Department of Health on its Strategic and Annual Performance Plan

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17 April 2015
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Department of Health (DOH) presented the Strategic and Annual Performance Plans (APP). The main challenges which this Department was working to address included the improvement of audit outcomes, through better administration, improved training of nurses, and the re-launching of effective education campaigns in the fight against HIV and TB, which was linked to some extent with maternal and neo-natal death rates. The training of doctors posed a major headache, with South African facilities not being able to provide adequate numbers of graduates and the 2 800 students being trained in Cuba being a costly and sometimes problematic alternative solution. In relation to the audits, the DOH was targeting improving its performance to unqualified reports with no matters of emphasis in three provinces. Tracking tools were in place to monitor expenditures against priorities. The DOH recognised that better communication was needed to address the ongoing and worrying incidence of HIV and Aids, and misconceptions around the Ebola epidemic needed to be corrected through public health information communication. The Department needed to speed up recruitment processes, invest in staff and reduce vacancy rates to 5%. Compliance needed to be implemented through the signing and submitting of performance agreements, according to public service regulation time lines. THe DOH was trying to cut back on instances for litigation.

Programme 2 covered the White Paper for the National Health Insurance, and an appraisal of the pilot sites was shortly to be done. Control towers systems were already in some provinces and would be introduced in others and distribution of medicines improved through collection points. The resistance of the HIV and MDR strains of TB was increasing and this posed a serious challenge. Another challenge was that there was currently no register for African Traditional Practitioners and regulation of this area was needed. The e-Health system would be installed in 698 facilities. The National Research Strategy would be finalized, costed and linked to priorities. Fees would routinely be negotiated with stakeholders and the Single Exit Price, which was to be Rand-based, would be reviewed in conjunction with National Treasury. The ideal situation was to finance the NHI through a fund rather than grant system.

Members asked for more information on the challenges with having students in Cuba. They questioned whether the stated aim of prevention rather than cure was working, saying that oral health campaigns in schools did not appear to be effective. Prevention of HIV was no longer being emphasised by the media, and not enough information was being given to young people. ,Members asked about the current vacancy rate, asked if the DOH was likely to achieve targets for recruiting GPs, and questioned why training was being done in Cuba, and why there was not consideration of raising the salaries for nurses. They asked whether pharmacy fees were being adequately monitored and regulated, and why there was not a greater push for private institutions to come on board with the NHI. Members were worried that provinces were not always apparently in alignment with the national Department, and also questioned why the decision on who should pay for healthcare was so long delayed. Members were in support of National Treasury allowing some hospitals to retain revenue, as this would incentivise them. Members wondered why the DOH was aiming only an unqualified audits in some provinces, saying that it appeared to be a little complacent. They called for clarity on the status of the Bill and White Paper, and whether some NHI sites were being abandoned. Members asked for what purpose the Demographic Health Survey was being conducted, and where the money would come from, and what the DOH was doing to address rural areas. Several were concerned that there were no quarterly targets set for some programmes, even for campaigns launched in previous years, and wanted to know what exactly was being done to improve health education among the population. Members questioned the note that some data may not reconcile and asked whether the licensing fees payable by doctors was being adequately monitored. They were interested in what was being done to ensure that all CEOs of hospitals were up to scratch, how they were held accountable. One Member commented that the Auditor-General had said that some data was unreliable and asked how this would be addressed, and also questioned the timing of the Mum Connect programme and why it did not continue after birth.

Members expressed concern that the Department had transferred the functions of the Emergency Medical Services (EMS) from municipalities to provincial level without consulting the Financial and Fiscal Commission (FFC), as this was against the FFC Act. What would be the impact of the R1.4 billion reduction of conditional grants allocated for provinces? Members also wanted to know about progress on the establishment of nursing colleges, as this had been long overdue in the country. What systems were put in place to address the under-spending on the scourge of HIV/AIDS in the county?

Meeting report

Department of Health on its Strategic and Annual Performance Plan 2014 financial year
Ms Malebona P Matsoso, Director-General, Department of Health, took the Members through a presentation of the Annual Performance Plan, which was in alignment with the Strategic Plan, of the Department of Health (DOH or the Department) She noted that there were six programmes. Under Programme 1: Administration, .the Department intends to improve audit outcomes to an unqualified audit report with no matters of emphasis in three provinces for the coming year. Chief Financial Officer (CFO) Forum meetings were being held in each province to this end. Tracking tools to monitor expenditures against priorities, such as sufficient stock, were being monitored by MECs and the Minister. Effective communication was recognized as an important tool in decreasing the incidence of HIV Aids and the loss of effectiveness in this regard needed to be addressed. Misconceptions around the Ebola epidemic needed to be corrected through public health information communication. The Department needed to speed up recruitment processes, invest in staff and reduce vacancy rates to 5%. Compliance needed to be implemented through the signing and submitting of performance agreements, according to public service regulation time lines. Litigation was consuming precious resources unnecessarily, and the Department was addressing this as well. The upgrading of all Assistant and Deputy Directors was being done to bring entry levels into alignment. Back pay would have to be paid. The programme also covered maintenance of the DOH building which needed its lifts replaced. This was the reason why payment of R50 million to the Department of Public Works had been delayed. Lastly, payment to the Auditor General fell under this budget, and received an allocation of R389 650 million.

