Department of Health on its 2nd and 3rd quarterly reports; DPME on Health Department performance outcomes

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18 March 2015
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Department of Health (DoH) briefed the Committee on its performance in Quarters 2 and 3, followed by an evaluation report presented by the Department of Performance Monitoring and Evaluation (DPME), explaining how it categorised performance, and that it was done to assess how the sector as a whole was adhering to Medium Term Strategic Framework plans, in turn aligned to five year implementation of the National Development Plan. The top ten priority areas of the Framework set out the desired sub-outcomes for the health sector, prioritising health care for the poor. South Africa's performance was measured against BRICS countries, and it was concluded that it would have to push very hard to reach certain targets in relation to reducing maternal and neonatal mortality. The DPME confirmed that, like the DoH, it saw the main problem as lack of progress on the legislation and financial planning for the National Health Insurance (NHI). Training and quality of staff had improved, but implementation in the nutrition field was still lacking, as well as follow up for screening beyond Grade 8. The DPME urged that the nursing colleges must urgently be addressed, along with poor financial management in the provinces, medical circumcision, behavioural issues around HIV and information systems. Its performance on TB, and addressing mother-to-child infections was good.

The Department of Health presentation largely revealed similar results, but presented more details. Some provinces were identified that needed more assistance with the audit function, and a tool was developed to track spending and whether it was related to the specific function. It had improved ICT, but was not so efficient in filling vacancies, although it was implementing a wider wellbeing programme. There were attempts to standardise Annual Performance Plans between national and provincial departments. There was a need to address the White Paper legislation and National Health Insurance urgently, as well as set up more pilot sites and a Fund. Further initiatives described were the adjustment of prices for medicine dispensation, regulation around the private healthcare sector, reviews of methodology for dispensing, and mixed results were shown in management of essential medicines with good performance at chronic level but poor at adult level and reasonable for child level. Hospital revenue services needed more attention. A e-Health business model was developed and better disease surveillance models were being developed. There had not been improved monitoring of prevalence of HIV in the general population and data on the infection rate had not been released. Other areas highlighted included male circumcision, assessment of risks in prisons. Maternity and infant death schemes, which were not able to be reduced to the figures targeted. The DoH had also failed to meet targets on Primary Health Care facilities increases, but outlined its plans for the ports of entry and rodent inspections. It was working with partners on malaria control, non-communicable disease and integrated screening. Emergency Medical Services (EMS) monitoring had improved, and DoH had taken initiatives to prevent forensic laboratories closing, although this was strictly outside its competence. New plans were needed for nursing colleges, food regulation and a few other issues. The National Public Health Institute of South Africa (NAPHISA) was attending to research.

The DoH conceded that there were serious backlogs in Human Resource management and financial management at provincial level. The DoH aimed to lower dependence on tertiary health care and improve primary healthcare but this comes at the cost of improving clinic infrastructure and staffing, whereas presently there were serious concerns about quality, mix and attitude of nursing staff. The Phakisa policy required rapid "leaps" and accelerated implementation. Another major problem was the performance of the provinces, with generally poor financial performance and only two achieving unqualified audits. NHI pilot sites would be described as "ideal clinics" with all resources and infrastructure. The problems with maternal and neonatal mortality were set out in the presentation and questions by Members in some depth. It was concerned about the prevalence of under-nutrition in children under five, and Members highlighted that if the DoH wanted to address this, it would have to embark on aggressive campaigns, and also work with the Department of Basic Education on school feeding schemes. Members also noted the Department's family planning strategy but pointed to the recent case of a young girl of 10 years old giving birth, and wondered if it was pitched at the right level. "Mum-Connect”, an innovative on-line application to assist pregnant with SMS health tips, was commended. Members were less happy with the reports that the DoH was unsure when digital migration and use of uniform Emergency Services would happen.

Meeting report

Department of Health: 2nd and 3rd quarter 2014/15 reports
Ms Malebona P Matsoso, Director General, Department of Health presented the 2nd and 3rd quarter performance reports for the 2014/15 financial year. She noted, upfront, that these reports did exclude some operational plans of the Department of Health (DoH or the Department) and reiterated that those operational functions could be included should the Committee request, but noted that the reports were already very long, at 167 pages. She apologised for the absence of some of her officials and introduced others.

She discussed the categorisation used by the Department of Performance Monitoring and Evaluation (DPME) to show the level of improvement or regression with regards to the performance of DoH. The categorisation was based on the red-yellow-green international standard but there was also an inclusion of blue, which highlighted standards for the indicators which had not been undertaken by DoH.

