Compensation Commissioner for Occupational Diseases; Office of Health Standards Compliance; Department of Health on their 2016 Annual Performance Plans and budgets, in presence of Minister

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Health

07 April 2016
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Minister of Health was present for and participated in presentations by the Department of Health (DOH) and two of its entities on their Annual Performance Plan and budget for 2016/17. The first briefing was from the  Compensation Commission for Occupational Diseases (CCOD), which was set up to grant compensation to former miners. It had faced a challenging few years because of past mismanagement and inability to draw financial statements, which also adversely affected its ability to carry out its mandate, coupled with enormous difficulty in tracing claimants, huge backlogs and a system that had formerly only been set up to give compensation to white miners. The process of restoring the CCOD, which granted compensation to former miners, to effective functioning was under way; with the appointment of a new head. The financial record keeping was being corrected, with assistance from the Auditor-General and it should be in a position to submit accounts and an Annual Report to Parliament this year, although the point was made that it had been reporting monthly to the DOH all along. Another significant initiative was the reform of the legislation governing the operation of the CCOD. Up to now there had been a very fragmented system for compensation for occupational disease with a low rate of compensation for TB claims, despite the fact that this was the disease affecting most claimants. Many beneficiaries had been from outside South Africa, due to the migrant labour system. There was a challenge in recruiting professional staff as this particular expertise was in short supply. The DOH was rolling out one-stop centres for mineworkers with occupational diseases. Members emphasised their view that mining companies should make more financial contributions to the CCOD, as they had the financial capacity.

Members queried the low rate of payout of claims, and stressed the need for the CCOD to carry out more outreach activities to ensure that the public is aware of its activities was also highlighted. They questioned the backlog in compensating claimants, asked about possible conflicts of interest in committee members,and noted that the one-stop centres were a good idea but did not seem to be used. They wanted to know if anyone was being held accountable for the past shambolic state of the CCOD. They questioned whether certain equipment could not be at all mines, noted that hearing loss should also be addressed, and thought more funding was needed. There was discussion over whether mining communities and mineworkers should be treated differently, and the Minister made the point that some mining companies have good initiatives for workers’ treatment and health. The Minister also explained, in answer to questions, how a number of states were sharing information. It was noted that there were other facilities also offering services.

The Office for Health Standards Compliance (OHSC) said it aims to monitor and enforce compliance by health establishments with norms and standards prescribed by the Minister in relation to the national health system. It also aims to deal with patient and community complaints about poor health care services. It therefore intends to increase public and stakeholder awareness about its operations. As it has only begun operating separately from the Department of Health in 2015; it intends to set up a fully functional office in this financial year. To achieve compliance of health establishments with prescribed standards, it will ensure that inspections of health establishments are carried out at least every four years. An Ombud is also to be appointed to hear complaints about non-compliance with prescribed norms. Personnel costs will take up the bulk of the OHSC’s budget.

Members asked who was responsible for inspecting food sold in tuck shops, asked why the appointment of the CEO had taken so long, and why there had not yet been appointment of an Ombud. They were critical of the fact that so many targets were stated in annual terms, which made it very difficult for the Committee to oversee on a quarterly basis. Members also questioned the effectiveness of the OHSC since it will only carry out inspections every four years. Officials from the OHSC discussed the resource constraints that they are operating under and stated that the four-year period was the best they could do with available resources. Progress on the call centres was discussed.

The Department of Health (DOH) described its programmes and the significant features of the outcomes on these. There had been were significant expenditure cuts because of fiscal constraints but it was concerned about reductions in budget items for staff remuneration as National Treasury had given a ceiling on staff salary expenditure. The Department had been obliged to reduce its budget for the intake of medical students. HIV/AIDS and tuberculosis treatment and prevention, revitalising public health care facilities, and ensuring the provision of specialised tertiary hospital services take up. 

Members  asked how the objective of having unqualified audits in provinces would be achieved. They felt there should be more focus on TB, and questioned whether a committee could not be set up to deal with this. They asked about vaccine development for TB. Emergency treatment is a constitutional right but it is not fully enjoyed by many people in South Africa, and so the Members enquired whether the national department would be picking up shortfalls from the provinces. .The Minister agreed that the TB goals for 2030 would not be reached unless a vaccine was developed. Members asked what the Department was doing to expand mental health infrastructure especially for users of drugs such as wonga and nyaope, and said that secondary health care also needed expansion, and asked if a state pharmaceutical company would be developed. .They questioned status of the school health programme and involvement of the DOH, asked about the maternal and neonatal mortality rates. They wanted to know the extent of the DOH work with municipalities, questioned the current state of nursing training and the curriculum and asked about the physiotherapy pool in Natalspruit. A Member expressed the view that public hospitals should be more broadly used by even those holding medical aid, in order to allow extra funding to come to those hospitals, but the Minister said that this could be problematic although it was true that public hospitals did some fine work that was underrated.  They questioned the appointment of the CEO of the OHSC, and Ombud and discussed other outside sources of the funding for the Department, as well as why targets were drawn annually or quarterly. They questioned what DOH was doing to address outstanding invoices from suppliers,  and the problem of antibiotic resistance.
 

