Department of Health Strategic and Annual Performance Plan 2013

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Health

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

The Chairperson prefaced the Department’s presentation by commenting that if Parliament wanted to practise more evidence-based decision-making, it had to communicate more with the Medical Research Council and Human Sciences Research Council so that policies and laws were informed by what was happening in SA.  Parliament had to take responsibility for this lack of communication.  In future, all law and policy-making processes would have to include inputs from the research institutions.
  
The Department said its Medium Term Expenditure Framework (MTEF) priorities were derived from the Government’s outcome-based approach to service delivery.  The health sector was responsible for the achievement of Outcome 2 -- a long and healthy life for all South Africans. Under this, four outputs were identified: increasing life expectancy; decreasing maternal and child mortality; combating HIV and AIDS and decreasing the burden of disease from tuberculosis; and strengthening the health system’s effectiveness.  Further MTEF priorities were also derived from Millennium Development Goals 2000-2015 as well as health goals from the National Development Plan.

Life expectancy would be improved by implementing the expansion of antiretroviral coverage, reducing new HIV infections.  The effectiveness of the health system would be enhanced by the re-engineering of Primary Health Care, a functional District Health System, preparation for the implementation of the National Health Insurance scheme, the improvement of health workforce planning, management and development, the efficient management of health technology and an acceleration in the delivery of health infrastructure.

Key interventions to reduce new HIV Infections included conducting at least 600 000 medical male circumcisions during 2013/14, increasing contraceptive prevalence, and expanding the Prevention of Mother to Child Transmission Programme for pregnant women.   Preparations for the implementation of the National Health Insurance scheme were proceeding.  The legal framework for the establishment of the scheme would result in the White Paper being finalised and gazetted, and the Bill being tabled in Parliament next year.
Members asked why the Department still spent so much on consultants, while there was no skills transfer to staff, to make their use sustainable. Members also asked why there was still disparity between provincial and municipal clinics, and why clinics in metros did not offer comprehensive primary health care. Members also probed why there was still a disparity in remuneration packages in the public service between staff practising the same profession, depending on geographic location or whether they worked for the province or the local municipality.  Other issues dealt with how far the re-engineering of primary health care had progressed, whether functional district health systems had been established and how many ward health units had been set up.

Members asked whether the increased availability of contraceptives translated into a decrease in HIV transmission, why male circumcision could not be done with safer modern devices and whether sufficient good quality condoms were spread evenly over the breadth of the country. Had the Department measured the impact of regulations it had instituted -- for example, the regulations on smoking it instituted a few years ago?  How did the Department plan to strengthen its TB Control Programme and involve communities in the Directly Observed Treatment Short-course (DOTS) Programme?   Did it concentrate its programmes in the cities only, or also focus on the peripheries? Members wanted to know how the Department planned to increase deliveries carried out in health facilities and decrease neonatal deaths in order to reach Millenium Development Goals, which had to be reported on by 2015.  Members also asked how far the Department had implemented the Campaign on Accelerated Reduction of Maternal Mortality in Africa, and whether rural areas were targeted with this campaign.
 

Meeting report

The Chairperson welcomed all present.  The delegation was led by Dr Yogan Pillay, Acting DG and DDG: HIV,TB and Child and Maternal Health.

The Chairperson said the Portfolio Committee had seen the Council for Medical Schemes (CMS) three weeks before. The Council was not funded by the state, but generated its own revenue through the medical aid schemes. It wanted to increase these funds due to inflation. The Council had received an unqualified audit report, which was not yet a clean audit report, and the report had not said anything about service delivery.

The Medical Research Council (MRC) and the Human Sciences Research Council (HSRC) had reported to the Portfolio Committee the previous day and both seemed to have experienced many challenges.  If the three pillars running the country -- Parliament, the Judiciary and the Cabinet -- wanted to transform the country, one of the things it had to do was to have a far closer relationship with the Medical Research Council (MRC). If Parliament wanted to practise more evidence-based decision-making, it had to communicate more with the MRC and Human Sciences Research Council (HSRC) so that policies and laws were informed by what was happening in SA.  Parliament had to take responsibility for this lack of communication.  Fortunately, the MRC had a much closer relationship with the Department of Health (DoH), because it was funded by the DoH.  In future, all law and policy-making processes would have to include inputs from the research institutions. The MRC had complained that it was under-funded. A body would report to the entity from which it received its funding, so if the MRC received more foreign donor funding than funding from government, it would report to the foreign donors more than it would report to the SA government. This was something to consider. Scientists were not corrupt and only focused on their work. Funds given to the MRC would be well spent.

There were challenges with the National Health Laboratory Service (NHLS), but a solution would be found.

Briefing by the Department of Health on their Strategic and Annual Performance Plan 2013
Ms Nobayeni Dladla, Chief Operations Officer, DoH, said that the Medium Term Expenditure Framework (MTEF) priorities of the Department were derived from the Government’s outcome-based approach to service delivery: The health sector was responsible for the achievement of Outcome 2: A long and healthy life for all South Africans. Under this, four outputs were identified: increasing life expectancy; decreasing maternal and child mortality; combating HIV and AIDS and decreasing the burden of disease from tuberculosis; and strengthening the health system’s effectiveness.  Further MTEF priorities were also derived from Millennium Development Goals 2000-2015 as well as Health Goals from the National Development Plan.

