National Health Insurance preparedness, and grants: Department of Health briefing

Standing Committee on Appropriations

07 March 2013
Chairperson: Mr E Sogoni (ANC)
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Meeting Summary

The National Department of Health addressed the Committee on the National Health Insurance (NHI) readiness, the pilot projects and linked this in to reports on the infrastructure grants and the changes made to link them to the NHI. Extensive work had been done to prepare for implementation of the NHI. She noted that the first aspect of importance was the definition of “access”, and although some documentation suggested that a five kilometre radius was desirable, the Department of Health (DoH) believed that no person should have to travel more than two kilometres to access a clinic. Problems in access points were shown in tables and maps, and one of the initiatives was to try to contract in GPs. The DoH set out the four main streams of work that it was doing in relation to primary health care streams, ward based and community based and district specialists, the School Health Stream and the GP Contracting Stream. Each of them was briefly explained. It was consistently emphasised that the DoH had amassed data to inform all its decisions and was basing its calculations on headcounts of how many people used the facilities, and to what extent they were being properly utilised. In each case the infrastructure needs were also investigated to ensure that the duplication, which had hindered the Department in the past, was addressed. It was stressed also that too many people were hospitalised due to lack of preventative steps such as immunisation and antenatal care, and this was also being addressed, and GPs contracted in to attend to those who would now received services at a community level. Provinces were being asked to tell the national DoH how the funds were being allocated. District Specialists were being appointed, primarily focusing on reducing child and maternal mortality, partially in order to report on the Millennium Development Goals, but more importantly to improve the quality of life for families. Examples were given of the approach at certain of the pilot sites. The GP contracting scheme was also explained, and the DoH was actively consulting with private practitioners to try to assess their readiness to assist. On the School Health side, mobile clinics were being deployed to, in particular, Quintile 1 and 2 schools located in the poorest areas, and these would include dental and ophthalmology services, as well as general health assessments.

The Department noted that Development Aid and European Union funding was being used for many of theses initiatives, but pleaded that government must take responsibility, as she did not believe that use of donor funding for such important aims was in principle correct.

A particular problem was highlighted in relation to informal settlements, where people were paying large sums of money for travelling to access health care. The DoH was trying to ensure that roads and mobile clinics were in a fit state for use, and was dealing with the provinces to ensure not only that they had proper planning for maintenance, but also put aside set amounts for maintenance of their facilities to avoid excessive capital costs later. Many facilities had been shown, in an audit, to be in poor condition with about 30% requiring urgent attention. However, it was also noted that in some cases the problems could be easily fixed, for instance by tightening loose screws, with no capital expenditure, but this needed attention by the institutions to detail. It was also noted that teams from the DoH had been deployed to hospitals and were helping provincial departments, particularly on recovery of outstanding funds, in many cases managing to achieve considerable success simply through setting up good systems, checking HR records, and doing a range of work from basic through to more technical.

Members were pleased to hear of the progress, but asked if the DoH was essentially having to reinvent the systems, how planning was actually being done, and it was noted that the DoH had actually gone further and had managed to make improvements in areas that were not the pilot sites. The DoH stressed again, in answer to questions that core issues should not be funded by donor funding, but urged that government made appropriate allocations. They asked if unemployed graduates would fill posts, if the Hospital Revitalisation Grant was likely to be spent by the end of the year, and what was being done to assess what was needed. They also asked how the mobile clinics would be allocated and accessed, and the costs, and asked also about specific problems in relation to the Zola Hospital commissioning in Soweto, and problems in the Free State. Although the DoH said that a moratorium had been imposed by provincial treasury, on spending, the National Treasury said that this was not quite correct and explained the circumstances in which National Treasury would intervene.

Meeting report

National Health Insurance preparedness and grants: Department of Health presentation
The Chairperson said that the country faced challenges on the division of revenue in that its time frames were very tight. He said that Parliament was working on amending the Division of Revenue Bill, understood the challenges around money bills, and appreciated that the Department of Health was able to make this presentation to the Committee.
Ms Precious Matsoso, Director General, Department of Health, said she would address the level of readiness of the Department of Health (DoH or the Department) and deal also with the two new grants that had been presented to the Committee. She said that the Department had done extensive work at national level in preparing for implementation, and wanted there to be clear links between the National Health Insurance (NHI) and the infrastructure grants, to show how planning and infrastructure would take place.