Meeting report

Compensation Commissioner for Occupational Diseases (CCOD) 2016 Annual Performance Plan and budget briefing
Dr Aaron Motsoaledi, Minister of Health, introduced the presentation on the Annual Performance Plan (APP) and budget for the Compensation Commissioner for Occupational Diseases (CCOD). He noted that the CCOD had had a turbulent history but was now on its way to functioning effectively. One of the problems that affected the CCOD in the past was that it had a large budget, but there were inadequate financial controls. The Auditor-General had refused to audit the CCOD’s financial records for three years because they were “in shambles”, but the situation was on its way to being normalised.

It had been challenging to find the right professionals to work for the CCOD because there are only 40 occupational disease specialists in South Africa; but the Department had finally obtained the services of Dr Barry Kistnasamy to head the CCOD.

The Department of Health (DOH or the Department) was currently preparing to submit proposals for amendment of the CCOD’s governing legislation to Parliament. One of the main problems to be rectified in the proposed amendment is the fragmentation of the compensation system. Compensation under the CCOD is less than that available under the Compensation for Occupational Injuries and Diseases Act (COIDA) administered by the Department of Labour. The Minister said all workers should be protected by the COIDA; or that there should be one law governing all workers’ compensation. A decision was taken some years ago to migrate the CCOD to the Department of Labour, but the Department of Labour refused to take it because it was in a bad state.

One of the main challenges in making the compensation payments had been that the Department is struggling to locate people who qualify for payment. The Department had established one stop centres (supported by the Global Fund) in labour sending areas to assess former and current mineworkers for qualifying ailments, commence treatment if the assessment shows that the worker has a qualifying ailment and to help affected workers to obtain compensation. There are two such centres in Carltonville and Mthatha, and two new centres are planned for 2016 - 2017 in Burgersfort and Kuruman.

Dr Barry Kistnasamy, Head of the CCOD, continued with the presentation. He said that the CCOD was experiencing difficulties recruiting professional staff (legal, actuarial and medical) because specialists are not prepared to work at public service salaries. He repeated that the CCOD also faces legacy challenges due to the mismanagement of the organisation in the past, and some claims have not been paid out to non-locatable claimants, many of whom were migrant labourers from Lesotho, Swaziland, Mozambique and other countries. The company responsible for recruiting mineworkers (TEDA) had been unwilling to share any information with the CCOD. In general, the rate of paying out claims declined markedly after 2000. This was attributed to the fact that before 1994, compensation from the CCOD was available only to white workers. The compensation scheme now covers workers of all races, but this means it is harder to pay out all deserving claims. Workers with TB make up 54% of claims, but the bulk of payments go to workers with silicosis.

The Minister made the point that this was another reason supporting his argument to merge the CCOD compensation system with that of COIDA.  TB affects many workers, yet compensation levels for it are set low by the legislation regulating the CCOD.

Dr Kistnasamy continued that other challenges in paying claims were related to lack of ID details of claimants and  identified claimants not having bank accounts, because CCOD could only pay into accounts.

or the 2016 – 2017 financial year, the CCOD is targeting the integration of payment systems by reforming the policy and legislative framework. The CCOD is working jointly with the Departments of Health, Labour and Mineral Resources to achieve this. It is also aiming to set up a Legacy Fund to cover compensation for loss of income, as well as a Care Fund to cover compensation for medical expenses. It is negotiating with the mining industry for the mobilisation of funding. Another target is to increase access to medical examinations. Some of the measures  to achieve this target include training of health personnel on diagnosing occupational health diseases, rolling out mobile testing facilities and establishing certification committees.  Although the CCOD last submitted its financial statements to the Portfolio Committee in 2009, it is now preparing financial statements that it intends to submit to the Auditor General in September 2016.

