Medical Research Council & National Health Laboratory Service Strategic & Annual Performance Plans 2013

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Health

15 April 2013
Chairperson: Dr B Goqwana (ANC)
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Meeting Summary

The South African Medical Research Council (MRC) and the National Health Laboratory Service (NHLS) presented their Annual Performance Plans and Budget for 2013/14.

The MRC had exceeded all its quarterly performance targets except in regard of publishing of policy briefs from research results and was on track for a clean audit. MRC challenges included the decline in scientific stature of medical research and citation rate; it was not fulfilling its custodian role in medical research in South Africa (SA) as only 19% of baseline budget was allocated to Universities for all medical research; expansion on the number of intramural units meant duplication of research; and twice the amount of funding came from external funders compared to government funding and the MRC could only research what donors were willing to fund. Also, SA had an ageing cadre of scientists and retention of scientists was important. While scientists did not toyi-toyi, they did walk out, not only because of salary but also because of lack of equipment. Another issue was that the MRC Act had not been updated since before 1994.

The challenges were brought about fundamentally due to lack of funding. With inflation of 6-7% and with the baseline grant growing only by 3.5% per annum over the past four years, the budget had been steadily diminishing over the past four years. The deficit for 2012 was R42 million but this had been accommodated by a buffer reserve of R42 million. However, there was currently no buffer to accommodate another budget deficit. Of significance was that the baseline grant (2012/13) from National Treasury was less than 10% of what the National Institutes of Health (US) funding was to SA.

The baseline allocation from Treasury (via the Department of Health) for 2013/14 was R326 million. Additional funds from Treasury from the Competitiveness Fund for university flagship projects were R90 million. The Gates Foundation had offered R100 million over a three-year period for HIV and tuberculosis (TB) technology, provided that the Department of Health funds from Treasury would match that amount. Treasury pledged that this amount would be made available in 2015. The Department of Science and Technology provided R29 million for HIV, tuberculosis (TB) & malaria technology development. The National Health Research Committee and Discovery Health contributed R15 million for PhD Training (target 100 PhD students).

Revitalisation of the MRC was underway to increase funds for long term development of new drugs, vaccines and diagnostic tests for malaria and TB. While funding had doubled for universities and medical schools, the MRC needed to raise R100 million per annum to reverse the shrinking budget.
While external funds were currently being sourced, the MRC was cautious with external donations, not only because ‘he who paid the piper called the tune’, but because Western economies were fragile and posed a risk should there be a change in government and/or if those funds dried up. There was a need to become dependent on internal resources rather than external resources.

The MRC had negotiated closely with the three relevant trade unions over the past six months and come to an agreement that the MRC would prioritise the 10 most common causes of death and disease in SA. Focus would also be on increasing the number of peer-reviewed quality research; efficiency and effectiveness of administrative systems; reorganisation of intramural research to focus on high impact research and improved laboratory and space utilisation (share equipment across units); and research support functions, such as medical journals. These activities were being implemented and would be on track by the end of the year.

The strategic plan would focus on impact, with new strategic goals and targets. Some of the detail on programmes such as SHIP (Strategic Health Innovation Partnerships – the funding and project management department of the MRC) had not been incorporated in the presentation, but resources, time and sustainability would ensure that the 2030 National Development Plan (NDP) and National Health Insurance (NHI) were incorporated in the MRC plans going forward. Ultimately, the MRC would continue to generate new knowledge to improve the health of the country. The MRC was on track for a clean 2012 Public Finance Management Act (No. 1 of 1999) (PFMA) audit.

Members asked for more information on the NHI and SHIP; the reasons for low performance on publishing of policy briefs; if revitalising and reorganising of the MRC would involve reducing the number of MRC units; if the Department of Higher Education and Training was providing adequate funding for research at universities; and if the MRC considered importing scientists who could add skills. They asked if maternal and child mortality rate was still a priority for the MRC; if violence and rape were prioritised within the 10 most common causes of death and disease; why the incidence of TB was escalating; what impact the unions were having on the MRC; and to what extent there was collaboration with other science research institutes.

The most important focus for NHLS was the NHI Green Paper and related planning documents. NHLS needed to identify where diagnostic laboratory medicine fitted into the NHI and position itself as the ‘provider of choice’ for the NHI. NHLS was looking at how it would provide NHI with diagnostic services in the pilot districts and how to respond to new requirements and demands on laboratory services. Because NHLS was slightly outside the Department of Health, it had to be proactive and mobilise resources so that teaching and new medical schools of pathology and teaching hospitals were not an after-thought.

The NHLS 5-year strategic plan included a 10-point plan in line with the Minister’s 10-point plan, with the most important point being development of a new service delivery model that was more affordable for the public sector. Innovation, teaching and research were possibly the most important of NHLS mandates as these would ultimately deliver the affordable new service delivery model.

