The Department of Health (DoH) briefed the Portfolio Committee on the progress made in the implementation of the National Health Insurance (NHI) Pilot Project over 12 months. The eleven districts included: Eden (Western Cape), Pixley ka Seme (Northern Cape), OR Tambo (Eastern Cape), Gert Sibande (Mpumalanga), City of Tshwane (Gauteng), Amajuba, uMgungundlovu and Umzinyathi (KwaZulu-Natal), Vhembe (Limpopo), Dr Kenneth Kaunda (North-West) and Thabo Mofutsanyana (Free State). The April 2013 rapid appraisal enabled progress to be assessed and provided a framework for future monitoring. The DoH believed that if money for each district was ring-fenced for that district, and when the right people were appointed to run the districts, NHI would succeed.
The pilot districts incorporated 764 Public Health Care (PHC) facilities, which included mobile units and Community Health Centres. The facility assessments were focused on infrastructure, the Workload Indicator of Staffing Need, essential equipment, access to drugs and pharmacy services, transport costs, and other minimum requirements. Office of Health Standards Compliance follow-up inspection scores for 385 PHC facilities showed a slight fall in health facility standards in the majority of pilot districts, largely due to more robust tools being used in the follow-up inspection. It was reported that Gert Sibande, City of Tshwane and Vhembe had spent only 55%, 52% and 50% of their conditional grants respectively. All others, however, had spent over 78% of their grants, and Pixley ka Seme had overspent by 14%. DoH was motivating strongly for creation of a district health authority that had a dedicated budget and the authority to plan and execute responsibly. It was seeking to contract services of general practitioners (of whom there were 300 contracted so far), specialists, pharmacists and other professionals.
Members asked if the district managers were ready to be accounting officers or whether they still had to be trained; if the Leadership and Management Academy training was relevant to NHI officials; what happened to the existing chief executive officers at hospitals and how the new skills criteria would be different; if revenue collection would be part of the chief executive officer’s performance indicators; and if performance of hospital boards had been assessed. They also asked how DoH planned to purchase services of specialists, such as anaesthetists, in the rural areas; what the rationale was for the Office of Health Standards Compliance not being independent from the DoH; how the Public Health Care referral system would be marketed; why the large sums of conditional grants had not enabled the building of hospitals to be completed; and at where exactly the problems in the OR Tambo and Dr Kenneth Kaunda districts existed.
The Department of Performance Monitoring and Evaluation then presented on Outcome 2: a healthy life for all South Africans, and identified a number of NHI challenges, including inequitable distribution of resources in the national health system; a shortage of health professionals in the public sector; limited expenditure on the NHI conditional grant (which had subsequently, to boost spending, been split into a direct component to provinces and an indirect component, managed by the national department); huge infrastructure and maintenance backlogs in some districts; concerns about quality of public health; spiralling private health care costs; and historical inequities between the private and public health sectors. It was reported that the lack of progress in the previous financial years towards unqualified audits was largely due to weak asset management and supply chain management in provinces.
Members asked what was being done to improve the shortage psychiatrists and hospital beds in the psychiatric hospitals; asked if any other avenues for revenue had been explored to fund the establishment of the NHI; what plan was in place to reduce the maternal mortality rate; and to what extent the department followed up on drug abuse. The Chairperson concluded that health promotion and the role of the Office of Health Standards Compliance were vital, and a good balance was needed with of delegation of power. In future, the Committee would be deliberating on monitoring of remunerative work outside of the public sector (RWOP). One of the major challenges would be whether board members and clinical committees had the skills to direct and manage a hospital or whether they would be driven by the very people who they were supposed to be driving.
National Health Insurance: Progress Report on pilot districts by Department of Health
Ms Malebona Matsoso, Director-General, Department of Health, said that in April 2012, when the eleven National Health Insurance (NHI) pilot districts were identified, the Department of Health (DoH or the Department) had not yet established whether it would purchase services, how it would engage the private sector and how it would introduce a district health authority. Therefore a number of models were tested during the following twelve month period. The April 2013 rapid appraisal enabled progress to be assessed and to provide a framework for monitoring.
