The Department of Health (DoH) presented its Annual Report 2014/15. For the past four years it had obtained an unqualified audit opinion from the Auditor General (AG) and three out of nine provinces obtained an unqualified audit for their 2014/2015 financial year compared to two provincial Departments for the 2013/2014 year. A framework was developed and implemented in all the levels of the health sector for the purpose of providing leadership in the health sector and providing support for developing identified plans. The health sector continued to implement strategies linked to the National Health Insurance (NHI) pilot sites. The first phase of implementation of the NHI was still ongoing and that was planned to take five years. The process of developing and testing Diagnosis-Related Groups (DRG) as an alternative reimbursement tool for hospitals was in place.
The Council for Scientific and Industrial Research (CSIR) was commissioned to assess the level of Primary Health Care Patient Information Systems implemented in the country against the published National Health Standards Framework. DoH wanted to increase the number of HIV positive people who were being managed so that they did not contract opportunistic infections, especially tuberculosis. The planned target of 64% was exceeded, with 73.7% reached. The number of hospitals assessed according to the Multi Drug Resistant TB treatment criteria was targeted at 50, but only 43 hospitals were reached.
Laboratory surveillance for the Ebola Virus Disease (EVD) was also intensified through the National Institute for Communicable Diseases, which was designated as a Centre of Excellence for testing samples and training on EVD in the SADC. A process was started to assist public nursing colleges to be ready to offer nursing qualifications aligned to the National Qualifications Framework and an assessment was done of the state of readiness of selected nursing colleges to offer such qualifications. Guidelines for medical devices and in vitro diagnostics were published and proposed legislation was introduced in November 2014 for stakeholders to comment. A definition for complementary medicine and guidelines on vitamins and minerals and ten Care Management Systems applications were under review.
During the financial year the DoH filled 435 posts in the Administration programme, 155 posts in the NHI programme, 123 posts in the HIV/AIDS and child health care programme, 100 posts in the PHC services programme, 281 posts in the Hospitals, Tertiary and Human Resources programme and 292 posts in the Health Regulation and Compliance Management programme. The final appropriation was R33.9 billion, across all economic classifications and the DoH achieved R33.1 billion expenditure. In relation to grants there was spending of R30.29 billion of the R30.38 received. 63% of targets were fully achieved and 31% partially achieved. Challenges experienced by the Department would be addressed in the next Annual Performance Plan.
Members asked questions about the audit comments, including irregular expenditure, the concern around their Department’s supply chain, the functioning of the internal audit and the ICT in the DoH. There was a great concern about the mortality rate of mothers and children in the country, the slow progress in revamping public hospitals, and questions were asked about the strategies in place to deal with mental health issues and decreasing number of nurses in hospitals. The Committee pointed out that the Department’s performance and its budget did not correlate. There was a concern that pharmacies in hospitals did not operate around the clock
Department of Health Annual Report 2014/15
Ms Malebona Matsoso, Director General, Department of Health, said the Annual Performance Plan (APP) of the Department of Health (DoH or the Department) is designed to deliver on specific commitments such as improving the quality of health care, reducing health care costs, improving health management and leadership and implementing the re-engineering of primary health care.
She took the Committee through the performance of the DoH in the last financial year, as set out in its Annual Report.
Programme 1: Administration
The vacancy rate was 6%, which was below the 10% target performance of Department of Public Service (DPSA). The turnaround time for recruitment process was within six months, which is within the 6 months benchmark of the DPSA. The Department had for the past four years obtained an unqualified audit opinion from the Auditor General (AG) and three out of nine provinces obtained an unqualified audit for the 2014/2015 financial year, compared to two provincial Departments for the 2013/2014 year.
For the Department to focus on the continuity of an ICT plan, which could be inclusive of an ICT disaster recovery plan, the Department had to develop and implement a ICT governance framework. This target was achieved and the Department did develop a Disaster Recovery Plan (DRP). To ensure efficient and responsive human resources services the Department’s target was to develop and implement an employee wellness programme that complied with the Public Service Regulation and Employee Health and Wellness (EHW) Strategic Framework. This target was achieved as all four new EHW pillars improved the well-being and productivity of the employees. A framework was developed and implemented in all the levels of the health sector for the purpose of providing leadership in the health sector and providing support for developing identified plans. This target was reached as the health service improved.
