Briefing by the Department of Health on their Strategic Plan and Budget Vote 2013

Meeting report

Briefing by Department of Health Strategic and Annual Performance Plans 2013
Ms Nobayeni Dladla, Chief Operations Officer, Department of Health, briefed the Committee on the Health Sector priorities and key interventions.

The Medium Term Expenditure Framework (MTEF) priorities were derived from the 10 point plan 2009-1014 and government’s outcome-based approach to service delivery. It included four outputs: increasing life expectancy, decreasing maternal and child mortality, combating HIV and AIDS and decreasing the burden of disease from TB, and strengthening health system’s effectiveness. This was related to the Millennium Development Goals 2000-2015 and the National Development Plan 2030.

The priorities were to reduce new HIV infections; expand the Anti-retroviral coverage; expand the prevention of mother-to-child transmission programme for HIV and pregnant women; reduce maternal, youth, child and infant mortality; reduce the burden of TB; improve collaboration between TB and HIV programmes; strengthen management of non-communicable diseases and reduce the burden of disease from communicable diseases; improve quality of health services; re-engineer primary health care; improve health workforce planning, management and development; functional district health system; preparation for the implementation of NHI; efficient management of healthcare technology; accelerate the delivery of health infrastructure.  The key interventions for priority areas were listed (see presentation attached).

Dr Ian Van der Merwe, Chief Financial Officer, Department of Health, explained the allocations assigned to the projects over the MTEF period. The government baseline grant had grown to R27.9 billion since 2009 (an average annual rate increase of 13.3%). Over the medium term, expenditure was expected to grow to R36.7 billion and growth rate was expected to be 9% toward 2015/16. The increase was driven largely by revitalisation of conditional grants - transfers to provinces – with the main increase being on HIV and AIDs grants and the introduction of the NHI grant. The budget included large grants of: R800 million for 2015/16 up-scaling of anti-retroviral (ARV) treatment; R100 million (2014/15) and R384 million (2015/16) to offset the decrease in funding over the medium term from the US President’s Emergency Plan for AIDS Relief (PEPFAR); and R90 million, R100 million and R250 million over medium term for the Medical Research Council. More detail on the medium term allocations can be found in the attached document.

The three health infrastructure grants (Hospital Revitalisation, Health Infrastructure and Nursing Colleges and School Grants) had been consolidated into a single direct grant called the Health Facility Revitalisation Grant to allow for more flexibility to shift funds between the three windows and ensure timely delivery of infrastructure. Essentially, a portion went directly to provinces as a direct grant and a portion via DoH to provinces. Spending increased from R3.2 billion in 2009/10 to R5.8 billion in 2012/13 and was expected to increase to R6.5 billion over the medium term.

The new indirect schedule 6A grant, the National Health Grant, was established with two components. The first was NHI (R291 million to DoH on behalf of provinces) which was made up of R40 million for Diagnostic-Related Group for central hospitals and R251 million for contracting of general practitioners. The second was Health Facility Revitalisation (R807 million). DoH would monitor spending on the specific projects in the provinces relating to Hospital Revitalisation, Health Infrastructure projects and Nursing Colleges and School Grant. Procurement of projects would also be done by DoH. In the first year, the R807 million DoH allocation to provinces would vary from province to province, depending on the requirements of the project. For example, allocation for the Eastern Cape was R135 million, Limpopo R155 million and Western Cape R27 million.

There had been some changes in terms of the Division of Revenue Bill schedule. Supplementary grants to provinces were now 4A grants, the Specific Purpose grant to province was now 5A and allocations in kind to the provinces, previously called schedule 7, were now 6A. This was expected to be signed in May 2013.

Ms Dladla concluded that DoH had flagged interventions to improve the health sector and that achieving its objectives would require fundamental reform in the health systems of the country, including, amongst others, improving infrastructure, human resources (HR) and management capacity, accountability in training and budgeting, assistance with financial management, reform of key strategic institutions and establishing the goals of national health through the NHI.

Discussion
Ms B Mncube (Gauteng, ANC) asked what was being done about services belonging to one province ending up being used by another province, such as Mpumalanga patients being transported to Gauteng for certain treatments.

Ms M Boroto (Mpumalanga, ANC) asked if the revitalisation strategy would include Memorandums of Understanding (MOUs) between hospitals in Mpumalanga and Gauteng, so that patients from rural Mpumalanga could have access to hospitals which had the resources and treatment they required and so that they could be transported directly to the hospital rather from one place to another over long distances.

Ms Malebona Matsoso, Director-General, Department of Health, said that she would answer the questions in a roundabout way. In order to address the issue, an intervention task team met regularly and Drs Pillay and Van Der Merwe had been appointed to that team.