Programme 2 covered the White Paper for the National Health Insurance (NHI), legislation and the funding of the NHI. The draft White Paper needed to be presented to Cabinet and thereafter to Parliament. An appraisal of the pilot sites would be available by the end of April. An electronic system to provide early warning on stock-outs was to be installed mostly in hospitals. Control towers would monitor suppliers and ensure distribution of supply so that there would be no lag time. Such a system was already in place in Limpopo and Gauteng. Free State and Eastern Cape would follow next.  Distribution of medicines would be increased from 200 000 to 500 000 patients through the use of collection points such as mosques, churches and the like. The Department welcomed innovative ideas in this regard, such as the system in the Western Cape where a delivery system using bicycles had been implemented.

South Africa had the highest rate of HIV in the world, with resistance of the virus increasing as adherence to treatment decreased. Similarly, multi-drug resistant (MDR) strains of Tuberculosis (TB), as well as the reduced effectiveness of antibiotics, posed a serious challenge.

There was currently no registrar for African Traditional Practitioners. This area needed to be better regulated.

The Department would continue to support the provinces to collect revenue and so far R1.6 billion had been collected, some of which the Department believed should be retained by certain hospitals for basic necessities.

The IT system, eHealth, would be installed in 698 facilities, which would involve 200 000km of travel. The National Research Strategy would be finalized, costed and linked to priorities. International and bilateral agreements were also covered in this programme. Fees would routinely be negotiated with stakeholders and the Single Exit Price, which was to be Rand-based, would be reviewed in conjunction with National Treasury. Licensing of pharmacies and inspections would continue. Exemption mechanisms for patients had to be reviewed Linkage between national and provincial APPs would be made and brought into alignment, except where certain provinces had unique priorities. Cuts in the NHI budget had been made. Ms Matsoso stressed that the ideal situation was to have a separate fund for NHI, and not to finance it by way of a grant. The medical students in Cuba were a challenge and further research on collection points needed to be conducted. The burden of disease needed to be determined through a proposed Demographic Health Survey.
Dr W James (DA) asked for more information on the situation with the Health Attaché in Cuba.

Mr S Emam (NFP) said that while prevention was always highlighted in the mission  statement of the DOH, the reality did not not seem to bear this out. The campaign for oral hygiene was a case in point. He did not see this campaign being practised in schools. Audit reports indicated that in primary health there was not enough accountability. The prevention of HIV did not seem to be a concern by the media any longer. Not enough information was being disseminated to young people regarding the dangers of catching and suffering with this disease. Mr Emam asked what the current vacancy rate was in the Department. He was concerned that temporary workers should become permanent after three months. He doubted whether the 2030 NHI target for GPs was attainable. He asked why South Africa was training doctors in Cuba and not making plans to increase training capacity in South Africa. He asked whether pharmacy fees were being adequately monitored and regulated. He asked why private institutions were not being compelled to come on board with the National Health Insurance (NHI), since they were very wealthy and charged astronomical fees. He asked how exactly the Department intended funding the NHI.

Ms C Ndaba (ANC) asked why some provinces did not follow national policies. She asked why nurses’ salaries were not also being upgraded, since they were extremely hard working. Such an increase could go some way towards addressing the shortage of people entering this field. The question of deciding who can and cannot afford to pay for health care was an urgent issue, and should have been resolved. She asked for a time line in this regard. She asked why foreign nationals were not expected to pay for health care. She agreed that National Treasury should allow hospitals to retain some of their revenue, as an incentive to become more efficient at collecting revenue.

Mr A Mahlalela (ANC) said that there were errors in the APP, with pages 11 and 12 being repeated. This needed to be corrected. He asked whether the Council of Traditional Healers fell under the Ministry of Health. He pointed out the South African Health Practitioners Registration Authority (SAHPRA) was not supposed to include considerations of cosmetics and foodstuffs.  He asked why there had been a R1.4 billion reduction in the conditional grants. He asked why there seemed to be no intention to come up with a clean slate of audits in the coming year and why instead the DOH was aiming only for audits with findings. While clean audit reports were stated as objectives in the later years, he could not understand why this was not an immediate goal. It seemed the Department was too easily satisfied with the status quo instead of demanding an unqualified report with no findings. Only two provinces had received unqualified reports and the coming year was aimed at adding only one more province. He asked why the rest of the provinces could not comply. He was confused by the fact that there was still no White Paper but that there was a Bill and asked for clarity and time lines on this. He asked if some NHI pilot sites were being abandoned and whether they were under performing, since the budget had been reduced. He said that while the NHI could not be implemented through a grant, the pilot sites were being operated through the use of an indirect conditional grant. He asked whether the Department had sufficient funding to run it. Also, there needed to be consensus with the provinces to convert a direct grant to an indirect grant.