Results of the appraisal of the eleven districts were tabulated (see attached document). The eleven districts included Eden (Western Cape), Pixley ka Seme (Northern Cape), OR Tambo (Eastern Cape), Gert Sibande (Mpumalanga), City of Tshwane (Gauteng), Amajuba, uMgungundlovu and Umzinyathi (KwaZulu-Natal), Vhembe (Limpopo), Dr Kenneth Kaunda (North-West) and Thabo Mofutsanyana (Free State).
The key areas appraised were: NHI management, hospital reform, quality, Primary Health Care (PHC) re-engineering, infrastructure and equipment, human resources, health information, District Management Teams, conditional grants, referral and contracting of private service providers. Monitoring and evaluation would be performed at a later stage when impact assessment would be conducted.
Full-time NHI Project Managers were in place in Pixley ka Seme, Gert Sibande, Vhembe and Dr Kenneth Kaunda, while the other districts had interim managers only.
Dr Kenneth Kaunda did not meet the score for district hospitals, defined as having 50 beds or more, and having services provided in alignment with prescribed regulations and an established catchment area. No data was available for uMgungundlovu.
Eden, Pixley ka Seme City of Tshwane, Umzinyathi, Vhembe and Dr Kenneth Kaunda hospitals all met the score for appointment of Chief Executive Officers (CEOs). At OR Tambo, only two of the nine district hospitals had a full-time CEO appointed. After receiving these results, the DoH ran a leadership programme at the Leadership and Management Academy for all CEOs, and gave all CEOs 100 days to correct problems relating to their particular hospital’s maternal mortality and infant mortality rates and other matters of concern. Follow-up assessments showed that CEOs could solve problems by reorganising services - without injection of further resources. CEOs from Eden and Thabo Mofutsanyana districts were not sent to participate in the programme.
The Office for Health Standards Compliance (OHSC) overall score for the facilities audit showed that the outcome for hospitals was much better than that of clinics. No data was available for the hospitals in Amajuba, uMgungundlovu and Dr Kenneth Kaunda as they had not yet been inspected. The differences in the baseline audit results and follow-up OHSC inspection scores for the 385 PHC facilities showed a slight fall in health facility standards in the majority of pilot districts, but this was largely due to more robust tools being used in the follow-up inspection, using “risk-of-death” based tools. While the methodology was not the same, the scores were still useful. Improvements in scores in Thabo Mofutsanyana, Pixley ka Seme and Gert Sibande were related to the facility improvement teams having devoted time to these PHC facilities.
DoH had come up with a clinic prototype for general operation for the facilities. By end of June 2013, 589 of 609 facilities had been assessed for standard equipment and availability of medicines.
City of Tshwane and Dr Kenneth Kaunda had the full complement of specialist teams, while other districts did not. The most difficult specialist to attract was the anaesthetist. DoH was currently preparing a model contract to attract specialists in the private sector. In the first phase of the pilot, DoH had been focused on contracting of private providers, with specific reference to GPs. In some facilities, there was simply not enough working space for GPs.
Ward-based outreach teams did not reach 25% of the full complement of teams in place in OR Tambo, Gert Sibande, City of Tshwane, Amajuba, uMgungundlovu and Thabo Mofutsanyana. KwaZulu Natal (KZN) had a development system of its own for outreach teams, which was actually more organised than was reflected in the results. Eden and uMgungundlovu had achieved 100% of the required number of school health service teams, while Pixley ka Seme, OR Tambo and Vhembe had not established more than 12% of the requirement. Amajuba had achieved 92% and the other hospitals fell within the range of 28%-60% of the requirement.
DoH wanted to ensure that district officers were trained in the National Health Information Repository and Data Warehouse (NHIRD) and these officers were provided with the required infrastructure before they were required to process information. The first phase required rolling out of the training. The second phase, beginning in August 2013, would involve the processing of patient registrations and linking of information between the facilities.
Ms Milani Wolmarans, Policy Coordination and Integrated Planning official, Department of Health, explained that training in the NHIRD had been delayed by the need for collating information received from the Census 2011 and the updated information received from the Space Agency on geospatial coding, as well as mapping of all private service providers in the country. All district management teams would be trained on information processing and how to use the information for purposes of planning and addressing the need of the district populations, through gap analysis.
Ms Matsoso continued that DoH had completed annual district health expenditure reviews and had found problems in the way in which district health was financed, particularly in the public sector. A “post office” approach was in place, where district managers did not have authority to determine budgets nor make decisions on how money should be spent and monitored. DoH was motivating strongly for creation of a district health authority which would have a dedicated budget, and whose authority would be styled as an accounting officer, with planning responsibility and the authority to execute.