DoH had recruited 400 unemployed graduates (interns) in information technology (IT), HR and finance. They had been trained in a pilot project to improve revenue and HR at Charlotte Maxeke Academic Hospital in Gauteng, where IT systems had been dysfunctional and employees could not collect the R230 million in revenue over the past three years. DoH bought computers and people were trained and over a five month period alone, the hospital was able to collect revenue of R39 million.

These interns had been allocated to different provinces and DoH would expand the project to all regional, tertiary and central hospitals in the country, although unfortunately Mpumalanga did not want such assistance. So far, George Mukhari, Steve Biko, and Chris Hani Baragwanath were being assisted with basic improvements such as training on data capturing and efficient patient record-keeping, specifically to collect and generate revenue. DoH was negotiating with Treasury to come up with a proposal for incentives to generate revenue in hospitals, whereby they could retain a proportion of the revenue for improvement in general operational activities in the hospitals.

Ms Boroto asked if grant allocations for hospitals were adapted over time. A small hospital in Mpumalanga, for example, which accommodated 50 beds 10 years ago, was now under pressure as the community had grown and there was a lack of professional nurses and doctors.

Ms Matsoso agreed that Mpumalanga had relatively few facilities and was overburdened. Part of the reason for categorization was to be able to re-categorize when a hospital population expanded. DoH was in a controversial debate with the provinces about the option to adequately resource all central hospitals, including the two in the Western Cape, so that services were not province-specific but were accessible across provinces by all South Africans.  

Ms Mncube commended the DoH for improving the status of district hospitals and for accommodating social services and home affairs in the hospitals. She suggested that other district hospitals should include these services as they added value to the life of the people. One of the problems she noticed was a shortage in project managers to drive the building of hospitals. She asked if there were bursaries to assist training of project managers.

Ms Matsoso replied that the HR strategy for health had been problematic because various themes of HR were assessed at the same time. DoH had subsequently assessed all hospitals for Chief Executive Officer (CEO) competence and had removed some of them and appointed new CEOs, who were then being trained after being appointment. DoH was following the same procedure for District Managers, some of whom DoH believed should not have been appointed.

The integrated model for district hospitals was a good model and the CEOs appointed in Gauteng would assist so that hospitals could be commissioned as soon as possible. DoH was working together with Development Bank South Africa (DBSA) to address the shortage in project managers by appointing project managers and by staffing project manager support units (PMSUs). DoH would like to invest the infrastructure grant in maintaining and retaining existing health facilities, rather than erecting new buildings. It was also working in partnership with higher education on a pilot project at further education and training (FET) technical training colleges to train final year students as artisans for maintenance of boilers, and similar tasks, in hospitals, rather than contract to private companies who may use unskilled labour off the street.

Ms Boroto asked what was being done about the issues in the districts where it appeared that the district managers were not reporting on implementation at local level. She asked if the quarterly reviews by DoH could include reports received by the district managers.

Ms Matsoso said the DoH was addressing these concerns through the district health model which looked at both allocations and management, as provinces historically had not been allocating according to primary health care principles. There would be a workshop the following week specifically to address such concerns.

Mr S Plaatjie (North West, COPE) said that in the previous Annual Performance Plan (APP), DoH committed to a District Specialist Team per province. He asked what the status was of the commitment.

Ms Jeanette Hunter, Deputy-Director General: Department of Health, replied that there were 34 District Specialist Teams with at least 3 in each of the districts – a total of 174 specialists around the country.

Ms Mncube asked how the DoH decided on how ambulances were allocated to provinces so that they could respond to the needs of the provinces.

Ms Matsoso replied that it was not only ambulances that were a problem, but most of those trained in emergency services were unemployed because they could not be absorbed by the system.  An advisory committee had completed a report on a model for the norms and standards for training of emergency service personnel in both municipalities and provinces.

During the World Cup, ambulances were bought and post-World Cup they were donated to provinces. A report for all provinces was available, except for Limpopo, which had chosen to buy a helicopter. KZN had a very good ambulance information tracking system and DoH had requested that those responsible for implementing such a system share the model for use by the other provinces. The system could track not only where the ambulance was, but tracked the activity of the vehicle, such as when the door opened and when the engine was running at any given time. The Western Cape also had a good tracking system.

Ms Mncube asked how DoH could assist with compensation for community workers and how volunteers could have access to basic medical equipment, such as gloves.

Ms Matsoso replied that DoH had begun assisting in this regard but was engaging provinces on accountability for provision of this basic equipment. A report would be made available to the Committee.

Ms Mncube asked when the addictive drug, Nyaope, would be classified so that the illegal manufacturers could be prosecuted and addicted persons could be helped. Gauteng was faced with high manufacture and abuse of the drug.

Ms Matsoso replied that this was indeed a problem and the Medicines Control Council was reviewing how the scheduling status of ARV treatment could address the problem of Nyaope which included ARV drugs. There were pieces of legislation in place, such as the warning label on rat poison which stated that it cannot be consumed by humans as it was a hazardous substance. DoH was in the process of addressing the problem.