For Programme 1 she noted three areas of emphasis. The internal audit function would be reported on more fully at the end of the financial year, but DoH had identified the provinces which would need more assistance and monitoring in term of the financial management - namely, Gauteng, Eastern Cape and Free State. North West and Western Cape had unqualified audits. There would be a system created to deal with these auditing outcomes. The DoH had also created a model to track the spending of provinces to help with financial management and planning, the so-called Non Negotiable Tool, which would not only track spending, but also whether the spending occurred in the stipulated function. The Corporate Activities undertaken at national level largely centred on ICT services and the DoH had continued to do very well in meeting its target. Management of Human Resources issues included the vacant posts. Various service charts and service delivery charters had been implemented, which measured how long it takes to fill vacancies. The targets were set to four months and this had only reached 58% efficiency. The DoH was implementing the Employee Well-being Programme, which was not limited only to the employees of DoH, but also was being advocated at large gatherings. This programme entailed the health testing of people, and education on overall well-being.

There had been a programme between national and provincial DoHs, to finalise Annual Performance Plans (APPs). These plans were to be standardised across all provinces through the use of guidelines but there would be some context specific plans to meet the demands of each province.

In Programme 2 there had been an addition of a new area in the National Health Insurance (NHI) which would be undertaken when the White Paper about NHI was finalised. DoH emphasised the need to push legalisation forward and have the White Paper and Financial Paper drafted. There needed to be an establishment of NHI Forums which will allow for stakeholder engagement. There was also a need to have more NHI pilot sites in selected districts. A report would be produced to highlight the performances of the existing pilot sites, and this would be presented to the Portfolio Committee in April. The next area would be to establish a NHI Fund, which would finance the plans which NHI would undertake.

There had also been an adjustment of the prices for medicine dispensation, which will apply for pharmacies, especially for doctors and nurses. There had been regulation around the health care in the private sector, and the review of the methodology used to determine the dispensing fee of medicines. The methodology used was still under review. The National Pricing Commission was seeking to establish a single exit price to apply across the board, and as a result the DoH had decided not to implement the system at present. The management of Essential Medicines in primary health care, for infants and children, had improved in the both quarters. The management of Adult Essential Medicines continued to be poor, something that Dr Yogan Pillay and his team of experts would confirm. The central Chronic Medicines dispensing and distribution had improved, and these centres, which included churches and other social structures, offered and distributed medicines for chronic conditions. There was also an emphasis on the need to improve hospital revenue services, as not much improvement was seen in the last two quarters.

The business enterprise model for eHealth was based on the business architecture for a National Integrated Patient Based Information System, and it had been developed and had experienced a limited growth. There had to be a National Interpreted Data set (the one in Western Cape had to be confirmed) that would establish that the queues in clinics and hospitals had decreased. Another area was diseases surveillance, in collaboration with Statistics SA, which aimed to know the number of people who were sick and the types of diseases that DoH had to address. This would happen in collaboration with the Departments of Social Development (DSD) and Home Affairs (DHA).

Programme 3 emphasised HIV and TB prevention, with particular focus on male circumcision. The programme had performed adequately, but the problem has historically been the Eastern Cape, due to the prevalence of traditional circumcisions. The data for this province and the Western Cape had not been made available to DoH; the reasons for this in the Western Cape were not clear. Progress was seen, in Kwa-Zulu Natal (KZN) but the overall programme had, in recent times, experienced stagnation in numbers of male circumcisions. In the Department of Correctional Services (DCS) the prevention programmes had regressed, especially ones assessing the risk to disease in prisons, but the screening of TB and HIV in prisons had improved.

Other focus areas under this programme were the maternity and infant death prevention schemes and overall health care for this group. The maternal death rate had decreased but the antenatal and neonatal check-ups had not increased, but had regressed. DoH was unable to reduce the neonatal deaths to the target figure. There had been a decrease in the testing of children in senior education. More young children in Grade 1 had been screened. The fight against child malnutrition had improved but the targets set by DoH and Department of Basic Education, for both primary and secondary schools, have maintained steady throughout this analysed period.

Programme 4 dealt with primary health care (PHC). The National Health Commission (NHC) was an inter-sectoral forum that would plan and oversee the implementation of interventions across all sectors. The structure of the NHC would ensure that everyone was held accountable for the function which he/she oversaw. Another area of focus was the WBPHCOTs, a programme to have primary health care delivered to people who otherwise did not have geographical access to PHC facilities. DoH had not met its target with regard to increasing the number of these facilities. DoH also discussed the need of all spheres of government to address environmental health. At national level, environmental health pertained to the ports and ensuring that there was compliance with international health standards. DoH had intended to start an initiative to deal with rodent infestation, and to establish inspectors to monitor the health conditions within shops.

The next issue was malaria control and subsequent elimination. Ms Matsoso emphasised that cross border incidents of malaria were the main concern of the Department, and so the Department had continued to work closely with SADC counterparts to address the measures taken in the control and eventual elimination of the disease. The focus of these collaborations had been largely with Mozambique. The issue of non-communicable diseases was a further issue that DoH struggled to address, and there had been an initiative to promote better diets and lifestyle choices to help stop the surge of the diseases. There had been an initiative by DoH also to have integrated screening of people, which would include the screening of non-communicable diseases, along with HIV testing. Another issue raised was the screening of mental health and rehabilitation services, although DoH had been unable to deal with the organisation limitation of screening the population, so that targets set were not achieved.