After HIV and TB, NHLS was focused on prevention and treatment of the ever-increasing incidence of non-communicable disease. To strengthen programmes against TB, multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB), by September 2013 the GeneXpert programme would have 100% coverage at all the priority districts identified by the Department of Health.

NHLS was in consultation with the Department of Health about a separate conditional training grant to pay for teaching, research and surveillance costs, which were currently built into the price of the test and thus put an additional burden on provinces. The difference in funding between what the Department of Health provided and what NHLS carried would then be in the form of a grant, resulting in a price reduction of as high as 10% across the board. Also, operational research work was looking at platforms for laboratories and pooling of resources and training, as well as centralisation of some aspects of NHLS to drive down costs. NHLS would revert back to the Committee before implementation of any operational changes. Another unit NHLS planned to create was the Health Technology Assessment Unit, which would not only evaluate the economic viability of importing diagnostic equipment but also ensure that the manufacture of technology was in line with World Health Organisation standards.

NHLS would continue to work actively with provinces but could not sustain the volume of consumption by provinces with the current debt, and debtor days currently averaged 185 days. At least, conditional grants given to provinces should be paid without delay as this money was given to provinces to pay for NHLS tests. Conditional grants constituted R500 million of NHLS total debt. Non- payment to NHLS has led to the NHLS also transgressing the PFMA requirements. A detailed presentation on the budget would be made to the Committee in September 2013.

A task team was mandated by the Department of Health to amicably resolve the current conflict in an out of court settlement. It consisted of members from the national Department of Health, KwaZulu-Natal (KZN) Department of Health, NHLS and the accounting general’s office of National Health. The outcome would have huge financial implications and drastically impact on the functioning of NHLS.

Members asked if mobile laboratories would service some of the NHI districts; if it was likely that the private sector would abuse the services of the NHLS; if the mines were abusing the public health system; if lack of accreditation of labs was a cost factor; if the accredited laboratories could be trusted; and if pathologists were not in rural areas due to cost. Members also asked if universities could train pathologists and thereby reduce the burden of teaching on the NHLS; if NHLS appeared in peer-reviewed journals or in-house journals; if NHLS had exchange learning programmes with other African learning institutes; why the turnaround time for pap smears was slower than other tests asked; and for clarity on specimen results being delayed at forensic labs. Finally, members asked who would ultimately approve the price increase of the tests; if there was a contingency plan for non-payment; if NHLS consulted National Treasury on its 40-day creditor time; and how confident NHLS was that the provinces would pay for services and adhere to debtor time.
 

Meeting report

Opening Remarks
The Chairperson said that while life expectancy had improved and the rate of HIV transmission had declined, it was important that the Committee ensured that funds were allocated effectively and in line with the strategic plan. The Committee should perhaps take responsibility for not performing adequate oversight on the MRC. In examining how SA could become a better country, without crime, one wonders how many people in jails were suffering from psychiatric problems and how many people in their homes suffered from paranoia and were obsessed with guns. Historically in South Africa, migrant miners had left their families to work elsewhere and children were brought up fatherless. This alone could lead to psychopathic tendencies. He questioned whether there were statistics that showed what societal issues needed to be addressed so that the Department of Health could move forward and address all the issues.

The recurring problem for the MRC was that it was not funded adequately and could not retain staff. In the previous year, the problem was a lack of reports from the MRC. Ideally, the Committee would like the MRC to report more to government than to any other entity. However, reports would always be more forthcoming to donors – to those who paid more. The Committee was interested to know how the MRC planned to restructure the organisation so that it was more effective and also, as the labour unions viewed the transformation as ‘not assisting them’, how the Committee could assist as mediator between the MRC and labour unions.
 
South African Medical Research Council (MRC) Achievements, Performance & Budget briefing
Professor Salim Abdool Karim, President: MRC said that the MRC took its responsibilities seriously and welcomed meeting the Committee on a more regular basis. MRC met with the Department of Health (DoH) on a monthly basis to share its findings and overall status on the organisation, as well as share its requests for funding. He highlighted the MRC’s achievements, performance and challenges, as well as how the organisation planned to revitalise itself.

According to the MRC Rapid Mortality Surveillance (RMS) Report in 2011, through the work of all the role-players involved in administering ARV drugs and AIDS treatment, a proud achievement for South Africa (SA) was that life expectancy was currently >10% than it was 5 years earlier. Over the past three years, life expectancy increased from 56.5 to 60 years; death in children declined from 56 to 40 per 1000 children and in infants from 40 to 30 per 1000. The RMS system, which made the report possible, monitored the trend in the number of deaths recorded on the national population register, adjusted for known bias in the data and accounted for deaths not registered and people who were not on the population register, enabling key health status indicators for SA from the vital registration system for the first time. This was done in collaboration with University of Cape Town (UCT)’s Centre for Actuarial Research. The MRC was proud that the Minister of Health quoted from this report in the online issue of The Lancet (30 November 2012) and that this MRC study was further noted by the 2012 President in the State of Nation Address. The MRC further showed that mother-to-child transmission of HIV reduced to 2.7% in 2011 from 25% ten years earlier.