Mr W Faber (Northern Cape, DA) said that an ARV pill label said that the pill was not recommended to people who were pregnant as its safety and efficacy had not been established, yet it had been approved by the Medicines Control Council.

Ms Matsoso replied that use of medicines in pregnant women was always a concern. Thalidomide was supposed to help suppress nausea but resulted in deformation in babies. Package inserts were only written after epidemiology studies and the risk and benefit were accessed through pre-clinical testing in animals. Phase 1 and 2 clinical trials further assessed whether the risk/benefit safety ratio would benefit use in human beings.

Ms D Rantho (Eastern Cape, ANC) said that on oversight to the Chris Hani district municipality in the Eastern Cape, they had learned that nurses and doctors at the Glen Grey Hospital were reluctant to go to work because they had not received their salaries. This affected the health of the people.  In the Dordrecht area, the South African Police Service (SAPS) had told Members that doctors arrived sporadically and as a result the rape and other contact cases in the area could not be followed up as there was no statement from a doctor. This resulted in people not receiving the health care they needed.

Ms Matsoso agreed that access was a concern. She had categorised four key areas of technical access: therapeutic, financial, physical and quality. Lack of skills was part of quality access. DoH had come up with norms and standards and the interns would ensure compliance in the Dordrecht and Glen Grey hospitals. The project would be starting in May and would require every province to comply. DoH would also like to write regulations for norms and standards for staffing according to hospital size as this would be helpful for spread and distribution of HR.

Mr Faber asked if DoH had a specific unit which looked into the progress towards the ARV treatment targets.

Ms Rantho said that in some provinces ARVs were not distributed to the districts.

Ms Matsoso replied that while there had been a “go slow”, DoH had identified partners with civil society and private partners and NGOs which assisted on the project.

Dr Anban Pillay, Deputy-Director General, Department of Health, added that DoH was in contact with provinces to monitor the situation on a monthly basis to detect problems between supply from supplier and demand from provinces, provinces not paying accounts on time, etc.

Ms Rantho said that she was concerned that education about contraception had diminished. The Chairperson said that she shared Ms Ranto’s sentiments on education on contraception and pregnancy. She asked how education in schools was being conducted.

Mr M De Villiers (Western Cape, DA) asked what programmes existed to address the misunderstandings around HIV treatment.

Ms Matsoso replied that she did not want to reveal the details of a huge launch which would happen very soon.

Ms Rantho said that in oversight, the problem around sex workers was accessing ARVs, condoms and health services. They were part of the community and could not be ignored.

Dr Nonhlanhla Dlamini, Chief Director, Department of Health, replied that commercial sex workers fell into a group referred to as key populations, together with two other HIV high-risk populations: long-distance truck drivers and seasonal farm labourers. They received a package of services, from education to diagnosis to treatment. Provinces assisted by mapping these key populations for intervention. DoH also funded commercial sex workers to peer-educate: distribute condoms to other sex workers and show them how to use them. Medical male circumcision also involved a package of services: counselling, testing, how not to transmit an infection, etc. No one HIV prevention intervention was 100% effective, however Combination Prevention which included the biomedical intervention (circumcision); post-exposure prophylaxis; social intervention; and structural intervention hoped to achieve an impact.

Ms Rantho asked if the health technology strategy programme had been completed.

Ms Matsoso said that the health technology strategy was more about equipment to be used. E-health technology – health information systems – in the past had been allocated which has not materialised. Therefore DoH had come up with norms and standards for e-health.

Ms Rantho asked if the pilot study using the finger print to track patients had been implemented.

Ms Matsoso replied that the DoH was working together with the Department of Home Affairs on rolling out a pilot project for a patient identification system using the patient’s ID number to track their movement between facilities.

Ms Rantho asked if there was a sector in South Africa that manufactured laundry machinery for the hospitals such as irons, and what DoH was doing to encourage use of locally manufactured equipment. She had heard that machines were imported from overseas and the local people of the village did not know how to use them.

Ms Matsoso replied that DoH had invited the hotel industry to train CEOs on laundry, security, catering, and cleaning. The issue was not about machines imported abroad, but about centralisation of laundry services whereby laundry was not returned to the districts. DoH was contemplating each district having their own laundry office, or use of co-ops. Once it was decided what would and should be done, the decision would be shared with the Committee.

Ms Boroto asked if DoH had engaged with municipalities on the primary health care packages and if they were working together on ward-based primary health care.