Discussion
Mr H Volmink (DA) asked about the backlog in compensating claimants. What was the turnaround time from an application for compensation to completion of the compensation process, and what is the ideal turnaround time in order for a significant dent to be made in the backlog? On the matter of the certification committees that were being set up, he asked whether there were any safeguards in place to prevent conflicts of interest arising on the part of the committee members, since some of them would be medical professionals who may have ties to mining companies. Referring to slide 11 of the presentation, he said it was unacceptable that the rate of payment of claims had decreased so sharply and that someone had to account for it. He questioned the reason for the high management staff turnover experienced by the CCOD. The establishment of one-stop centres was laudable, but he had been concerned to see that there were no people using such a centre when he visited. He asked what was the ultimate goal of harmonising the legislation that governs the CCOD? Who was responsible for the shambolic state that the CCOD had been in and were any measures taken to hold anyone accountable?

The Minister responded that the CCOD faced significant legacy challenges and that this had a negative effect on its performance. Some files go back to the 1960s and clearing this backlog was difficult. There was no drop in performance, as slide 11 seemed to suggest,  but statistics are now being recorded on an annual basis so it appears there is less performance compared to the pre-1990s days, when information was recorded at 20 year intervals. Despite the lack of people utilising the one stop centre on the day of the Member’s visit; the Department’s statistics showed that people are using the centres. It is important to remember that the centres are new, and that these are not the only intervention directed at occupational diseases. The centres are only meant to increase access to healthcare services and information on compensation for occupational diseases for mineworkers and former mineworkers. There was a need for a new law to harmonise the COIDA and the CCOD, and the new legislation would address the current fragmentation. The shambolic former state of the CCOD was symptomatic of and encouraged corruption, stealing and mismanagement. Low payment rates resulted from claimants not coming forward or being difficult to trace. The people responsible for the mismanagement of the CCOD had since left the civil service and could not be held accountable unless criminal processes were initiated. CCOD preferred to focus on the future, rather than expending resources on past issues.

An official from the CCOD assured the Member that doctors on certification committees are not in a situation of conflict of interests, because the certification committees are made up of doctors from different private and public practices.

Mr P Maesela (ANC) stated that it was important that mining companies should pay for compensation costs for mineworkers with occupational diseases. He asked why the machine that is used to perform TB screening for mineworkers in a few sites was not used in all mines, to make the screening process more efficient.

The Minister replied that the machine is not a screening tool but a diagnostic tool. It is very expensive and for this reason it cannot be put in every mine.

Dr W James (DA) stated that hearing loss on the part of mineworkers is also a serious concern, especially among machinists. Machinists tend to be Shangaan speakers from Mozambique. It would be difficult to track these workers because many of them have returned to their country of origin.

The Minister answered that the Department intended that audiology equipment should to be present in one-stop centres.

Dr Kistnasamy responded that hearing loss was covered by COIDA.

Ms D Senokoanyane (ANC) recalled the harshness of the migrant labour system and how little concern there was for the health and welfare of mineworkers. She commended the CCOD on its work and acknowledged the challenges it faced, such as the fact that some potential beneficiaries had died and the difficulties of tracking those who are still alive. She asked what the current status of occupational diseases such as TB is. She agreed that the Commission needed more funding; there is plenty of money in the private sector and it had the capacity to provide more funding to the CCOD. The country as a whole was struggling to control TB; so more widespread screening could make a big contribution in curbing the spread of the disease.

The Minister replied that occupational diseases are still a big problem. In general, people are not taking TB seriously enough. There is a focus on other infectious diseases, yet TB is a very big problem in South Africa.

Dr H Chewane (EFF) welcomed the report by the CCOD, and encouraged it to report more regularly, whatever its constraints. He urged all relevant stakeholders to mitigate the condition of mineworkers, especially on occupational health issues. In the past; mining companies had hospitals directed at mining employees. He recommended that mining communities should be treated differently from mineworkers, meaning separate facilities for each. He pointed out that mineworkers are prone to multidrug resistant (MDR) TB, a more severe strain. Mining houses should be encouraged to take proper traceable details of workers upon recruitment, to prevent tracking challenges. He said he was not convinced that mining houses are doing enough. He agreed that the fiscus should not be strained further to fund the CCOD’s work when mining houses had deep pockets.

The Minister answered that the Department’s policy was not to separate mineworkers from the community. Some mining companies have good initiatives for workers’ treatment and health. However, TB is a ‘community disease’, due to its nature as an airborne disease. The Department has therefore asked mines to extend the healthcare services they provide to their miners, also to the communities. He gave the example of healthcare services in Carltonville that were sponsored by mines. The Department had advocated for access to be expanded to surrounding communities because miners with TB could spread the disease to the communities. Some of the districts with the highest TB prevalence rates were not gold mining areas, which showed that the disease had migrated with the miners. It is important to have treatment facilities open to all communities and not to have initiatives that solely target mining areas and mineworkers. It is also important to integrate TB treatments into the community. The old approach to treatment worked by isolating people who were on treatment and this led to the stigmatisation of people infected with TB. It is better to have an approach that keeps people who are on treatment integrated in their communities.