The monitoring of the prevalence of HIV in the general population had not improved, and the data used to analyse the infection rate had not been released. When the details were released, they would be made public. DoH has multilateral and bilateral agreements with other countries and there had been, on all sides, great implementation and adherence to the international guidelines. Examples of these were the tobacco agreements between Southern African Nations and the BRICS countries.

The monitoring of the provision of Emergency Medical Services (EMS) had improved and the provision of these services had also improved. In KZN, there had been introduction of a new initiative, to move the function of EMS out of municipalities and to the province, but to achieve greater efficiency DoH must firstly improve ICT systems, so that this could be a model to be adopted in other provinces also. The state of forensic laboratories in the country had been assessed to be in a bad condition due to payment non-compliance by provincial departments. However DoH has managed, in both financial quarters, to improve the baseline of the laboratories, except in relation to the testing of food.

Ms Matsoso noted the need to strength food regulation, especially content and quantity, but the testing of the food was not actually improving, due to the situation of the laboratories.

Programme 5 detailed the nursing education plan and the accountability legislation within hospitals. Ms Matsoso stressed the need to have reinforced and strong systems of accountability within hospitals which operated as semi-autonomous to internal hospital structures. This would enable DoH to implement norms and standards with which hospitals must comply. This was created with the intention of having packaged functions for hospitals. Nursing education had been highly debated, and DoH had started to have the established nursing colleges accredited by the South African Qualifications Authority, but the target set was not met. 

Programme 6 addressed regulations and compliance management. DoH had not been able to improve the regulation of complementary medicines and medical devices yet, as these products were still being addressed in proposed legislation. She noted that there had been workshops in previous weeks between traditional healers and World Health Organisation (WHO) experts, who would use a specially compiled book which documented all of the indigenous plants and their uses. The legislation to make the South African Health Products Regulatory Authority (SAHPRA) a statutory body was still under review by Parliament, and few processes had been implemented on its functions and jurisdictions.

DoH had made progress on corporate governance and compliance in health entities. The timeline for the approval of medicines had been decreased to 16 months for known medicines, and 22 months for unknown medicines which required testing. The DoH had enhanced governance and management by establishing all committees at the Compensation Commission for Occupational Diseases (CCOD/ formerly MBOD) and it had met its target. The DoH provided for coordinated disease and injury surveillance and research, by establishing the National Public Health Institute of South Africa (NAPHISA). The targets for establishment had been limited to conceptualising of the framework which would govern the Institute.

Department of Healths performance outcomes: Department of Performance Monitoring and Evaluation briefing
Ms Nombonisa Gasa, Acting Director General, Department of Performance Monitoring and Evaluation started by acknowledging the passing of Minister Collins Chabane.

She explained the categorisation of the performance and outlined that the evaluation of the DoH was to be aligned to assess how the sector was adhering to the medium-term strategic framework, as outlined on Slide 10. This framework was in line with the goals of the National Development Plan (NDP). The presentation focussed on what the following speaker would be detailing about the health sector.

Mr Thulani Masilela, Outcome Facilitator, DPME, outlined the roles and responsibilities of that Department, as set out on slide 2. He also outlined the vision for the NDP, and focused on the intended health outcomes. He explained the significance of the Medium-term Strategic Plan (MTSF) and emphasised the 5 year implementation plan of the NDP, and also drew attention to the top ten priority areas of the MSTF, which outlined the desired sub-outcomes for the health sector, prioritising health care for the poor. He moved on the indicators that the DoH had already touched on, such as reducing maternal mortality and neonatal mortality, both of which DoH needed to improve, although there was great progress across other indicators. A comparison of maternal and neonatal mortality rates across provinces illustrated the provinces which needed the most support with this issue.

The following issue drew comparisons between the BRICS countries and depicted that South Africa was doing quite well, but he cautioned that a comparison with other African countries alone could induce a sense of complacency. South Africa must push hard to reach the target of 14 neonatal mortality per 1000 babies by 2019. Slide 15 set out the WHO comparison of maternal deaths and lifetime risk, highlighting that women giving birth in Africa had a higher chance of dying in childbirth. Mr Masilela pointed out that the indicators given by the DPME were the same as those of DoH.

The main problem on NHI was lack of progress in the legislation, and lack of progress on financial planning. He highlighted that had been near-impossible to collect data on patient satisfaction, which was why it had been given the blue categorisation. The training and quality of staff had improved in the Health Sector. He also commented that there had been 38 different pieces of legislation passed to deal with nutrition, but no plan on how to implement and deal with nutrition.

The DoH has not made progress on primary care and screening of pupils beyond Grade 8. On slide 28, the DPME gave recommendations for how the DoH could improve performance in this area. The rehabilitation services lacked coherence and functionality and the DPME made recommendations as to how the Department of Health could address these issues. DPME cited the need to decrease the costs of NHI, by addressing HR and financial management issues. The DoH has a serious problem with the nursing colleges that must be addressed. The other issue highlighted was that 7 out of 9 provinces had qualified audits, a clear indicator of problems in the financial management of the DoH in each province. For Infrastructure development and management, DoH had also not reached its targets but there had been some progress, and the DPME made recommendations on Slide 38.