Ms Matsoso moved on to speak of the performance. There had been under-performance on the NHI conditional grants by Gert Sibande, City of Tshwane and Vhembe, who had, respectively, spent only 55%, 52% and 50%. All others had spent over 78% of their grants, with Pixley ka Seme having overspent by 14%.
DoH had designed referral protocols and reorganisation of emergency transport, which was currently a weak link in the health system. Results would be shared on how transport in the Free State impacted on patient care, particularly in relation to maternal mortality.
As of 31 March 2013, assessment of facilities for GPs services had not been completed. However, DoH would share the results which had been obtained up to June 2013. The facility assessments were focused on infrastructure, personnel and the Workload Indicator of Staffing Need (WISN), essential equipment, access to drugs and pharmacy services, transport costs, and other minimum requirements. In total there were 764 PHC facilities in the 11 pilot districts, which included mobile units and Community Health Centres.
A prototype for improvement of pharmacy services would be announced. The problem was that medicines were available but were not at the clinics. Either a clinic did not order or the depot did not deliver. At hospital level, direct delivery was being proposed. For clinics, recommendations were being made.
Challenges were identified for each facility and were being addressed specifically. Most of the facilities did not have a service improvement plan to address areas of weakness arising from the assessments; deadlines by NHI coordinators and District Managers were not being adequately met; the three streams of PHC facility teams (district clinical specialist/ward-based/schools) were not yet complete; and health staff were insufficient. WISN norms and standards were being used to motivate for increased funding.
In summary, DOH had begun to engage provinces on feedback sessions and would develop and monitor progress. NHI management and coordination was in place and District Health Management Teams (DHMTs) were realigning their priorities. DoH was currently calculating the services required per catchment population. DoH sought to purchase services and this NHI model would be different from the current system. The contract model would not be confined to GPs, but would extend to pharmacists and other professionals. So far, 300 standard contracts had been written for GPs but there were also special contracts for GPs who would work in rural areas. Recruitment would be incremental, as only those facilities ready to accommodate GPs could be used.
Ms B Ngcobo (ANC) asked if the district managers were ready to be accounting officers or whether they still had to be trained.
Ms Matsoso replied that DoH had been working with the Health Systems Trust to assess the capacity of the district managers, as well as the team within the district office. She reiterated that because of the way district health had evolved in South Africa, district managers had acted more like coordinating officers. In order to effect change, the district head had to see the total needs of the district and take into account all resources and service providers - public, private, civil society and public health - in that district. While serving a population of two million people, it was necessary to look at the demographic profile, the health indicators and how to respond to those indicators. For example, a mining or farming industry would need health services designed to respond to those industries. The person running the district must be senior enough to oversee all these aspects.
Ms Ngcobo said that in their oversight work, Members would like to see a pilot district in each province. She asked if DoH was now ready for this, as previously the districts were not ready for oversight visits.
Ms Matsoso replied that indeed Members could visit the pilot districts. There were health service performance indicators per facility and per district, and service delivery profiles which would assist Members with their oversight work. Ms Wolmarans would provide Members with the access codes and PIN numbers to access the profile of the district, from baseline to current status. WISM work had been completed at district level and it would be clear to see how each facility should be staffed. Expenditure on human resources differed from province to province, but the balance between spending on human resources and on services was important.
Ms D Robinson (DA) asked how NHI would be rolled out on a large scale to the entire population when there were so many problems in the pilot project. It was necessary to look at funding models, staffing and facilities. She asked how DoH planned to contract or purchase services of specialists such as anaesthetists, for the rural areas.
Ms Matsoso said that it was not yet necessary to commit to a massive recruitment drive, while some doctors were in training, and there were also already doctors in the private sector who would respond to the purchase model. DoH had met with South African Medical Association to work on future models of purchasing and contracting doctors, as well as with nursing groups and Labour. It had also met with pharmacy groups to come up with proposals to solve the drug stock-out problem.
DoH had to assess what was scalable to rural areas. Some services were specific and confined to peri-urban, rural and urban models. However, with GP contracting, one option was being explored where GPs could cover a certain number of clinics in the morning, when they were most needed, and return to their private practices in the afternoon.