Programme 2: National Health Insurance, Health Planning and Systems Enablement
The health sector continued to implement strategies linked to the National Health Insurance (NHI) pilot sites. The country was still within the first phase of the implementation of the NHI, which was planned to take five years. The process of developing and testing Diagnosis-Related Groups (DRG) as an alternative reimbursement tool for hospitals was in place. Phase 1 of the process involved developing a base DRG tool for the ten central hospitals across the country. A target, for the purpose of developing legislation for the NHI, was achieved and gazetted for public opinion. The draft White Paper for the NHI Bill had been revised and prepared for submission to Cabinet.
The Department wanted to revise the instruction document on how to calculate the logistics fee for the 2015/2016 financial year for the purpose of regulating the health care in the private sector by establishing a National Pricing Commission and legislation methodologies for calculating fees. This target was achieved and the Department revised the logistic fees regulation, which was published. To improve the management and control of pharmaceutical services the Department wanted to review 20% hospital level paediatric Essential Medicines List (EML). It managed to review 24% of the paediatric EMLs and this review was also published for the public.
The Council for Scientific and Industrial Research (CSIR) was commissioned to assess the level of Primary Health Care Patient Information Systems implemented in the country against the published National Health Standards Framework. Ms Matsoso added that the report is available for the Committee. Under the National Health Research Ethics Council the national health ethics guidelines were revised and released, regulations on human subjects were published and the 2006 national good clinical guidelines for clinical trials were reviewed. The Department planned on developing a plan for the purpose of monitoring and evaluating health development in the country, and this target was achieved as the plan is currently being revised.
Programme 3: HIV/AIDS, Tuberculosis and Maternal and Child Health
The Ward-based Primary Health Care Outreach Teams were now following up new mothers within six days of giving birth. At the end of 2014/2015, 73% of mothers received a post-natal visit. The Human Papilloma Virus (HOV) immunisation campaign was largely successful, with 91.8% of the target number of girls reached for the first dose HPV immunisation.
The Department wanted to increase the number of HIV positive people who were managed so that they did not contract opportunistic infections, especially tuberculosis (TB) . The planned target was 64% and the DoH exceeded this target and reached 73.7%. In addition, DoH also wanted to reduce the mortality rate to less than 23 per 1 000 live births, by promoting early childhood development. The planned targets for this was 3.5% for children less than five years with diarrhoea cases, 8% for a child fewer than five years in severe acute malnutrition case, 90% for immunisation coverage of children less than one year and 82% for measles second dose coverage. The Department managed to achieve four of the targets and in three cases had exceeded the target.
To improve the functioning of the Multi Drug-resistant Tuberculosis (MDR-TB) control programme, including earlier initiation and decentralised treatment, the Department wanted to increase the number of professional nurses trained to initiate the MDR-TB treatment by 25. That target was exceeded since it had 72 nurses trained. The number of hospitals assessed according to the MDR Treatment Criteria was targeted at 50, but the Department did not reach target and managed to reach only 43 hospitals.
Programme 4: Primary Health Care
The Ideal Clinic initiative was launched in July 2013 and culminated in the Operation Phakisa Ideal Clinic Laboratory from 12 October to 21 November 2014. In addressing the management of Ebola disease outbreak in Northern Africa, an Emergency Operations Centre was established at the National Institute for Communicable Disease (NICD). Laboratory surveillance for Ebola Virus Disease (EVD) was also intensified through the NICD that was designated as a Centre of Excellence for testing samples and training on EVD in the Southern African Development Community (SADC).
A draft policy framework and strategy for persons with disability was developed, cataract surgeries were performed for 43 742 older persons, and, in order to improve oral health care the Department provided fissure sealants, toothbrushes and toothpaste for 12 000 children in primary schools.
To improve district governance and strengthen management and leadership of the district health system the Department targeted to implement approved plans and monitoring and evaluation (M&E) system. The implementation plan formed part of the approved ideal clinic scale-up plan. The ideal clinic software was developed as the M&E system to measure functionality of clinic committees. The Department also managed uniform structures for Primary Health Care (PHC) facilities approved and resources secured. The Workload Indicators of Staffing Need (WISN) process and normative guidelines for PHC facilities was completed. The target for improving environmental health services in all 52 districts and metropolitan municipalities was to develop an environmental health strategy, and this happened. The Department also finalised the health care waste management regulations.
