South Africa, the life expectancy had risen by two years. In the last 24 months there had also been a reduction in mother-to-child transmission, from 8% in 2010, to 3.5% in 2011, and to 2.7% in 2012.

South Africa had been lauded internationally for having contributed to the reduction in cost of the anti-retroviral treatment (ARVs). So far, R4 billion had been saved in the total cost of ARVs. This had enabled the Department to increase access to treatment. The Deputy Minister was aware of the criticism that the Department had been putting too much focus on HIV/Aids, but she said that in fact this focus had the offshoot of alleviation other diseases and conditions as well. The Department had started negotiations with the National Treasury on what it called “non-negotiables”. These were front-lines services that would help improve services overall, and that would strengthen the programme rollout of the National Health Insurance (NHI) scheme.

 Dr Yogan Pillay, Acting Director General, Department of Health, highlighted the priorities of the Department, saying that the four main outputs were to achieve increased life expectancy, a reduction in maternal and child mortality rates, to combat HIV and Aids and decrease the burden of diseases from tuberculosis, and to strengthen the effectiveness of the health system.

He noted that there were about one thousand days still to go, to reach the deadline for the achievement of the Millennium Development Goals.

He said that the National Department of Health had received an unqualified audit opinion from the office of the Auditor-General, the second in the last three years, but there were still challenges however with the provinces and four of the provinces had overspent on their budgets.

He highlighted some specific achievements. The annual National Antenatal (ANC) Sentinel HIV and Syphilis and Prevalence Survey Report had been produced. There was now a 20-year database of HIV prevalence amongst ANC attendees. A National Health Research Summit had been held in July 2011, and the subsequent report had been published in the prestigious Lancet Journal in April 2012.

The Department had implemented a three-tier monitoring and evaluation system for the provision of anti-retroviral therapy (ART). Ten pilot sites for the National Health Insurance had been identified, with KwaZulu Natal having two sites. The NHI Conditional Grant Framework was approved by National Treasury.

80 students were recruited to study medicine in Cuba. These were drawn from seven provinces, excluding Western Cape and Free State.

In the area of Combating HIV/Aids, he noted that 617 147 new patients were put on ARV treatment in 2011/12, compared to 418 677 in 2010. 9.6 million South Africans accepted HIV testing in 2011/2012. 6.353 million female condoms were distributed, exceeding the target of 6 million. 397.1 million male condoms were distributed, far less than the target of one billion. The availability of latex worldwide had hampered the efforts, and several suppliers had not delivered as promised on contracts. The Department had approached the United Nations to help provide the shortfall in the number of condoms.

In the area of improving TB management, he noted that a TB cure rate of 73.1% was achieved in 2010/11, against a target of 75%. This was an improvement on the 2009 rate of 71.1%.

The steps to improving child health achieved a national immunisation coverage rate of 95.2%,  against a target of 95%.  The prevention of mother-to-child transmission (PMCT) programme was working well. Although more people were accessing antenatal care,  there was still a challenge in people accessing it early enough in their pregnancy. All of those who received antenatal care were tested for HIV. Cervical care screening was also increasing.

He noted that the HIV prevalence amongst antenatal attendees increased from 29.4% in 2009 to 30.2% in 2010. This was in line with expectations, because the number of HIV–positive people on treatment was rising. Dr Pillay stressed the distinction between the number of people on treatment and the number of new cases. The former needed to increase, while the latter decreased.

Dr Pillay then outlined the achievements in Primary Health Care (PHC). He noted that a PHC utilisation rate of 2.5 visits per person was achieved in 2011/12, against the target of 2.6 visits.

The Vitamin A supplementation coverage rate among children aged 12 to 59 months was 43%, exceeding the target of 40%.

Because non-communicable diseases and chronic diseases were becoming more prevalent, the Department was reviewing and revising the way in which the Health Services operated, with the implementation of the Integrated Chronic Disease Management (ICDM) model in 41 facilities, in three districts, across three provinces.

Injuries and trauma were another increasing burden and source of concern. A Strategic Framework for the Prevention of Injury in South Africa had been produced.

The Department was monitoring the performance of district hospitals. A Usable Bed Utilisation Rate (USBR) of 67.1% was achieved, against a target of 70%. Average length of stay was 4.3 days, slightly above the 4-day target.

The PHC supervision rate was at 66.6%, below the 70% target. A workforce strategy had been developed in response to the service delivery platform. A rural health workforce plan had been incorporated. An audit of Community Health Workers was completed, as part of the re-engineering of the PHC. 42 technicians were trained to conduct health technology audits. By March 2012, 3 780 facilities (90%) had undergone a baseline audit.

On the pharmaceutical side, Dr Pillay said that the establishment of the new Pharmaceutical and Related Products Regulatory Authority (SAHPRA) was approved by Cabinet.