The four strategic goals, in line with four Health Sector Negotiated Service Delivery Agreement  (NSDA) which contributed to outcome 2, “a long and healthy life for all South Africans” were: to promote health and quality of life through research; promote health and quality of life through public health innovation, technology development and transfer; collaborate sub-national, national, supra-national and global partners to improve health outcomes for South Africa and citizens of MRC’s collaborative partners i.e. in the Southern African Development Community (SADC) region; and improve organisational performance as a health research organisation.

The MRC had exceeded all its quarterly performance targets except in regard of publishing of policy briefs from research results.

The MRC was on track for a clean 2012 Public Finance Management Act (No. 1 of 1999) (PFMA) audit.

Challenges included: the decline in scientific stature of medical research – sub-optimal intramural research productivity, few articles in the top medical science journals and citation rate was steadily declining over the past decade; the MRC was not fulfilling its custodian role in medical research in SA as only 19% of baseline budget was allocated to Universities for all medical research and this small budget compromised clinical research. Expansion on the number of intramural units which exceeded the number of extramural units meant duplication of research. Also, the MRC intramural units spent around 90% of their budgets on salaries. Therefore MRC had to look externally for funding of research and was heavily dependent on external funding. As mentioned by the Chairperson, he who pays the piper decides the tune. Twice the amount of funding came from external funders as from government and the challenge was that donor funding came with donor agendas. The only research that the MRC could perform was that which donors were willing to fund. Another issue was that the MRC Act had not been updated since before 1994.

To revitalise the MRC and address these challenges, the MRC negotiated closely over the past six months with the three trade unions, which operated within their environment. They agreed that the MRC would prioritise the 10 most common causes of death and disease in SA; double the extramural funding for research to universities and medical schools; create new funding approaches for the long term development of new drugs, vaccines and diagnostic tests as opposed to surveys and smaller projects (Gates Foundation large grant); improve the efficiency and effectiveness of administrative systems; peer-reviewed quality research; improved laboratory and space utilisation (share equipment across units); and research support functions, such as medical journals. These activities were being implemented and would be on track by the end of the year. Part of the new vision for the MRC would be its new strategic plan.

The challenges were brought about fundamentally due to lack of funding. Due to inflation (6-7%), and with the baseline grant growing only by 3.5% per annum over the past four years, the budget had been steadily diminishing over the past four years. The MRC was in a dire financial state and was heading for repeated budget deficits. The deficit for 2012 was R42 million but this had been accommodated by a reserve of R42 million. However, there was currently no buffer to accommodate another budget deficit. Of significance was that the baseline grant (2012/13) from Treasury was less than 10% of what the National Institutes of Health (NIH) (US) funding to SA, which was the single biggest recipient of funding for medical research outside the US.

The baseline allocation from Treasury (via DoH) for 2013/14 was R326 million / R1 037 million for 2013-2015). Additional funds from Treasury to make SA research globally competitive was from the Competitiveness Fund for university flagship projects (R90 million 2013/14 / R340 million over three years). The Gates Foundation had offered R100 million over three year period for HIV and tuberculosis (TB) technology, provided that the DoH funds from Treasury would match that amount. Treasury pledged that this amount would be made available in 2015. The Department of Science and Technology provided R29 million for 2013 and R122 million over three years for HIV, TB & Malaria technology development. The National Health Research Committee (NHRC ) and Discovery Health contributed R15 million and R45 million over three years for PhD Training (target 100 PhD students).

Mr Nick Buick, Chief Financial Officer: MRC presented the MRC financial summary of income as explained by the President. There had been a baseline allocation improvement for 2013/14, an increase of 8%. The total anticipated income for 2013/14 was R729 million, a 31% increase from the R557 million, which was anticipated for the current year. The deficit in the current financial year of R42 million was in line with the budget. The revitalisation project funds would reduce the deficit in the new financial year and ensure that the balance sheet was strong. (See page 8 for the breakdown of the income for the Medium Term Expenditure Framework (MTEF) period and page 9 for the overview of the budget).

Professor Abdool Karim said that the strategic plan would focus on impact with new strategic goals and targets.  The MRC would continue to seek R100 million per annum over and above the funds already raised to reverse the decline in the budget. Ultimately, the MRC would continue to generate new knowledge to improve the health of the country.

The Chairperson added that the less economically effective mining areas had been neglected. Statistics were required to address health issues in those areas. It would be helpful to look at the National Development Plan (NDP) and decide on a long term plan for the health of South Africans. Parliament expected that the MRC would report on those areas so that the Committees could use evidence-based research to make laws. He added that local, not foreign scientists should be graduating with the PhD’s. SA was fortunate in that unlike other new democratic African countries, there were learned South Africans who could benefit others and a good thing about scientists was that they usually loved their work and were unlikely to toyi-toyi for a raise in salary or commit corrupt acts. They should be encouraged to do the work that they loved.