Ms Robinson commented that in some rural areas, the quality of equipment was poor and basic facilities such as electricity and clean water did not exist at all.
Ms Kenye asked why PHC refurbishment had not been completed. It appeared to be neglected although it was the focus of the 10 point plan for PHC.
Ms Matsoso replied that DoH had recruited clinical engineers, on a pilot basis, to repair equipment at facilities.
Ms H Msweli (IFP) asked how much money had been spent on the three pilot projects in KZN and how far the projects had progressed, as well as how projects in other provinces, which were not pilot projects, had progressed.
Ms Matsoso replied that the KZN grant was specifically for the two districts and did not include Amajuba. KZN did its own allocation for Amajuba and therefore there was no NHI report on that spend. Each of the two districts had spent 78%.
Mr D Kganare (COPE) asked what was the rationale was for not taking the same road as England, where the OHSC was independent from the DoH.
Ms Matsoso responded that inspectors had been trained and the UK training used as a mock inspection for the officers to refine their tools and see how the system worked and be ready when the offices were established. Once the board was established and a CEO was appointed, the Ombud and certification units (and other units) could be set up and people employed. DoH had completed its work in that regard.
Mr Kganare asked how the PHC referral system would be marketed so that people understood that the quality of service at PHCs would be the same as that of hospitals.
Ms Matsoso replied that at least forty case studies had been analysed. Officials from Thailand would be visiting South Africa the following weekend to train the NHI officials on PHCs and marketing. Thailand had established a commission and invested heavily in health promotion, rather than curative services. Thailand could share the “nuts and bolts” of practical implementation of such policy. In addition, a team from the African Development Bank and Ghana, which had also implemented NHI, would be involved in the debate.
Mr Kganare asked how DoH would mitigate the impact of re-categorisation of NHI facilities.
Ms Matsoso replied that this was a sensitive issue. Typically, people in the community wanted to be seen by a doctor at a hospital. The DoH had introduced a transitional phase for provinces, which had two options: either the small hospitals could increase the number of beds to 50; or they had to start educating the public on the fact that they would be a community centre and not a hospital. The latter option would be more difficult.
Mr Kganare asked what happened to the existing CEOs at hospitals, and how the new skills criteria would differ. He also asked if there would be conflict of interest between district managers and project managers in a particular district.
Ms Matsoso replied that once the Act was signed and the board appointed, the board would have to engage DoH with regard to existing staff. All CEOs were assessed and therefore the profile of all CEOs was known. The CEO profile for a specific hospital was given, and DoH had received about 2 000 applications for those posts. The majority of applicants had post-graduate degrees but despite qualifications, they were not necessarily people who had a diverse background of work and were skilled for the job as CEO of a hospital. Hospitals involved catering, cleaning, security and other type of services. Management skills were required, and clinical services had to be understood, as well as the administrative arm which dealt with human resources, finance and IT. The biggest weakness in public hospitals was customer service, the very place where people needed the most care. She added that a central hospital would need to be run by a senior person at DG level. Tertiary hospitals would be run by people at director level and regional hospitals would be run by people at chief director or at director level. The pilot project would be run by a project manager. During the project, district managers were assessed. The Health Systems Trust had completed a study to assess whether the capacity of the district managers was desirable and how best to build capacity.
Mr Kganare asked if the Leadership and Management Academy training was relevant to NHI officials and whether it was an accredited course.
Ms Matsoso replied that the training provided was not yet designed specifically for hospital management. DoH was making a case for this type of formal training and the International Hospital Federation was working together with the Academy to come up with suitable accredited models of training.
Mr Kganare asked if revenue collection would be part of the CEO performance indicators.
Ms Matsoso replied that DoH was passionate about designing a proper revenue collection model. If tools were not in place, revenue collection would not happen. Four district hospitals were assessed in the pilot phase, and issues such as lack of basic administration, finances, computers and cabling were thwarting revenue collection. Trained graduates, who were currently unemployed and resident in the districts, had been recruited, with a specific brief to attend to revenue collection at hospitals as part of the 100 days exercise toward 100% revenue collection. The performance of CEOs would be measured in this respect. Incentives for revenue collection, such as retention of a proportion of the revenue should the target be exceeded, had been proposed to achieve the 100% target.
