Integrated Model for District Hospitals and the provision of mental health services: briefings by the Department of Health

Meeting report

Briefing by National Department of Health
The National Department of Health briefed the Committee on the Integrated Model for District Hospitals as well as on the provision of mental health services by the Department.

Briefing on the Integrated Model for District Hospitals
Ms Jeanette Hunter Deputy Director General: Primary Health, National Department of Health, said that a National Health System should be concerned with keeping people healthy as it was with caring for them when they were unwell. The concepts of “caring” and “wellness” were promoted most effectively and efficiently by creating small management units of the health system, adapted to cater for local needs. These units provide the framework for South Africa’s district based health system. The rationale for the District Health System amongst others was to overcome fragmentation, the need for equity, the need for access and quality and the need for comprehensive services.

South Africa’s health system structurally was made up of a National Department of Health, nine provincial departments of health and fifty two health districts. The district hospital played a pivotal role in supporting primary health care on the one hand and being a gateway to more specialist care on the other. Integration with regard to district hospitals took place on two levels. The first was integration between higher level and public health facilities from community level and the second was integration within the district hospital. The first type of integration was between primary health care facilities like district hospitals, mobile clinics etc and district clinical specialist teams who were based at regional or specialised hospitals which assisted the primary health care facilities with patients who had special needs. The second type of integration was within district hospitals and was the smallest type of hospital providing generalist medical services like oral health and eye care.

Emphasis was placed on key district health indicators. The key indicators were usable bed utilisation, average length of stay, usable beds per 1000 uninsured population and expenditure per patient day equivalent. Members were provided with 2011/12 figures on the various indicators across South Africa.
The District Health Expenditure Review (DHER) provided a clearer picture of funding, distribution and use of health resources in the district and the province. The DHER was a diagnostic tool used to assess to what extent the allocated budget and the resource expenditure advanced the district and province objectives of access, quality, efficiency, equity and sustainability.
Some areas identified for further strengthening include services and service delivery platforms, human resources, finances, governance and leadership, community ownership and referral systems.

Briefing on the provision of mental health services by the Department of Health
Professor Melvyn Freeman Chief Director: Non Communicable Diseases, National Department of Health, briefed the Committee on the state of mental health and mental health services in South Africa. Mental disorders were associated with significant distress and impairments of human functioning. Members were given insight into the prevalence of mental disorders. Twelve month prevalence of adult mental disorders in South Africa was at 16.5% in a survey done in 2002. Twelve month prevalence of child and adlolescent mental disorders in the Western Cape was 17%, unfortunately there was no national data available. For people living with HIV and AIDS the prevalence of mental disorders was found to be 43%. More than 25% of people developed one or more mental or behavioural disorder in their lifetime. 1-2% of South Africa’s population suffered from severe mental disorders such as schizophrenia and bipolar disorder. Around three quarters of people in South Africa that suffer from a mental disorder did not currently receive any mental health intervention.

In the first nationally representative survey of mental disorders in South Africa, lost earnings among adults with severe mental illness during the previous 12 months amounted to R28.8 billion. This represented 2.2% of Gross Domestic Product in 2002, and far outweighed the direct spending on mental health care for adults (of approximately R472 million). In short, it cost South Africa more to not treat mental illness than to treat it.

When looking at mental health in SA one must consider amongst others the association between poverty and mental health, that large numbers of children were orphaned by AIDS and other diseases and that people in their youth was part of liberation campaigns involving violence.
Members were given insight into the objects of the Mental Health Care Act of 2002. He noted that South Africa was someway towards achieving the goals of legislation and policy but there was no doubt a long way to go.

61% of all hospitals conducted 72 hour assessments of patients. As at 2010 in the public sector there were 0.28 psychiatrists, 0.32 psychologists, 10.8 psychiatry nurses, 0.40 social workers and 0.13 occupational therapists per 100 000 population. Up until now the emphasis had been on care, treatment and rehabilitation rather than prevention and promotion. Greater emphasis should be placed on substance abuse. The Drug Master Plan was but one government initiative to address the issue. Members were given a breakdown of the Ekurhuleni Declaration on Mental Health that was made in latter part April 2012. The decision was taken to promote mental health as an important development objective. After the National Mental Health Summit which took place on the 12 and 13 April 2012, under the stewardship of the Deputy Minister of Health, a working group of stakeholders met to draw an “action plan/strategic plan” to implement the resolutions from the Summit.Eight catalytic objectives were selected and were recommended by the task team for implementation. The selected catalytic objectives were to implement a district based mental health service and as part of primary health care re-engineering; institutional capacity building; surveillance, research and innovation; infrastructure and capacity of facilities; mental health technology, equipment and medicines; inter-sectoral collaboration; human resources for mental health and lastly advocacy, mental health promotion and prevention of mental illness.