To reduce the risk factors and improve management for non-communicable diseases the Department had to find ways of reducing obesity in both men and women by 65% in women and 31% in men. The indicator for the target was still to be collected. The Department targeted to have 500 000 people counselled and screened for high blood pressure; but the target was not reached and it only screened 169 418 people.
Programme 5: Hospitality, Tertiary Health Services and Human Resource Development
An audit of the profile and capacity of nurse educators to offer service-oriented nursing education and training programmes within a re-engineering primary health care approach was determined. A process was started to assist public nursing colleges to be ready to offer NQF-aligned nursing qualifications. An assessment of the state of readiness of selected nursing colleges to offer NQF-aligned nursing qualifications had been completed. At the end of the 2014/2015 financial year, there were a total of 1761 infrastructure projects at 888 facilities, and the Health Infrastructure Norms and Standards Guidelines were published in the Government Gazette on 30 June 2014.
To ensure equitable access to tertiary service through implementation of the National Tertiary services plan, the Department targeted to have two gazetted tertiary hospitals providing the full package of Tertiary 1 service. The target was exceeded and the Department gazetted 3 Tertiary hospitals. The target aimed at ensuring quality health care, by improving compliance with National Core Standards at all central and regional hospitals, was to have 100% compliance with extreme and vital measures of the National Core Standards, in five central hospitals. The target was not reached, and only one hospital, the Steve Biko Hospital, fully complied with the standards. To improve the quality of nursing training and practice by ensuring that all nursing colleges were accredited to offer the new nursing qualifications, the Department targeted having five public nursing colleges accredited to offer the new nursing qualification. The target was still being achieved as the Minister of Higher Education, Mr Blade Nzimande, and the Minister of Health, Mr Aaron Motsoaledi, had agreed to re-direct nursing colleges.
Programme 6: Health Regulation and Compliance Management
In relation to regulating Complementary and Alternative Medicines (CAMS), Medical Devices, In vitro Diagnostics (IVDs) and African Medicines, there was a target to have CAMS for Oncology, Cardiovascular diseases, HIV/AIDS and diabetes regulated. Medical devices and IVDs guidelines were published and proposed legislation was published in November 2014, for stakeholders to comment. A definition for complementary medicine, and guidelines on vitamins and minerals, as well as ten CAMS applications were presently under review. The Medicines and Related Substances Amendment Bill was developed in order to improve the efficiency of the regulation through restructuring by establishing South African Health Product Regulation Authority (SAHPRA) as a public entity.
Consultations and two draft Memorandum of Understandings (MOUs) with food testing institutions to enable testing for adulterants in food products had been done. There were on-going internal consultations to establish the extent of the capacity and capabilities to conduct testing of food.
To provide for coordinated disease injury surveillance and research, a National Public Health Institute of South Africa had to be established. The target here was to conceptualise a framework and business case for the Institute and that had been approved. The Department targeted to have 70% of its patients surveyed, in order to get information to improve the acceptability, quality and safety of health services. The target was not reached as the Department only managed to survey 49% of patients.
To monitor the existence of and progress on annual and regular plans that addressed breaches of quality, safety and compliance in all public sector establishments, the Department targeted to dealt with 45% of the plans. The target was exceeded and 63% was achieved. In addition, the Department also targeted establishing one occupational health service in one health facility in each of the Eastern Cape and Gauteng provinces. The target was achieved.
During the financial year the Department filled 435 posts in the Administration programme, 155 posts in the NHI programme, 123 posts in the HIV/AIDS and child health care programme, 100 posts in the PHC services programme, 281 posts in the Hospitals, Tertiary and Human Resources programme and 292 posts in the Health Regulation and Compliance Management programme.
The final appropriation for the programmes was R33.9 billion, with an actual expenditure of R33.155 billion. The Department spent only 97.8% of the final budget. The deviation was due to delays in negotiating additional funds for the South African Demographic and Health Survey and the processes involved in appointing General Practitioners in the National Health Insurance Pilot Districts. The printing of promotional material was not received from the supplier before the end of the year. The transfer payment to the Kidney Foundation could not be effected due to challenges with banking details. Other reasons for deviation were that although the compensation of employees and transfers was spent within the target norm, the contracts which were issued had not yet been rendered and there were incomplete infrastructure projects which are funded through Health Facility Infrastructure Indirect Grant.