There was a backlog in the registration of medicines, and DOH specifically was trying to reduce the backlog and the time to market. 386 generics were registered.

On the complaints side, only 40% of complaints from users of public health services were resolved within the set target of 25 days. A database of complaints had been established, which facilitated the monitoring of progress.

Financial statements
Mr Ian van der Merwe Chief Financial Officer, Department of Health, presented the financial results of the Department (see attached presentation for full details).  He noted that the DOH had a final appropriation of R25.97 billion, and had R25.71 billion, representing 99.0% of the budget. There was R255 129 million under spending.

He detailed the expenditure per economic classification. 96.4% of the employee compensation budget was spent. Under goods and services, only 74.8% of the budget was spent. There were now systems in place to ensure less underspending. The main reasons for underspending were procurement issues, where items could not be paid for during the financial year.

He reiterated that the national DOH had received an unqualified audit opinion. The Department had worked hard to address some of the issues that had been raised by the Auditor-General (AG), and several of those raised in the last financial year were now cleared and had not been raised again.  Some of the matters cited in the 2011/12 year included the fact that not all senior managers had signed performance agreements, as required by the Public Service regulations. Payments to NGOs had not been properly monitored, to ensure that they been used for the intended purpose. Several other grants had also not been monitored properly. Some of the payment schedules had not been adhered to.

There was a plan in place to further improve coordination and communication with the AG, and weekly steering committees were arranged, at which issues were raised. This had identified a possible future audit risk with the inventory. The Department would have to keep an eye on this, and deal with it at an early stage, to ensure it did not become a problem later on.

Mr van der Merwe explained the expenditure of the provinces on the conditional grant. Provinces had underspent on their HIV/Aids grants, due to several factors.

The pathology grant had shown 99% expenditure. This was the last year which the grant would be issued this way. In future, provinces would have to make provision for it out of their equitable share. This was a grant that had, traditionally, been mismanaged by the Provinces.

Funding to the Medical Research Council amounted to R271.2 million in 2011/12. The National Health Laboratory Services (NHLS) received R82.1million, although their main source of income was providing laboratory services to the entities like the provincial departments. 

The South African National Aids Council Trust had been dormant for most of the year. However it had recently appointed a Chief Executive Officer, and would be operational by the end of the financial year. It would then get an annual transfer. 

The Deputy Minister concluded by re-iterating that life expectancy had risen by two years. The figure for maternal mortality ratio had been revised down to 310 from 600, after advice from experts. She also highlighted the launch of the Integrated School Health Programme by the President, and asked MPs to keep an eye on how it was being implemented in their provinces.

She added that the Minister of Health had engaged intensely with the deans of the medical schools in the country, to increase their output. The intake across all eight schools of medicine was 1200, but this was insufficient for the needs of the country. The schools were co-operating with the government. The training of doctors in Cuba was going a long way to address the shortfall.

Finally, she noted that DOH was looking closely into non-negotiables, which would mean that provinces could not divert funds from certain functions.

The Acting Chairperson thanked the Department for the presentation, saying that the achievements could be seen on the ground and in people’s lives.

Mr T Makunyane (ANC, Limpopo) asked why the Western Cape had not been included when selecting the doctors going to Cuba.

Mr Makunyane noted that the Eastern Cape had exceeded its conditional grant expenditure in all the categories and asked from what source it received the extra funds.

Mr De Villiers wondered about the vacancy rate of the Department, especially in senior management. He asked what was being done about asset management, wondering if there was a proper system in place, and pointing out that if assets were lost, it would be the people who were affected

Mr De Villiers asked  what the Department of Higher Education was doing to address the shortage of doctors in the country, and stressed that this should not be an issue left only up to the Department of Health.

Mr De Villiers questioned what the DOH was doing to address male circumcision, and why the targets were not reached.

Mr Faber asked where the NHI pilot sites were and how the system was being implemented there.

Mr Faber was worried about the spending at the new psychiatric hospital in Kimberley, where originally R350 million had been budgeted, which had now risen to R1 billion and the hospital was still not near completion. Money had been transferred from the hospital in De Aar to fund the one in Kimberley, and this was surely incorrect.

Mr Plaatjie also wondered about the training of doctors in Cuba, asking if the numbers reflected the doctors sent by the Provinces or whether the Department ran its own recruitment.

Mr Plaatjie asked if there was a negative impact on the National Department if the provinces received negative audit opinions. He also enquired if there was any system to penalise provinces that did not spend their allocations properly. Despite the Department’s attempts, there were pockets of appalling conditions in some state facilities. The Department needed to inspect conditions at hospitals and clinics.

Ms D Rantho (ANC, Eastern Cape) added to Mr Plaatjie’s comments about the conditions of care at public facilities, and said that it went back to the Human Resources question. Often, there were no senior personnel in some sections of the hospitals, and this had to be seen to.