Mr Kganare asked if the Inspection Unit had been properly staffed and how DoH ensured that the inspectors did their job properly, and also asked how the WISM staff were appointed; if the Certification Unit would do the same work as the Inspection Unit, and if there would be two or three components to certification.
Ms Matsoso replied that after the Bill had been enacted, the board would be responsible for appointment of staff.
Mr Kganare asked why the large sums given by way of conditional grants had not enabled the building of hospitals to be completed.
Ms Matsoso replied that DoH had the responsibility of monitoring performance of the provinces in terms of the conditional grants. The district managers were not aware of the grant details. DoH had proposed that the district managers should be informed of the budget at the time of the annual expenditure review and told how it should be spent.
Mr Kganare asked if security issues had been included when considering infrastructure.
Ms Matsoso replied that security was included in the National Core Standards. In-house security was the predominant security, and information would be shared with the Members on the options and preferences between in-house and outsourced security services.
Mr Kganare asked what the problems were at OR Tambo and Dr Kenneth Kaunda, whether it was at the level of the DoH, provincial department, district, employees or environment of the district.
Ms Matsoso replied that the problems at the two districts were caused by a combination of lack of support by provinces and lack of capacity at district level.
Ms T Kenye (ANC) asked what mechanisms were in place to assist facilities with a service improvement plan to address the weaknesses found in the assessments.
Ms Matsoso replied that a service improvement plan and quick monitoring tool was in place and these would be shared with Members.
Ms Kenye asked if performance of hospital boards had been assessed and what training would be offered to capacitate them to improve their work.
Ms Matsoso replied that DoH had not started with hospital boards, except for those which related to central hospitals. However, responsibilities were applied according to the way the Act was written. Since these were government structures, the criteria for appointment of people to clinic committees and hospital boards should be determined in the Act. This would also relieve the problem of role definition and interference with the running of the institutions.
The Chairperson said that money had to be injected into the pilot project to establish whether NHI would work or not. While universal coverage would remove the inequalities and differences between rural and urban and public and private healthcare, he asked for assurance that NHI would, in fact, work.
Ms Matsoso replied that within the existing environment, NHI would obviously not work. DoH had the view that if all the money for a district was ring-fenced for that district, and not touched by other districts, that may result in a shortfall. However, if people with the proper profile were appointed to run the districts, there were many great opportunities ahead, and NHI could succeed.
The Chairperson concluded that despite the challenges identified in the pilot projects, it seemed that the DoH was promising the Committee that NHI would succeed in offering universal coverage to all South Africans and thereby improve the health indicators of the country. He said that matters of particular importance included health promotion, the amendments by the OHSC and the fine balance of delegation of power. Another issue which would be discussed in a future meeting was monitoring of remunerative work outside of the public sector (RWOP). Lastly, a big challenge would be whether board members or those in clinical committees had the skills to direct and manage a hospital or whether they would be driven by the very people who they were supposed to be driving.
Outcome 2: Department of Performance Monitoring and Evaluation assessment
Mr Thulani Masilela, Official responsible for National Development Plan Outcome 2, Department of Performance Monitoring and Evaluation (DPME), noted that Government Outcome 2 envisaged a healthy life for all South Africans. He presented an overview on life expectancy, the status of child and maternal health, HIV, AIDS and TB, and quality of healthcare.
While progress had been made with re-engineering of the health care delivery model, he noted that significant challenges remained. These included: exodus of trained medical practitioners to other countries and shortage of local health professionals and medical specialists; limited expertise in intersectoral action to address social determinants of health; and limited public awareness about benefits of health promotion and prevention. Medium to long term strategies included the Cuban Medical Training Programme and increased intake of medical students at universities.
In an attempt to strengthen management of the health system, regulations had been promulgated for minimum competency criteria for hospital CEOs. 102 new hospital CEOs were appointed in January 2013, the Health Leadership and Management Academy had been established; and national monitoring of non-negotiable provincial budget components had been introduced to ensure appropriate expenditure. Additional management challenges included: limited delegation of powers by provinces to district and facility health management; poor maintenance of infrastructure, lack of cleanliness, weaknesses in infection prevention and control, patient safety problems, staff attitudes and insufficient capacity for patient registration and drug management; and inadequate governance and management at district and sub-district levels.
Establishment of the OHSC had enabled the introduction of core health service delivery standards, and monitoring had commenced.
