Progress towards attaining the Millennium Development Goals & Update on situation in the Eastern Cape: briefing by Department of Health, with Minister; Pharmaceutical Logistics Association of South Africa on Single Exit Price

Meeting report

The Chairperson welcomed everyone to the meeting. Thereafter, he indicated that the Pharmaceutical Logistics Association of South Africa (PLASA) would address the Committee first before it engaged with the Department of Health.

PLASA Presentation
Mr Trevor Philips, Executive Director, PLASA, explained that PLASA was a trade association and comprised of 12 companies with 30 specialised warehouses throughout the country for medicine distribution. 
Mr Philips indicated that the Association appeared before the Committee to speak about the pricing system introduced in 1995 by the first Minister of Health called the Single Exit Price (SEP). The goal of this was to provide affordable medicine for all by keeping one price through each step of the process, from production, to shipping, to distribution.  In theory, SEP should protect the patient, but the legislation governing SEP was flawed and had loopholes which entrepreneurs could expose ultimately affecting the patient.  PLASA felt that with some minor amendments those issues could be fixed. PLASA had met with the Department of Health in the past and offered solutions, but despite their agreement the Department rarely implemented anything.

Logistics service providers had been complaining to PLASA and the Department about the legal shortcomings that negatively affect them, including the exchange rate on imports.  At the end of 2012, PLASA had appealed to the Minister for help as many smaller businesses were struggling due to the lack of adjustments made to the pricing system.  “There was an island of free enterprise but it was on a regulated ocean, resulting in the wholesalers who have more resources to benefit better”.

PLASA felt that the only option it had left to insight change was litigation.  It had met with the logistics task team, headed by Mr Gavin Steel, and stated its case. The task team had agreed with its point of view and noted that the formula for determining SEP increases was not appropriate when considering the logistics fee.  Those meetings happened in February and May and PLASA had been told that the proposed changes would be put out for public comment, however nothing had happened yet.  PLASA found itself in the same position in 2013 as it was at the end of 2012. It was still appealing to the proper bodies in order to get the Department to work with it in order to achieve a better SEP formula.

Mr Philips said that a concise note would be sent out to the Members explaining the position of PLASA.  He reaffirmed PLASAs ultimate goal of ensuring access to affordable medicine and to provide an efficient and effective method of the distribution of medicines.

Discussion
The Chairperson noted that the Members would need the document to look over due to the technical nature of the problem. This problem needed to be solved before it evolved into a legal battle. He assured PLASA that the Committee would engage the Department.

Ms M Segale-Diswai (ANC) commented that it was difficult for Members to follow the presentation without having a document in front of it.  She added that PLASA needed to take the issue up with the Department.

The Chairperson noted that PLASA had met with the Department and made little progress. It was meeting with the Committee in order to avoid a legal battle. 

Ms M Dube (ANC) noted that both sides of the story must be told and the Committee did not want to start “a tug of war” between the Department and PLASA.  Both sides needed to make an informed decision.

Ms Malebona Precious Matsoso, Director-General, Department of Health, explained that the Department had previously invited PLASA to work with it to improve the distribution of medicine. PLASA was present at a stakeholders meeting earlier in the year.  Although PLASA claimed that it had met with the Department many times, it had only met with junior officials.  The concern PLASA was raising was legitimate but it had yet to reach out and meet with the proper people.

Mr Philips first apologised to the Committee for not having a physical copy of his presentation but assured Members that he would send it as soon as possible. He stated that PLASA was under the impression that the representatives from the Department that it had spoken to would have taken the problem seriously and communicated it to their seniors.  PLASA had been complying with the requests of the Department for years and since 2004 had been sending regular requests and compiled documents to the Department.  It was willing to do anything else that was requested from the Director-General as long as it helped in getting its point across.

The Chairperson stated that as MPs their interest was in service delivery and they were happy that the Director-General had been present to hear the grievances of PLASA.  The problem should not reach the point in which legal action needed to be taken. Rather, it could be solved between the two bodies and legal action should be the last resort.  He thanked the delegation from PLASA for their presentation.

The Chairperson welcomed the delegation from the Department of Health and noted that it would brief the Committee on its progress towards achieving the UN Millennium Development Goals (MDGs). He noted that the Minister of Health would be arriving late.

Department of Health Presentation on the progress made towards attaining the Millennium Development Goals
Ms Matsoso stated that the MDGs were adopted by the UN in 2000 with the deadline of meeting the goals set at December 31, 2015.  Statistics South Africa co-ordinated the writing of the national report presented to the UN by the President using verifiable data.  There was a total of 8 MDGs and the Department of Health dealt directly with three; to reduce child mortality, to improve maternal health and to combat HIV/AIDS, malaria and other diseases.