Using Thabong Mofutsanyane as an example, it would appear that the cluster of clinics represented “access”, as defined by the World Health Organisation, which allowed for a travelling distance of five kilometres from residence to clinic. However a distance of five kilometres was a lot, especially for sick people, and the Department’s view was that it was more reasonable to use a measurement of two kilometres. She said that although the Department had a norm for community health centres, it also checked if South Africa was facilitating access or not, through infrastructure delivery. She believed that this was the first question that needed to be answered. The clustering of clinics in Thabo Mofutsanyane showed that there were many in Phutha Ditjhaba area than elsewhere. She explained that the community health care centres were slightly bigger than clinics and that at community health care centres, patients could be observed overnight.  |

The National Department data also showed that hospitals had more severe access problems – this was indicated in the presentation with the red markings. Those who wanted to access regional hospital had to travel far. Districts needed to have sufficient facilities so that people should not travel long distances. There was a risk to the patient in travelling and that could be one of the factors affecting early mortality. This was based on the hospitals observed.

Ms Matsoso argued that the data on Phutha Ditjhaba showed that people had to travel two kilometres to clinics (depicted by the green circles) and also indicated that the large circle on the presentation depicted the Community Health Centre. In other areas, facilities were scattered. The Department took the view that the main purpose of planning should be for access. In future, the national Department would be asking provinces to explain why they wanted to build clinics in areas where there was already access, instead of in other areas where there was limited access.

The Department went to places that had limited access to clinics and hospitals, and asked what other facilities people could access, observing some private sector facilities such as the surgeries for General Practitioners (GPs) as well as private hospitals. The Department was particularly interested in the GP sites, and the impact of this on the contracting model.

In relation to the National Health Insurance (NHI) Ms Matsoso said that DoH intended to do four streams of work namely:  the Primary Health Care Streams: Ward-Based and Community Based and the District Specialist Stream, School Health Stream and the GP Contracting Stream.

She explained these in turn:

Ward-Based Primary Health Care stream
The first area for the DoH in terms of Primary Health Care (PHC) planning was the headcount of how many people used the facilities, and various calculations were done to inform the DoH about the utilisation rate of a facility, and an assessment of whether it was being under or over-utilised. This would then in turn inform the DoH if it needed to expand the facility to avoid overcrowding, and this would have implications for staff and performance of nurses.

Although the Department was aware of the numbers of each facility, her main concern was to answer the question concerning the level of planning and readiness of the Department by linking that to both the existing infrastructure and how planning was done for the new infrastructure. More clinics should be built in certain areas, for the reasons she had mentioned earlier, which were linked both to distance and use. The Department would try to avoid duplication, which had happened in the past, and was working closely with the provinces on planning, agreement of time lines and delivery.

Community Based Primary Health Care
Ms Matsoso said that from the service point of view she had indicated to the Committee the number of encounters. Too many people were entering facilities because the PHC approach had not been introduced earlier. Ward-based outreach teams were needed to go to communities, check whether children had received immunisation and whether women were attending the antenatal clinics. This of course did have the potential to increase the encounters at the clinics, and this again could impact on the staff and services. The DoH was currently establishing where the workload was, and had realised that the numbers needed to be increased. DoH needed to contract with GPs to render services, and to attend the National Department of Health facilities.

The data indicated that many people were visiting the hospitals because they wanted to be seen by doctors, but that was not possible as there was a shortage of doctors at the DoH facilities. She was adamant that doctors would be brought in to the clinics, on the basis, particularly, of GP contracting and sessional services.

Ms Matsoso said that the data depicted in the presentation related to Free State and Thabo Mofutsanyane in particular, in relation to community health workers and ward based services. The DoH had information about the ward, the area, ward ID, the districts and about how municipalities’ services were being used, relative to the potential services. The DoH would use that information as the basis of planning for the people, which would also involve community health workers. The districts would be included so that the DoH became aware of which areas lacked facilities. The DoH was now insisting that the provinces must give information on how they had allocated funds, something that had not happened properly in the past.