Professor Lizo Mazwai, Chairperson: MRC said that during the Board’s three year tenure - they were in the third year - they had taken almost a year to establish the executive management and internal procedures before starting to make an impact. The focus was on mobilisation of ideas and people with appropriate skills and funds. While external funds were being sourced, the MRC was cautious, not only because ‘he who paid the piper called the tune’, but because Western economies were fragile and posed a risk if there was a change in government and the funds dried up. There was a need to become dependent on internal resources. SA had an ageing cadre of scientists and this continued to be a challenge. While scientists did not toyi-toyi, they did walk out, not only because of money but also because of lack of equipment. The retention of trained and scientists was important not only for the MRC but also for the country as a whole. Revitalisation of the MRC had short and long-term implications. Growth may be retarded temporarily, such as signing of agreements with the unions. In changing things, new challenges arose. However, the executive management team was full and the board supported revitalisation implementation, which was underway. Some of the detail, such as SHIP (Strategic Health Innovation Partnerships – the funding and project management department of the MRC), had not been incorporated in the presentation, but resources, time and sustainability would ensure that the 2030 NDP and National Health Insurance (NHI) were incorporated in the MRC plans going forward.

Discussion
Ms D Robinson (DA) said that it was clear that lack of funding from government was a concern, especially since (the public was aware that) money was being wasted by government.

Dr Trish Hanekom, Chair of Auditing Committee and Member of the Board: MRC said that the overall budget had increased by 31% and this was quite remarkable (slide 18). The issue for the Committee was how to increase the envelope so that the MRC could make an impact, with the potential it had, with sufficient funds going forward. The MRC President had achieved remarkable success in mobilising resources to make significant impact on medical research in SA and ensure that health service would improve.

Another concern was that while scientists were leaving the MRC due to frustration about inadequate equipment to do research that they were trained to do, there was also the case that high-tech equipment could not be operated due to lack of skilled researchers. It took time to produce PhD students and it was important that the conditions for retaining these skilled scientists were addressed. 

Ms Robinson asked for more information on NHI and SHIP and the approach to ensure that people and resources were brought together between the private and government sectors to create a sustainable model.

Professor Abdool Karim replied that one of the 13 units for restructuring was a unit specifically for research on the NHI. The issue of collaborating with the DoH on this research was raised at the last meeting with the Minister. The MRC had put their strength on the table, and would support the government effort in the health field. It planned to go to the 10 pilot NHI districts and measure all disease to identify areas strength and weakness. There were already three groups working on the finances and the organisational aspect was fluid. The NHI was here and was the best way to walk forward. How it was implemented would define its success.

Ms C Dudley (ACDP) asked if there was a decrease in spending on consultants and whether this reflected a positive or negative change.

Professor Abdool Karim replied that the MRC spent very little on consultants and spent less than 1% on consultants. They were for short-term managerial skills.  The MRC was a long-standing institution and those who ran the organisation had institutional memory.

Ms Dudley asked what the reasons were for low performance on publishing of policy briefs.

Professor Abdool Karim replied that the idea was good but an alternate must be sought. MRC had to figure out how to communicate their message more effectively, perhaps generate a short video. However, the MRC was in the news every day and was part and parcel of everyday debate on SA health.

Ms Dudley asked if maternal and child mortality rate was still a priority for the MRC and what the current findings were.

Professor Abdool Karim replied that the Minister launched The Lancet series on child mortality published by the MRC between 2009 and 2012 which was packed with scientific data to showed how badly SA was doing with regard to its health millennium goals. The updated series in 2012 is packed with scientific evidence backing up results showing that SA is making achievements. However, maternal mortality continued to increase and the MRC had programmes in place to understand the problem. HIV was part and parcel of the problem. The MRC would continue the fight to stop maternal deaths and would generate data on the possible solution, the shift to ‘option B’.

Ms Dudley asked if violence and rape were prioritised within the 10 most common causes of death and disease.

Professor Abdool Karim replied that the MRC had an injury and violence research programme and a special gender unit for violence and rape. It was the only organisation which had data on rape in SA and it had huge programmes to try to figure out the pathology problem, the masculinity problem and the policing problem. Understanding rape was extremely complicated.

Ms B Ngcobo (ANC) asked to what extent there was collaboration with the Department of Science and Technology (DST) and Council for Scientific and Industrial Research (CSIR) on TB treatment; if the MRC collaborated with the Human Sciences Research Council (HSRC) and other science research institutes which were also involved in areas of health; and if revitalising and right-sizing of MRC would involve reducing the number of units and researchers in traditional medicine. DST was also funding traditional medicine.

Professor Abdool Karim replied that the heads of science institutions met formally and informally. The HSRC performed a great deal of medical research and there was no point in duplicating it. Also, the CSIR had unique skills and facilities for researching traditional medicine and it made more sense to collaborate with them.

