NHI Pilot Districts progress report; National Health Insurance Grant Expenditure 2012/13

NCOP Appropriations

04 June 2013
Chairperson: Mr T Chaane (North West, ANC)
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Meeting Summary

The National Department of Health briefed the Committee on the third and fourth quarter expenditure of the National Health Insurance (NHI) grant, the NHI pilot districts 12-month progress report, and the National Treasury’s NHI grant for the third quarter of the 2012/13 financial year.
The Department said it had allocated R150 million for the 2012/13 financial year to test innovations that were necessary for the implementation of the NHI, to undertake health system strengthening initiatives in identified districts, and to provide strategic resources for supporting the pilot districts in implementing selected health service delivery interventions.  The challenges faced by each province were summarised, indicating issues such as a lack of capacity, supply chain hurdles, delays in getting information on budget codes, limited delegations, lack of support, and inability to spend on infrastructure.
The total expenditure by province, from April 2012 to March 2013, and the total NHI-Conditional Grant (CG) allocation per province, were outlined.. The way forward was summarised, focusing on the strengthening of capacity, monitoring and evaluation, and the appointment of provincial coordinators.  In the 2013/14 financial year, the grant had been divided into two components -- direct district piloting, and in-kind support, such as general practitioner (GP) contracting and central hospitals work.  New focus areas involved the strengthening of supply chain management, supporting  the roll-out of primary health care (PHC), strengthening district monitoring and evaluation, and mobilizing the funding for the appointment of provincial NHI coordinators.

A detailed report on the NHI district pilot progress over the past 12 months was presented, covering
improvements in quality, hospital reforms, primary health care (PHC) re-engineering, infrastructure, human resources for health, district management, referral systems, and cooperation with private doctors at district level.

The National Treasury’s report focused on the main purpose of the NHI grant.  It advised that issues such as the administration, lack of dedicated staff, and facilities needed to be dealt with, as they had an impact on the operation of the NHI. The Treasury also stressed that the funds had to be used for what they had been allocated.

Members asked a number of questions around revenue collection, the challenge of capacity, a possible constitutional amendment, the problem of cables cost, delegations to district level, and the development and maintenance of hospital infrastructure.  Members commented that the NHI initiative was a socialist model, but the conditions in which South Africa operated were capitalist, and they asked how the NHI was going to operate under such conditions. Other questions asked by Members were around the withholding of funds by the National Treasury, the use of consultants, monitoring and evaluation, why Gauteng had under-spent, as well as the role of hospital boards and clinical committees.

Meeting report

National Department of Health: National Health Insurance Grant
Ms Jeanette Hunter, Deputy Director General, National Department of Health, said that the Department of Health had allocated R150 million for the 2012/13 financial year to test innovations that were necessary for the implementation of the NHI, to undertake health system strengthening initiatives in identified districts, and to provide strategic resources for supporting the pilot districts in implementing selected health service delivery interventions.  Each pilot district had received R11.5 million.  
Graphs were presented to indicate the expenditure and challenges during the third and fourth quarters in the various provinces.   The Eastern Cape faced challenges such as the provincial office delaying notification of the availability of funds to the district, capacity constraints (such as a lack of key personnel in important categories and inadequate technical support), and supply chain hurdles (delays in getting approvals). 
In the Free State, challenges included the reprioritization of funds allocated to activities, and supply chain management (SCM) hurdles. Challenges faced by the Gauteng province were a lack of support from relevant officials at the provincial office, significant hurdles in procurement processes, and delays in getting information on the budget codes, and staff shortages in key areas. 
The challenges identified in KwaZulu-Natal included bureaucratic processes that hampered innovation, the process for obtaining signatures needed to be streamlined (huge delays at provincial level), limited delegation to allow for activities to be undertaken, and significant supply chain hurdles.  
The Department reported that the challenges faced by Limpopo province included incorrect coding, SCM hurdles which had to do with significant delays in getting approvals, problems in identifying relevant providers to undertake some activities due to a limited database, and inadequate technical and administrative support from the province.
Challenges identified in Mpumalanga province included the majority of the District Health Management Teams (DHMT) had not been appointed, there were very limited delegations to allow for activities to be undertaken (district level delegations were very limited), and SCM hurdles had an impact on key activities.
In the Northern Cape, there had been delays in Provincial Treasury providing information regarding the availability of funds, SCM hurdles, significant delays in getting necessary approvals, a lack of technical support in key areas, and challenges in identifying relevant providers to undertake some activities, due to a limited database.