Key challenges identified was inadequate community care, the stigma attached to mental illness, lack of human resources, dealing with “common mental disorders”, inadequate infrastructure, the need to prioritise mental health in annual performance plans.

Discussion
Mr W Faber (DA, Northern Cape) referred to Ms Hunter’s presentation and asked how one would know whether a public hospital fell under the control of a municipality or a district. All public hospitals were under the National Department of Health.
Mr Faber noted Professor Freeman’s reference about the shortfall in mental physicians and asked whether the nurses and doctors coming into the system would be fully equipped. Did they not need some sort of psychology background? In the Northern Cape Province a mental health hospital costing millions was being built. He felt that West End Hospital in the Province was inadequate. He added that in the Northern Cape many persons were in prisons because no mental health facilities were available.

Professor Freeman responded that the Department would ensure that persons coming into the system had the necessary skills. He explained that a psychiatrist would stabilise a mental patient first. Thereafter general practitioner doctors and nurses would provide primary ongoing care. The specialist teams mentioned in the briefing would see to the more serious mental patients.
He mentioned that two weeks ago he had visited Kimberley Hospital and had written a report to the Minister of Health on his observations. Work was being done to get persons with mental illnesses out of prisons.

Ms Hunter responded that all district hospitals were with the respective province. Some clinics were however with local authorities. A decision had been taken by government to provincialise all clinics. There were two reasons behind the decision. The first was that local municipality facilities did not provide a full range of services. The second was inequity of service benefits. She added that district service councils were provincialised. She was not always sure whether clinics were under local authorities or their respective provinces. To level the playing field provinces said that if local authorities appointed new persons then they would be appointed by provinces. In the big metros it was more likely that clinics fell under local authorities. Local authorities tended to pay its staff more than provinces.
She noted that the Department had started off by provincialising emergency medical services.

Ms B Mncube (ANC, Gauteng) said that staff at clinics under local authorities was opposed to being transferred to be under provinces. She emphasised that this affected service delivery in the Gauteng Province.

Mr M De Villiers (DA, Western Cape) referred to Ms Hunter’s reference to communities and representatives in the district health system and asked how many members there were in the sector and on committees. He also asked where the District Health System fit in with the National Health Insurance. What period of visiting was expected to take place to farm workers and farm schools in terms of efforts by the Department on school health? He asked if usable beds per 1000 persons needed to be 0.6 or above, what if the figure was below 0.6. He added that if smaller hospitals amalgamated then there would be less services provided. He referred to the expenditure per patient day by district and asked how it could be improved.

Mr De Villiers highlighted that Professor Freeman was able to provide statistics on the 12-month prevalence child and adolescent mental disorders in the Western Cape (17%). He therefore queried why no national data was available in this regard.

Mr De Villiers noted that prior to the introduction of Antiretrovirals, the figure for people living with HIV and AIDS with the prevalence of mental disorders was 43%. He asked what the figure was at present. He referred to the statement that more than 25% of people developed one or more mental or behavioural disorders in their lifetime and asked Professor Freeman to elaborate. He pointed out that doctors often put overworked persons off for depression. He considered it a dangerous practice in that a history of depression could affect future job prospects. There were individuals that were falsely arrested and jailed because of mental illnesses. People also lost jobs because of it. What outreach programme did the Department have to educate the public about mental illnesses?

Professor Freeman conceded that current data was needed on both the 12-month prevalence of child and adolescent mental disorders and for people living with HIV and AIDS with the prevalence of mental disorders. It was however an expensive process to compile such data. The Department was in the process of doing a surveillance of health as a whole. The idea was to set up a national health institute.
He confirmed that more than 25% of people developed one or more mental or behavioural disorder in their lifetime.
It was prejudicial for persons suffering from depression to be negatively affected on the job front. The Mental Health Care Act protected persons with mental diseases. A person with mental illnesses who was falsely imprisoned and had been fired was due to public ignorance. Better knowledge at different levels would make a huge difference. The police for instance should know where to refer a person that had a mental illness. There was a public perception that persons with mental illnesses were dangerous and violent. The sooner these individuals were treated the less likely they were to be violent.
The more violent a society, the more violent the mental person. If there were more facilities to accommodate mental persons then there would be no need to lock them up.
He pointed out that the Mental Health Care Act spoke about the role of police in regards to mental persons. The police were supposed to take mental persons that they picked up to a clinic for an assessment. Perhaps the police needed to be given a refresher on this requirement.