The grants received by the DoH amounted to R30 380 282 and the amount spent by the Department was R30 296 953. The National Tertiary Services Grant spent by the provinces was R10 168 235, with no rollovers or adjustments. Four of the nine provinces spent the budget which was allocated to them. In addition, the Hospital Revitalisation Expenditure Grant, as per the DORA, was R5 239 981. Two provinces spent their entire budget, while two overspent and five provinces underspent their budget. The expenditure of the NHI for provinces, as per the DORA, was R70 000.
Key milestones were achieved during the financial year 2014/2015, in relation to the objectives and targets set by the National Department of Health. 63% of the targets for the year were fully achieved while 31% were partially achieved. Some of the challenges which the Department experienced would be addressed in the Department’s APP for 2015/2016.
Mr I Mosala (ANC) asked, in relation to revenue, what measures the Department had put in place to ensure that its revenue does not decrease. Noting the under expenditure on all programmes, he asked what measures the Department had to prevent this from happening again. The AG found that the Department’s supply chain and ICT was a concern, and there was no assurance as to whether the internal audit was working effectively, and he asked for an explanation of the irregular expenditure of R400 million.
Mr H Volmink (DA) asked what was being done to decrease the mortality rate in the country. He said that many clinics were being built in areas which did not have good roads and were just unsafe. He asked if, prior to building the clinics, the Department would carry out any inspections of the environments in which clinics were being built. He wanted to know the stage of development of the learning academy which was meant to provide skills of hospital management for Chief Executives. He also asked what the feasibility costs will be.
Dr H Chewane (EFF) said the Department did not have a decisive approach. He asked that the trend of pharmacies closing early should be addressed. He suggested that pharmacies should be opened around the clock. He asked if the DoH had the statistics of the people who made use of health facilities, and he raised the issue of the state of buildings belonging to public hospitals. He asked if the Department had a budget to revamp the old buildings.
Ms V James (DA) asked how the Department would improve issues relating to mental health services and educating the public about mental health issues.
Dr P Maesela (ANC) said when the Department addressed the issue of service delivery other factors such as staff members had to be addressed too. The Department of Health could not depend on the Department of Education to provide qualified nurses but must also try and help to improve the number of nurses in the hospitals and clinics. The Department should consider forming partnerships with the Department of Social Development also, to resolve the matter of malnutrition.
Mr A Mahlalela (ANC) said there was no correlation between the budget and the Department’s performance and he asked the Department to explain why this was so. He wondered how the Department was not able to pay the invoices within the requisite 30 days and yet at the end of the year show an underspend of R130 million. He said that 21% of the Department’s staff members had resigned and asked what measures the Department had taken to ensure that this problem did not occur again.
The Chairperson asked if the Department’s provincial probation had been monitored, and what challenges were incurred during the monitoring. She also asked for a breakdown of the cases relating to malnutrition and to also indicate in which provinces this was most prevalent.
Ms Matsoso replied that many people (around 2 000) had applied for the CEO positions in the hospitals but the problem was that they do not have the necessary skills to manage a hospital. One of the major issues with these applicants is that they struggled to understand medical data. She said the Department would investigate why pharmacies did not operate 24/7 and the utilisation rates of public health facilities will be made available to the Committee. The Department had met with the Nursing Council to discuss issues relating to staff and how best to retain and increase the number of staff members. In addition, DoH have also developed a website for Members of the Executive Council (MECs) so that they can know the status of their clinics. The training programmes have already started and some CEOs of the hospitals were currently undergoing training. She concluded that when the Department compiled the APP it could not always wait for the provinces to send their APPs, but it would wait for the AG's comment on the APP before it was tabled in Parliament.
Dr Yogan Pillay, Deputy Director General: HIV/AIDS Unit, DoH, said the Department would submit a report on the average mortality rates of mothers who died in hospital after giving birth. KwaZulu-Natal, Mpumalanga, Western Cape and the Northern Cape had reduced their mortality rates, but it was important to note that a number of things, such as level of education, also contributed to the mortality rates. The Free State, Limpopo and the Eastern Cape had the highest malnutrition rates in the country. The solution was to identify the children who were at risk, and the number of households.