Challenges in North West province included incorrect capturing of the budget at provincial level (the district had submitted an incorrect business plan to provincial treasury), poor prioritisation of allocated funding, a lack of technical support in key areas, and an inability to spend on infrastructure, such as clinics and motor vehicles.
The Western Cape Province’s challenges were delays in finalizing the business plan impacting on progress, difficulties in undertaking work around governance arrangements at the community level, delays in getting a supporting legal opinion on the exact roles, responsibilities and functioning of clinic
The total expenditure by province for the full year, from April 2012 to 31 March 2013, was described, Western Cape had spent 52.0%, North West  86.0%, Northern Cape 69.6%, Mpumalanga 48.8%, Limpopo 35.8%, Gauteng 25.6%, Kwazulu-Natal 48.9%, Free State 56.6% and Eastern Cape 70.4% (see attached document).

Ms Hunter summarised the NHI Conditional Grant (NHI-CG) provincial commitments and roll-overs for the 2012/13 financial year, broken up by province.  (See presentation)  The national total NHI-CG allocation was R150m, with commitments of R49 350 765 (32.9%).

Overall, key challenges included weak human resource (HR) capacity in some districts, weak provincial technical support, delays in budgets being communicated to some pilot sites, significant SCM challenges in many districts, and a lack of necessary delegations to perform outlined activities. Monitoring and evaluation had been undertaken by the Grant Management Unit.  All provinces had submitted month to month financial data, quarterly reports and meetings with all sites. The way forward would be the implementation of the Division of Revenue Act (DORA) framework to adjust the purpose, focus activities and funding allocations to provinces.  This would allow the DoH to adopt a stronger and more interventionist approach, influence the scope of work to be carried out at national and pilot site levels, and allow for changes in allocations across districts.

Ms Hunter said that for 2013/14, the grant had been divided into 2 components -- direct district piloting, and in-kind support, such as general practitioner (GP) contracting and central hospitals work.  New focus areas involved strengthening of SCM, support the roll-out of primary health care (PHC), strengthening district monitoring and evaluation, and mobilizing the funding for the appointment of provincial NHI coordinators.

NHI pilot districts 12 months progress report
Ms Hunter said that the NHI Green Paper, or action plan, had been put together in August 2011. In April 2012, NHI pilot districts had had to prepare for the purchasing of services, engaging the private sector, and introducing a district health authority. In April 2013, a rapid appraisal had been conducted to assess progress in preparing for the NHI and to provide a framework for monitoring. The Department had reported that NHI domains appraised had included NHI management, hospitals, quality, primary health re-engineering, infrastructure equipment, human resources, health information, district management teams, conditional grants, referral and contracting private providers.

A tabular summary was presented, indicating which districts had full-time or interim NHI project managers, which district hospitals had been re-designated, how many full-time CEOs were in their posts, and how many CEOs had been oriented at the leadership and management academy (See report). The quality of facilities in districts was improving, with a facility improvement team in place. However, the Office of Health Standards Compliance (OSC) score for PHC facilities and hospitals had shown a downward trend in eight districts, and only two had shown significant improvement.

PHC re-engineering indicated varying levels of progress in the different districts.  Only two district clinical specialist teams were fully staffed, none of the districts had all their ward-based outreach teams in place.  Two of the districts had the required a number of school health teams in place. As for infrastructure development, the facility maintenance plan was in place, and there had been a major refurbishment of hospitals and PHC facilities over the past 12 months in some districts, except for Vhembe and uMgungundlova.  Equipment audits at 301 of the 609 primary health care facilities had been conducted.

Statistics on human resources showed that there were doctors, nurses and data capturers available at most district hospitals and PHC facilities. The Department reported that the health management information system was improving, with four districts receiving information from the Department of Human Settlements (DHS) within the 15-day timeframe target.  The Department had completed the review of annual district health expenditure, and a NHI master plan, a referral systems protocol, a planned patient transport system, and an emergency transport system, were in place.

In conclusion, Ms Hunters said that NHI management and coordination was in place and district health management teams had realigned their priorities.  The NHI conditional grants had contributed to progress, and quality improvement interventions were underway.  Hospital reforms had been introduced, and referral mechanisms were in place.   PHC re-engineering was not yet complete, with the district clinical specialist, ward-based outreach and school health teams still to be fully manned.  There was insufficient health staff, and World Health Organisation norms and standards were being used to motivate increased funding.  Districts were ready for private doctors to work alongside nurses in primary health care facilities.

National Treasury: National health Insurance Grant 3rd Quarter 2012/13 briefing
Mr Edgar Sishi, Chief Director, National Treasury, said that the National Insurance Grant’s aim was to  provide a scale model, including the required institutional arrangements, for a district health authority (DHA).  It would test the connection between health service management and administration and how it related to the function and responsibilities of the DHAs, undertake health system strengthening initiatives, support selected pilot districts in implementing identified service delivery interventions, provide a model for revenue collection and a management model for identified central hospitals.