Dr Kistnasamy replied that the CCOD is getting support from the Chamber of Mines on the issue of tracking and tracing potential beneficiaries. The people who were most difficult to trace are ‘people operating under the economic radar’ - people who are not registered for RICA and/or FICA.

Mr A Mahlalela (ANC) asked what the correlation was between slides 17 and 19 on the issue of non-performance caused by staff shortages. What is the value of the CCOD presenting an annual performance plan if it will not produce annual reports? This is the third APP being presented by the CCOD, yet it has not produced a report to the Committee. The CCOD cannot draw Annual Reports because it has no financial statements to include it such reports, according to the National Treasury (NT) guidelines.  Annual reports are very important because they allow for an organisation’s performance to be measured.

He also asked to what extent are one stop centres being used, and are they accessible especially to people in rural areas. How can the CCOD’s activities be enhanced in terms of outreach so people can know about the centres and be able to access them, taking into account the CCOD's resource constraints? He asked if efforts have been made to engage potential beneficiaries in neighbouring countries.

The Minister responded that a SADC conference had been organised to handle the issue of the compensation of migrant labourers from across the region. Ministers for health, mining, labour and finance from the region attended this meeting. The meeting resolved to establish a common database of people who acquired TB in mines in South Africa, and to create a unified treatment strategy across the countries. Funding for these outcomes was obtained from the Global Fund. The International Organisation for Migration had also indicated interest in the meeting’s outcomes.

The Minister stated that the one stop centres  are open to mineworkers and former mineworkers only. This is because other community members have access to normal public healthcare facilities, and if they are allowed access to one stop centres there will be undue strain on the centres.

Dr Kistnasamy accepted that the CCOD had not reported to the Committee for some years but said that it did submit monthly reports to the Department of Health. The CCOD is open to presenting to the Committee as often as the Committee wishes, despite the absence of financial statements. A major obstacle to preparing financial statements in the past has been the lack of independent auditors willing to audit the CCOD’s financial records, but this is being rectified. He explained the discrepancy between slides 17 and 19 by saying that there was a lack of professional staff such as legal and analytical professionals. Slide 19 showed administrative staff who generally only have matric. The CCOD is working on narrowing this gap.

Ms C Ndaba (ANC) stated that the statistics presented showed that payments have been made to a small number of potential beneficiaries. The problem is that of outreach and she wondered if there should not be more use of the media to promote awareness of the CCOD’s work.

The Chairperson stated that there were high levels of corruption in the tracing process. Some people were claiming to be former mineworkers but were in fact not former workers, and were therefore not entitled to benefit from the CCOD. She asked if there was any process to ensure that doctors who diagnose occupational diseases have sufficient knowledge to refer people to the CCOD? She agreed that the additional funds required for the CCOD to function optimally should come from mining houses and not from the fiscus. There were limited one stop centres and poor people will have to travel long distances to reach them. She too had been part of a visit to a one-stop centre that had no patients using it at the time of the visit.

The Minister replied that although there were few one stop centres this was an improvement on the past, when all potential beneficiaries had to travel to Braamfontein for the services that are now being provided by the one stop centres. He reiterated that one stop centres are not the only medical facilities run by the Department for this purpose; there are a number of other medical facilities that provide these services.

Office of Health Standards Compliance (OHSC) 2016 Annual Performance Plan and budget briefing
Mr Bafana Msibi, Acting Chief Executive Officer, Office of Health Standards Compliance, presented the organisation’s APP and budget. Programme 1 covered the Office of the CEO. Some of the strategic objectives under this programme are to create stakeholder awareness of the OHSC, to certify healthcare facilities found to be in compliance with relevant standards and to carry out enforcement action against non-compliant medical institutions. Programme 2: Corporate Services intended to ensure that a fully functional office is set up for the OHSC, as it operated from the Department of Health until 2015. It also aims to comply with the Public Finance Management Act by obtaining an unqualified audit report. Programme 3: Compliance Inspectorate covered the inspections of regulated healthcare institutions that are to be carried out at least every four years, and inspectors are to be trained and accredited. Under Programme 4: Complaints management and Ombud, an accessible mechanism to lodge complaints with the OHSC is to be set up, the Ombud’s recommendations are to be monitored and complaints on non-compliance by health establishments with applicable standards are to be effectively resolved. Programme 5 dealt with health standards design, analysis and support. This programme’s strategic objectives for 2016/17 included the registration of regulated health establishments for monitoring and inspection purposes, and the development of norms and standards for submission to the Minister for promulgation.