Life expectancy would be improved by implementing the expansion of the antiretroviral (ARV) coverage, reducing new HIV infections, the burden of TB, maternal mortality, infant, child and youth morbidity and mortality, and the burden of communicable and non-communicable diseases.

The effectiveness of the health system would be improved by the re-engineering of Primary Health Care (PHC), a functional district health system, preparation for the implementation of the National Health Insurance (NHI) scheme, the improvement of health workforce planning, management and development, the efficient management of health technology and an acceleration in the delivery of health infrastructure.

Key interventions to reduce new HIV Infections included conducting at least 600 000 medical male circumcisions during 2013/14, testing at least 98% of all TB patients for HIV by 2015/16, increasing contraceptive prevalence (couple year protection rate) from 32.5% during 2011/12 to at least 38% during 2015/16, and expanding the Prevention of Mother to Child Transmission (PMTCT) Programme for pregnant women. 

Expanding the PMTCT Programme for pregnant women included the initiation of at least 500 000 new clients on ARVs per annum and at least 85% of all TB and HIV co-infected patients on ARVs.  It also included increasing HIV positive pregnant women initiated on ARVs from 80.4% in 2011/12 to at least 97% in 2015/16 and reducing the proportion of HIV positive babies born to HIV positive mothers from 4% in 2011/12 to at least 2% by 2015/16.

Key interventions to reduce maternal mortality included increasing the proportion of antenatal clients attending a health facility before 20 weeks, from 40.2% in 2011/12 to at least 68% in 2015/16, increasing the proportion of deliveries taking place in health facilities under the supervision of trained personnel in a public health facility from 89.3% in 2011/12 to at least 97% in 2015/16, and increasing the percentage of mothers and babies who receive post-natal care within six days of delivery from 56.9% in 2011/12 to at least 84% in 2015/16.

Measures to reduce infant, child and youth mortality included maintaining the percentage of children fully immunised under one-year of age at a minimum of 90% and the measles immunisation coverage rate of 90 % throughout the MTEF period, and expanding the implementation of the Integrated School Health Programme.  (See presentation for details).

Key interventions to reduce the burden of TB included increasing the TB cure rate from 73.1% in 2011/12 to the World Health Organisation (WHO) target of 85% by 2015/16, reducing the TB treatment defaulter rate from 6.8% in 2011/12 to less than 5% by 2015/16, and reducing the turnaround time of TB test results by increasing the number of tests conducted, using GeneXpert. An estimated 800 000 tests would be conducted using GeneXpert during 2013/14, increasing to one million by 2015/16.

Measures to improve collaboration between TB and HIV programmes to reduce the co-infection burden, included increasing the percentage of TB patients tested for HIV from 82.9% in 2011/12, to at least 98% in 2015/16 and increasing the number of HIV positive patients that receive Isoniazid Preventative Therapy (IPT) from 360 168 patients in 2011/12, to at least 525 000 in 2015/16.

Key interventions to reduce the burden of disease from communicable diseases included the establishment of a National Public Health Institute to reform and strengthen the capacity of the National Institute of Communicable Diseases (NICD) over the MTEF, improving access to cataract surgery to at least 1 500 operations per million  population in all nine provinces, increasing the cervical cancer screening coverage from 55% in 2011/12 to at least 60% by 2015/16, and decreasing the incidence of malaria from 0,58 cases per 1 000 population in 2011/12 to at least 0.45 per 1 000 population at risk in 2014/15, in keeping with the target to eliminate malaria by 2018.

Measures to improve the quality of health services included increasing the number of districts supported by Facility Improvement Teams to two, and establishing full Office of Health Standards Compliance by 2015/16.

Key interventions in the re-engineering of PHC included increasing the number of municipal ward-based primary health teams to 750 in 2013/14, 1 000 in 2014/15 and 1 500 in 2015/16, improving  access to primary health care services with an increased utilisation rate of at least three visits by 2015/16, expanding the number of districts with the full complement of members of the district clinical specialist teams to at least 20 districts in 2013/14, up to 25 during 2015/16, improving access and quality of PHC supervision and implementing  the Integrated School Health Programme, among others.

Key interventions to improve health workforce planning, management and development, included development and implementation of norms and standards for health workforce planning, increasing the number of medical students registered at South African universities by at least 10% every year over the METF, increasing the number of hospital managers trained as per the training programme developed by the Academy for Leadership and Management in Health – 105 during 2013/14, 100 during 2014/15 and 100 during 2015/16.

Key interventions to create a functional District Health System included the development and implementation of an inter-sectoral framework for addressing the social determinants of health, developing a district quarterly review guideline during 2013/14 to institutionalise district quarterly reviews, and strengthening the disease outbreak response by establishing trained disease outbreak teams in 20 districts by 2013/14 -- to be implemented in all 52 districts by the 2015/16 financial year -- and developing a revised District Health System strategy which would be inclusive of a District Health Authority.

Preparation for the Implementation of NHI
Key interventions include:
Preparation of the legal framework for the establishment of the NHI; 2013/14 White Paper on the NHI to be finalised and gazetted; 2014/15 NHI Bill to be tabled to parliament; 2015/16 Implementation of regulations; the development of a conceptual framework for the creation of the NHI Fund in 2013/14 with the first phase of implementation in 2014/15;[
Increase revenue collection in central hospitals -- four in 2013/14, seven in 2014/15 and ten in 2015/16; Contracting of the general practitioners (GPs) and other health service providers; 2013/14: 600 GPs to be contracted to work in 533 clinics in NHI Pilot Districts

Key interventions to accelerate the delivery of health infrastructure include procuring and signing the agreement for Chris Hani Baragwanath hospital during 2013/14, issuing the Request for Proposals (RFP), procuring and signing the Request for Qualification (RFQ) and RFP for Limpopo Academic Hospital, completing feasibility studies for Dr G Mukhari, Nelson Mandela Academic Hospital and King Edward VIII projects, and procuring transactional services for the Mpumalanga Tertiary and Tygerberg hospital projects.