Dr Jeanette Hunter, Deputy Director General: Primary Health Care, DoH, said that through the Minister’s and Director General’s leadership, the Department wanted to move away from having specific days which were dedicated to mental health issues; such as “mental health awareness days” and “mental health month”, because that created the impression that the issues were only important for that time. The Department had regular slots on community radios where it would have discussions about mental health issues and how to get treatment. In the last year, the Department had contracted the services of community theatre groups, who would go into communities and educate them about issues like depression, as a way of trying to de-stigmatise the illnesses. She admitted that the Department was not yet doing enough and the Director General would talk more about the interventions towards broader health issues. The aim would be to prevent mental illness, and to emphasise that if people felt that they were suffering, they should have access to mental health services. For this reason a strategy had been developed, and the Department had established mental health programmes in the different districts.
Dr Terence Carter, Deputy Director General: Hospital Services, DoH, said the Learning Academy had not yet been established. The DoH had hired Professor Jacobs to do the induction. DoH had realised that in order to run a hospital, very specific requirements were needed. It had been established that all the CEOs have a tertiary education, plus management skills. The Academy was very important especially since the Department had realised that the CEOs needed other necessary skills. There were some complexities linked to the Academy being able to operate effectively.
Dr Carter said that the main problem behind pharmacies not operating 24/7 was due to the fact that only large hospitals were able to provide that kind of service. It was important to note that there was also a shortage of pharmacists in the country. Another solution could be to consider other ways in which hospitals could make medication available for patients.
Dr Massoud Shaker, Head of Infrastructure and Facilities, DoH said that, in terms of the feasibility study and Public Private Partnership Projects (PPP), seven PPP projects had already been registered with the National Treasury. The projects had been allocated in the Dr George Mukhari Hospital, Nelson Mandela Academic Hospital, Mpumalanga and Tygerberg in the Western Cape. The PPP that was adopted by the National Treasury was regulated by Regulation 16 (Design, Construct and Operate). This regulation did not require much feasibility. The model cost component and feasibility study covered the design, construction, and what it could do in consultation with the National Treasury and DPSA as the implementing agent of the contractors. The DoH managed to ensure that about 50% of the capital and operation costs would go towards clinical operations. This would be handled by the State. The maintenance costs would be picked up by the private sector. This was the only feasible way to enforce the model adopted by the National Treasury. The cost component covered the financial part of the capital cost, the maintenance cost and operational cost and that was why it was so expensive.
The challenge would be that it would be difficult to design exactly what the client wanted in terms of services needed within the design hospital. The Chris Hani Baragwanath Hospital (CHBH) feasibility study was already initiated by the Gauteng Department of Health, and so was in a more advanced state, so the Department decided to use the feasibility study of the CHBH to construct the other hospitals. Although the value for money for the CHBH was 11%, it was still not affordable. After consultations with the National Treasury and the Development Bank of Southern Africa (DBSA), there was an agreement on a more affordable model, he Design and Construct model. This model allowed that the design be done under the supervision of the client, to make sure that the needs of the client were complied with. The Dr George Mukhari Hospital, the Limpopo, and King Libode Hospitals would still be constructed but the Department was still finalising the feasibility study.
Dr Hunter said that in 2010 the Department commissioned a health facilities audit because the Department was suspicious that health facilities were not up to standard. The results came out in 2012, which confirmed that primary healthcare facilities were not up to standard. The organisation that did the audit also took pictures of the facilities and the results indicated, at worst, that there were snakes entering the buildings through broken windows, or that trees were growing inside the buildings and through the ceilings. The system was overwhelmed with HIV, although earlier on, in the 1980s, the focus had been more on trying to tackle TB. The system was overwhelmed as there were more patients than staff could handle, and then the Department had not tried to increase staff numbers. The DoH met with four facilities in Tshwane who helped the Department by indicating areas in which the Department had to improve. In the process, it had developed a training programme, web-based software, where facilities can network and monitoring software.
Ms Tiny Rennie; Head of Corporate Services, DoH, said the 21% of staff who had left the Department did so for many reasons; some were wanting to explore other avenues, some left due to ill-health or early retirement. The 24 contracts which had expired were those of clerks, and since the majority of the clerks in the Department were not needed as permanent employees the Department had decided to terminate their contracts. Some Deputy Director Generals were still appointed on contracts, until they could be made Director Generals or until the posts of Director Generals can be filled.