The OHSC has a budget of R88.9 million for 2016/17. Personnel costs are the highest cost element, due to the nature of the OHSC’s work. For the 2016/17 financial year; staff costs will take 62% of the OHSC’s budget, rising to 67% for the 2017/18 year, and then to 73% for 2018/19. 63% of the budget is allocated to core operations such as compliance inspections, complaints management and standards design.

Discussion
Ms C Ndaba (ANC) commended the report and the work that the OHSC is doing. She asked who is responsible for inspecting food sold in tuck-shops. In her constituency, there have been some issues with people from Pakistan allegedly selling poisonous food that led to fatalities.

An official from the OHSC replied that inspections for food safety are the responsibility of environmental health inspectorates which fall under local government, not the OHSC.

Mr Mahlalela asked why the CEO’s appointment has not been prioritised and how long it will take the Board and the Minister to finalise this issue. He also asked about the appointment of an Ombud, since last year the Committee had been told it would be done, but no indication was given in today’s presentation of the timeframe for this. The legislation governing the OHSC states that the Minister can appoint someone to act as an Ombud pending appointment of a substantive Ombud and he asked why this had not been done? Considering that there is no Ombud, he asked what the rationale was for putting indicators in the APP that pertain to the Ombud’s office, for he feared that in a year's time the OHSC would say that the target has not been achieved because there is no Ombud.

Mr Mahlalela criticised the quarterly targets included in the presentation, pointing out that  about 70% are annualised, meaning that the OHSC cannot report to the Committee on a quarterly basis if the Committee desires. The Committee is obliged to wait until end of year for a report, although it is entitled to exercise oversight on a quarterly basis. Annualised targets are not easy to measure in terms of tracking performance. He asked that the information on personnel under Programme 2 of the presentation be correlated to that on page 41 of the presentation, as the relationship between these two was unclear.

Mr Msibi replied that it was not for lack of trying that the OHSC did not have a substantive CEO. The OHSC had advertised the vacancy and after carrying out recruitment procedures, had recommended a candidate to the Minister in July 2015. The Department had not concurred with the choice of candidate and so the recruitment process had been re-initiated. There had been no successful candidates at this second round. Some of the individuals did not have good recommendations and had left former organisations on bad terms. There had been progress on the appointment of an Ombud. The Minister had identified someone but the process to appoint them, which involved the National Treasury, was still under way. He noted the issue of annualised targets and stated that this would be rectified in the next  APP. The OHSC is still in its infant stage and therefore, is still learning. However, the OHSC reports to National Treasury and to the Department of Health on a quarterly basis. Some targets were annualised because for example, the Auditor-General carries out audits once a year.

Mr Maesela asked about the staff complement taking up the bulk of the OHSC’s budget, and wondered if the personnel would be able to  cover all health establishments on a yearly basis. He also asked who will carry out the function of adjudication of conflicts of standards since an Ombud had not been appointed yet. He suggested that it would be more economical for the OHSC to settle in one place rather than to move from one office to another, as had been the case.

Mr Msibi replied that the OHSC intended to find its own premises, from which to operate. It had initially been housed at the Department of Health, but had now engaged the National Treasury and Department of Public Works  because obtaining premises was quite a large financial commitment. The OHSC wants to stay on the right side of leasing and procurement laws. The OHSC will cover more health facilities if it gets more funding. The current coverage is based on available resources.

Ms Senokoanyanesought clarity on funded staff appointments, asking why this was at 90% and not 100%, as she would have expected. She  also asked about why the OHSC was aiming for “unqualified” audits and not “clean” audits. She enquired about the status of call centres and whether this would be revised. The manner in which strategic targets was expressed in the presentation was confusing as in some places they are cumulative (such as page 16) but in others they were totalled. 

Mr Msibi replied that the OHSC had initiated a tender process for the call centres, for which the offers were being evaluated. In terms of this tender; the operation of the call centre would be outsourced for three years, following which the call centre would be run as a lease. The ultimate goal was for the OHSC itself to run the call centre . Tenders are being evaluated. It was hoping to conclude the tender process in two weeks from now. On the staff complement he explained that  during the year there would probably be staff turnover. The figure in the report was a minimum and OHSC did not intend to fall below that. OHSC is aiming for a clean audit gradually.

Mr Volmink referred to the second point on slide 11  on enforcement action, saying the the target of 100% was predicated on promulgation of regulations. This is not something within the OHSC’s control so he felt that it was not appropriate to call it a target. He wondered if targeting a 20% increase for staff establishment was realistic. He asked if the four -year cycle for assessments of health facilities, as mentioned on slide 21, was not too long. Slide 27 mentioned call centres and he pointed out that although this would carry huge costs, the budget did not show a line item for setting up a call centre.