Mr Masilela noted that the DoH has done well to manage the screening and treatment of TB in correctional services and mining sectors. Prevention of HIV had also improved, but medical circumcision had been emphasised as one area that needed to be improved, along with the testing of young people. The DoH had to make progress in addressing behavioural issues to prevent HIV, as a recent survey by the Human Sciences Research Council (HSRC) had revealed that 76.5% of the participants did not believe they were at risk of contracting HIV, and also revealed that 10% of those taking the survey were already HIV positive. The DoH had done well to address mother-to-child transmission of infections and HIV and it has improved on this every year since 2009. The final area the DoH has to improve was the management of the health sector by means of Information Systems which hoped to improve decision-making. The DoH had to make a serious move into digitising the health system.

Ms Gasa said that MTSF was closely linked to the performance agreement between the President and the Minister. There was a high level of consistency within the DoH, and the DPME hoped that this remained the same in subsequent years

Dr H Volmink (DA) said that there were some great improvements and some serious regressions. He asked the following questions: Who would be paying for the NHI, and how would it be financed? When will the White Paper on NHI be available? How will DoH ensure that NHI will not experience system-difficulty? Why is there no initiative to convert all clinics into "ideal clinics"?

Dr Volmink noted that DoH had highlighted the call centres to be introduced for EMS, but also read out to the Committee a response by the Department of Communications (DoC) to questions about plans to establish call centres, in which the DoC stated that there were in fact no plans between the two departments to establish call centres, and that DoC had thus reprioritised the funds. He wanted, therefore, to know what DoH planned to do in this regard.

Mr A Shaik Emam (NFP) said that there was a continued shortage of quality nurses, and suggested that the DoH should begin to promote nursing at basic education level and encourage the right type of people to become nurses. He asked what measures were in place for the monitoring and evaluation of clinics which were in constantly bad condition.

Ms C Ndaba (ANC) said that, in relation to with CCOD, the Director General had promised to make a separate presentation detailing the progress, and wondered when this would be given.

Ms M Scheepers (ANC) enquired whether the DoH had any intention of taking over pre-existing call centres, and how the ambulance system would be made more efficient. In her constituency the inefficiencies in the system were so bad that paramedics in training would be first to attend a scene.

Ms L James (DA) asked if the DoH was doing enough to address the maternal death rate. She asked about male circumcisions, as well as those who had traditional circumcisions. She urged DoH to be vigorous on environmental health, shop inspection and rodent control, and work closely with the municipalities. She was pleased to hear clarity on all the areas she regarded as important.

Mr N Matiase (EFF) referred to slide 7, dealing with Programme 2, and enquired what lessons the DoH had learned from the NHI process. He asked whether the DoH had looked into the possibility of cross-subsidisation to finance the health system, instead of NHI.

Dr P Maesela (ANC) said malnutrition should be a central issue. He urged the DoH and Portfolio Committee to prioritise on building the capacity of those who provided services to the public. He believed that the Committee and Department had prioritised some things that did not need immediate attention. He used the immediate example of the introduction of ICT systems in the health care system. However, he also recognised that some changes required political will, which both the Committee and DoH seemed to lack. He also said that there needed to be legislation on food content and quantities, because there was too little regulation of food.

Mr I Mosala (ANC) asked what progress had been made with addressing the Auditor-General’s findings, and wondered if there would be any recourse for provinces with bad results?He asked how often the DoH would visit the NHI pilot sites. He also asked for elaboration on the progress made with TB screening in the mining areas, particularly the broader communities

The Chairperson requested the data from the Enterprise Architecture of Programme 2. She expressed disappointment at the pace with which the DoH had been addressing mental health, and requested the Director General to elaborate whether this process was complex or not. She asked how confidential the DoH managed to keep the information that it received. She asked about the exact delay with the accreditation of nursing colleges, and agreed with Dr Maesela that HR issues had been hindering the progress in the health sector.

Ms Matsoso responded by saying, firstly, that if there was a problem, that would be shown by an indicator. All the high impact problems had indicators.

She then dealt with comments and questions on the NHI, reminding Members that this programme was announced in 2011, and the Minister of Health had called for public comments. The Minister had also conducted national road shows about NHI, addressing different stakeholders. There were four pillars to NHI. The first pillar was the approach about financing NHI, and this was a point that DoH continued to debate with National Treasury (NT). The second pillar was the package of services which NHI will provide, and that would be determined by the money allocated to NHI, and there are various options that had been been made available that linked to the funding measures. The third pillar had to do with governance, and this detailed the governance of finances and services. After the White Paper and relevant legislation had been made public, the DoH would have to create a committee which will be solely responsible for the rolling out of NHI, because it could not be prioritised by the DoH. This should not be an ad hoc committee but a continuing committee.