Ms Hunter said that the Health Act established the National Health Council. Most of the provinces established provincial health councils. In some provinces district health councils were not established.
Regarding traditional health forums she said that there needed to be communication and co-operation. She was not to sure how active traditional health forums were. The Department intended to set up a framework for co-operation between traditional healers and formally trained medical doctors.
The district health system fit in nicely with the National Health Insurance. The principles of the district health system and the National Health Insurance were the same.
Regarding visits to schools, the Department at present was focusing on quintiles one, two and three. At least once a year Grades One would be visited. Grades Eight and Nine would also be visited. Those schools that needed it would be visited at least once a year.
On the issue of usable beds per 1000 persons needed, she said that in some areas the figures were high whereas in other areas figures were low. The figures tended to be lower in big cities as there were private hospitals. The National Health Insurance would take into account all beds not only public sector hospital beds.
On expenditure per patient day by district, she said that the figures tended to vary. Where expenditure was more perhaps the elements that more funds were spent on should be looked at. On the other hand perhaps more could be learnt from those districts that spent less. How were they more efficient?

The Chairperson said she was looking forward to the National Mental Health Programme to be rolled out by the Department. She pointed out that there were so many persons with mental illnesses roaming the streets, what plan did the Department have to address the issue. What were the plans of the Department to revive mental health boards? On the integration of mental health care, what protection was there to patients? If the referral system mentioned by Ms Hunter was to improve service delivery, what plans were in place to ensure that it was implemented? Referring to traditional medicine, she asked whether traditional forums were still functioning within the Department.

Professor Freeman agreed that there was a need for more community facilities to prevent mental persons from roaming the streets. He added that the money needed to follow the patient.
On the issue of mental health review boards, training was taking place and a manual had been published.
A couple of mental health review boards were stable but most had rotations. The intention with integrating was to protect mental health patients. If mental health persons were treated early then there was no need for them to be violent. 
 
Ms Hunter noted that there were referral systems in place already in South Africa but that they were not efficient. The issue was about re-skilling people. For example doctors and nurses were being trained on how to examine a pregnant woman. These health practitioners needed to know when patients needed to be referred. The referral model rolled out in the Free State Province had been perfected. It could be a model for the rest of South Africa.

Mr S Ramokgoase (ANC, Free State) commented that the district health system together with the National Health Insurance was heading in the right direction. On the issue of community education and participation systems needed to be put in place. Local government needed to be brought on board as they were at grassroots level and had health structures of their own. The Department had to come up with a package.

Mr De Villiers addressed the issue of psychotropic drugs and asked whether it was correct that essential drugs would be provided to mental patients. What programme did the Department have in place to ensure that essential drugs would be provided? He also asked which health centres and clinics did not have necessary equipment. Regarding the Department’s School Programme he noted that learners, teachers and parents should be involved.

Professor Freeman responded that the issue of medicines needed to be looked at holistically and not by disease. On equipment needed, it depended upon the level of services on offer. At district clinic level more equipment was needed. There were shortages of Electrocardiography (ECG) machines and staff.
Teachers at schools also needed to be educated. It was one of the strategies of inter-sectoral collaboration. The Department had to work hand in hand with the Department of Education. The Department did liaise with the Department of Education on a regular basis.

Ms Hunter pointed out that the Department considered the unavailability of one drug just as important as the unavailability of another. The Department had done away with multiple depots. There was a system in place to monitor the stock levels of drugs from national to health facilities. 

Ms Mncube pointed out that during oversight visits by the Committee to certain areas the rate of teenage pregnancies was high. With the Schools Programme did the Department prioritise certain schools over others?

Ms Hunter on teenage pregnancies said that the issue was about being proactive and educating communities. Schools needed to be targeted through the School Health Programme. At present the Department was only targeting schools based on their social conditions.

The Chairperson noted that the provicialisation of health was an issue that was always coming up but proper responses were never given on it. The Department needed to provide the Committee with more information on it. Perhaps when the Department presented its Annual Report to the Committee the Annual Report could speak to the issue of provincialisation and the progress made on it. 