Ms Hunter replied that community health workers not being paid was indeed a problem. Historically they were employed by DoH and paid through NGOs and these workers worked parallel with one another to cover the communities’ needs. As part of the Minister’s priority for primary care re-engineering, particularly through the Awards-based Outreach Programme, community health workers were being retrained to go into homes and screen elderly, babies, school children, youth, young adults for healthcare and to give advice and refer them to clinics where necessary. DoH had exceeded the 10 000 limit for retraining and had so far established 600 teams of these retrained workers. DoH was lobbying provinces and would work through the National Health Council, the DG and the Minister to bring the community health workers to DoH establishments, to do away with the problem of transferring money to NGOs and workers not being paid. Some services that should be within the primary health care package also existed in big metro clinics and this was being addressed by DoH.

Ms Boroto asked if cataract treatment would be performed at mobile clinics or hospitals and how DoH ensured that those living in rural areas were aware of the treatment for cataracts.

Ms Matsoso replied that DoH had a partnership with the Ophthalmology Society for treatment of cataracts and that some ophthalmologists volunteered their services. However, DoH may be taking for granted that people would know about the service. She would ensure that the service was promoted.

Mr Plaatjie said that in the Integrated Health School Programme there was no mention of farm or rural schools. He asked how these schools were sampled and accounted for.

Dr Dlamini replied that the comprehensive health package would be phased in for quintiles 1 and 2, farm and rural schools. At Grade R, children were assessed for learning barriers, and in high school they were assessed for mental health and given age-appropriate education on safe sex and gender-based violence.

Ms Boroto asked how DoH was assisted by the Department of Education for recruitment of students to study medicine.

The Chairperson asked what measures were in place to resolve the problem with student conduct in Cuba and what platform was available to assist students whose training was disrupted due to lack of finances for training.

Mr De Villiers asked how DoH interacted with Departments of Basic and Higher Education and universities to reach the target for medical students.

Ms Matsoso replied that to increase intake from rural communities, DoH signed a MOU with medical schools at universities asking them to specifically recruit from rural communities and ensure that those recruited were provided with support, including financial support. Mindful that some students would be seeing a test-tube for the first time, DoH in the previous year had spent (the CFO would inform the Committee on this amount) on the support programme in place for these students, but was not satisfied with how it was running. All investors were now requesting how the support programmes were operating. The conduct of students in Cuba was of concern. The DoH was addressing value systems through the support programme.

The Chairperson asked how DoH monitored the three health infrastructure grants implemented in the provinces and what caused the slow spending on programmes in provinces.

Mr Plaatjie asked the Chief Financial Officer (CFO) what the status was of grant allocation of provincial spending and how they were improving on financial accountability for spending.

Mr Van der Merwe replied that spending on all grants at the end of February was 83% and DoH had made significant contributions to increase expenditure, especially on infrastructure PMSUs, monitoring and evaluation of conditional grants through monthly provincial visits. For example, some provinces had used money to buy equitable share and for payment of laboratories. This money was being returned and was being addressed and treated as misconduct. Introduction of non-negotiable expenditure items were also being monitored.

Ms Matsoso added that the non-negotiables were tracked on a monthly basis and these would be presented to the Committee. The problem was equitable share and generalisation at the end of the financial year.

Mr De Villiers asked why there was such slow spending on the NHI Grant.

Dr Van der Merwe agreed that the NHI spending was slow - at 2% of the allocation in December. The new business plan intervention took time to go through Division of Revenue Allocations. NHI expenditure had jumped to 10% in January and to 27% in February. 85% had been committed in terms of province expenditure (but would not yet be spent) by the end of March.

Mr Faber asked for clarification on the grant allocation per province for the NHI pilot projects.

Dr Van der Merwe said that the R4.8 million NHI grant allocated to each district included the revised business plan. KwaZulu Natal had 2 districts. The amount was not enough but covered small maintenance projects. R291 million of DoH funds had been retained for GP contracting and Diagnostic Related Group so as not rely on provinces to do that.

Mr De Villiers questioned whether the target of 98% of all TB patients being tested for HIV was not too high and if resources were adequate to reach the target.

Mr Plaatjie suggested that CEOs of hospitals and Heads of the Office of National Standard Compliance report on the issues that had been raised – cleanliness, attitude, etc – to give the Committee an idea of what was happening on the ground. He asked what the current status was of the Office of Health Standards and Compliance.

Ms Matsosa replied that this was in the hands of the Members and was in the process of going through mediation.

Mr Faber asked how the sisters and nurses were expected to cope with the pressure of seeing 120 patients per day and also had to clean the clinic themselves and what DoH was doing to attract younger nurses to work at the clinics.  He felt that they were being exploited and would leave the clinic after becoming exhausted.

Ms Matsoso replied that the problem was not older nurses in the facilities – retired nurses had been recruited in the facilities. The problem was older nurses teaching at the training institutions. As part of the nursing strategy, DoH had ensured that during revitalising, each institution started a programme to replace the older teachers. The strategy would be shared with the Committee.

The Chairperson thanked the Department for the interesting presentation and apologised for having to end the meeting abruptly.

The meeting was adjourned.