Ms M Scheepers (ANC) asked whether the cost of the Demographic Health Survey, noted as requiring R80 million and for which only R30 million had been obtained, would be conducted on a proportional basis through the provinces. She asked how this survey would be funded. She asked what the Department was doing about reaching people in rural areas. She had seen a clinic caravan standing unused in the parking lot of a clinic, simply because it could not be transported.   

Mr A Mahlalela (ANC) said there seemed to be a common problem across most of the programmes - namely, that there were no quarterly targets set, through which the annual target was to be achieved. This made oversight especially difficult since there was nothing to measure performance against, on a quarterly basis and before the end of the year was reached. The hand-washing campaign was launched during the previous year but no quarterly targets in this regard have been formalised, to which the Department could be held accountable.

Ms L James (ANC) asked what information the Demographic Health Survey was supposed to generate. She agreed with Mr Mahlalela that proper oversight required quarterly targets which could be measured against budgetary expenditure, since sometimes budgetary expenditure did not make sense. She wanted to know what exactly was being done to improve health education among the population.

Ms Dunjwa pointed out that her questions would refer to programme 2 only. She asked what research was to be conducted by the Human Sciences Research Council (HSRC) in order to understand the oversight role by the Committee. She asked for an explanation of a note in the APP at page 27, referring to data which might not reconcile. She asked which areas were being serviced by the bicycle system referred to in the presentation. She asked whether the licensing fees payable by doctors was being adequately monitored.

Ms Matsoso said there were Health Attache’s based elsewhere in the world and they were paid according to rules prescribed by the diplomatic handbook. The office in Cuba was established to provide counselling for the students for whom the transition was problematic, and the students received support from a Review Committee which prepared them for graduation. She said the existing South African medical institutions could not possibly accommodate the number of students needing training, and while it had been acknowledged that expansion in this area was needed, this process would take time. The Minister had requested that institutions increase their intake, which they were gradually doing. Everyone recognised that Cuba was a short-term solution.

Ms Matsoso said that one of the DOH's prevention strategies involved encouraging the food industry to lower its salt content and trans-fat acids in food products, in an effort to increase healthier options. New regulations in this regard were in the pipeline. Schools were being approached to stop selling sweets and chips laden with artificial colourants, and restaurants would start providing a calorie count of every meal on their menus. Government departments were also included in the drive to raise health awareness. For example, in the Presidency,  carbonated drinks had been banned and only tap water was used. The HIV prevention strategy was being informed by data from CAPRISA in determining what strategies were effective. Girls between the ages of 15 and 24 were at highest risk for contracting HIV and this group needed to receive greater attention.

In regard to questions of staffing, Ms Matsoso said the DOH had employed 380 graduates as well as another 70 persons, of which all whom were now employed permanently. Community health workers needed to be integrated and the process had already taken place in Gauteng with other provinces to follow. While some of the community health workers did not have the same qualifications as other medical personnel, this challenge was being addressed by through Recognition of Prior Learning, but this had to be determined objectively by institutions of higher learning. Ms Matsoso said that the training of CEOs for hospitals was also a priority and was being addressed through a partnership between private sector and the Public Health Enhancement Fund.

The only instances where priorities in provinces differed to those of the National DOH was where where they had unique challenges, like the occurrence of malaria in Mpumalanga. Otherwise, national and provincial priorities were very much in alignment. There were many different nursing fields and specialisations. Availability of posts as against qualified personnel was being analysed and nursing bursaries were being given according to the need. It had also been found that many nurses were inadequately trained and that infection control was affected as a result. The DOH had raised R1.6 billion in revenue for the purpose of addressing these needs. Central and tertiary hospitals would be involved in this process.

Ms Matsoso said that African Traditional Practitioners did indeed fall under the Ministry of Health.

In relation to the audits, she agreed that clean administration reports was the objective with very few matters of emphasis, and to this end she was engaged in introducing some very tough measures.

Dr Terence Carter, Deputy Director General, DOH, added that the position of the Health Attaché in Cuba was in some ways unique because this was the only country where there were such large numbers of South African citizens located for which the DOH had to take responsibility - some 2 700 students. This was also significant in view of the fact that some of the local medical institutions could not accommodate more than between 1 600 and 1 800 students at their institutions. The Cuban Health Attache's office was responsible for administration, support and all aspects that needed to facilitate that, like IT and security. The Minister had, since 2011, been asking institutions in South Africa to increase their intake and Wits had already begun to do so with an extra 40 students. Other universities were following suit. Seven universities were participating in this process, with the exception of the University of the Free State. Local intake had thus increased by 600. The programme in Cuba had started with 80 students initially and had grown to 902 students under the agreement between Presidents Castro and Mandela. The vacancy rate among nurses had to be categorised in order to efficiently meet needs, and this analysis had not been done until recently.