Another issue was the paperless environment. Nkosi Albert Luthuli had an ICT system, but this would require overhaul where people were to be trained to work in a digital environment. To have this across the country would require a lot of investment and change, but the DoH was ready to institute that, once training of staff and change in management style has been addressed. Another issue was the question around the "ideal clinics", and Ms Matsoso pointed out that the goal was to have all clinics become what had been defined as an ideal clinic with the total service package. Using the example of a cellphone, she noted that communication had been greatly simplified by this device, bringing communication available to all people across all socio-economic areas. There was a plan to prioritise the fixing of hospitals and clinics rapidly to get them to an ideal status to ensure that all health facilities in all areas were improved. She mentioned that the implementation of this leaping programme would require assistance, and there was a need to workshop the ideas with experts to determine how the implementation would take place.

Referring to the attempts to have a EMS number made uniform, she reported that there was ongoing work on this. The collaboration between the DoC and DoH had been slow, and there had been a request from DoH to move forward and have a uniform number which would be regulated.

She noted that, in relation to nursing, many people in the profession had a problem with attitude. The suggestion to have recruitment begin in the Basic Education phase was important, because any problem around attitude could also be addressed at that level.

The clinics in Khayelitsha had been addressed by Thulani Masilela and his team, as they went on a site visit, and they had compiled a report. Any misconduct was directly investigated by the DoH. The CCOD Commissioner was responsible for funding, and this body must prepare its own report. She requested that the DoH be allowed to check out the call centres in Bloemfontein and she agreed that there was a need to set standards and norms to govern the call centres, and to close down those who did not comply.

She fully agreed that the maternal deaths and conditions of maternal health were problematic, as was the fact that there had not been improvement. The DoH had to interact with the communities and use community structures to educate communities about health care.

Ms Matsoso addressed the issues around cross subsidisation and said that this extended beyond the subsidisation between rich and poor, also to deal with questions of subsidisation between the young and the old, and the healthy and those in poor health. This system was very important for financing and structure of how NHI would be rolled out.

In response to comments about environmental health she said that the DoH would be working to create a system of maintaining and regulating environmental issues, especially those of rodent control and food expiration control. Nutrition was an issue that Ms Matsoso had highlighted, along with the need to regulate food content and taxation of certain food as a mechanism to fund the health sector. However there was a need to address insufficient nutrition in children under the age of five. There would be legislation regulating food content, and it would be presented to the Portfolio Committee in due course.

She noted the questions around recourse for the provinces. DoH did have systems of recourse but there was also a Chief Financial Officers Forum, where all provincial and national CFOs engaged about capital spending. The system was a partnership, and not a dictatorship or overarching oversight.

In relation to the NHI sites, there were partnerships with various stakeholders, such as the appraisals with institutions such as University of Cape Town, and these stakeholders had assisted with the process of review.

In relation to the TB screening of mine workers and mining communities, she said that most people would have to travel from all over the country to acquire the correct screening and health assistance with mining related illness, in particular with TB. The DoH had begun an initiative that brought the services to the mining communities, by way of a One-Stop Service. There were two operating pilots, in Carltonville and in the Eastern Cape.

Ms Matsoso agreed with the Chairperson that mental health had been slow, but it had since improved, and the DoH had to address the pace and had instituted a strategy to do this.

Dr Yogan Pillay, Deputy Director General: HIV and TB, Maternal and Neonatal Health. Department of Health, responded to the question on neonatal mortality. He said that neonatal death was commonly caused from prematurity, asphyxiation and infections. The prematurity of babies was related primarily to unplanned pregnancy in young women and teenage mothers. The DoH had changed its family planning policy and this had increased the uptake of contraception, especially the contraceptive implant. There had been, since the inception of the family planning policy, 800   000 implants performed country wide. The DoH had acquired the help of a neonatal specialist who was teaching healthcare practitioners in high risk regions how to resuscitate asphyxiated babies. The Free State had seen a decrease in the neonatal mortality rates and KZN and Limpopo had seen the same result. The DoH had acquired 65 sophisticated machines which assisted babies to breathe. Together with the family planning policy, this should address premature and asphyxiation causes in neonatal mortality. The issue of infections in babies was being addressed by the limiting of transmissions of viruses and infections from mother to child. The DoH had set a goal of less than six mortalities per 1 000 births by 2019. "Mum-connect" was part of the "leaping forward programme". It was launched in August 2014 and over 300   000 women were registered on this system. This equated to one-third of the women who gave birth in the public sector, as there were about one million births a year. This was the largest programme of its kind and the only one in the world. The messages assisted women with every step of their pregnancy. On this, the DoH had gathered compliments and complaints. Most complaints were about the facilities where the women were receiving their treatment, and these complaints would be sent directly to the provinces, for them to address the issues raised.