In terms of child mortality the Department felt that is was likely that it would reach its targets by 2015. The Department believed that it was unlikely that it would meet the life expectancy goals by 2015 as the target had been set at 70 and as of 2013 the life expectancy in the country was only 60. Although it had made achievements they were not likely to be able to improve enough to meet their objectives. 

Dr Nonhlanhla Dlamini, Chief Director, Department of Health stated that most infant deaths were when they were newborns.  HIV/AIDS, diarrhoea, pneumonia, tuberculosis and malnutrition were the major causes of child mortality. With newborns the causes were broken down into three categories- premature births, infections and birth asphyxiation.  A strategy had been developed to intervene and reduce the number of child deaths.  The Newborn Care Strategy ensured that nurseries were fully equipped and the staff properly trained in newborn resuscitation. The health system needed to identify children born with HIV/AIDS in order to begin medicating immediately.  Babies would be tested at birth in the case that they may have been exposed to HIV and underweight babies were a target due to it being a sign of stress during development.  Testing for HIV on babies began at six weeks and if they tested positive, medication would begin immediately and if they tested negative they would be retested at 18 months.

Diarrhoea was one of the most preventable causes of child death.  A salt-sugar solution was a simple homemade remedy that parents could utilise in order to combat diarrhoea.  Pneumonia was a difficult illness to deal with as in many cases parents struggled to tell the difference between pneumonia and a cold.  Parents needed to better understand the difference between the two and look at the breathing of the baby to properly diagnose it.  Malnutrition amongst infants could be combated if parents practiced exclusive breastfeeding as it contained all the nutrients an infant needed to be healthy.  Tuberculosis testing was done at the same time as HIV testing.

Ms Matsoso then spoke about MDG 5 which was to improve maternal health. This was one of the biggest challenges facing South Africa and specifically the Department of Health. The three biggest causes of maternal mortality were HIV, Hypertension and Haemorrhage.  The maternal mortality ratio was set at number of deaths per 100 000 live births, the UN set a target of 38 per 100 000 by 2015. The rate in South Africa had been going down but in 2010 it peaked and the Department felt that it would be unlikely to reach the MDG target by 2015. Positive steps had been made towards the proportion of births attended by skilled health personnel and the Department was likely to reach their targets. One thing that made obtaining comprehensive statistics difficult was that there were no numbers for maternal deaths that occurred at home, the numbers only reflected data obtained from hospitals.

Ms Matsoso informed Members about the improved access to lifelong ART for pregnant women taking antiretroviral drugs for their own health.  There had been a significant decline in the maternal mortality rate in the Free State after the reorganisation of that province’s emergency medical services which included the improvement of its facility transfer times and the realignment of services for caesarean section times.

MDG 6 was to combat HIV/AIDS, malaria and other diseases.  South Africa had made great strides as a society in its attempt to achieve this goal. The Department was likely to hit its targets on HIV prevalence amongst the population aged 15-24 years and for the proportion of the population aged 15-24 years with correct knowledge of HIV/AIDS. South Africa was on track to achieve the target of 80% for the proportion of population with advanced HIV infection with access to antiretroviral drugs. Targets set for the reduction of malaria had already been achieved in South Africa.

Ms Matsoso concluded that the impact of social determinants had on health outcomes must be considered and that as a country there had been a lot of progress since 2009.  But work needed to be done in specific areas to achieve as much as the Department could before the 2015 deadline.  The fight against many of the problems raised by the MDGs would continue post 2015, including universal health care and the fight against non-communicable diseases.

Discussion
The Chairperson thanked the Department for its presentation and noted that the Minister had arrived.  He asked about infant deaths, and sough clarity on what “premature death” meant as referred to in the presentation. He further noted that there was no mention of illiteracy in South Africa and it was a major concern.

Mr Aaron Motsoaledi, Minister of Health, stated that the Department was aware of where it stood on meeting the MDG targets and of its shortcomings.  In sub-Sahara Africa there was a great deal of concern on achieving the goals set out by the UN and doing so was a societal responsibility. If there was mass mobilisation throughout society some of the goals the Department falling short could be achieved.  He used the success the country was having with HIV as an example, in 2009 many people would not have believed that the numbers the country was achieving would be possible, but people willed themselves to get tested and understood the importance of it.