Five of the seven planned tertiary hospitals (Nelson Mandela Academic (EC); Chris Hani Baragwanath (GP); Dr. George Mukhari (GP); Limpopo Academic (LP); King Edward VIII (KZN)) would have commenced with construction by 2015/16.

Resource Envelope for Implementation of the National DoH Plans For 2013/14 To 2015/16
Trends

The Department’s expenditure grew from R19.2 billion in 2009/10 to R27.9 billion in 2012/13 at an average annual rate of 13.3%. Over the medium term period, expenditure is expected to grow to R36.7 billion, at an average annual rate of 9.4 %. The increase in both periods is driven largely by transfers to provinces for the conditional grants, with the main increase being on the HIV and AIDS programmes, and the introduction of an NHI grant.

Allocation
The Budget included additional allocations of R800 million for 2015/16 for increasing the provision of antiretroviral treatment.  These were:

●          R100 million for 2014/15 and R384 million for 2015/16, partly to offset the decrease in funding over the medium term, would come from the US President’s Emergency Plan for AIDS Relief (PEPFAR). This programme had contributed roughly R4 billion per year towards the South African national HIV and AIDS and tuberculosis response. The amount was likely to decrease by 50% over the next five years.

●          R15 million in 2015/2016 for the South African National AIDS Council for HIV and AIDS programmes.

●          R22.1 million, R28.3 million and R41 million for improved conditions of service, to cover high personnel costs.

Cabinet had approved reductions of R531 million over the medium term.  Reductions of R26 million (R11 million, R10 million and R5.2 million) over the MTEF period had been made to the National Health Insurance grant due to slow expenditure.

The Department had reviewed the staff establishment in 2010/11 in relation to its human resources needs and the functions assigned in terms of the approved budget structure . The establishment was projected to increase moderately to strengthen skills and experience.

Infrastructure Spending
The three health infrastructure grants (Hospital Revitalisation, Health Infrastructure and Nursing Colleges and Schools grants) had been consolidated into a single direct grant, called the Health Facility Revitalisation Grant, with three windows.

Spending on infrastructure had increased from R3.2 billion in 2009/2010 to R5.8 billion in 2012/2013, and was expected to increase to R6.5 billion over the medium term.

The Health Facility Revitalisation Grant had been allocated R14.9 billion over the MTEF period (R5.1 billion, R4.7 billion and R5 billion.

The new indirect schedule 6A grant was called the National Health Grant. This grant would have two components, one for National Health Insurance (NHI) and one for the Health Facility Revitalisation Grant.

The new National Health Grant contained a Health Facility Revitalisation component. This grant had been allocated R4.2 billion over the MTEF period (R807 million, R1.7 billion and R1.7 billion) and wais a grant-in-kind to the provinces.

Conditional Grants
C
onditional grants, which could be withheld due to poor performance, were listed.

Conclusion
The National DoH Annual Performance Plan 2013/14-2015/16 reflected interventions to improve the health system and health outcomes for all South Africans.

Achieving the health sector objectives would require fundamental reform of the health system in the country.  This would mean focussing on improving infrastructure, human resources for health and improved management capacity, including norms and standards for staffing, accountability in planning and budgeting, development of capacity and systems in financial management, health financing reform and reform of key strategic institutions.

The Department would continue to work towards improving health care equity, quality and access through the introduction of the National Health Insurance scheme, and building human resource capacity in the health sector through various initiatives.

Discussion
Consultants
The Chairperson said the Portfolio Committee was very happy with some of the things the Department had done. However the Auditor General had mentioned in his report that many consultants were used and no skills transfer had happened.
Dr Pillay thanked the Portfolio Committee for acknowledging the progress made. He replied that the view of Parliament and SCOPA was that consultants could be used, but there had to be skills transfer to personnel in the public service to make it sustainable. There were areas where expert skills would be needed for short periods of time. There would be a role for consultants, but it would be in very specific situations and there had to be a skills transfer. The state had to have a relationship with the private sector and there was a way to bring the private sector into the public space. The Minister was talking to GPs about their future role in the NHI. The private and the public sectors had to work together in the NHI.

Re-engineering of the Health System
Ms M Segale-Diswayi (ANC) said according to the presentation, there was an improvement in service delivery, but she hoped the improvement on the ground was as visible.

Ms B Ngcobo (ANC) asked whether the NHI had kicked in, in April 2013, as the Minister had promised.

Ms Segale-Diswai said, the presentation indicated that there would be an increase in municipal ward health units to 750 in 2014/15. She wanted a breakdown of this information for when she went to do oversight in the Kenneth Kaunda or Bujanala regions.

Ms Jeanette Hunter, DDG: Primary Health Care and Nutrition, replied that the Department would send the information of a breakdown of the ward-based outreach teams to the Parliamentary Officer of the DoH.