District Specialist Stream
Ms Matsoso noted that the Minister of Health had managed to explain the specialist streams of work that had been identified, to reduce maternal and child mortality. In 2015, South Africa would be reporting about the progress made on reduction of maternal and child mortality. She said that the Department had appointed seven specialists per district namely: Anaesthetists, Primary Health Care Paediatricians, Gynaecologists, Obstetricians, Specialist Nurses, Family Physicians as well as the Advanced Midwives.

The Department also assessed whether these specialists would be supportive, using Thabo Mofutsanyane as an example. The Department had managed to appoint advanced midwives and family physicians. It had been unable to appoint obstetricians and paediatricians there, though it was able to get a paediatric nurse and the PHC nurse. It was still attempting to identify obstetricians of paediatricians who could join the team. The contractual model principle required that services should be brought closer to the sources, to reduce the burden of diseases and mortality rate.

GP Contracting stream
Ms Matsoso said that the Department should be able to contract those in the private sector, and had, for the purposes of GP contracting, determined exactly where all GPs were located, in the whole district. South Africa was close to having in total enough health professionals, although the majority were in the private sector. She emphasised that once the Department had increased its production, it should be in a position to contract in the GPs located in the private sector, and was trying to bring GP services closer to the areas where access was a problem.

There were GPs even in areas where there were no clinics, but in South Africa, those who lacked medical aid cover were often unable to access doctors’ services, as data on the numbers of those with and without medical aid cover showed. This was an inequality that should be addressed. In other countries people had access because, for instance, in a district, people had been assigned to facilities with GPs, unlike South Africa where they had to travel far to access affordable services.

The markings, by polygons and ringed circles on the presentation document, showed the inequities. She stressed that the DoH was addressing the issues, through the preparatory work of calling upon GPs to find out their willingness to assist, and try to persuade more to volunteer to help solve the burden of diseases and treat people who needed health services in South Africa.

School Health Stream
Ms Matsoso said that the data for school health services related to Quintile 1 and 2 schools, which were those located in areas of high poverty. The Department intended to solve school health and the burden of diseases for children, both for South Africa’s own purposes and to report on the Millennium Development Goals (MDGs). South Africa had a large number of these schools and it was impossible for every child to access health at the moment. The DoH had also created three types of mobile clinics. Dental clinics recognised that for children of a certain age, dental care was needed, and this was also needed depending on their eating habits. These could also pick up instances of malnutrition that could stunt the child’s growth. Visual problems were often not recognised until children under-performed, and once this was identified, help such as moving the children to the front of the classroom could be instated. Opthalmics were therefore part of the programme. General health assessments would also be done.

Ms Matsoso informed the Committee that Development Aid Funding (DEFEAT) and European Union (EU) funding had been used for most of the work done to date. She posed the question whether this was in principle correct that donor funding be used, as opposed to South Africa making sufficient investment into health for its future generations. She insisted that the responsibility should lie on government and that South Africa must prepare to make this investment. The Department had also bought mobile clinics to access these children and to do this assessment using the EU funds. According to Ms Matsoso the Department intended to buy 60 more mobile clinics that day and 60 more were being produced.

Ms Matsoso said it was important to set out the findings of the DoH in relation to informal settlements. Some people were paying R18 transport fees to access a clinic, and a church in the area had donated a health post to alleviate these expenses. Most people, however, had to travel by taxis, buses or trains or walk to facilities. The DoH was stressing to the provinces that whenever building facilities, they must ensure that they were placed where they would actually alleviate the problems of the poor.

The Department was also looking at the roads where the mobile clinics were expected to travel, and that meant ensuring that both the vehicles and the roads were maintained properly. Where ambulances had to drive on gravel roads, extra maintenance costs must be built in, and all of this had to be incorporated into the planning. The National Department wanted to plan with the provinces and  this was one of the reasons why the grant was created.

The Department had gone further to ensure that for every single facility it was able to get data about the state of that facility. In South Africa, the health sector was worth over R300 billion. This was a huge amount, but the audit had also shown that many of the facilities were in poor condition, and about 30% needed to be fixed urgently, to avoid a situation later where they would have to be replaced at huge cost. The Department needed to plan with the provinces around the specific focus areas, and they needed to ensure that 5% of the budget went to preventative and routine maintenance.