With newborns who died prematurely it was usually a case of lung diseases, their lungs were not mature enough to breathe or be in the environment of the outside world.   Underagers accounted for 36% of premature deaths but only 8% of overall pregnancies. By providing family planning for teen pregnancies and making more resources available for young girls the Department could prevent this 36% figure.  Teens did not go to their parents for help. They went to clinics and were sometimes met with hostility at these clinics. Newspapers had condemned the Department for providing condoms to schools and it was a factor in holding back the Department from achieving its goals. Why should nurses at a clinic not be able to give condoms to a sexually active teenager? This would lower the 36% a great deal.  The Children’s Act of 2005 promoted condom use as it was necessary in the fight against HIV/AIDS. With less than 1000 days left until the UN deadline, South Africa could still make some remarkable achievements. The age of menstruation was lowering and it made family planning more difficult.  The average man did not think he had anything to do with the MDGs, but this could not be more true and there had to be more awareness.

The Chairperson thanked the Minister for his comments and opened the floor for questions.

Ms B Ngcobo (ANC) stated that she was proud that the Free State was performing well.  She was concerned about the correlation between teen pregnancy and the maternal mortality rate. Lastly, she asked what the working relationship was between the Department of Health and the Department of Basic Education.

Ms Segale-Diswai asked about the strategic plan of the Department, was it available for Members to see? She asked how many women booked for checkups during pregnancy and if a campaign needed to be launched to convince women to book early checkups at clinics.

Mr D Kganare (COPE) noted that there was a great number of midwives retiring and asked whether the Department had taken the proper steps in keeping the numbers up.  There was a public perception that the condoms given out by the government were of inferior quality, how was the Department going to deal with this perception? There was a rumour that there was a substance in the condoms that relieved arthritis.

Mr G Lekgetho (ANC) asked who was responsible for the rest of the MDGs and what the salt-sugar solution mentioned was.

Ms Dube asked if home visit arrangements were available for family planning, especially in rural areas.

Ms D Robinson (DA) was happy with the Department’s new approach to family planning. She noted that the country had a shortage of nurses and doctors, was there any thought given to allowing them to train in private facilities and what about using retirees as midwives?  Was the early maturation of girls a problem specific to South Africa or a worldwide issue? Was there a difference between rural and urban areas in this regard? She expressed concern about violence towards nurses and doctors, there should be a campaign launch to protect them and get positive messages out to the wider community.

The Minister replied that there was nothing in the ingredients of the lubricant on condoms that helped arthritis. He noted that the relationship between the human mind and body was extremely strong and once an idea was internalised people would believe it. He hoped that the condom rumour did not spread.

The issue of HIV/AIDS across the borders of South Africa was a concern to the Department, and it understood that it had to work with other countries if it wished to win the battle.  There were cross border clinics in place that were funded by the Global Fund to Fight Aids that sought to reduce the number of cross border cases.  All the major borders of South Africa had them.

The Minister stated that the highest percentage of tuberculosis was in correctional services and the second highest area was the mines.  A large number of miners were not from South Africa, thus increasing the importance of cross border cooperation in combating diseases. There were over 17 000 miners in the country with tuberculosis and the investors in mines need to be shown that there were human beings behind their profits.  The mining companies needed to know that tuberculosis was a major problem at their mines and they needed to help.  The only cases of malaria in South Africa were imported and the Limpopo borders were difficult to protect.

The working relationship between the Department of Health and the Department Basic Education was at times difficult.  The latter had shown hesitation when the issue of reproductive and HIV/AIDS education was brought up. Teachers were sceptical about teaching these subjects and the Department of Health felt as though these issues had to be resolved locally.

The Minister noted that nurse’s uniforms had changed from earlier years and they no longer demanded the respect they deserved.  He felt that the nurses should have brought back the old white uniforms. Nurses in KwaZulu-Natal wanted them back.  There was a uniform allowance provided to nurses and there was a debate on whether they would keep the allowance and receive a state supplied uniform.  Unreceptive and rude nurses in clinics were problematic and the Department needed to ensure that there was compliance to the standards.  A training programme had been started in order to help the problematic nurses better understand the needs of young girls. 

The Minister stated that the Department was looking at changing the look of government issued condoms and adding colours and trying to engage university students.

The rest of the MDGs were spread across the other Departments.  The salt-sugar solution was salt and sugar in water and it helped treat diarrhoea.  This solution was present in many hospitals and was very simple to make and administer but the public had to be aware and understand this.

Ms Matsoso informed Members that only 19 of 52 districts had reached their targets for visits to clinics or hospitals during pregnancy.