Ms Segale-Diswai asked how far the country was in creating a functional district health system. Regarding the devolution of power, from where to where should it move. Should it move from province to local government?  She asked, because clinics in metros still felt like local municipal clinics. She was once in a clinic in Cape Town where she had been told the clinic did not do adult curative, only immunization. Adults were referred to other clinics. Most clinics in metros did not do comprehensive health care. There was a vast difference between clinics falling under the provincial government and those under municipalities.  Remuneration for nurses had to be uniform, whether they worked for the province or the local municipality.  Because of the Occupation Specific dispensation (OSD), nurses left the municipalities for the provincial health facilities.

Dr Pillay replied that PHC was the foundation of the DoH health system.  A new DDG for PHC, Ms Jeanette Hunter, had been appointed.  He hoped the new energy and focus she brought along would accelerate implementation. The Minister had been talking about three streams. He would elaborate on each of these.

Ward-based Outreach Teams
With regard to the ward –based outreach teams, the annual report would show that at the end of the 2012/13 financial year there were 500 teams in place, and currently there were between 500 and 700 teams in place. There were 4 000 municipal wards countrywide and there had to be a team in each ward, meaning there was still much to do in this regard.  

Integrated School Health Programme
In October 2012, the President had launched the Integrated School Health Program in partnership with the Department of Basic Education. The national DoH, with assistance from the European Union, had bought 30 school mobiles units, which were being deployed in the NHI pilot districts. Another 60 would be bought before the end of October. These would also be deployed in the rural areas. Some of these mobiles would be 4x4’s so that they could reach places with poor road infrastructure as well. The ward- based outreach teams would also be targeting the NHI pilot areas and be concentrated in rural areas. Rural areas had less access to fixed health facilities, which meant that services had to be taken to the people, whether it was promoting health, preventing disease or curative health. It was not feasible to put fixed facilities everywhere. School health was doing well and exceeded the targets for 2012/13 for Grade 1’s in Quintile 1 and 2 schools. It was still a challenge to reach the Grade 8’s.

District Clinical Specialist Teams
District clinical specialist teams consisted of four doctors and three nurses and the aim was to put a team in every district.  34 districts had three of the seven personnel already.  It was difficult to recruit doctors for these programmes. There were a few districts which had full teams.

Impact
Dr Pillay said the DoH could already see the impact of these programmes. He had visited OD Hospital In Gauteng north of Pretoria. At Jubilee Hospital, close to OD Hospital, three babies had sustained burn injuries in 2012 because they had been put into incubators which had been poorly maintained. Both Jubilee and OD Hospitals had new state-of-the art new-born care units installed. Between 2010 and 2012, these hospitals had reduced neonatal deaths from seven to eight, to between one and three per month. There were pockets of good things going on, but the DoH had to figure out how to make this happen everywhere.

Contraceptives
Ms Segale–Diswai said she had noticed that the availability of contraceptives had been increased, and would have. expected the infection rate to have decreased accordingly.

Dr Pillay replied that the DoH had adopted a new contraception and fertility policy. It was increasing the training on the administering and removing of a number of intra-uterine devices (IUDs). There would also be implants, which was new. The DoH was waiting for one more product to be registered at the Medicines Control Council (MCC), before going out on tender. The idea was to expand the contraceptive method mix. There was the injection, the pill, IUDs, the male condom, the female condom and now, the implant. The DoH had trained people on UID insertion and removal and would do the same for the implants.

Condoms
Ms D Robinson (DA) asked how the distribution of condoms was progressing. There was a shortage of latex. Could the DoH make sure the condoms were of a good quality and were evenly distributed?

Dr Pillay replied that the DoH had not reached the 1 000 000 target for condoms. There were not enough supplies. The DoH was working with the United Nations Family Planning Unit (UNFPU) to see whether SA could not buy condoms off its tender, because it went out on a global tender.  There was a possibility of buying 500 000 male condoms through the UN tender, which meant that male condoms could increase. The DoH had also received a donation of female condoms from the UNFPU, but female condoms were still available in far lesser numbers than male condoms.

Male Medical Circumcision
Ms Robinson asked how one would match up the traditional male circumcision with modern medical practice. Young people were being butchered. In England she saw a circumcision device and wondered whether it could not be applied in SA. Male circumcision needed to be improved and increased to help curb the spread of HIV.

The Chairperson replied that medically trained people approached traditional surgeons and offered to train them to perform safer circumcisions, taking care not to belittle the tradition. Initially they had refused, but later agreed. Now even traditional circumcisions were medical circumcisions, but they happened in the bush. Traditional circumcision was more than mere circumcision. The young man changed his culture from that of a boy to that of a man. The clamp was problematic to use on adults.

Dr Pillay added that the WHO was almost ready to pre-authorise a device to be used for doing medical male circumcisions. Clinical trials had been done in Zimbabwe, Rwanda and Uganda. The DoH had sent a team to Rwanda to learn how to use it. As soon as this device was pre-authorised by the World Health Organisation (WHO), SA would consider using it. It was a ring device.
SANAC
Ms Segale-Diswai said she wanted to see performance in concrete terms. The South African National Aids Council (SANAC) received huge amounts of funding, but the Portfolio Committee (PC) did not know how it was performing. The Portfolio Committee did not know how the nine Provincial Councils on Aids (PCAs), District/Metro Aids Councils (DACs) and Local Aids Councils (LACs) were performing either. The Portfolio Committee was also to blame because it never called SANAC to Parliament to account and no performance report of the DoH said anything about SANAC either. The Portfolio Committee heard about SANAC only when the DoH talked about money. She wanted the Portfolio Committee to get performance reports on SANAC during this financial year.