Ms Matsoso said the both the White Paper and the Bill had been drafted and were now ready for public comment. This needed to coincide with the release of the Treasury Finance Paper, since this would speak to the financing of the NHI grant. Every grant required a business plan. The business plan for the NHI grant could be made available. In the meantime work was going ahead in rolling out the NHI programme through the three streams of primary health care, district specialist teams and school health. The DOH was not waiting for the White Paper and work was continuing beyond the pilot sites. The only area where there was under-performance in the pilot sites was the contracting of GPs. 

Ms Matsoso explained that the Demographic Health Survey would provide data necessary for comparison with other countries and was required by the World Health Organisation (WHO) and the UN. The cost of R80 million was steep and was largely due to the cost of having the survey conducted by Stats SA. Other institutions involved were Human Science Research Council (HSRC) and the Medical Research Council (MRC). The former brought its studies of HIV to the table and the latter had brought studies on the extent of the burden of disease. Ms Matsoso agreed that health education needed improvement and that strategies to address this were being implemented.

Dr Anban Pillay, Deputy Director General, DOH, said there was a maximum cap on the fees that pharmacists could charge. Some medical aid schemes had negotiated a lower rate with certain pharmacies within a reasonable distance, who then became Designated Service Providers (DSPs). Levies were charged on more expensive medicines, which were favoured above the generic. He said the distribution of medicines in the Western Cape had been initiated by a young entrepreneur in Khayelitsha, whereby people had their medicines delivered for a small fee.

Ms M Wolmarans, Acting Chief Operations Officer, DOH, referred Members to page 92 of the APP, regarding the business plan for the conditional grant. She said National Treasury allowed for both annual and quarterly target setting and that each of the Deputy Director Generals had decided on which route to take in this regard. However, they all had quarterly targets for operational plans and they used a measuring tool called milestones to determine performance.

Miss Valerie Rennie, Head of Corporate Services, DOH, said there had been an improvement in the vacancy rate from 4.3% to 4%. She said the foot note referred to by the Chairperson was inserted in case there was a variance between the database which had not yet been updated and the information which was required for audit purposes. She agreed that communication was of paramount importance and that this should be done in an integrated way to be effective. Currently this fell under Primary Healthcare.

Ms Jeanette Hunter, Deputy Director General, DOH, noted the recommendation made in terms of quarterly targets. Sometimes this proved challenging, where for instance the DOH might set a target for immunisation against influenza, but most of these immunisations typically took place from February to July, sometimes up to one million immunisation. However, in the third quarter there was a significant dip, perhaps even to 0% of quarterly target, which, although expected, could be recorded as a red flag by the auditors. However, there certainly were places where setting of quarterly targets made sense and she would indicate to what extent targets had been reached. While communication on a national level was possible, the rural areas would require professionalisation on a district, and then sub district, level. The Department had not confined its work to the pilot sites, and was expanding its reach in primary health clinics, with the use of complementary doctors. Over 200 GPs were contracted, in ten pilot sites, and the Department was also using its own full time doctors from hospitals to do this outreach work. Some of the doctors had refused to come on board because of the low rate, but the DOH was reluctant to increase the rate, because this risked the loss of their own doctors to the system.

Ms Dunjwa said she was not satisfied with the response from the Department regarding variances in data in the APP.

Ms Matsoso expanded on the point. She said that Stats SA released figures which needed to be adjusted. In terms of maternal mortality, the DOH had launched a campaign called Mum Connect. One of the indicators used to determine whether this campaign was actually working was the number of post-natal visits conducted. The DOH had also conducted enquiries into the causes behind maternal deaths, among which were haemorrhage, requiring urgent access to blood, sepsis and HIV-related causes. Therefore preventative strategies for HIV prevention directly related to the reduction of maternal and neo-natal deaths. Here, dual protection, in the form of contraception and condoms, screening and immunisation were relevant to the rate of maternal and neo-natal deaths. Immunization against pneumococcal disease was having a significant impact, even among the elderly, and the measles immunisation coverage had to be increased to 90%. Coverage for the HPV vaccines was aimed at 92%. Other rates of vaccination were adequate. Malnutrition, as well as breastfeeding, remained an ongoing challenge and people in the primary health care clinics were involved in education in this regard. Ms Matsoso said TB was a major challenge, a disease which was exacerbated by smoking. Multi-drug resistant strains of TB added to the challenge. Where patients were co-infected by HIV/Aids it was found that an integrated treatment programme increased survival. In the fight against the endemic, the DOH was campaigning for circumcision and condom use. All circumcisions, no matter where done, had to be conducted using safe practices. Both male and female condoms were being distributed. When testing for HIV, the DOH would be screening for things like high blood pressure, diabetes and other diseases at the same time, instead of conducting a separate test every time. The Department aimed to test 3.8 million people in the coming year, which was ambitiously increased from last year’s 3 million.
Prevention and treatment of breast cancer, which was high among African women, would be addressed and the DOH had already made some headway in this regard with an increase of 5% of patients staying on treatment. Substance abuse among the youth was high and needed to be addressed. The budget for this programme was significant also. The highest amount was allocated for HIV grants to the amount of R14 billion. Such a hefty amount came with risk and had to be well managed with effective monitoring tools.  