A serious area of concern was the state of financial management in the sector. In 2009, only North-West, Western Cape and the DoH received unqualified audits. Lack of progress in the previous financial years towards unqualified audits was largely due to weak asset management and supply chain management in provinces. The audit process for 2012/13 was still in progress.
He referred to the indicators for the NHI Pilot discussed earlier, and confirmed that there was inequitable distribution of resources in the national health system, coupled with a shortage of health professionals in the public sector. There had been limited expenditure of the NHI conditional grant – but this grant had subsequently been split into a direct component (to provinces) and an indirect component (managed by national) with the aim of accelerating expenditure. Other challenges included huge infrastructure and maintenance backlogs in some districts, concerns about quality of public health services, which was being addressed by the establishment of Health Facility Improvement Teams; spiralling private health care costs; and historical inequities between the private and public health sectors.
According to the World Bank’s World Development Indicators 2013, South Africa had the second highest health outcomes, after Botswana, within SADC. However, South Africa was ahead of Botswana in addressing malnutrition. Within BRICS, only India’s health outcomes were lower than that of South Africa.
He noted the table on page 19 of the attached document, pointing to consistency between the 10-point plan 2009-2014, the National Service Delivery Agreement outputs (2010-2014), the Millennium Development Goals (2000-2015) and National Development Plan targets for 2030. Over the next five to fifteen years, the focus would be on continuity, but with accelerated delivery.
The Chairperson highlighted that this presentation was under the auspices of the Minister in the Presidency, not the Minister of Health.
Ms Robinson commented that the current month was Mental Health Care Month and that South African society was plagued with violence, abuse and crime - factors which were often the result of instability or problems with mental health. The Committee had noted, during oversight visits to provinces, that there was a serious lack of psychiatrists. She appealed to the two departments present to be aware of this need. She proposed that presence of psychiatric nurses at the primary health care level would help to identify problems and treat children before they reached puberty and problems associated with mental illness escalated. Another issue was that there were not enough beds in the psychiatric hospitals. She asked what was being done to improve the situation.
Mr Masilela replied that DPME was aware of the 5-year comprehensive strategic plan set forth by DoH which prioritised the above concerns. The DoH could provide the specific details to the Committee. A society that was not functional had a higher prevalence of mental illness, HIV, violence and other factors.
Ms Matsoso added that since DoH had briefed the Committee on DoH mental health services, it had drawn a list of all the mental health facilities which required attention, including infrastructure such as beds. Teams had been sent to deal with the infrastructure issues in the previous week. DoH was working with the disability sector to ensure that it was equipped with psychiatrists and this sector included the mental health sector.
Ms Kenye asked if any other avenues for revenue had been explored, to fund the establishment of the NHI and whether public-private partnerships had been explored in the NHI pilot project to boost resources.
Ms Masilela replied that the avenues for revenue were documented in the DoH documents.
Ms Matsoso replied that DoH would refrain from commenting on funding options, precisely because it would like to leave sources of revenue in the hands of National Treasury, which had to juggle what funds were available. She added that countries that had shown growth in development after world wars or recession were those that invested in health.
The Chairperson commented that increasing life expectancy meant that increased geriatric health services were to be expected.
Mr Masilela added that people were living longer with HIV, due to ARV drug treatment. It was encouraging that in the group of 15-24 years old, there was a reduction in prevalence of new HIV infections.
Ms Robinson asked what plan was in place to reduce the maternal mortality rate.
Mr Masilela replied that the DPME was aware of the 5-year strategy plan which included reduction of maternal mortality rate and that the DoH had implemented the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA).
Ms Matsoso added that the results of the CARMMA strategy implemented in the Free State showed positive outcomes.
Ms Msweli asked to what extent the DPME followed up on drug abuse, which ultimately contributed to the need for hospitalisation.
Ms Masilela replied that the DPME was directly involved in the monitoring of progress with drug abuse interventions and met weekly with an inter-ministerial task team, led by the Department of Social Development. The team was established in Gauteng as a direct result of the President’s visit to Eldorado Park on the 14 May 2013, after he had received a letter from concerned residents. The Revised National Drug Master Plan (2013) on demand reduction, supply reduction and harm reduction had been implemented by various departments which reported to the inter-ministerial committee.
The meeting was adjourned.
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