Mr Msibi responded that the call centre was budgeted for under the ‘complaints management’ item in the budget. The regulations were close to being finalised. The OHSC had comments from the State Law Advisors, who recommended minor changes to the regulations. The OHSC’s Board would finalise the regulations soon and send them to the Minister.

The Chairperson emphasised that the OHSC should use the media to promote its work, so that people would become aware of it and exercise their rights. She agreed with Mr Mahlalela on the annualisation of targets; stating that this hampered the Committee’s ability to conduct oversight more frequently.

Department of Health (DOH) 2016 Annual Performance Plan and budget
Ms Malebona Matsoso, Director General, Department of Health, presented the Department’s Annual Performance Plan for 2016 – 2017.

She took the Committee briefly through the programmes and their targets. Programme 1 is support services. The target is to increase the number of provincial unqualified audits because this had been an issue in the past. The Department would also like to maintain its vacancy rate for this financial year at 5%.

Programme 2 deals with National Health Insurance (NHI) planning and systems enablement. A White Paper on the NHI is currently out for comment and is open until the end of May. Public consultations are also being held. For the next financial year, the Department is working on a draft bill as soon as the White Paper is adopted as policy. The Department is targeting reducing incidences of medication stocks running out. One of the ways in which this will be done is the introduction of an electronic stock management system, as well as the intended handover of the Department’s procurement functions to National Treasury. The Department also intends to regulate traditional medicines and to this end has held road shows and consulted different stakeholders. It will appoint a registrar and staff to regulate traditional healers.

Another indicator under this programme is the implementation of a number of international treaties. The United Nations has reviewed treaties on drugs and substance abuse to reflect a greater concern for drug users and to avoid penalising them. The Department has a position paper for discussion and consultation within South Africa on this issue. At African Union level, there is a treaty on local production of pharmaceuticals, and establishment of an African Centre for Disease Control.

Programme 3 relates to HIV, TB, Maternal and Child Health. This programme targets (among others) the reduction of the neo-natal mortality rate, increased access to reproductive health treatment and facilities especially to increase cervical cancer screening access and provision of the HPV vaccine to protect young female learners. It aims to lower child deaths from diarrhoea, pneumonia and measles. The Department intends to lower the death rate from MDR TB to 12 %. On HIV, the target is to maintain the number of people being tested for HIV (at 10 million) and to increase the number of men undergoing circumcision as a preventative measure. The Department has also identified high transmission districts in order to craft targeted and specific interventions. There will be training on cervical cancer for health professionals, and breast cancer treatment guidelines as part of women’s health. The Department has also come up with a broad policy on treating the different types of cancer in general. The Department is looking at options in terms of TRIPS flexibilities for women who need access to medications that prevent cancer.

Programme 4 is on primary healthcare. The Department will continue with cataract surgery activities. It is also working on the elimination of malaria. Seven out of nine malaria districts should report within 24 hours to avoid the risk of cerebral malaria. She highlighted some districts are failing, especially in the Limpopo Sekhukhune area. The Department has a rating system for primary health care facilities to motivate staff. It will conduct a campaign on hand washing which has been proven to lower the incidence of some infections. The Department will ensure that Port Health authorities comply with relevant standards. It also intends to reduce the incidence of non-communicable diseases, especially diabetes. In collaboration with the Department of Basic Education, the Department of Health is developing nutritional guidelines for children. In regard to influenza, the Department is targeting high-risk individuals to drive vaccinations. It intends to release regulations for public comment on organ transplants. In addition, regulations for dialysis are being drafted.

Programme 5 is on hospital, tertiary health services and human resources development. Under this, the Department is planning to bring 26 hospitals into compliance with national standards. Mental health services are to be set up at eight district and two regional hospitals. The Department aims to complete the nursing and midwifery curriculum, in preparation for nursing to be part of higher education. A compliance checklist for provinces for emergency medical services (EMS) is planned. Additionally, a checklist of education and training for EMS personnel and regulations for emergency care centres will be drafted and adopted in this financial year. Health regulations have been created for mass gatherings.

Programme 6 relates to health regulations and compliance management. The Department has created a governance model on monitoring performance of the different entities that fall within its mandate. The model covers human resources management, compliance, board member performance and procurement. The Department also intends that vacancies should be filled timeously.