Ms Matsoso said the hand washing campaign was part of the anti-microbial resistance strategy, which formed part of a global action plan, in which South Africa was a frontrunner, since the plan had been adopted in May last year already. The programme also regulated waste management. Healthy eating habits had been initiated in all government departments, including the Presidency, as part of setting healthy examples. The tobacco regulations were ready for publication. Again, tobacco use was a major factor involved in TB.

High blood pressure screening would go up steeply, from 500 000 last year to 8 million in the coming year, since now tests were going to be integrated. Improvement in mental health treatment involved targets for screening, treatment and in-patient units linked to hospitals, as well as specialist mental health teams being coordinated. Targets for support and access to appropriate devices for the disabled and those in need of rehabilitation were set. A large number of cataract operations, the elimination of malaria from the provinces of KZN, Limpopo and Mpumalanga were further objectives falling under this programme, which was allocated a budget of R225 million in comparison to the previous year’s R87 million. The level of midwifery training needed to be improved and the training needed to be fully integrated.

As far as emergency services were concerned the Department would be releasing new regulations which, among other things, would be standardising the colour of ambulances. It would also address access to emergency services across provincial boundaries. The backlog in blood alcohol toxicology tests would be addressed and the training, mentoring and coaching of CEOs would be started in an effort to improve their performance.

Programme 5 had a budget of R1.5 billion. This included complementary medicines and pathology services, the former representative body having taken the Department to court, but having subsequently withdrawn their case. These practitioners had also requested training in order to become compliant. The latter involved a set of guidelines which pertained to sexual offences as well.     

Dr W James (DA) remarked that since such a large portion of the budget had to be allocated to the treatment of HIV and Aids, it left proportionally less available for other, also pressing, health needs. This meant that prevention was of paramount importance in order to counter this scourge. He asked whether present strategies to educate and empower the youth were really effective. 

Dr James said that his experience was that a well functioning hospital required a good CEO. He asked what the Department was doing in regard to measuring the performance of CEOs, and to what extent accountability was being implemented. He asked if enough resources were being allocated to the training of CEOs. 

Mr Mahlalela commented that previously the AG had found the data referred to in Programme 3 as being "unreliable" and asked how the Department had addressed this deficiency. In regard to Primary Healthcare, he questioned why government should review norms when current norms had never been fully implemented in certain provinces. Surely government should impose adherence to these standards first? He asked what process was in place to ensure implementation of norms and what interventions were in place when this was not the case. He questioned why the "Mum Connect campaign" ended straight after delivery of the child, when in fact the first twenty-eight days of the baby’s life were critical.
Mr Mahlalela expressed concern that the Department had transferred the functions of the Emergency Medical Services (EMS) from municipalities to provincial without consulting the Financial and Fiscal Commission (FFC) as this was against the FFC Act and he wondered whether the matter had been resolved. He asked for clarity on the discrepancy in the number of hospitals that had already been built and those that were currently under construction. What was the impact of the R1.4 billion reduction of conditional grants that had been allocated for provinces? It is disappointing to see that the focus of the Department for the entire year will be on gazetting instead of addressing serious challenges of Emergency Medical Services (EMS), especially in rural areas, as the system was dysfunctional. The EMS programme of the Department for the first quarter had been generally centred on urban areas instead of remote rural areas where services are still lacking. He also asked whether the Department had a system in place to continuously evaluate the number of condoms distributed relative to its impact of reducing the scourge of HIV/AIDS in the country. The President had indicated during the 2015 State of the Nation Address (SONA) that the country needs to put more focus on reducing the spread of TB, especially around mining and correctional facilities.

Mr Mahlalela asked whether the Department would be able to effectively reduce the spread of TB in the country considering the budget that had been allocated. It is also important to ascertain whether the Department had consulted the owners of the mining companies and the Department of Justice and Correctional Services (DJCS) on the role they would play in the fight against the spread of TB, especially on funding. What practical strategy is in place to deal with the problem of malnutrition in the country? Is there a relationship with the Department of Social Development (DSD) and Department of Basic Education (DBE) in relation to dealing with malnutrition? The relationship between the two departments could assist in determining the kind of food that should be consumed in the feeding scheme programmes provided in schools in order to prioritise on nutritious food.