Ms Dudley asked what impact the unions were having on the MRC.

Professor Abdool Karim said that there were too many TB research units and they would be reduced.  This was negotiated with the trade unions. Over 60% of MRC staff was unionised and this was their right and offered a collective voice with which to work. There were challenges but the relationship was steadily improving. There was an unprecedented broad agreement (1 March 2013) that the intramural programme would be reduced from 27 to 13 units and agreement on the structuring thereof.

Ms Ngcobo asked why the incidence of TB was escalating.

Professor Abdool Karim said that there was no doubt that SA was the epicentre of TB. It had the third largest number of TB patients, the other two being India and Indonesia which had much bigger populations. SA had the highest incidence of TB in the world, as it had the preconditions for TB: HIV, mining and alcohol. The growing prevalence of diabetes was also a major contributor. Fundamentally, TB was a curable condition but SA could not get 85% of TB patients to take their medication. Treatment strategies were not working and MRC was putting energy behind both short-term therapy (one-week course) and vaccine therapy. The other problem was that diagnosis of TB was often difficult and there had been a shift from sensitive TB, to drug-resistant TB, to multi-drug resistant TB, extreme drug-resistant TB, and recently SA has seen its first few cases of totally drug-resistant TB, where nothing works. There has only been one TB drug in the past 30 years and SHIP will be implemented to develop drugs, vaccines and diagnostics and to bring role-players together. It will take millions of rands to develop a new drug for TB through SHIP.

Ms Ngcobo asked if the Department of Higher Education and Training was providing adequate funding for research at universities.

Professor Abdool Karim replied that the Department funded the salaries of medical research staff and therefore contributed to medical research. They also had a separate research fund, which was government grants based on productivity of papers. All research institutions contributed to medical research in SA.

Ms Ngcobo asked if the MRC considered importing scientists who could add skills.

Professor Abdool Karim replied that SA had great minds that competed comfortably on a global scale. The level of research, especially on HIV and TB, was unparalleled in the Brazil, Russia, India, China, and South Africa (BRICS) group of countries. SA was weak in technology: India and China were just too good. They were masters of taking knowledge and converting it into new innovations and drugs. They copy and reverse engineer in huge factories. SA has to learn how to walk amongst those giants of BRICs - learn the language and skills and strengths and weakness. The MRC was very much part and parcel of SA’s strength.

The Chairperson also asked if the MRC considered searching for brilliant foreign scientists who would be an asset to the country, as some other countries did. South Africans had brains but whether we could keep them was the problem.

Professor Abdool Karim replied that the nature of research is that it is globally competitive and therefore the MRC collaborated with researchers around the world. Currently SA students were learning new techniques for separating cells at Duke and Harvard Universities so that they could return to operate advanced equipment owned by SA. Brain drain was routine and not an issue. Researchers were highly mobile. They had unique skills, owned a commodity in scare supply and could “just walk”, as they were in demand.

National Health Laboratory Service (NHLS) Annual Performance Plan 2013/14 presentation
The Chairperson opened the meeting with the NHLS by assuring members that the DoH had handled the problem which the NHLS had been experiencing with provinces. He also pre-empted that if there was to be restructuring within the NHLS, it would be necessary for the Committee, in its oversight role, to know how the NHLS planned to restructure, whether the process would require amendments to the law and what funding requirements would be involved.

Professor Gonda Perez, Chairperson: NHLS said that most members on the Board were new members and their first Indaba had taken place the previous weekend. Fortunately, the previous Board had built a solid foundation and the new Board was taking over a strong organisation. At the Indaba, one of the emphases was on how to ensure that structures were in place to respond to the laboratory needs of the country, particularly the poorest of the poor. CEO would present the plans put in place by that Board and the achievements thereof.
 
Mr Sagie Pillay, Chief Executive Officer: NHLS presented the documents that informed the 2013/14 Annual Performance Plan which was in line with the 5-year strategic plan of the NHLS and DoH, and which kept in mind the rapidly changing environment with regard to NHI, the new imperatives that the Minister had identified, as well as having a new Board which may have new perspectives on matters. (the supporting documents can be found on page 3 of the attached presentation). NLHS was now in the third year of the 5-year plan and had reviewed the 2012-13 performance plans and the previous two financial years to identify priority areas.

The most important focus for NHLS was the NHI Green Paper and related planning documents. NHLS needed to identify where diagnostic laboratory medicine fitted into the NHI and position itself as the ‘provider of choice’ for the NHI.

The strategic plan was presented to the Minister of Health and was recently approved. The NHLS 5-year strategic plan included a 10-point plan in line with the Minister’s 10-point plan (see page 5 of the presentation) with the most important point being development of a new service delivery model that was more affordable for the public sector. The NHLS was also focusing on proactively responding to the needs of the provinces, such as military and correctional services.