The Minister stated that the whole of sub-Sahara Africa had been declared a crisis area in terms of the shortage of health care professionals.  Laws forced older doctors to retire even if they were still capable.  Some of these force-retired doctors still saw patients on an unofficial basis, but there needed to be flexibility and the matter needed to be reconsidered to try and help the bigger problem.

The Chairperson thanked the Department for its presentation and stated that the Committee would present it to Parliament. He asked the Department to commence with its second presentation.

Department of Health Presentation on health in the Eastern Cape
The Minister stated that there was very little being done in the Eastern Cape and in 2011 the Minister of Finance had visited the province due to the issues of financial management. There were many issues found, from finances and infrastructure issues to equipment and HR issues.  Any findings in regards to corruption were handled by a different body and some incidents discovered were put aside for further investigation. It was found that the majority of problems in the Eastern Cape were in the OR Tambo district. 

The Department had been aware of the troubles in this district and previous audits had shown that OR Tambo was in a poor state. Based off the findings made it was realised that basic infrastructure was needed and representatives were sent to thoroughly check on the state of facilities and prioritise what needed to be fixed. It was determined that most facilities in OR Tambo needed a great deal of repairs.  Three hospitals had to be demolished and rebuilt from scratch. These projects had already been budgeted. A further eight clinics needed to be demolished and started anew, five of which would be done in the year. Thirty clinics in the region suffered from a major space problem and basic equipment was missing. Holy Cross Hospital was an example of a facility that had a serious lack of equipment. A big problem in OR Tambo was ambulances and EMS services, they had to travel long distances and the roads were in poor shape.

The Chairperson noted that the Committee had travelled to the Eastern Cape and were disappointed with its findings.

Dr Thobile Mbengashe, Superintendent General, Department of Health, then commenced the slide show and noted that significant backlogs in the Eastern Cape were inherited in 1994 and the area suffered from significant levels of poverty and under-development of infrastructure.  He then moved on to the report from the Ministerial team’s visit to Holy Cross Hospital on September 13, 2013. The visit was prompted by a report written by a suspended doctor who spoke about the poor state of affairs at the hospital. The team went to see firsthand whether the accusations brought forth were true. The visit uncovered that there were many issues with Holy Cross, including the lack of key pieces of equipment, lack of consistent supply of oxygen, poor record keeping, poor staff attitude, poor quality of care, irregularities in procurement, and inadequate emergency medical services in the OR Tambo area.

The Ministerial team had brought back a variety of suggestions on how to begin fixing Holy Cross Hospital including the immediate suspension of the CEO as she had neglected to do her duty and manage the hospital properly. An investigation into her work needed to be done.  The Ministerial team had further recommended that the Nursing Services Manager should be suspended and a full investigation into her roll should be done.  Progressive disciplinary measures should be instituted against the Hospital Administrator for her role in the poor management of the oxygen supply to the hospital. All of the suggestions had been put into effect.

Strengthening hospital management was a key focus of the Department and progress was being made in this regard. Provincial management had been workshopped on the key issues in hospital management including governance, procurement, financial management, and human resources management. The Department had arranged for the delivery of essential equipment to hospitals in the OR Tambo district, particularly Holy Cross Hospital.  A Facility Improvement Team from the Department had been working in the OR Tambo district for 18 months focusing on strengthening infrastructure and quality improvement.

Dr Mbengashe then presented the OR Tambo Action Plan, which highlighted the areas that needed improvement, the causes and the actions to be taken. The first problem noted was in human resources where there were inadequacies in management, leadership and accountability. The Department recommended fast tracking the filling of critical posts.  Financial support was an issue on account of the misalignment of planning and budgeting and the lack of integration between the two. A proposal had been made for additional financial resources based on the plans made to which ensured that hospitals in the district were fully functional. Compliance to policies and procedures was found to be a big issue and a lack of accountability was prevalent in the region and the Department called for the implementation of a coaching and mentoring programme and for code of conduct and work ethics to be revived.  More disciplinary measures needed to be taken against those who did not comply to rules and regulations.

Dr Mbengashe went through the rest of the areas which were: drug management, information management, community mobilization, referral systems, EMS transport, functioning of WBOTS, supply chain management, and clinical governance.  He listed the root causes and the activities/actions taken as they were noted in the presentation.  See slides for full details.

He noted that the Eastern Cape Department of Health had appointed a provincial team to work with other departments in support of OR Tambo. The team was there to ensure that the recommendations given to the hospitals were being implemented.  More teams were being established for other areas.  Despite the many challenges that remained in the Eastern Cape, the Eastern Cape Department of Health and the National Department of Health had a robust plan to strengthen health care in that province.