The meeting was adjourned.
Briefing by National Department of Health
The National Department of Health briefed the Committee on the Integrated Model for District Hospitals as well as on the provision of mental health services by the Department.

Briefing on the Integrated Model for District Hospitals
Ms Jeanette Hunter Deputy Director General: Primary Health, National Department of Health, said that a National Health System should be concerned with keeping people healthy as it was with caring for them when they were unwell. The concepts of “caring” and “wellness” were promoted most effectively and efficiently by creating small management units of the health system, adapted to cater for local needs. These units provide the framework for South Africa’s district based health system. The rationale for the District Health System amongst others was to overcome fragmentation, the need for equity, the need for access and quality and the need for comprehensive services.

South Africa’s health system structurally was made up of a National Department of Health, nine provincial departments of health and fifty two health districts. The district hospital played a pivotal role in supporting primary health care on the one hand and being a gateway to more specialist care on the other. Integration with regard to district hospitals took place on two levels. The first was integration between higher level and public health facilities from community level and the second was integration within the district hospital. The first type of integration was between primary health care facilities like district hospitals, mobile clinics etc and district clinical specialist teams who were based at regional or specialised hospitals which assisted the primary health care facilities with patients who had special needs. The second type of integration was within district hospitals and was the smallest type of hospital providing generalist medical services like oral health and eye care.

Emphasis was placed on key district health indicators. The key indicators were usable bed utilisation, average length of stay, usable beds per 1000 uninsured population and expenditure per patient day equivalent. Members were provided with 2011/12 figures on the various indicators across South Africa.
The District Health Expenditure Review (DHER) provided a clearer picture of funding, distribution and use of health resources in the district and the province. The DHER was a diagnostic tool used to assess to what extent the allocated budget and the resource expenditure advanced the district and province objectives of access, quality, efficiency, equity and sustainability.
Some areas identified for further strengthening include services and service delivery platforms, human resources, finances, governance and leadership, community ownership and referral systems.

Briefing on the provision of mental health services by the Department of Health
Professor Melvyn Freeman Chief Director: Non Communicable Diseases, National Department of Health, briefed the Committee on the state of mental health and mental health services in South Africa. Mental disorders were associated with significant distress and impairments of human functioning. Members were given insight into the prevalence of mental disorders. Twelve month prevalence of adult mental disorders in South Africa was at 16.5% in a survey done in 2002. Twelve month prevalence of child and adlolescent mental disorders in the Western Cape was 17%, unfortunately there was no national data available. For people living with HIV and AIDS the prevalence of mental disorders was found to be 43%. More than 25% of people developed one or more mental or behavioural disorder in their lifetime. 1-2% of South Africa’s population suffered from severe mental disorders such as schizophrenia and bipolar disorder. Around three quarters of people in South Africa that suffer from a mental disorder did not currently receive any mental health intervention.

In the first nationally representative survey of mental disorders in South Africa, lost earnings among adults with severe mental illness during the previous 12 months amounted to R28.8 billion. This represented 2.2% of Gross Domestic Product in 2002, and far outweighed the direct spending on mental health care for adults (of approximately R472 million). In short, it cost South Africa more to not treat mental illness than to treat it.

When looking at mental health in SA one must consider amongst others the association between poverty and mental health, that large numbers of children were orphaned by AIDS and other diseases and that people in their youth was part of liberation campaigns involving violence.
Members were given insight into the objects of the Mental Health Care Act of 2002. He noted that South Africa was someway towards achieving the goals of legislation and policy but there was no doubt a long way to go.

61% of all hospitals conducted 72 hour assessments of patients. As at 2010 in the public sector there were 0.28 psychiatrists, 0.32 psychologists, 10.8 psychiatry nurses, 0.40 social workers and 0.13 occupational therapists per 100 000 population. Up until now the emphasis had been on care, treatment and rehabilitation rather than prevention and promotion. Greater emphasis should be placed on substance abuse. The Drug Master Plan was but one government initiative to address the issue. Members were given a breakdown of the Ekurhuleni Declaration on Mental Health that was made in latter part April 2012. The decision was taken to promote mental health as an important development objective. After the National Mental Health Summit which took place on the 12 and 13 April 2012, under the stewardship of the Deputy Minister of Health, a working group of stakeholders met to draw an “action plan/strategic plan” to implement the resolutions from the Summit.Eight catalytic objectives were selected and were recommended by the task team for implementation. The selected catalytic objectives were to implement a district based mental health service and as part of primary health care re-engineering; institutional capacity building; surveillance, research and innovation; infrastructure and capacity of facilities; mental health technology, equipment and medicines; inter-sectoral collaboration; human resources for mental health and lastly advocacy, mental health promotion and prevention of mental illness.