NHLS believed that revenue would take care of itself, while the NHLS facilitated provincial and national needs. Innovation, teaching and research were possibly the most important of NHLS mandates as these would ultimately deliver the affordable new service delivery model. Stakeholder collaboration allowed for sharing of resources and new opportunities, such as with NGOs.

After HIV and TB, NHLS was focused on prevention through screening and testing and treatment of the ever-increasing incidence of non-communicable disease i.e. high blood pressure and cardiovascular diseases, diabetes mellitus, chronic respiratory disease and the various cancers and mental health. NHLS was looking at how it would provide NHI with diagnostic services in the 11 pilot districts and how to re-engineer public and district health care to respond to new requirements and demands on laboratory services. Because NHLS was slightly outside the DoH, it had to be proactive and mobilise resources so that teaching and new medical schools of pathology and teaching hospitals were not an after-thought. To strengthen programmes against TB, multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB), by September 2013 the GeneXpert programme would have 100% coverage at all the priority districts identified by the DoH.

Affordability for the public sector: NHLS was in consultation with the DoH about a National Institute of Public Health and a separate conditional training grant to pay for teaching, research and surveillance costs, which are currently built into the price of the test and thus put an additional burden on provinces. The difference in funding between what the DoH provided and what NHLS carried would then be in the form of a grant, resulting in a price reduction of as high as 10% across the board. Also, operational research work was looking at platforms for laboratories and pooling of resources and training, as well as centralisation of some aspects of NHLS to drive down costs. NHLS would revert back to the Committee before implementation of any operational changes. Another unit NHLS planned to create was the Health Technology Assessment Unit, which would not only evaluate the economic viability of importing diagnostic equipment but also ensure the manufacture of technology was in line with World Health Organisation (WHO) standards.

NHLS electronic gate-keeping called for a complete change in the behaviour of clinicians and lab staff. Mobile phones and internet – electronic access to laboratory results would be encouraged at all labs to speed up turnaround time. NHLS aimed for each of its 268 laboratories to have internal accreditation and in addition, all the academic labs having ISO accreditation.

The modern Trakcare Lab system would be rolled out across the country and completed by August 2014 which will include the billing system and eliminate many problems of the previous unstable system.

NHLS salaries could not compare with the salaries of private sector technicians and pathologists and therefore wished to grow its own employees for the public health system through succession planning, from the level of CEO to lab managers, to serve the 8 out of 10 patients who presented themselves for public health care.

In 2013 there was a strong focus on taking completed research studies and converting them into policy. This had been a weakness in the past.

For the 2013/14 budget, NHLS used assumptions: 5.9% inflation; salaries 6.6% increase (salaries were slightly lower than the public health sector); zero% growth in volume - NHLS would work actively with provinces but could not sustain the volume of consumption by provinces with the current debt; test price increase 4%; debtor days was 45 for provinces – currently averaging 185 days and creditor days was 40 – currently over 100 days. If NHLS was not paid, it could not pay others.  The budget cash cover was 1.2 months and the targeted cash cover was 2-3 months.

Some provinces were sitting at high debtor days. At least, conditional grants given to provinces should be paid without delay as this money was given to provinces to pay for NHLS tests. Conditional grants constituted R500 million of NHLS total debt. Non- payment to NHLS has led to the NHLS also transgressing the PFMA requirements.

The budget was based on approval of the price increase of 4% and the summary can be found on page 29 of presentation. Should the price increase not be approved, the budget would be revised. Turnover was R4.8 billion with zero % growth in volume. Material costs were directly linked to the number of tests performed and would constitute R1.35 billion. Labour constituted 65% (R1.7 billion) and overheads 35% of total cost. Teaching and research constituted R370 million. In the context of 3 years of capital backlog and assuming that the KwaZulu-Natal (KZN) payment dispute would be resolved, NHLS had provided around R400 million for capital expenditure (8.4% of total spend). A more detailed presentation would be made to the Committee in September 2013.

Discussion
The Chairperson asked Ms VM (Tiny) Rennie, DDG: Corporate Services, DoH to share the outcome of the dispute between KZN and the NHLS.

Ms Rennie said that a task team was mandated by the DoH to amicably resolve the current conflict in an out of court settlement. It consisted of members from the National Health, KZN DoH, NHLS and the accounting general’s office of National Health. The accounting general’s report was presented to the Minister by the end of March and once approved by the Minister would be communicated to the task team for recommendations. The outcome would drastically impact on the functioning of NHLS. The report was being presented to the Exco of KZN upon the request of the MEC for Health in KZN who had an interest in resolving the matter. The outcome would have huge financial implications.

Ms Ngcobo asked to what extent NHLS was involved with the NDP.

Mr Pillay replied that the NHLS was not directly involved in the NDP, but that there was alignment with the NDP.

Ms Ngcobo asked if the NHLS model will be implemented incrementally.