Discussion
The Chairperson thanked the Department for the report and stated that this was an update that the Committee had been waiting for.  He noted that there were people who were illiterate in the area and this posed a problem for service delivery. Those who had the means to leave OR Tambo usually did so in order to get better health services elsewhere. Those who were illiterate were left with no money or resources.  He asked whether the new leadership in place in the Eastern Cape would be able to continue with the plans of the Department of Health. There was a denial of the reality and severity of the situation in OR Tambo and the leadership there had to know this. Despite the Committee’s acceptance of the report, there was still a lot to be worried about.

Ms Matsoso stated that the data they had and the results of the district health barometer demonstrated that the OR Tambo district was struggling and intervention was needed.

The Chairperson expressed his concern with the state of affairs in the Eastern Cape and opened the floor for discussion.

Mr Kganare stated that the Member of the Executive Council (MEC) for Health in the Eastern Cape felt that many problems in the area stemmed from political interference. The MEC should have been present at the meeting. All the problems brought forth by the task team had previously been denied by the MEC, it was cases like this when people must step down from their position rather than be fired.  The Minister could not fire the MEC, but the Premier could. The MEC had misled the public and failed to do his duty in the Eastern Cape and must admit so. 

Mr Kganare spoke about a doctor in the Eastern Cape who had been suspended for whistle blowing and asked if he had been reinstated?

Ms Ngcobo noted that many of the concerns raised in OR Tambo had been known for four and a half years, the ministerial team were not the first people to have discovered these issues.  Nothing in the solutions was geared toward proper management and the concrete roles of management.  Was there sufficient budget to move forward with the plans set out? Where would the Department motivate for its funding? 

Ms Robertson commented on the unions and stated that they were controlling health care, would new management be able to control the unions?

The Minister replied that for a long time the Eastern Cape had been weak at the top level. The Provincial Department of Health had no CFO for a long time. There had only been a stable CFO in place for six months. Human resources was an area that struggled and with the appointment of a new DDG changes were already being made.  Previously the Department of Treasury had taken over the HR department because it was worried about its well-being. 

The Minister addressed the question about the doctor who was suspended for whistle blowing. He would have done the same as the doctor because the patients were the main priority. He had attempted to contact the doctor but was told by the hospital that he had resigned. No doctor should have to resign because they raised concerns about the treatment of patients. 

The Minister stated that Health was an area that had concurrent powers.  He had the power to do certain things while some things were up to the provinces. The provinces and Premiers appointed their own MECs.  This was why the MEC had loyalty to the Premier and answered to her, the Minister could do nothing. To solve the problem Members must directly address the Premier.  The Minister agreed that the Eastern Cape MEC for Health should have been present at the meeting.

The Minister stated that the Eastern Cape had the biggest number of health care facilities, but this was because of what passed as a health care facility. You could not just put up a couple of walls and a bed and declare it a hospital. The Department was trying to define what a facility was and the requirements it needed. Upon inspection by the ministerial team many facilities in the Eastern Cape were downgraded and reclassified.

The Minister indicated that the Department had commenced advertising to fill the vacant CEO posts around the province in order to introduce new leadership. It was no longer acceptable for nurses to take two hour lunches. He recounted a story told to him by some hospital employees- before the installation of new leadership they would leave for lunch and not return to work. With the new leadership they had realised how wrong they were and the new leadership brought a sense of professionalism. Stories such as that showed the importance of strategic leadership. The Eastern Cape government had provided R300 million in funding in order to fill vacancies, and he had recommended that it start with the OR Tambo region.

Dr Mbengashe answered a question about the financing the employees. There was R10.9 billion in the budget for compensation of the 48 000 employees of the Department. Half of the budget had been spent and there was a saving of R140 million at that point of the year.  These savings would help in financing the new positions made, especially in the Eastern Cape.

The Minister clarified that one of the CEOs suspended in the Eastern Cape was not one of the new appointments made by the Department.

Dr Mbengashe stated that the interventions taken by the Department were difficult but he believed they had the capacity to implement them and be successful in doing so by the time his contract expired in five years.  There was a lot of support for the Department in its attempts at changing health care in the Eastern Cape.

Mr Kganare asked about a statement from a spokesperson for the Department who was reported to have stated that when they visited health care facilities some of the equipment was hidden, was this true?

Dr Mbengashe clarified that there was eight haemoglobin meters that were bought for a hospital and when the ministerial task team was there they were not being used.

The Chairperson thanked the Minister and the Department for their input.  The Members were representing communities and their concerns were based off this.  They accepted the report from the Department and would bring it to Parliament.

The meeting was adjourned.