Mr Sishi said that provinces had administrative problems that had an impact on the operation of a system of National Health Insurance. Facilities needed to be improved, and the issue of procurement needed to be dealt with. There was a need for norms and standards for the type of personnel required by the National Health Insurance. The National Treasury had emphasised that the money allocated for particular projects needed to be used for those particular projects, and had to be monitored. On the issue of holding back of funds by the National Treasury, he said that the National Treasury team would talk about that next week.

Mr B Mashile (Mpumalanga, ANC) noted that the NHI was a socialist initiative, and the conditions in which South Africa was operating were capitalist. He asked how the NHI was going to work under such conditions. There was much to be done in skilling people before giving them jobs, and the administration process seemed to have some problems. He sought clarity on revenue collection, and delegation at district level. How was the infrastructures grant, in relation to the pilot project, going to be incorporated into the National Insurance Grant? He suggested that the information from the NHI pilot report had to be correct and appropriate.

Mr C de Beer (Northern Cape, ANC) noted that the National Treasury had not released funds at the beginning of the financial year, and hospitals should assist in rolling out the National Insurance Grant. He asked why the National Treasury had not released the money.

Mr D Josephs (Western Cape, DA) asked whether the National Health Department worked with provincial and local authorities, and why there was no support in Gauteng. He asked whether the problem of capacity was due to a lack of professionalism or a lack of HR capacity, and whether all facilities were on-line with the computerised system. He wanted clarity on the national master plan. He asked how long consultants would be used, and he wanted clarity on the constitutional amendments. What was the role of hospital boards and clinical committees?

Mr S Montsitsi (Gauteng, ANC) welcomed the NHI initiative, and also noted that it was a socialist model. He wanted clarity on the current rate of revenue collection, and asked whether the issue of costing cables had been resolved. He noted that there were 360 doctors available to be distributed to hospitals, and asked which hospitals in Gauteng were going to receive doctors. He sought clarity on the Sedibeng laundry, the role of the private sector, and the readiness of district health authorities. He asked if the Department had monitored provincial spending, and why Gauteng under-spent

Ms Malebona Matsoso, Director General, National Department of Health, replied that the Department had been working very hard to get quality CEOs, and had conducted an assessment on them.  Once the CEOs had been assessed, the Department had checked to see if they matched the required skills and knowledge levels of the NHI. The training academy had been established to assist in training people to become good health managers. The Department had found that most people had post-graduate qualifications, but some of them had been doing the same job for many years. The Department had realised that training people was a necessary investment, so it had partnered with other institutions to do training. UK and Harvard training institutions had come to South Africa.  
On the issue of NHI being a socialist initiative, Ms Matsoso said that on 6 December, 2012, the United Nation had passed a resolution on health, and South Africa's NHI was a reflection of that resolution, which had been sponsored by 21 countries.  If the health sector had to change, then the way it was financed, run and governed had to change.  South Africa would made progress as it learnt from other countries.

Ms Matsoso said that health could be privatised and corporatised. However, South Africa was not interested in privatisation, but preferred the delegation model, where each province and district received delegations to work with people out there. What the Department of Health was doing was to create efficiency and achieve value for money. The Department of Health’s aim had been to make sure that every hospital had facilities ready so that the NHI pilot districts were efficient and proper. People would be taught how procurement really worked, as it was an important area that needed to be explored further. The Minister of Health had established a review team to look at the state of ambulances across the country. Local authorities had met to hear what NHI was all about. The Department was not really sure  whether the Constitution had to be amended. The Department had assessed whether there was enough capacity in districts. The Department’s budgeting approach had not been good, as there had been no norms and standards for budgeting. The pilot would run for the whole financial year and progress would be evaluated. On the issue of master plan, The Department had white paper and amendment bill that needed to be completed. The Department had used one consultant for assessment of the NHI. The nursing grant was not performing well.  The Sedibeng district was not improving.

Ms Matsoso indicated that hospital boards differed from each other, and the Department wanted to review some hospital boards.

Ms Hunter said that clinical committees were different, as some committees were functioning, and others not functioning.

Mr Ian van der Merwe, Chief Financial Officer, said that provinces had problems with compensation of staff, and that was the reason why some staff had not been employed.  This was why Gauteng province had under-spent. The Department’s focus was on having good equipment.

In concluding, the Chairperson requested the Department to update the Committee about the investigation conducted in the North West Province. The Department should send the report in writing, and then the Committee would decide whether to arrange a meeting to discuss it.

The meeting was adjourned


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