The Department had already done some work in ten districts, and for every single facility, either toilets for healthcare workers or for patients were broken. The national Department had instructed provinces to fix the facilities, and had in fact already initiated this itself at some facilities, with the Facility Improvement Teams. Some of the problems did not even require budget but were simply a case of tightening screws with a screwdriver.

She also noted work done in hospitals, which consumed a large slice of the budget because these were the facilities where the most expensive treatment was provided, and where specialist services were provided. If PHC worked properly, it could reduce the hospital budgets. The DoH had started a pilot project in Gauteng. The computer systems were not working properly, with about 80% of stations malfunctioning, and this raised the question of what the workers in charge of maintenance were doing. When work started on putting this to rights, more problems with Human Resources (HR) emerged, when it was noticed that payslips were being produced but not collected. The DoH had demanded that each worker should bring his/her identity book for a head count and to check leave. Within five months the Department had managed to find R35 billion that would not otherwise have been detected. The province had been ordered to stop using consultants and to do the work itself, since the consulting firm had been charging 28% of the revenue as its collection fee.

Ms Matsoso said that long queues were the norm. At one facility it was discovered that files were scattered on the floor, and so every time a patient arrived, a new file would be opened. The national Department had employed and trained interns, and the filing problems were resolved in a short time, and proper systems were set up. The Department was thus essentially going back to basics. However, it was also dealing with technical work. It was helping hospitals to create systems that would allow them to collect revenue.

National Treasury had allocated funding to do preparatory work for the NHI. Part of this was to assess the performance of every Chief Executive Officer in a hospital.

Ms Matsoso concluded that the Department had a document detailing eighteen months of work with NHI, which detailed what the Department had done until December.

Discussion
The Chairperson indicated that in some of the provinces, particularly Gauteng, the infrastructure spending was very poor, for instance 37% of the budget was spent by end of September. He asked whether the work that the Department was doing was supposed to re-invent the system.

Ms Matsoso answered that in the past, planning had not been properly informed and provinces had not been required to check back with the national Department in the past, if they intended to build a clinic. Secondly, this work was done for the whole country, so it should not be seen as only being done for the purposes of piloting.

The National Department of Health had also looked at the burden of disease, and the very high maternal mortality ratio in particular, across 25 of the 52 districts. The question was what the DoH needed to do to meet the target in two years. In 2015, the Department would have to make its report to the World Health Organisation (WHO). The pilots had done much to improve the lives of South Africans, but DoH had gone further - for instance in Mangaung, KwaZulu Natal and Sedibeng, which were not NHI pilot districts, development funding was used to effect improvements.

The Chairperson asked if she was suggesting that the NHI pilot should depend on development funding.

Ms Matsoso said that she was not suggesting this. There were certain matters key to the country’s development. The audit position did not give a good picture. Some workers employed in the finance, HR and IT sections were allocated to different provinces and they had been paid with development aid money, and in cases were doing the work that the hospitals should be doing to generate revenue. When the Department’s report was issues, this would indicate what had been spent using development funding. She, however, was calling for government to make appropriate allocations, and she was urging the DoH to cut down spending on workshops and meetings.

Ms A Mfulo (ANC) said she was impressed by the steps that the Department had taken and she was appreciative of the fact that the presentation addressed the basics. She agreed that everybody needed to accept accountability, including National Treasury.

Mr Ndinannyi Mphaphuli, Acting Chief Director: Infrastructure, Department of Health,  said that expenditure was the key driver, but added that the decisions on the provincial rollovers were taken very late, and that there had been an agreement with the National Treasury three years ago that the rollover would be in the first quarter of the financial year.

Ms Mfulo asked if the unemployed graduates would eventually fill the vacant posts.

Ms Matsoso replied that the undergraduates were being taught how government worked; for instance they learned about the Public Finance Management Act and Public Service Act, and they were being deployed to different provinces. They were given a one-year contract. The Department would be recalling them for retraining if they were to be taken over into posts.

She added that the HR strategy was launched in 2011, and was due for rollout from 1 April. If one province had a shortage of staff, and another a surplus, there would be reallocation of posts. Norms under the National Health Act would be applied. The finance staff would be located with the IT staff, to ensure that the right systems were implemented and working. One facility had claimed to have been unable, over three years, to collect R215 million, but the interns had managed, through concerted effort, to get in R35 million in five months by contacting the medical aid schemes.