The Chairperson agreed that the problem was with the PC, for not calling SANAC to come and account. The DoH was running HIV programmes, but it saw the need for a comprehensive HIV strategy involving all facets of society, which resulted in the formation of SANAC. For financial security reasons, funds could not be transferred directly to SANAC. An alternate mechanism to transfer funds had just been finalised. The Portfolio Committee would call SANAC, the DACs, and the PCAs to come and account.

Dr Pillay replied that SANAC used to be a program in the DoH, run by a director.  Over time, the Department had taken SANAC outside the Department.  There were 19 sectors in SANAC, of which the government was one, and the DoH was one role player within the government sector.

SANAC now had its own bank account. It was chaired by the Deputy President and co-chaired by civil society. It had large plenaries, which were large stakeholder meetings.  The next one would be held on Friday, April 19 2013, in Secunda. The idea was to take the plenaries to the different provinces to hear from the premier of every province how they were doing in terms of TB and HIV. The Premier of Mpumalanga would do a presentation on the progress made in the province in terms of TB and HIV. The previous one was in KZN.

The Programme Review Committee reviewed what sectors in SANAC did. One of these meetings had taken place two weeks before. The idea was that all sectors had to contribute to prevent the spread of TB, HIV and other STI’s. SANAC had a new chief executive officer (CEO). The new CEO had to come to the Portfolio Committee to be introduced. One of the mandates the Deputy President had given the SANAC secretariat was to strengthen provincial and local AIDS councils. The SANAC secretariat had visited the provincial and local AIDS councils in the North-West. The provincial AIDS council was the best staffed provincial AIDS council in the country, with 60 people working there. The national SANAC secretariat had also been to Limpopo and Mpumalanga to see how to strengthen and restructure these entities.

PEPFAR Funding
The Chairperson said the reduction in the Presidential Emergency Plan for AIDS Relief (PEPFAR) funding was not only impacting on SA, but also on its neighbours, because many citizens from neighbouring countries came to SA to get their ARVs.

Dr Pillay replied that the US government, though PEPFAR, have been providing the SA government with just under $500 million per year for the last ten years for HIV and AIDS work. Because of the economic situation in the US and globally, and because SA was seen as a middle-income country which could fund its own programmes, there was an agreement that over the next five years, from 2012, this amount would be halved. Some of the money went to NGOs and some went to different government departments. The DoH was the biggest beneficiary. The agreement was that funding for treating people with HIV would be decreased but technical assistance and prevention would continue at the same level. This implied that government had to bear the cost of treating HIV patients who had been treated using PEPFAR funding in the past.

There had been a transition plan in place to oversee an orderly switchover and this had lasted for 18 months. Apart from a few hiccups the transition had happened. The SA Minister of Finance was in Washington during the week of 16 April, and one of the things he would be discussing with the US Administration would be PEPFAR funding. National Treasury had given more money to make up for the deficit.

The Chairperson said Consul General of the USA in SA had invited him to a meeting. He would use the opportunity to address the issue of the PEPFAR funding.

Medical Supplies Crisis in Limpopo
Ms Robinson was happy with the improvements in the delivery of health services. At the national level, everything seemed to be fine. There were, however, problems at provincial level. On TV news on the night of 16 April, the MEC for Health in Limpopo had said there was no immunisation stock at some clinics, while the National Minister had said there was plenty of stock. Why were children’s lives and health being compromised? There was an excuse that there had been a lack of funding earlier on.

Ms V Rennie, Head of Corporate Services, DoH, replied that the contradicting statements were the result of a lack of communication and misunderstandings. There were vaccines at the depot, but there had been internal mismanagement. Manufacturers supplied to the depot and the depot distributed to the hospitals. There had been a delay in the distribution due to a transport contract having lapsed and a new one not being negotiated in time.
The medical supplies had been at the depot and not at the clinics. The MEC had not been given a detailed briefing before he spoke to the media. The Minister had been briefed, resulting in them making contradicting statements in the press. It was true that there had been a problem with funding in 2012. This problem had been addressed by means of the adjustment budget and the medication had been procured.

The Chairperson said the Portfolio Committee would send two Members to Limpopo province to go and verify what was happening there. A member of the DoH delegation said the National Council of Provinces (NCOP) was in the province until 19 April, and she suggested that the Portfolio Committee communicate with the Members that were there already and ask for a report. The Chairperson said he would contact the Members of the NCOP.

Maternal and Child Mortality /CARMMA/MDGs
Ms Robinson said she was concerned about the maternal and child mortality rates.  The Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) was launched in SA in April 2012. Was the DoH able to reach out to the rural areas? Hospital and clinic deliveries had to increase, but how was that going to happen?  Would more staff be deployed to do these deliveries? Would the people who would be trained, be responsive and caring?  She asked how one would improve the work ethic in medical personnel at ground level, as there were still complaints of negligence. How would one increase the points for deliveries in order to reach Millenium Development Goals (MDGs)?

Ms B Ngcobo (ANC) said 2015 was the year when the MDGs would be evaluated. How would SA do in terms of maternal health?

Ms H Msweli (IFP) asked whether the Department could explain the results from the National Committee on Confidential Enquiries into Maternal Deaths, which reflected that institutional maternal deaths had decreased from 180 per100 000 beds in 2010 to 160 per100 000 beds at present.