There had been a decrease of mortality of children under five years, but the mortality continued to be mainly caused by malnutrition, diarrhoea and pneumonia. Malnutrition in children was in turn largely determined by three factors:
- Poor assessment of patients by nurses and doctors
- Poor management
- Late referral from PHCs.

There was a need to moderate malnutrition. There had been a plan by DoH and there would be collaboration with the Department of Social Development. There needed to be a maximisation of social services and health services, as had been done in South America. The decrease in pneumonia and diarrhoea in children was due to the vaccines introduced in 2009, but the prevalence of mis-diagnosis of TB had led to an increase in perceived pneumonia deaths in children. She pointed out that it was very hard to diagnose pneumonia in children.

The Deputy President would be outlining the TB programmes in mining communities and correctional services. The aim, for 2015, and beyond, was to screen all 152   000 Correctional Services inmates at least twice a year. There were 500 000 mine workers, and there was already a collaboration between government and mining companies to screen all mine workers for TB and other non-communicable diseases, along with HIV. The DoH had identified six districts where TB was significantly high and there was a need to have a full screening of every adult. The Deputy President would give greater details about the programme on 24 March.

The DoH agreed that the targets for male circumcision were very ambitious but the problem had been that men were not going to get themselves circumcised. The Minister had entered into an agreement with the traditional leaders, and tried to reach a compromise of having circumcisions being performed by doctors who had, themselves, been traditionally circumcised themselves, but this suggestion had met with resistance by leaders in the Eastern Cape. If implemented, it should help to address the botched circumcisions. There were measures implemented to assist the young men who had suffered castration as a result of traditional methods having gone wrong.

Dr Anban Pillay, Deputy Director General, Department of Health, responded further on the questions around the CCOD. It would be assuming responsibility for compensating mine workers who fell chronically sick through their work. Measures were in place to ensure that mine workers could access the institution from where they lived, instead of having to travel to Braamfontein to have their claim processed, as the DoH would be establishing a satellite office in every province, with a particular focus on those mining communities. The CCOD would have to appoint a Chief Financial Officer to address the financial issues.

Ms Christie Engelbrecht, Director, Department of Health, noted that in regard to mental health, the Department had set visible targets but there was a need for greater resource investment in every district, and the provinces must then be responsible for this.

Dr Terence Carter, Deputy Director General, Department of Health, responded to the question about nursing programmes, training and placement. The pace of implementation of nursing strategy, dealing with all the aspects of training and quality, had been slow. A Chief Nurse would have to be appointed, who would be in charge of the overall training programme. There was a need to accredit the nursing training, which focused on the quality of the nurses. The acting Chief Operations Officer had been working with the nursing colleges and the Department of Higher Education and Training and the Nursing Council, to create a training framework from which to work. There was an assumption that the nursing colleges would be absorbed by the universities, but the DoH would ideally like the colleges to be stand-alone entities, under the Department of Health. There had been a focus on improving the quality, the curriculum and the infrastructure. The attitude of the nurses was often problematic and he agreed that nursing recruitment must start from a young age.

The workload indicator tool used the workload of clinics to determine the correct staffing patterns in the clinics, to create ideal clinics. The nursing shortages were not as bad as they had been in 2012 and some provinces had excesses of nursing staff. Expenditure was needed on HR and therefore there was a need to look at training and bursaries, in order to create a system that was able to absorb crucial skills, and create posts for community service doctors, as well as equip the sector with the necessary people.

The Chairperson pointed out that remuneration of crucial staff needed to be prioritised, and that the country was losing nurses and doctors to other countries. The issue of nutrition must be addressed by promoting household gardens and including a varied diet in the school food scheme.

Dr W James (DA) asked what the current expenditure was for the forensic chemistry labs and infrastructure expenditure. He referred to page 37, and asked what Programme 5 looked like today, pointing out that the chart was recorded in September.

Ms C Ndaba (ANC) asked about performance. At page 26, it noted that for Programme 6, performance had been 64% with Gauteng, North West and Western Cape counted, but she asked what the other provinces were doing. She asked how the DoH was addressing compliance. She asked for any feedback about suppliers. In the last year, there was a delay with the supply of condoms because of a container being delayed, and she wanted to know the current status around supply of condoms. Finally, she wondered why the various entities under the DoH were to put up separate presentations.

Dr Volmink asked where the initiative to implement 112 call centres would start, and wanted to know the cost. He also wondered when the amendment to the Communications Act was likely to go be implemented

Ms James asked whether drugs and alcohol would be included in the integrated testing. There was a need to have intervention and trained staff to address this problem, particularly when misdiagnosis was prevalent. She wondered if the DoH had considered having men's health clinics that would focus on men's health issues.

Mr Shaik Emam asked about the compliance of provinces to IED programmes, issue of NHI and doctors. He wondered if it was possible to train doctors specifically for NHI programmes.

Dr Maesela said that the DoH should have clear timelines. He pointed out that much time was being wasted. He wanted to know what its plan was for achieving clean audits - not just improved audits -   and said that the DoH must capacitate health facilities to ensure this happened.