Ms Ndaba expressed concern about the poor state of primary health care clinics in the country as she had a personal experience when she visited the clinic at OR Tambo International Airport, and suggested that the R180 million should have been allocated for treatment. The Department had been under-spending in the treatment of HIV/AIDS and she wondered whether the Department would be able to spend the allocated budget. What systems were in place to address the under-spending on HIV/AIDS? There should be a concerted effort to improve the state of Primary Health Care in the country as this affected the poor. How does the Department relate to the Early Childhood Development (ECD) centres, both in the private and public sector, so as to deal with challenges facing children at an early stage?

Ms James asked whether the Department had any strategy in place to deal with teenage pregnancy as there had been an increase in HIV infection between the age group of 15-24, especially since the problem is also related to drug and alcohol abuse. The Department had been particularly silent on ways to comprehensively deal with drug and alcohol abuse that leads to a number of problems, including the spread of diseases, fatal accidents, and even death. She suggested the Department must reconsider the way the presentation had been structured to make it easy for Members to ask questions. It is important to also provide a breakdown of the reflected programmes in place in terms of location and purpose of the programme, and this is for the purpose of oversight visit. Why was it so difficult to have a pilot of the nursing college as the country had been experiencing a shortage of nurses?

Ms James suggested the Department focus on providing general assistance, clerks and porters to assist people entering hospitals as part of reengineering the primary health. The focus on Public Private Partnership (PPP) should be related to vaccination of children. It is critically important for Government departments to work together so as to deal comprehensively with challenges such as lack of funding. The Department needs to ensure that resources are distributed evenly so as not to disadvantage rural areas, especially in cases of cleaning of the district municipalities. It is important to know whether there is a programme in place to deal with waste management, as filthy places are often a health hazard. 

Ms Matsoso responded that in the 2010/11 financial year, the Minister had looked at the issue of staffing in the health sector and the Department had significantly increased the utilisation of general assistants. Employment of doctors had increased by 1.8% and nurses by 2% and the Department now had more administrators in the health sector, both in the provincial office and nationally, than the actual health workers. The employment of administrators had also consumed a significant proportion of the allocated budget. Currently for some health facilities, there are more professional nurses than enrolled nurses and this ratio is skewed and the Department wanted to rectify this by having more enrolled nurses and nursing assistants than professional nurses. The Department wants to implement an Act that will ensure that health facilities are allocated with enough staff in order to be able to operate efficiently.

Ms Matsoso responded that the Human Sciences Research Council (HSRC) had released a report claiming the country had been doing well in reducing incidents of HIV/AIDS and putting more people on treatment like anti-retrovirals (ARVs). The only measure of success in the fight against HIV/AIDS is to see whether the country had been seeing new infection rates and the interventions are mostly based on the most affected age group. A study was done in KwaZulu Natal (KZN) where it showed that intergenerational relationship had also contributed significantly to the spread of HIV and this was not just a health issue but also social. The prevalence of intergenerational relationship between older men and younger girls also perpetuates the risk of girls spreading HIV to younger boys (15-24 age-groups). The EMS had been the competence of municipalities and this in itself had presented a problem as municipalities work in boundaries and the Department had been pushing for the function of EMS to fall under the provinces so as allow the movement of ambulances to any part of the country. The Department consulted with provinces and the level of readiness differed from province to province and KZN had already set up an Information System (IS) to prepare for the migration of EMS functions and the Department was hoping that municipalities will agree with the movement of functions.

Ms Matsoso agreed that the Department needs to focus on post-natal related interventions support in the Mom Connect programme for women to visit the facilities so as to ensure that children are immunised annually. The Department ran a workshop with the FFC on the need to centralise budget beyond the provinces to go further down to the district and the Department had been proposing about the manner in which the NHI should be run in future. There seemed to be a disagreement between the Department and NT especially on enough capacity at the district level and there is now a concerted effort to build capacity on district health authorities. The Department had just taken over the functions of Port Health Services (PHS) on 1 April 2015 and there is now focus on improving the services for screening of communicable viruses such as Yellow fever and Ebola for both those departing and arriving in the country.

Ms Matsoso responded that the Department was now looking at ways to expand the PHS to include emergency services. The expenditure on HIV/AIDS as at February 2015 was at 94% and the indicative figures show that the Department will reach 99.8%. The Department had heard reports about the misuse of condoms by students and also older women with arthritis who rub their feet with lubricant of condoms and this had created an impression that the condoms could be used for other purposes than those intended. It is often terribly difficult for the Department to determine whether those who had taken the condoms will use them as this is a personal issue and the only solution is to educate people about the importance of condoms. The Department had been making progress in the fight against TB in both the mining sector and correctional services and 87 000 inmates that had been tested for TB. The Minister had met with mining bosses before the World TB Day to ensure that there is a co-ordinated effort to fight against the scourge of TB in the country. Primary health is working with the DJCS in order to determine other health services needed by inmates beyond just TB as some end up not receiving ARVs in time.