Ms Ngcobo said there was a report published in May 2012, when CARMMA was introduced. How far had the Department implemented CARMMA?  By May 2013, the DoH would have to produce a report.

Dr Pillay replied that for maternal health there was a significant reduction in institutional mortality due to the HIV programme. The more women were HIV-free or on treatment for HIV, the less likely they were to die during childbirth, but there were other reasons for maternal mortality during birth. Obstetric haemorrhage was a big problem. Since June 2012, the DoH had a team training doctors and midwives on the ways to manage it. The Department was concentrating on the 25 worse districts and the 12 worst of the 25.  This was an intervention that would save many lives. Hypertension was also one of the major causes of maternal mortality which had to be managed.

The DoH was targeting geographical areas with high incidences of mortality, as well as the specific causes of mortality, to reduce the rate.

What the DoH would not know immediately was the rates of mortality in communities post discharge. This would only come to the DoH via the research of the MRC.

The district clinical specialist team’s role was specifically to work with every facility in every district to ensure a decrease in infant, child and maternal mortality rates in their district, together with the PHC facilities staff and the district management team. The DoH felt it had the right interventions in place. It now needed to measure the impact of these interventions.

The major causes of mortality for children under five was in this order: HIV (40%), pneumonia, diarrhoea, severe malnutrition and increasingly TB. 

With regard to HIV, the lower mother-to-child transmission was, the lower the mortality rate due to HIV would be. The DoH had introduced two new vaccinations in 2008, one for diarrhoea and one for pneumonia. The National Health Laboratory Services (NHLS) had been monitoring the impact of these two new vaccines. Each vaccine had reduced mortality by 5% at 80% coverage.

The HIV programme and the two vaccines had had a positive impact. Where the DoH was not doing very well was with severe malnutrition. Severe malnutrition was still the same. The DoH also had a challenge with neonatal mortality -- death during the first 28 days after delivery – where the country was stuck at 14 per1 000 against a target of 12 per 1 000 by 2014.

The DOH had a package of interventions to deal with neonatal mortality. It had sent letters to hospital CEO’s and copied the district manager and the district clinical specialists. The letters stated the mortality rates for the country against MDG targets, and listed what was happening at a provincial level and what was happening at that particular institution. A list was given from the three ministerial committees of the major causes of mortality. They were asked what should be done to decrease the mortality rate.  They were then given the space to set their own targets. The DoH hoped that the district specialist teams would work with each facility to set targets and to put the right interventions in place to reduce neonatal mortality.

 Dr Pillay said he would give copies of these letters to Members for facilities in the areas where they lived, so that they could follow up.

Regarding re-engineering of the health system, the DoH was doing all the right things. It only needed full coverage and good quality

Dr Pillay said that the DoH, jointly with the African Union, would do a review of CARMMA and the implementation of CARMMA on the continent.  Dr Nkosazana Zuma would give a report in South Africa between 1 and 3 August 2013.

The state of health facilities
Mr G Lekgetho (ANC) said the presentation talked about accelerating the delivery of health infrastructure. He lived in Mafeking and had received complaints about Victoria Hospital. He would investigate and communicate with the Dr Pillay about the case.

The Chairperson asked how health facilities could be spread around, so that people could receive good health care where they were, instead of having to flock to the cities as was currently the case.

Ms Ngcobo said there was a disparity between government and municipal clinics. When would there be negotiations to get all clinics to do the same work?

Dr Pillay replied that over an 18-month period, the Health Systems Trust (HST) and a consortium lead by HST had been to every health facility and done a facility audit so that every facility knew what its baseline looked like. The Minister and the DG had then set up teams from the national Department to go to these districts to develop improvement plans tailored for that specific district. Each person in the national department management team had a district to fix and had to be able to show the “before and after” pictures.

The DoH would provide a report on all facility improvement projects, as well as the remaining challenges. The DoH tried to focus more on the rural areas, but there were significant challenges in the rural areas and they would be there for a while, until there was a more robust programme and a whole-of-government approach to the rural areas. It could not be done department by department.

TB Control Programme
The Chairperson said it had been very surprising when the Statistician-General had mentioned that the commonest cause of death in the country was TB.  TB was an infectious condition and it meant that there was a huge gap between the rich and the poor, because TB thrived in poverty-stricken communities. The fact that instances of TB were on the increase, meant that the gap between rich and poor was becoming wider.

Ms Msweli asked how the Department would strengthen the National TB Control Programme. How would the Department involve the community in the Directly Observed Treatment Short-course (DOTS) TB Programme?

Dr Pillay replied that a project had started on World TB Day three years ago in one of the hot spots for TB.  It had involved case-finding in communities by going into households and doing screening tests for HIV and TB in order to increase contact tracing.

Ms Ngcobo said it could not be denied that SA was an epicentre of TB.  SA had mines, rural areas and informal settlements, which were ideal breeding grounds for TB. Where did the department focus its treatment programmes -- only in the cities, or on the peripheries as well?

Dr Pillay replied that the HIV epidemic was driving the TB epidemic -- 60% of HIV positive people also had TB, which meant that HIV positive people had to be protected from getting TB.  TB had existed since antiquity and was a disease of poverty. On the mines, the incidence of TB was seven times higher than in the general population. Gold mines were the worst, because they were old and deep and contained silica dust. The contributors were also poor nutrition and poor living conditions, like single-sex hostels and cramped accommodation.