Key challenges identified was inadequate community care, the stigma attached to mental illness, lack of human resources, dealing with “common mental disorders”, inadequate infrastructure, the need to prioritise mental health in annual performance plans.

Discussion
Mr W Faber (DA, Northern Cape) referred to Ms Hunter’s presentation and asked how one would know whether a public hospital fell under the control of a municipality or a district. All public hospitals were under the National Department of Health.
Mr Faber noted Professor Freeman’s reference about the shortfall in mental physicians and asked whether the nurses and doctors coming into the system would be fully equipped. Did they not need some sort of psychology background? In the Northern Cape Province a mental health hospital costing millions was being built. He felt that West End Hospital in the Province was inadequate. He added that in the Northern Cape many persons were in prisons because no mental health facilities were available.

Professor Freeman responded that the Department would ensure that persons coming into the system had the necessary skills. He explained that a psychiatrist would stabilise a mental patient first. Thereafter general practitioner doctors and nurses would provide primary ongoing care. The specialist teams mentioned in the briefing would see to the more serious mental patients.
He mentioned that two weeks ago he had visited Kimberley Hospital and had written a report to the Minister of Health on his observations. Work was being done to get persons with mental illnesses out of prisons.

Ms Hunter responded that all district hospitals were with the respective province. Some clinics were however with local authorities. A decision had been taken by government to provincialise all clinics. There were two reasons behind the decision. The first was that local municipality facilities did not provide a full range of services. The second was inequity of service benefits. She added that district service councils were provincialised. She was not always sure whether clinics were under local authorities or their respective provinces. To level the playing field provinces said that if local authorities appointed new persons then they would be appointed by provinces. In the big metros it was more likely that clinics fell under local authorities. Local authorities tended to pay its staff more than provinces.
She noted that the Department had started off by provincialising emergency medical services.

Ms B Mncube (ANC, Gauteng) said that staff at clinics under local authorities was opposed to being transferred to be under provinces. She emphasised that this affected service delivery in the Gauteng Province.

Mr M De Villiers (DA, Western Cape) referred to Ms Hunter’s reference to communities and representatives in the district health system and asked how many members there were in the sector and on committees. He also asked where the District Health System fit in with the National Health Insurance. What period of visiting was expected to take place to farm workers and farm schools in terms of efforts by the Department on school health? He asked if usable beds per 1000 persons needed to be 0.6 or above, what if the figure was below 0.6. He added that if smaller hospitals amalgamated then there would be less services provided. He referred to the expenditure per patient day by district and asked how it could be improved.

Mr De Villiers highlighted that Professor Freeman was able to provide statistics on the 12-month prevalence child and adolescent mental disorders in the Western Cape (17%). He therefore queried why no national data was available in this regard.

Mr De Villiers noted that prior to the introduction of Antiretrovirals, the figure for people living with HIV and AIDS with the prevalence of mental disorders was 43%. He asked what the figure was at present. He referred to the statement that more than 25% of people developed one or more mental or behavioural disorders in their lifetime and asked Professor Freeman to elaborate. He pointed out that doctors often put overworked persons off for depression. He considered it a dangerous practice in that a history of depression could affect future job prospects. There were individuals that were falsely arrested and jailed because of mental illnesses. People also lost jobs because of it. What outreach programme did the Department have to educate the public about mental illnesses?

Professor Freeman conceded that current data was needed on both the 12-month prevalence of child and adolescent mental disorders and for people living with HIV and AIDS with the prevalence of mental disorders. It was however an expensive process to compile such data. The Department was in the process of doing a surveillance of health as a whole. The idea was to set up a national health institute.
He confirmed that more than 25% of people developed one or more mental or behavioural disorder in their lifetime.
It was prejudicial for persons suffering from depression to be negatively affected on the job front. The Mental Health Care Act protected persons with mental diseases. A person with mental illnesses who was falsely imprisoned and had been fired was due to public ignorance. Better knowledge at different levels would make a huge difference. The police for instance should know where to refer a person that had a mental illness. There was a public perception that persons with mental illnesses were dangerous and violent. The sooner these individuals were treated the less likely they were to be violent.
The more violent a society, the more violent the mental person. If there were more facilities to accommodate mental persons then there would be no need to lock them up.
He pointed out that the Mental Health Care Act spoke about the role of police in regards to mental persons. The police were supposed to take mental persons that they picked up to a clinic for an assessment. Perhaps the police needed to be given a refresher on this requirement.