The Chairperson reminded members that they had every right to put their questions in writing and the DoH had the responsibility to reply in great detail. He reminded Members also that there were certain constitutional issues around the powers and functions of national government and provincial government.

Ms Matsoso requested that perhaps the financial performance must address the third quarter. Remuneration had improved in the public sector, in order to adequately remunerate health workers. Points to be immediately addressed were the OSD for midwives, and diseases control, and the scarce skills allowance. The nutrition programme required the investment of communities and the food programme of schools needed to be addressed, with more needs to be included.

Dr A Pillay responded to queries raised on page 28, and noted that the role of the national DoH was to inspect, and it is was for the province to ensure compliance.

Ms Matsoso said that in the case of provinces which had been performing badly, there had been an implementation of scheduled inspections. However, DoH also encouraged unplanned inspections, to get a real sense of the health facilities.  She noted that the entities were statutory institutions which operated with autonomy from the DoH, although DoH could intervene if there were serious problems. She cited one example where laboratories were threatened with closure because the provinces were not paying for them; the national Department had intervened and got the laboratories back on track. She had written to the Committee in this regard. She noted the amendments to the communications legislation, and said that some of the interventions now being implemented were the result of Inter-Ministerial Committees, with the DSD, led by Prof Wallace. She noted that the concept of the "ideal clinic" model would be implemented everywhere. She also noted that the doctors who were trained in Cuba would be placed in both primary health care, and some at tertiary institutions.

Dr Y Pillay reported further on the condoms in the container that was delayed. Some had not passed the SABS testing: other flavoured condoms would be launched at a Soweto campus, as part of the safe sex campaign, and were aimed at making condoms more user friendly for young people. In regard to men's clinics, he noted that the only ones presently specialising were clinics for MSM, or men who have sex with other men. In general, men did not use health facilities, although men did need to have specialised treatment.

Mr Ian van der Merwe, Chief Financial Officer, DoH, drew Members' attention to slide 52 and highlighted that by the end of December there was 73% of the total budget spent, and it was slightly over in the direct line objectives. Expenditure issues had been experienced with the health grants. There had been increased expenditure for demographic health. The NHI Pilot Site spending had started and it was being financed in the form of grants. The spending on SAHPRA had been provided for in the budget, and there was a large investment in their ICT system.

He noted that in regard to Programme 5, spending at the Forensic Chemical Laboratories was at 55.07%, that ten tenders had been awarded for specialised machinery, which was between R30 and R35 million in cost. There had been implementation of the Linux system in KZN. Overall, there was 68.3% spending of the total budget of R21 billion. Main expenditure had increased. The spending on grants had increased, including the Schedule 4 and 5 grants, and 33% spending on NHI, which included provincial roll over. Some provinces had not passed over all the money, and Provincial Treasury was still holding R1.5 billion excess not given to provinces for health. Limpopo had an excess of R 236 million. Mpumalanga was at 36% not spent. Recourse was very low. Eastern Cape did not have a proper cash flow and the leadership in the provinces was an obstacle. Some provinces had a more mature level of leadership, which made intervention easier, but other provinces made it hard for DoH to intervene.

The Chairperson requested the names of the provinces which were not complying with the recourse measures by national DoH

Dr Volmink asked about the expenditure on NHI, pointing out that there was also Programme 2 and conditional grants. There were issues around compensation of employees, and chain supply management. What measures would be taken to ensure better progress in both areas?

Mr Shaik-Emam said that the Department did not have infrastructure development capacity. He asked what steps the DoH would be taking to address the shortcomings in provincial performance.

Dr James asked about the readiness of the laboratories in KZN.

Dr Maesela said that the grants which were granted to provinces should be paid to ensure that the work under the grant was done. Provinces often found a way re-prioritise the money for other emergencies.

Ms Matsoso responded by pointing out the Constitutional limitations between the powers of provincial and national departments. Grants given to the provinces could not be monitored strictly by the national DoH. She returned to the question of the laboratories and said that the national Department had paid for those laboratories to avoid them being closed down in Gauteng and KZN. The legal parameters did limit what the DoH could do. The DoH gave student bursaries for crucial skills but the problem was that the provinces did not have money to employ the students once they graduated, and this was thus an investment lost. The DoH wanted to halt the development of infrastructure and invest in paying for crucial skills staffing, because HR was an ongoing problem in the health sector.

Ms Engelbrecht responded to the question on lessons learned from the NHI pilot sites. She highlighted the need to have the DoH acting as the catalyst to address health sector issues. There was a need to remember that health was also an ethical issue. The ideal clinic idea must spread. In regard to contracting out, it was intended that there must be a doctor available in every clinic. There were 10% of doctors from private sectors who were overwhelmed by their own practices. The private doctors were there to complement the public sector staff. Some health professionals simply did not want to work in the rural districts. There had been a need to contract out specialists for areas where this problem of lack of health care professionals was apparent. The problem had been with spending and assistance from National Treasury.