Government as a whole, and in particular the Deputy President, had recognised the importance of dealing with TB on the mines. Two years ago, World TB day had been held on the premises of a mine at Carletonville to ensure that government, together with the mining companies and unions accelerated the process of dealing with TB.  World TB day 2013 had been held in Pollsmoor Prison, Cape Town, where he had repeated his message. Together with the Deputy President and SANAC, the DoH was increasing its focus on the mines.

SA had been accused by neighbouring countries of exporting TB via the mines. To combat this, there had been a regional initiative, led by the Stop TB Partnership and the World Bank as well as the Ministers of Health of all the participating countries.  Participating countries were Swaziland, Lesotho and Mozambique. The regional initiative would firstly, harmonise treatment protocols over the region, which meant that it should not matter whether the patient was in SA or in his home country, he could continue with his treatment regime.  Secondly, the initiative would develop a simple integrated referral system, which meant that the patient could have started treatment in SA, but could be referred for follow-up treatments and investigations to his local clinic in his home country. Thirdly, the initiative would trace family members of TB patients, irrespective of the country in which they found themselves. There would be a series of activities that would culminate in a regional summit, co-hosted by the Southern African Development Community (SADC), the World Bank, the Stop TB Partnership and the Ministers of the four countries. This would happen by late November/early December in SA. At this meeting, the steps that had been taken and implemented, to have a regional response to TB, would be announced. Regarding funding, the Global Fund had agreed to review a proposal to fund this regional response to TB. The DoH was involved in putting together a proposal for the regional TB control programme, which related largely to TB on the mines.

People migrated not only for mining, but a significant component of the mining community was affected. The new technology – GeneXpert improved case finding in all mines. Miners also lived in communities surrounding the mines and the Department worked with the big mines to roll out the services provided at the mines, to the communities surrounding mines as well.

ESKOM had built several new power plants in rural areas, and communities were fast developing around these power plants -- in the coal mining areas in particular. These were the next new hotspots for TB and HIV.  It had been agreed the previous week at an inter-ministerial committee chaired by the Deputy President that, together with each big tender for a big infrastructure initiative, there had to be a plan to mitigate the health risks which would result.

SA’s TB cure rate was 78.9% but the target was 85%, so SA was still far from the target.   The Northern Cape (NC) and North West (NW) were the worst provinces in terms of progress and this was due to bad management. The National DoH had gone to each province and each district in each province to assess what state its TB and HIV programmes were in, to determine what the challenges were and to make recommendations to the DoH as to how the programmes could be strengthened. Dr Pillay personally had been to the NW and found that there were some good things happening, but also huge challenges.

The Minister had highlighted three groups on which to focus, apart from the TB prevention and treatment programmes for the general population: Firstly, children, because it was hard to diagnose TB in children early, and secondly and thirdly, mineworkers and prisoners, because of the high incidence of TB in these environments. The prevalence of TB in prisons was the reason the Deputy President had hosted World TB day on 25 March at Pollsmoor Prison. The DoH now had a programme to improve and expand TB services in prison, in cooperation with the Department of Correctional Services.

Gateway Clinics at Hospitals
Ms Ngcobo said people always wanted to go to hospitals. In KZN there was a hospital known as Mshiweni, which had a gateway clinic. This eased the burden on the hospital, because the clinic would filter the people and refer them appropriately. Could this system be applied on a wider scale?

Dr Pillay replied that many facilities had gateway clinics, but not all.  In Pretoria there was Steve Biko Hospital and next to it was the District Hospital, which had a gateway clinic. 

Patients by-passed clinics for many reasons. They thought the quality of care was below standard, or there were no doctors. This was why the plan was to place doctors in PHC facilities. There had to be consulting rooms and all the equipment.  PHC nurses were well trained and they would be able to refer patients that needed to see a doctor, to the GPs in the clinics. The plan was to put 550 GPs into PHC in the next financial year. This intervention would increase user satisfaction and outcomes and decrease the load on secondary health care facilities.

Vacancies
Ms Ngcobo asked whether there were vacancies on the DoH and if they would be filled in the near future?

Ms V Rennie, DDG: Corporate Services, replied that vacancy rates were standing at 8.4%. In 2012 it had been 25%, but had been reduced due to the personnel and salary administration (PERSAL) clean-up process. The DoH was in the process of implementing a new organizational structure. The department had decided, in the light of limited funds, to prioritise the office of standards, provincial support units, and primary health care.

Over and above the current 50 posts to be filled, the department was hiring 371 interns. They had been appointed in 2012 to assist the provinces with turning around their audit findings. The interns’ term expired at the end of April 2013, but from 5 May 2013 they would start at the department on a contract basis for a further two years. The national DoH would employ them and second them back to the provinces to continue with the work they were doing.

Parity
Ms Segale-Diswai said there had to be parity in terms of levels and hierarchies in the public service, for example, the level and the remuneration for a director or deputy director had to be the same everywhere in the public service, but they were not the same. In 1994 there had been a demand for parity in the public service, but 20 years later there was still not parity. The lack of parity in levels of remuneration led to professionals constantly going after greener pastures, as well as professionals gravitating towards urban or more affluent areas and away from poverty-stricken rural areas, where they were needed more.

Ms Rennie replied that in 2010 a new organogram had been implemented in the national DoH. In 2011, the DoH had started engaging the provinces to align their organograms with the national one. The new Limpopo organogram had been completed and was awaiting approval. The issue the Member was referring to was the levels of managers at district level. At national level the DoH was busy, in partnership with the WHO, in determining norms and standards and staffing ratios. This had been done in conjunction with all the provinces, in terms of piloting, so that the provinces could take ownership of the projects.   The outcome would be presented to the National Health Council for adoption. Once adopted, the provinces could implement it. In terms of this model, district managers would all be at the same level across all provinces.