Mr Ian van der Merwe, Chief Financial Officer, DoH, said the AG had done a ‘Going Concern Assessment of Departments’, in which the AG would assess whether a department was able to continue with its work over the year. A major concern was the overspending which influenced the measures by the AG. The Supply Chain Management was also a concern, and this was partially the conclusion reached because of the provinces that all have findings of irregular expenditure. The DoH had put in measures at administrative level. The issue of governance had to do with the internal audit which had not been performing the way it should, and this had been caused by the timing of the report and reliability of the report.
Speaking to the questions about irregular expenditure, Mr van der Merwe said that the Department had tremendous contact with the National Treasury and AG. Although the Division of Revenue Act (DORA) required the Department to transfer funds to the provinces, the Department transferred funds to healthcare, and that classed it as irregular expenditure. The Department looked at the accruals based on when the invoices were delivered, to assess the 30 days payment, and it would also look at work done but not yet invoiced. He explained that this would be where services were being delivered, but the invoices did not reach the Department within the prescribed 30 days. It was moving towards the accrual system, based on accounting which takes note of any work done but which has not yet been invoiced.
Mr Volmink said the DoH did not appear to have a functional organisation and asked if representatives could submit a report on issues of bottlenecks. The Minister recently launched a probe into the Health Professionals Council of South Africa (HPCSA), and the Committee would like to see the report, and also wanted to know when that report would be made available to the public. He pointed out that when the Department had irregular expenditure, it affected other areas of the Department, and asked who must be held responsible for the irregular expenditure.
Mr Mahlalela said the AG indicated that the problem lay mostly with the provinces and the concern is that there was not much monitoring of the provinces, and hence the information was not reliable. He said that the provinces had to plan properly. If contract staff members leave the Department, this would surely affect the output of the Department? If contract employees decide to leave tomorrow the Department’s vacancy rate would be 12% and not 6.6%. He asked how the Department defined accruals, saying that he held a different view. He believed that accruals are services rendered and the invoices which are issued, so it did not rely only on the services which are rendered. He added that in terms of the Public Finance Management Act (PFMA) if an invoice was not paid within 30 days it meant the Department had not complied with the law. The accrual could not be recorded if the invoice had not been received within 30 days. If people did not submit their invoices, then how would the Department determine whether the work had been done or not?
Ms Matsoso replied that the Department recommended that the Commissioner should come and report to the Committee. The Minister was still awaiting the inauguration of the new Council because the investigation took place during the inauguration during the appointment of the Council; the Minister would make a public announcement and address the Committee. The AG was still to address the Minster on all the findings of all the provinces and each province would indicate its plans on this issue.
Dr Gail Andrews, Chief Operations Officer, DoH, said the Department should ensure that all plans were aligned with provinces. There may be weaknesses in determining the indicators which are set to monitor the progress of provinces and the Department should work more closely with the provinces. The Department was implementing strategies which would help in ensuring better data quality to be available and captured in real-time. A visit to the provinces would be done to check on the quality of facilities and services. She noted that there had been issues relating to the capturing of data, and quality of information.
Miss Rennie said that Mr Mahlalela's calculations were correct. The Department would take the issue up with the Public Servants Association of South Africa (PSASA) because it had been recorded that the Department had a vacancy rate of 6%, and that was based on the information received from PERSAL.
Mr van der Merwe also said that the issue of accruals mentioned by Mr Mahlalela was correct. When moving away from cash basis of accounting to modified accruals, the accounts would then recognise services which had not yet been invoiced. For example, telephone and electricity accounts were often not invoiced for 30-40 days, but it was still possible to recognise that the expense had been incurred. Due to the fact that the Department had project management systems it was able to track the progress on projects and see to what extent there were invoices and accruals for specific days. There was better functionality within the accounting system for the system of accruals which the Department used, and it would at times make it difficult for the AG to verify, hence there was now a system which could verify whether the invoices had been calculated correctly.
The Chairperson said the shortage of staff needed to be addressed in all the levels of the health sector. The shortage of pharmacists was also affecting nurses because they claimed that the Department forced them to dispense medication when they were not qualified to do so.
The meeting was adjourned.