Mr Ian van der Merwe, Chief Financial Officer, Department of Health, presented the budget. There were significant expenditure cuts because of fiscal constraints. The Department has cut back significantly on travel and catering expenses, and, for example, only essential staff will attend the Portfolio Committee meeting. The Department’s budget had been reduced by about R386 million for 2016 – 2017. The Department was concerned about reductions in budget items for staff remuneration as National Treasury had given a ceiling on staff salary expenditure. The Department had been obliged to reduce its budget for the intake of medical students. HIV/AIDS and tuberculosis treatment and prevention, revitalising public health care facilities, and ensuring the provision of specialised tertiary hospital services take up 85.1      % (R109      billion) of the department’s total budget over the MTEF      period. R4,5 billion was allocated to the NHI programme over the MTEF period.

Discussion
Mr Volmink made reference to programme 1 on slide 6, and asked how the objective of having unqualified audits in provinces would be achieved. Commenting on the goal for eliminating TB by 2020,he stated that there should be a focal point around TB. The current approach appears to be fragmented. He asked whether something similar to the South African National AIDS Council (SANAC) could not be set up for TB, and said that the key to fighting TB is prevention. The role of SANAC could surely be expanded so that it performs this function under Programme 3. He asked about vaccine development for TB. He asked about compliance under Programme 4 to ensure that medical facilities provide quality services. Under Programme 5 he pointed out that  emergency treatment is a constitutional right but it is not fully enjoyed by many people in South Africa. Although the provision of EMS is a provincial competence, provinces give very low budget allocations to EMS, and he wondered if this did not put pressure on national government to fill the funding gap. The presentation showed that the Department’s budget provided for staff remuneration would increase by slightly over 1%, and he wondered if wages should not be increased in a manner that keeps up with inflation.

The Minister replied that the co-infection rate between HIV and TB was very high. The Department had therefore been of the opinion that TB should be brought under SANAC, but it had encountered resistance to this idea. However, in effect, TB is being covered by SANAC’s operations. The Department considers vaccine development to be a missing part in the fight against TB. Within the Stop TB initiative, South Africa was lobbying international donors on this issue. The goal for 2030 on TB prevention would not be met without the development of a vaccine.

Ms Matsoso replied that in the last year, three provinces got unqualified audits, but two of these were close to getting clean audits. This was an aspirational goal and the Department wants to work in partnership to achieve good audit outcomes. The Department has started looking at how to develop TB vaccines and to enhance diagnostic tools. On the EMS question, she said that each province should be reporting on this to the Department. She acknowledged that access to EMS was a constitutional issue and stated that the Department was working with the SA Human Rights Commission to assess the status of each province in terms of EMS. The Department had hoped to provide a large amount of funding to EMS colleges (R680 million) for training, to ensure EMS personnel were of the requisite standard, but this will have to be reduced because of fiscal constraints.

Dr Chewane asked what concrete steps the Department is taking to expand mental health infrastructure especially for users of drugs such as wonga and nyaope. He commended the Department for expanding primary health care, but asked what the Department was doing on secondary health care, which also needed to be expanded. He asked what progress had been made with establishing a state pharmaceutical company. It would be good to stop outsourcing these services.

The Minister answered that the state pharmaceutical company fell under the Department of Science and Technology. This was done to avoid the conflict of interest if the Department of Health was acting as both a buyer and consumer.

Ms Matsoso replied that the mental health of drug users has become a priority area internationally. The international consensus is that the war on drugs has failed and a different approach is needed. The Department is looking at how it can accommodate this changed perspective within its practices and policies. She agreed with Dr Chewane that the Department was focusing on primary healthcare services, but stated that there is a plan for expanding tertiary healthcare services and institutions.  The Department has done an analysis and made recommendations, which were meant to be implemented in 2014 but should start soon.

Mr Maesela asked about the status of the school health programme, especially for learners with hearing and vision problems. He raised the issue of corruption in the school feeding programme  with some service providers supplying sub-standard food to scholars. He asked why the maternity mortality rate was not decreasing more, and why the neonatal mortality rate is stable and is not decreasing.

The Minister responded that the DOH is only responsible only for drawing up the menu for the school-feeding programme. He acknowledged the corruption around the programme and stated that to his knowledge, only the Northern Cape had a well functioning programme. The Minister believed that the tender process led to corruption and profit seeking. This was immoral, considering that for some children, this was their only decent meal of the day. The Northern Cape managed to have a well-run programme because parents were strongly involved in running the programme.

Ms Matsoso answered that the majority of services for learners with hearing and vision problems were in the private sector. However, the Department intended to initiate a programme to ensure that children in need had access to such services. On the question of the maternal mortality rate; she stated that it was hard to have absolute numbers such as reaching zero deaths. The goal was always to keep reducing.

Mr D Khosa (ANC) asked whether the Department was planning to work together with municipalities on health standards, because municipalities have limited capacity. Referring to slide 6, he questioned why the Department was aiming for unqualified audits and not clean audits.