Ms Matsoso responded that the Department is working with tertiary institutions to improve the quality of nursing and the possible establishment of a nursing college. The Department will still need to gather more information on the incident at Dora Nginza Hospital in the Eastern Cape where a six weeks old baby and a two-year-old child had allegedly been injected with antibiotics and died instantly. The Department prioritises on ensuring provinces work in a co-ordinated manner in order to ensure that there is a sharing of information on ways to improve the overall state of health facilities in the country and the Members of Executive Councils (MECs) had been driving process. The Department had been approached by the World Health Organisation (WHO) to be the main supplier of vaccines for the United Nations (UN) system and it will now be the Department of Science and Technology (DST) to be responsible for the supplier of vaccines.

Ms Matsoso responded that the message on the Mom Connect programme goes beyond the delivery of the baby as the mother continues to receive stage-based messages and the mother is often reminded about the 6 weeks check-up. The mother also receives messages on breast-feeding, immunisation and when the baby turns 6 months. Interventions for the prevention of teenage pregnancy go hand in hand with interventions for HIV/AIDS. One of the most effective interventions to reduce teenage pregnancy and HIV/AIDS in young girls is to keep them at school as the research shows that being in school is the most protective measure. The Department is working closely with DBE through a school health programme and within the programme there is a task team that meets every month. The task team is coached by the DOH, DBE and DSD. The Department looked at figures on the rate of teenage pregnancy and was now coming up with a strategic plan to address the different drivers of teenage pregnancy. The Department is using the District Health Information System (DHIS) data to look at deliveries in different facilities of those under the age of 18 and the DBE also collects data on teenage pregnancy at primary and high school. 

Ms Matsoso added that part of the package of the school health programme is that nurses had face-to-face intervention with learners of the schools they visited and there is also a discussion on sexual and reproductive health, substance abuse and non-communicable diseases. The Department had come up with the School Governing Body (SGB) toolkit so that the health intervention is implemented in a particular school with an opt-out approach, meaning the intervention is implemented and then it will depend on the SGB to decide whether the health intervention will be allowed or not in a particular school. It is easy to reach those schools with grade R as the school health team often visit primary and high schools in terms of prioritising on ECD centres. The challenge is the ECD centres that are not linked to schools and the Department gets the map from the DST in order to find the location of ECD centres to be included in the planning process by the school health team. The Department was also working closely with the PHC in order to reach those ECD centres that are difficult to reach, and clinics also offer the service as an outreach service.

Ms Matsoso responded that there is now a focus on the ward-based outreach team so as to assess the state of malnutrition in the country so as to immediately identify the development of malnutrition and intervene in ensuring that the household receives the social grant. The Department also prioritises on ensuring that children are weighed in the PHC clinic in order to intervene immediately when the child starts to growth-falter. The Department has the clearly outlined 10 steps on how to deal with malnutrition and there is now a focus on breast-feeding, as this was free of charge and healthy.    

Mr Ian van der Merwe, CFO, DOH, responded that the R1.4 billion is a reduction in the baseline allocation meaning there might be an increase in the budget where there had been a baseline reduction. This reduction covers the 3 years of the MTEF and the 4 direct grants affected by this reduction included infrastructure grant (R14 million), tertiary services grant (R8.24 million), training grant (R197 million) and NHI grant (R6 million). The reason for the reduction in the baseline allocation is the result of the entire fiscal pressure that had been experienced and it means the real growth of all the grants had declined from the usual 10% to 4%. 

Dr Carter responded that the Department recognises the importance of training staff members in order to improve the general service offered to the people. All the CEO posts in hospitals in 2012 were declared vacant and new CEOs were appointed with new requirements such as tertiary qualifications. All the current CEOs in hospitals have a tertiary qualification but there is still a massive failure in the operation of a number of hospitals and the Department had been working with International Hospital Federation (IHF) to develop a programme that will focus on new competencies to ensure that the current CEOs become successful, and this included mentoring and coaching. The Department had secured funding from the European Union (EU) to ensure that the programme brings the international experience to be utilised in the country so that the CEOs are sufficiently competent in delivering quality services within the health institution.

Dr Carter responded that the Department is aware of the delays in the establishment of a nursing college and a nursing strategy was adopted in 2012. This strategy recommended a number of different steps and one of those recommendations included the appointment of a Chief Nursing Officer (CNO), and it took a while for the Department to get the right person for the post. The number of credits that are accumulated in the training of the nurse was equivalent to that of a degree and there was a suggestion that the nursing colleges would need to move and fall under universities. There was engagement with the Council of Higher Education after the CNO had been appointed and the Department developed a new training framework for nurses and was now ready to be piloted, which complies with the South African Qualification Framework. This new framework also brings back the old method of nursing that had been successful in the past.