Ms Rantho said the Eastern Cape had been beset with strikes recently, and she felt that the National Department needed to engage the provinces on these problems, which ultimately would affect the National Department’s budget. She also wanted to know if the Department visited the rural areas, in order to monitor the impact of programmes there, and whether South Africa was making progress in regard to the Millennium Development Programmes.

Ms Rantho enquired if there was any programme to deal with the findings of the baseline audit, whether there a programme geared at preventing the breakdown of equipment and machinery.

Ms Rantho wondered if hospitals were ready for the implementation of the NHI.

The Acting Chairperson highlighted that the Free State was also not represented in the doctors going to Cuba.

The Acting Chairperson was worried about the serious gaps in the organograms in facilities and said that this was not followed as it should have been. The Department of Health had good documents and proposals but the implementation on the ground was poor. She asked who was responsible for the monitoring of the non-negotiables.

The Acting Chairperson wondered if there were not better ways to deal with procurement issues. Healthcare often did not happen because equipment and medicines could not be procured.

Overall, she commented that perhaps staff could be re-skilled or re-capacitated to help motivate them to perform better. Linked to this was the question of the reporting lines in the Department, and she asked if problems could be  escalated all the way to the national Department if not resolved lower down.

The Deputy Minister firstly addressed the question of the Cuban training programme. The Western Cape had never participated in the Cuban training programme since it had started in 1997, and she had held a very productive meeting with the MEC for Health, who explained that this province felt there was no shortage of doctors in the province, as whatever needs there were could be addressed by the two medical schools in the province. However, some poor students in the province had raised concerns and the MEC had undertaken to address these. Many doctors preferred not to service public facilities. Free State did not send students this year, although this provincial department had participated in previous years. The Department of Higher Education and Training (DHET)  was involved with medical schools producing doctors. However, There was a need to review the funding mechanism to ensure that they could be funded by the DHET as the Cuban-trained doctors did not qualify for DHET subsidies. Provinces also spent from their equitable share, not just on grants.

The Deputy Minister then addressed the questions on the structure and vacancies. She explained that DOH had sought to align the strategy with its new mandate, and the structure had to follow the strategy. There had been several new Deputy Director Generals appointed, to deal with specific goals. An improvement was anticipated in the current financial year.

The Deputy Minister answered questions on asset management and audits. She pointed out that the Auditor-General had recognised the improvements in asset management. The Audit included the national offices and all other relevant provincial entities, but not the hospitals and clinics, who fell under the provincial asset registers.

She noted that the DOH was working with the private sector to boost male circumcisions.

The Deputy Minister explained that the NHI was being piloted in one district in each province, but KwaZulu Natal also had an extra site, due to its higher disease burden. The criteria for the NHI pilot included considerations of mixed /rural areas, the disease burden, and whether “quick wins” could be gained, through ready availability of infrastructure.

In relation to staffing, the Deputy Minister conceded that there was a problem of retention in some areas. The provinces contracted the doctors to work for them for the number of years for which they had been subsidised.

The Deputy Minister agreed that negative audit outcomes by the provinces affected the National Department, in terms of meeting targets and the grants. The NCOP was meant to assist on the oversight of provinces in spending money. The provinces had a constitutional imperative to spend money well. It would be good to name and shame those who violated their codes of conduct. There were District Health offices to monitor health plans, supervise facilities and compliance. There were programmes in place to ensure that facilities did not deteriorate. There were facility improvement teams. Included in the National Norms and Standards were early warning signs.

The Department was trying to ensure that hospitals and clinics were ready for NHI. She noted that Brazil and Mexico had struggled initially, but these countries had managed to make their public health facilities the first choice for citizens.

The Deputy Minister urged South Africans to have confidence in themselves to achieve NHI. Even the World Health Organisation was going towards a model of universal healthcare. She insisted that healthcare was not to be seen as expenditure, but rather as an investment in human capital to sustain economic development. She appealed to Members to recognise that the main achievement was that people now had access to ARVs.

The Deputy Minister concluded that it was important to engage with provinces to align organograms with strategies and needs. It was up to the Members to ensure that legislatures held MECs accountable. Health professionals needed to be held professionally liable for their conduct. Unions needed to appraise members regularly, not just in regard to wages but for working conditions as well.

Mr van der Merwe explained that even though the Eastern Cape had shown more spend than budget, there was a difference between the conditional grant and the equitable share. In relation to the De Aar hospital, he said that the province would have to ask for an amendment to the budget. There had been engagement with the Province, and there was an ongoing investigation in regard to the Kimberley facility

Dr Pillay concluded that more detail could be given if the Department had more time to explain matters. Every Head of Department and MEC was provided with equipment to monitor each facility

He concluded that there was a move now to use ARVs to prevent more infections.

The Acting Chairperson reminded people that December 1 was World Aids Day. She said that South Africans were proud of the work of the Department.

The meeting was adjourned.


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