Ms Hunter said that the Health Act established the National Health Council. Most of the provinces established provincial health councils. In some provinces district health councils were not established.
Regarding traditional health forums she said that there needed to be communication and co-operation. She was not to sure how active traditional health forums were. The Department intended to set up a framework for co-operation between traditional healers and formally trained medical doctors.
The district health system fit in nicely with the National Health Insurance. The principles of the district health system and the National Health Insurance were the same.
Regarding visits to schools, the Department at present was focusing on quintiles one, two and three. At least once a year Grades One would be visited. Grades Eight and Nine would also be visited. Those schools that needed it would be visited at least once a year.
On the issue of usable beds per 1000 persons needed, she said that in some areas the figures were high whereas in other areas figures were low. The figures tended to be lower in big cities as there were private hospitals. The National Health Insurance would take into account all beds not only public sector hospital beds.
On expenditure per patient day by district, she said that the figures tended to vary. Where expenditure was more perhaps the elements that more funds were spent on should be looked at. On the other hand perhaps more could be learnt from those districts that spent less. How were they more efficient?

The Chairperson said she was looking forward to the National Mental Health Programme to be rolled out by the Department. She pointed out that there were so many persons with mental illnesses roaming the streets, what plan did the Department have to address the issue. What were the plans of the Department to revive mental health boards? On the integration of mental health care, what protection was there to patients? If the referral system mentioned by Ms Hunter was to improve service delivery, what plans were in place to ensure that it was implemented? Referring to traditional medicine, she asked whether traditional forums were still functioning within the Department.

Professor Freeman agreed that there was a need for more community facilities to prevent mental persons from roaming the streets. He added that the money needed to follow the patient.
On the issue of mental health review boards, training was taking place and a manual had been published.
A couple of mental health review boards were stable but most had rotations. The intention with integrating was to protect mental health patients. If mental health persons were treated early then there was no need for them to be violent. 
 
Ms Hunter noted that there were referral systems in place already in South Africa but that they were not efficient. The issue was about re-skilling people. For example doctors and nurses were being trained on how to examine a pregnant woman. These health practitioners needed to know when patients needed to be referred. The referral model rolled out in the Free State Province had been perfected. It could be a model for the rest of South Africa.

Mr S Ramokgoase (ANC, Free State) commented that the district health system together with the National Health Insurance was heading in the right direction. On the issue of community education and participation systems needed to be put in place. Local government needed to be brought on board as they were at grassroots level and had health structures of their own. The Department had to come up with a package.

Mr De Villiers addressed the issue of psychotropic drugs and asked whether it was correct that essential drugs would be provided to mental patients. What programme did the Department have in place to ensure that essential drugs would be provided? He also asked which health centres and clinics did not have necessary equipment. Regarding the Department’s School Programme he noted that learners, teachers and parents should be involved.

Professor Freeman responded that the issue of medicines needed to be looked at holistically and not by disease. On equipment needed, it depended upon the level of services on offer. At district clinic level more equipment was needed. There were shortages of Electrocardiography (ECG) machines and staff.
Teachers at schools also needed to be educated. It was one of the strategies of inter-sectoral collaboration. The Department had to work hand in hand with the Department of Education. The Department did liaise with the Department of Education on a regular basis.

Ms Hunter pointed out that the Department considered the unavailability of one drug just as important as the unavailability of another. The Department had done away with multiple depots. There was a system in place to monitor the stock levels of drugs from national to health facilities. 

Ms Mncube pointed out that during oversight visits by the Committee to certain areas the rate of teenage pregnancies was high. With the Schools Programme did the Department prioritise certain schools over others?

Ms Hunter on teenage pregnancies said that the issue was about being proactive and educating communities. Schools needed to be targeted through the School Health Programme. At present the Department was only targeting schools based on their social conditions.

The Chairperson noted that the provicialisation of health was an issue that was always coming up but proper responses were never given on it. The Department needed to provide the Committee with more information on it. Perhaps when the Department presented its Annual Report to the Committee the Annual Report could speak to the issue of provincialisation and the progress made on it. 

The meeting was adjourned.