Dr Carter reported that the laboratories would be ready by 1 April 2015.

Ms Ndaba asked about the relationship between the Division of Revenue Act, and the role of National Treasury. The Committee, in response to Ms Matsoso's outlining of the issues, had supported her in her application to NT for funding. She noted that the Committee had been expecting to hear of progress on this, and asked Ms Matsoso to explain the nature of the problem.

Ms Matsoso responded that she has written a letter to the chairpersons of the Committees on Appropriations, Finance and other stakeholders, and there was a need to get a response to that, in order to address the problem.

The Chairperson agreed that this was needed and undertook to organise a meeting with the Chairperson of the Committee on Appropriations. She urged Members to extend congratulations to the DoH for its progress in providing condoms, and the successful performance of penile transplants. She noted that she would have to excuse herself, to attend a meeting of Chairpersons.

Mr Mosala took the Chair.

Ms Ndaba referred to slide 47 which dealt with sexual behaviour in society, and cited the example of a ten-year old who gave birth, emphasising that sexual behaviour in society was problematic. She asked how DoH was dealing with this.

Mr Shaik Emam said he acknowledged the challenges of the DoH. There was, however, lack of coordination between DoH and DBE when it came to nutrition in schools. He pointed out the need for health infrastructure in schools and wondered how the DoH would be sorting out this issue. He wondered how South Africa was faring in comparison to countries of similar demography and population size.

Dr Maesela said that the nutrition and capacitation were a problem, but he was particularly disappointed that DoH seemed to have no concrete plan for dealing with nutrition.

Dr Volmink agreed that the DoH must be congratulated on its achievements and good leadership. He would like to see inclusion of data in the areas designated into the blue category, wondered why it was not included in the first place and felt that this was defeating the objects. He asked when the NHC was likely to be set up, and whether it would fall under DoH or the Presidency. He wondered if there was any way in which DoH could hold the provincial health departments accountable.

The Acting Chairperson asked whether the DPME would do the same evaluation of provinces as for the national departments and requested that if not, this should be done. He further asked whether this Department had done an isolated and independent assessment of the NHI pilot. He also recommended that DPME must come to present on any assessment being made on the health sector.

Ms Matsoso said she was shocked by the example of the ten-year old giving birth, as used by Ms Ndaba, and said that the current strategy did focus on older children, but perhaps there was a need to  move sexual education towards the lower grades as well. The purpose of the benchmarking was to show that South Africa wanted to be able to improve its own and not be banded with other countries on mortality rates. She said that the DoH was also not comfortable with the areas highlighted in blue, because they indicated that there was work to be done, but the DoH would include any available data. She noted that screening was important and more resources were being directed to health promotion; screening should be comprehensive. She asked that the Committee support this initiative because it required serious re-direction of resources.

Dr Y Pillay also responded on the sexual education question, saying that the information had been made available to primary school education at Grade 4 level, through a programme called "Know your Body",which focused on basic sexual education. This was repeated in Grade 8. There was a bi-weekly meeting between the DBE and Department of Social Development, and DBE published a document on school public health. There was screening being done at Grade 1 and Grade 8, but more sexual education for Grade 8 pupils. The initiative launched by the Minister in Soweto was to increase the awareness on the need to screen for non-communicable diseases amongst young people.

Ms Gasa responded to the issue surrounding the blue indicator, and repeated that the categorisation used was based on an international system of assessment, but the blue category was a compromise by the DPME. Essentially, it could be seen as an escape clause. It was inserted in recognition of the fact that it might not be fair to rate something that had not been measured, because the system used would rate it as "not achieved". The blue category was about compromise and best political consensus, but she would welcome further debate on whether it should be kept. DPME would be happy to make itself available to the Committee to verify or clarify any processes. DPME would be making a presentation shortly to the National Assembly about the Nutrition Report it had been working on, and could give a separate presentation to this Committee. She noted that there were ways to hold provincial departments accountable, and again the DPME could give a presentation on this. This has to be a collaboration with the National DoH,although the National Health Council has been meant to hold provinces accountable.

Mr T Masilela stressed that South Africa did not want to lag behind on the benchmarking processes, or become complacent. He agreed with Ms Gasa’s comments on national and provincial spheres, but pointed out that there was no consistency in the provinces. There were two approaches to this; one involved creating an agreement between the spheres of government, which would be based on cooperative governance, and the other would be to set norms and standards in the provinces, and have provinces as signatories with framework. The MEC for Health and Premier should also be involved in and create binding resolutions between National and provincial departments. The National Health Commission cannot sit in the Presidency due to too many single issues in the Presidency.

The Acting Chairperson thanked DPME for its presentation and work, and also thanked the DoH, noting that there was much work still to be done by the DoH and Committee.

Adoption of Minutes
The minutes of 4 March 2015 were adopted without any changes.

Minutes of 11 March were adopted, with technical changes.

The Acting Chairperson announced that the provincial oversight visit to Free State had been suspended, due to the budget voting.  

The meeting was adjourned.

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