Mr Pillay replied that the model was still in the development phase and once approved by the Board, Committee and Minister, it would develop an incremental plan. Without pre-empting the outcome, some elements would be incremental and others would be immediate.

Ms Ngcobo asked if there would be mobile laboratories to service some of the NHI districts.

Mr Pillay replied that NHLS was actively involved in the task team for all the districts. If NHLS laboratory footprint did not adequately fit a NHI district, then NHLS would determine the role of mobile laboratories and develop point of care solutions. The roadmap for NHLS factors in the NHI in developing a model for the future.

Ms Ngcobo asked if there was adequate intelligence in the unit to ensure that the private sector did not abuse the services of the NHLS, such as private hospitals sending patients to receive the service of the public hospital laboratories.

Mr Pillay said that NHLS would collect payment for a private patient, but if the patient was classified for public health care, there was not much NHLS could do. Registration and classification occurred at the hospital and overall there was currently improved control and gate-keeping at the hospital door. There could be a small element of abuse.

Ms Ngcobo asked if the universities could teach research on pathology and thereby reduce the burden of teaching on the NHLS.

Mr Pillay replied that throughout his presentation he talked about the second mandate. In terms of a “robust, responsive, affordable and sustainable organisation”, it was teaching and research that informed that process. Without training and research, NHLS would become a super-lab with nothing that informed the next generation. It would not be in the interest of NHLS as it would no longer be innovative, nor inform new technology. The relationship with universities was important for NHLS. Service providers are informed by what happens in teaching and research. The second point was that NHLS would struggle to attract and retain staff in a pure service delivery model. The glue for the NHLS was the technologists, pathologists and technicians and they came to NHLS for training and then stayed on. Taking away that mandate would actually put a burden on the province as it was built into costs. He suggested that ideally the NHLS should be seen as a 10th province and the training should be in the form of a grant, just as hospitals get grants for teaching doctors and nurses in a clinical setting.

Ms Ngcobo asked if NHLS appeared in journals or own in-house journal.

Mr Pillay replied that there was a partnership between the Health Science faculties and the NHLS. The NHLS pathologists had joint appointments with Health Sciences and the schools of pathology were run and funded by the NHLS which was subjected to the same rigour as that applied at the Universities. The 510 publications the previous year were all authored and co-authored in proper international peer-reviewed journals. The National Institute for Communicable Diseases and the National Institute for Occupational Health were subjected to the same rigour as any other academic publication.

Ms Ngcobo asked if NHLS had exchange learning programmes with other African learning institutes.

Mr Pillay replied that the Research Summit re-emphasised the need for increased south-south dialogue, in particular on the African continent. He would be expanding the agenda for African dialogue and the faculty’s research and service delivery improvement. There was a significant number of foreign professionals training in SA in the schools of pathology. The relationship with SADC was particularly strong. In addition, NHLS served as a supra-regional laboratory for many African partners, which did not have reference labs for TB, HIV and other public health diseases. NHLS provided these services in partnership with WHO, the African Society of Laboratory Medicine and the Ministry of Health. There was strong collaboration between countries at that level.

Ms Ngcobo asked if NHLS went through National Treasury to be able to breach the PFMA with its 40 days creditor time.

Mr Pillay said that NHLS had not engaged Treasury for approval but that this issue has been flagged by the NHLS. They would engage with Treasury at some point on the issue if it did not meet the target. It was unlikely that the NHLS would receive a waiver.

Ms Robinson asked why the turnaround time for pap smears was slower than other tests and if there was any relationship with NHLS and the Pink Drive which did screening for cancer and suggested that they could do the work for the NHLS.

Mr Pillay replied that the nature of pap smears was manual and required a technician and special preparation. Only 70 slides could be analysed per day and this was also an area where there was a massive shortage of technologists, despite bursaries and incentives to encourage young people to enter the profession. It also was not an easy area to train for. The service was now centralised as it was a scarce skill, and cytology backlogs had been caught up. While massive amounts of money could improve turnaround time, discussions in provinces were around whether it was worth investing in reducing the turnaround time when in fact the patient would only return to the clinic after four weeks. Where NHLS could not respond to a particular problem, it contracted with other providers to ensure that the work was done. He would follow up on the Pink Drive and revert back to the Committee.

Prof Perez added that researchers at UCT had found a cheap test for cervical cancer through a simple vinegar test. The pap smear could then only be used to confirm abnormal results if the vinegar test was positive.

Ms Robinson asked if accreditation of labs was a cost factor, if labs had just not got round to it, or if there had not been necessary follow up on implementation.

The Chairperson said that in their oversight on forensic cases, there was always a delay in court cases due to specimen results at forensic labs and asked what could be done about this.
Mr Pillay replied that forensic lab service was a national competency. NHLS was placed and competent to take over the technical aspect of the service and to provide support. This would also optimise the use of pathologists, but this would be a future discussion.

The Chairperson said it appeared that rural health had been neglected. He asked if pathologists were not found in those areas due to cost.