Monitoring the Impact of Legislation and Regulations
Ms Ngcobo said many regulations had been put in place since 1994. There had been a regulation on tobacco. Had they been evaluated?

The Chairperson said SA government had good policies and strategies, but weak monitoring. Laws were promulgated and regulation instituted. Did the DoH monitor the impact of regulations, for example the tobacco regulations, which had been instituted several years ago. These questions needed to be asked to see the outcome and if the outcome was not favourable, government had to re-regulate.

Ms N Matsau, Head: International Relations, Health, Trade & Health Product Regulation, replied that in SA there was very good evidence of the impact of these regulations, especially in the Youth Behavioural Survey. It showed a decline in the use of tobacco by youth. The smoking and TB tobacco regulations had helped to reduce smoking and smoking was an aggravating factor in the spread of TB.

Being signatories to the WHO Framework Convention on Tobacco Control bound the country to implement steps to control tobacco. The UN and WHO assessed how countries progressed towards meeting targets in tobacco control. There were no kudos for those who met the targets, but there were subtle social punishments for those who did not meet them. Four years ago, Switzerland was supposed to have hosted the Conference of the Parties (COP 3), but when the WHO assessed and compared SA with Switzerland, it saw SA was ahead of Switzerland in compliance and SA was given the honour of hosting COP3. Hosting big international conferences gave a name and a face to a country and put countries on the map.

SA waited until other countries had piloted some of the regulations and monitored how they stood up to legal challenges in court, before piloting the programmes in SA.

Dr Pillay added that the department had a unit which oversaw public entities.  Ms Mhloti Mushwana was head of Public Entities. At an operational level, the DoH had a good working relationship with its entities. Regarding governance, the Public Entities Governance Unit was responsible. The functions were split. An example was the NHLS, which dealt a lot with HIV and TB. A different part of the Department related to these entities on a day to day basis and a different part monitored their progress. The MRC, Human Sciences Research Council (HSRC) and Statistics SA were responsible to collect data, to determine whether things were working. The MRC did the prevention of mother-to-child HIV transmission surveys for two successive years. The DoH and the Centre for Disease Control funded the MRC to do this. The department funded the HSRC to do two surveys, the results of which should be available later in 2013. One was the SA Health and Nutrition survey and the other was the Under Five Neo-natal and Maternal Mortality Survey. The first one was an assessment of what the country could expect in terms of non-communicable diseases. The last demographic and health survey that was done, was completed in 2003 and the one before that was in 1998. The result would give an indication of the mortality rates at a population level. The DoH used the MRC and the HSRC to evaluate what progress it made, because while they were state entities, they were independent and objective.

Recently burden of disease statistics were released. It was 2010 data, but it was still useful. The data came from death certificates. The department had improved the way in which death certificates were filled in. The DoH, together with the Department of Home Affairs, had trained the doctors who filled in the death certificates to do it better, but it was still not perfect. It had used a combination of death certificate data and the 2010 health data. The DoH had to rely on the doctor to give the correct cause of death, as well as the underlying causes of death. A way had to be found to link the two.

Communication between the DoH and the Provinces
The Chairperson said most of the funds to combat TB went to the provinces. The DoH did not have an effective way of communicating with the legislators in provinces so that monitoring could be done more effectively. Most of the funds were spent by the provinces and this was the level where most of the work was done.

Ms Ngcobo said it seemed that there was a break in communication between the national and provincial spheres of government in this respect. Although there was a MinMEC, communication did not happen as it should have.

Dr Pillay replied that previously, the national department used to provide the guidelines and give the money to the provinces and trusted them to do the work. Now the National DoH and the provincial health departments assisted each other in doing the work.

Formula of the Presentation
Mr Lekgetho asked why the DoH did not, for this presentation, stick to the formula of the Annual Performance Plan as prescribed by National Treasury, using headings such as strategic objectives, indicators and targets etc.

Ms Dladla replied that there were guidelines provided by National Treasury to which the DoH adhered. The DoH had also submitted a copy of the Annual Performance Plan to Members, which indicated the vision, the mission, strategic goals, situational analysis and budgets. As a result of the level of detail in the presentation, the presentation did not follow the formula as prescribed by National Treasury, becauses he wanted the presentation to be accessible to Members.

Closing Remarks by the Chairperson
The Chairperson said the Portfolio Committee had observed was that while the DoH serviced both the public and private health services, there did not seem to be a good working relationship between the two.
The Office of Standards was almost finalised and would soon be waiting for the President’s ratification

The Chairperson said the high levels of violence and sexual violence in the country was an indication of high levels of mental health disturbances in society. Mental health was an area the medical profession had to pay much more attention to.  There were many psychopaths in SA society, and while he did not say criminals should not pay for their deeds, he believed it had something to do with the country’s past. He advocated that there should be mental health assistance for people after having served jail sentences. For him the levels of violence were abnormal and it was something which needed attention from the medical profession.

The Chairperson said the presentation of the Annual Performance Plan was the Department telling the Portfolio Committee what it planned to do with the money it had asked for. The PC was satisfied that the money would be well spent and would motivate for the DoH budget to be approved.

The meeting was adjourned.
 

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