Dr Carter responded that the Department would continue to deliver much better infrastructure by focusing on the quality, size and configuration of all the facilities and infrastructure to be built. There was also a signing of the standards on which all the building of the infrastructure needs to comply with, and facility audits identify all the poor health facilities and develop the implementation of the bill of quantity in terms of cost. The Department is also focused on maintaining the existing infrastructure in new and old hospitals so as to avoid the similar situation that is currently happening in Eskom because of poor maintenance of the infrastructure. 

Ms Hunter responded that at the moment the travel clinics are dealing with vaccinations that are required for individuals travelling between countries and the screening process is also related to that demand. Travel clinics also focus on the screening of outbreaks such as the recent Ebola. Port health services were under national competence in terms of international health regulations and the Department has decided to nationalise the PHS as indicated by the DG. The Department consulted provinces that were related to the importance of transferring the PHS from district municipalities to provinces and there were also discussions with NT about the transfer of funds and the provincial treasury departments were involved in these discussions. It was only 6 weeks ago that the Department was told that there should have been consultation with the FFC on the transfer of functions as required by the Act, and apologised for this omission. It is important that the bulk of primary health care resources must be under district level where the management of services is implemented and the Department was working on determining the actual costing of the primary healthcare packages and the improvement of the quality of clinics. The Department of Environmental Affairs has its own regulations on environmental hygiene and the Department on the other hand had passed regulation on managing safety and hygiene within health facilities.

Ms Carter responded that there is an inter-ministerial committee chaired by the Minister of Cooperative Governance and Traditional Affairs (COGTA) and health is part of this committee focusing on back to basic programme. The Department is planning to conduct a thorough assessment of the capacity of municipalities to be able to respond to the norms and standards of environmental health and there is a focus on food safety and various problems of rodents and pest control especially in most informal settlements.

Ms Wolmarans responded that the Department had been looking at ways to improve data quality and this is by rationalising the paper base for data collection tools, as it is prone to a lot of human error. Only 6 paper base data collection tools will be used in all the +3 500 primary healthcare facilities as from the 1 April in the current financial year. There is also a move into electronic data capturing and this is to completely remove the human error that could be possible in the data collection. The Department had taken the audit methodology of the AG and designed a tool that could be used by the facility manager to actually assess the quality of the data and this is helpful in identifying the problems and immediately rectifies them or makes adjustments. It is important for the Department to have an IS where information could be stored and this would require quality broadband Internet to deal with all the challenges in data collection and storage. It is expected that the process could be rolled out in the next 2-3 years.

Mr Mahlalela mentioned that the Committee had made a number of recommendations in the Budget Review and Recommendations (BRRR) and these included the consultation of the FFC for transferring the functions of the EMS from the municipal to provincial level, but it seemed the Department had ignored these recommendations. It will be critical for the Committee to get a progress report on some of the resolutions that had been taken by the Department. It is unfortunate that there is no system in place for the Department to report to the Committee on progress that had been made based on recommendations made by the Committee. This is particularly concerning as it continuously creates an impression that the Committee is only meeting for the purpose of compliance and not to delve into problems that significantly impact the masses. He requested more information on the claim that there is a post-natal care programme as the nurses in his constituency claimed that the Mom Connect Programme ends after the delivery of the baby. The NT and the Minster had indicated that the budget reduction will not affect the service delivery but the Department seemed to have made a contrary statement.  

Ms Matsoso responded that there is a need for intervention of the Minister in the contestation between the NT and the Department as it often creates confusion in the budget allocation of the Department. Some Non-Governmental Organisations (NGOs) are directly funded by the Department and it sometimes happens that the NT will increase the budget to be allocated to NGOs despite the Department’s request for a reduction.

Mr Carter responded that the Department was looking at an alternative funding model for the infrastructure projects and of the projects that were agreed on, 3 were prioritised and these were linked to new universities and King Edward Hospital. The other projects are quite extensive and the report also clarifies the stage of the projects whether on tender stage or physical competition stage and this allows people to easily see all the stages of progress.

Ms Ndaba requested the name of the clinics that are providing post-natal care so as to see if nurses had received adequate training and support.

The Chairperson concluded that there are fundamental issues that the Department needs to focus on as highlighted by Members, especially on the recommendations that had been made by the Committee on the Department and the importance of doing follow up. She also requested that the Department provide a reader friendly presentation that would allow Members to thoroughly interrogate the presentation and the documents provided. The Committee should be provided with more information on the issue of the nursing colleges and the staffing norms. She thanked everyone who had been present in meeting, particularly the Department.

The meeting was adjourned

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