Ms Mfulo asked if the Hospital Revitalisation Grant would be utilised by the end of that year, noting that only 58% had been spent.

Mr L Ramatlakane (COPE) said that there was a complaint that donor funding was not used for addressing core concerns, and he asked why was that the case.

Ms Matsoso replied that she was intending to go to every hospital in all the provinces to check what was happening. For instance in one of the hospitals it was reported that patients were without warm water. The DoH would also ensure that during the school holidays the community should still get access to mobile clinics. In the Eastern Cape there were many hospitals which were not used, some because they lacked staff.

Ms L Yengeni (ANC) asked if provinces were responsible for identifying the areas for allocation of mobile clinics, and asked how people could access those clinics.
 
Ms Matsoso replied that all allocations were being based now on data. The clinics could be located at Quintile 1 and 2 schools, according to a set basis for allocation.

The Chairperson commented that the audits of the facilities were not yet completed, and asked how expenditure could be improved.

The Chairperson noted that the Zola Hospital in Soweto had been built five years previously, but was not yet functioning, and he asked what the problems were. He also said he was aware that provinces were responsible, but asked if contractors were penalised for not finishing the allocated job on time.

Mr Mphaphuli said that the Zola Hospital was in the process of being commissioned and new staff were being appointed so that the hospital could start functioning. Infrastructure spending would be addressed when this happened.

He explained delays in some of the other areas. In one hospital, the contractors used wrong doors on the theatres, and only later was it realised that some of the procured equipment was not going to fit through those doors. The contractor had been asked to address this problem and replace the doors.

The Chairperson asked if there was intervention from the national level.

Ms Matsoso replied that DoH was trying to change its approach, and that an interventionist approach after problems had arisen did not help. The DoH was trying instead to implement integrated planning that brought all the parties together.

Mr Ramatlakane asked about the cost of the mobile clinics, what informed the distribution, and what the criteria were, and whether it took into consideration the existing data.

Ms Matsoso replied that the cost was about R1.2 million per mobile clinic. The Department would be paying R34 million for 30 mobile clinics. She said that these clinics were allocated for NHI but the Quintile schools allocations would look at existing facilities.

Mr Ramatlakane asked why the grant intended for a particular purpose seemed to be getting entangled in a provincial budget.

Mr Vishal Brijal, Official in the Office of the Director General, said that the challenges were mainly apparent in Free State, Gauteng and Mpumalanga. He argued that Free State could not spend R2 million because of a moratorium imposed by the Provincial Treasury in that province. In Gauteng there were a number of serious challenges. In Mpumalanga the main challenge was in procurement, challenges and a team was appointed by NDoH to work with the provincial team.  

Mr Ramatlakane asked why the National Treasury did not intervene to correct the situation in Free State.

Mr Andrew Donaldson, Deputy Director General: Public Finance, National Treasury, said that there was actually no such thing as a moratorium on infrastructure spending. National Treasury intervened from time to time if there were concerns about particular contracts, or if the budget for the year had been used.

The Chairperson noted that generally there were challenges in the Free State, and said that was also mentioned in a presentation given to the Committee a few days earlier.

Mr Donaldson agreed that National Treasury was aware that there were challenges in several provinces and was involved in dealing with one of the two provinces through the specific intervention teams.

The Chairperson said that the National Department of Health allocated the conditional grant, and that  those resources were meant for a specific purpose so there should not be challenges around the grants. The problem was that much of the discussion was focusing on the Free State. There had been substantial engagement, particularly in the Provincial Treasury, to improve infrastructure management and to ensure that spending was in line with the budget.   

Mr Donaldson answered that there were categories of conditional grants, but grant money should indeed only be spent on the specific purposes for which it was intended.

Mr Ramatlakane was satisfied with the answers provided by Mr Donaldson.

Ms Sonia Venter, Technical Advisor, Department of Health, said that the NDoH was aware of the situation in Free State, was looking at the issues, and promised to submit a detailed report on what exactly was happening in that province, and what interventions were put in place.

The meeting was adjourned   




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