Mr Pillay replied that there was no cytology programme in the rural areas. They were centred at the academic and urban areas. If they tried to encourage cytologists to work in rural areas, they would lose them to the private sector. NHLS had looked at improving the logistics. Where the lab was located was not the issue. The speed at which patients could get results was more important. There was not a single NHLS facility in SA that did not receive a daily collection. NHLS had to address what tools would be required to address challenges in primary health care restructuring and school health programmes in rural areas. Already NHLS had positioned pathologists in all the big cities. Of significance was that in the current year, for the first time in NHLS history, NHLS had received more than 100 applications to study pathology as a specialisation and the majority of applications were from black Africans. The majority of training pathologists were women and in the previous intake, 90% of the registrars appointed in the current year were black people.

To get technologists to the rural areas, NHLS was actively recruiting trainees out of those areas. Technologists were easier to attract than pathologists, as pathologists first had to train to be doctors. However, it was not necessary to have a pathologist in every village. Moreover, for every pathologist salary of R1 million pa, five technologists could be hired.

The Chairperson asked whether it was the DoH or Minister who would decide on the price increase of 4%, as the Committee would need to convince them of the need for the increase.

Mr Pillay replied that the tariff was set out in the Act. NHLS determined the budget six months in advance and this included the tariff.  The Board amended and approved, then the NHLS wrote to the Minister who consulted with the provincial MEC for Health and Finance and the national Minister of Finance. Once it was approved, NHLS would need to give provinces 30 days’ notice before effecting the new tariff.

Ms Ngcobo said that she was concerned that the NHLS offices were situated above horse stables.
Mr Pillay replied that while the horses were important as they were needed for anti-venom - NHLS was the only provider of anti-venom on the African continent - the health conditions were not ideal for staff and NHLS would be moving the stables onto land outside of the administrative building.

Ms Ngcobo asked if all the accredited laboratories could be trusted.

Mr Pillay replied that it cost too much to get all 268 labs accredited. The Stepwise programme and internal national quality programme ensured compliance with standards in all rural areas. However, there was a need to accelerate the accreditation of all academic and regional labs.

Ms Ngcobo asked if there was a contingency plan for non-payment.

Mr Pillay replied that in the previous year, NHLS tried to get over-draft facility and Treasury responded that NHLS had to collect the money from the provinces. However, the Minister intervened on a national level and identified the laboratory services as a strong non-negotiable. There was now a strong focus on provincial budgets, building in their price increases and this would be monitored on a monthly basis. Thus, NHLS was in a far stronger position than it was 18 months earlier.

Ms Ngcobo asked if the mines were abusing the public health system in that they received private healthcare but polluted the water. TB was rife in informal settlements too.

Mr Pillay replied that there was a discussion unfolding around TB in the mines. The Chair of National Institute for Occupational Health (NIOH) was now involved and the Minister had had several important policy meetings with the mines. NHLS had been involved in the laboratory aspect of the discussions – with regard to how it responded to the diagnostic requirements. The partnership between the mines, the DoH and NHLS with respect to laboratory medicine was now a high priority. Collectively and with regular monitoring, the situation should improve. The informal settlements were a highly mobile population with high levels of lost follow-up and defaulting was a major problem.

Dr Fazel Randera, NHLS Deputy Chairperson, added that since 1994, informal settlements had increased from 200 to 2500 and a majority of those were not settled around mines. Of importance was that there were informal settlements with unaccredited facilities, and with the NHI, they would need to be revisited, just as all hospitals will be re-negotiated. The mines needed to be held to the regulatory environment introduced by the National Health Act (No. 61 of 2003) in terms of facilities being accredited. The Department of Human Settlements reported that five to seven million people lived in settlements and it was clear that most of them did not have access to health services. Mines were the wealth creators of our country, and those living in those areas were primarily black people. Given the social plans and legislation, these areas should be receiving health care as a priority.

Ms Robinson asked how confident NHLS was that the provinces would pay for services and that debtor time would be adhered to, considering lack of finance being a major issue and after experiencing the problem with KZN.

Mr Pillay replied that while lack of finance impacted on NHLS ability to train and modernise etc, with payment for laboratory services being a non-negotiable, and with national health department applying pressure, the situation should turn around. Provinces received conditional grants for TB and HIV and they were called conditional grants because they came with conditions. Therefore payment for those services by provinces should be made without concern for cash flow.

Mr Patrick Lucwaba, Executive Director: Coastal Region, NHLS added that there were rumblings, rumours and potential insecurity amongst stakeholders with regard to the roadmap.

Prof Perez replied that all stakeholder issues would be directed to the Board and properly dealt with at that level.

The Chairperson said that communication was important and the Committee was ready to assist and listen to all sides and make informed decisions. Ultimately, the aim was to ensure that South Africans received the benefit of paying taxes, irrespective of who they were and where they came from.

The meeting was adjourned.
 

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