The Minister said that only the national Department, Limpopo, the Western Cape and North West provincial departments have been getting unqualified audits. Limpopo was the most recent addition to this group of entities obtaining unqualified audits. This had been achieved by carrying out personnel changes.

Ms Matsoso replied that when the National Health Act was amended, some functions had been delegated to municipalities and food standards inspection was one.  The Department was looking into assisting municipalities as far as possible.

Ms Ndaba asked about nursing training and the curriculum. She also asked about the status of the construction of a physiotherapy pool in a hospital in Natalspruit under the Department’s infrastructure development targets.

Ms Matsoso replied that a pilot training programme for nurse training had been started in some institutions. The programme would be rolled out in this financial year. It was important to remember that in the new system, everyone who qualifies as a nurse should have their qualification recognised as part of higher education although nurses would still be trained in colleges. The level of training had been raised but the Department did not want to miss out on clinical/bedside training. This must still be maintained but the nursing qualification should be recognised in the way that other higher learning qualifications are recognised. A report had been prepared on the physiotherapy pool and would be shared with Ms Ndaba.

Dr James stated that it was evident that there was a funding gap for healthcare. This was particularly so for the access of women and children to healthcare and men tended to go to hospital when it is too late. He suggested that tax incentives be given to primary healthcare services. There is need to audit all public and private healthcare facilities in the country and their quality, which was higher at some public facilities than at private ones. He gave the example of Groote Schuur Hospital and kidney transplants. Doing this would allow medical aid members to access public health care, and in that way public healthcare could receive funding from medical aid. There is also need for a special national grant so that hospitals can apply for additional money for maternal and paediatric services to fill the funding gap.

The Minister agreed strongly with Dr James on the issue of tax incentives. This had been proposed to National Treasury. He stated that some people with medical aid do go to public hospitals, but do not claim this money from medical aid. It could, however, be problematic to allow people on medical aid to access  public healthcare. In the past, there had been differential treatment of people in hospitals, based on whether they are on medical aid or whether they are not and those who are not tend to be prejudiced. Negative perceptions on public hospitals remained but they did do some good work and are highly underrated. He gave the example of the cardiology unit at Steve Biko Hospital, that has a mortality rate of 1%.

Mr Mahlalela asked how the Department could justify the increase in indicators in its APP with spending cuts. Annualisation of indicators is a problem from an oversight perspective, especially for programmes 4 and 5 where most of the indicators had been annualised. The Department should indicate the number of bills it intends to submit to Parliament this year.

He asked the Minister about the status of the appointment of a CEO and Ombud for the OHSC. How would quality of services in the OHSC be achieved? Referring to page 28 of the presentation on ward based primary health care teams; he asked whether the word ‘additional’ meant that new members had been added to community health teams.

The Minister replied that he is not responsible for choosing the CEO of the OHSC; it is the OHSC that must choose but in consultation with the Minister. He was not happy with the quality of candidates thus far in the selection process. The Minister stated that he was responsible for choosing an Ombud, but in concurrence with the Finance Minister. He was of the view that the Ombud should be a person with a medical background due to the nature of the functions that the Ombud must perform, although the former Minister of Finance had wanted a retired judge to act as an Ombud. After finally reaching agreement on this point with former Finance Minister Nene, Mr Nene had been removed from his post, and the new Minister of Finance, Mr Pravin Gordhan, had sent a letter last week approving the appointment of an Ombud. In relation to improving the OHSC’s quality of services, he said that the National Development Plan diagnosed two problems facing the South African healthcare system. The first is exorbitant fees charged by private healthcare providers. The second is poor quality of services in public healthcare facilities. The Department checked the causes of poor quality of services in public healthcare, and found four problems: human resources, financial management procurement challenges and infrastructure delivery and maintenance. If these four problems were solved, the quality of public healthcare can be resolved. He stated that the programme on community health workers had the potential to be a game changer in terms of providing community healthcare.

Ms Matsoso replied that the OHSC had reported significant improvements in the Department’s healthcare facilities. The funds from National Treasury are not the Department’s only source of funding. Development aid from development partners such as the EU, Global Fund and PEPFAR played a role in funding some of the Department’s initiatives. The Department had the ability to decide on how to spend these funds without being dictated to by the donors. Although this amounted to only about 2% of the Department’s budget, it still adds up to a significant amount. This explains the fact that the Department has increased its indicators, despite receiving reduced funding from National Treasury. The Department had engaged with the South African Law Reform Commission to review all the legislation that falls within its mandate. The Department could share the Law Reform Commission’s very useful report with the Committee. On the annualisation of targets, she stated that indicators have three levels; structural indicators, process indicators and outcome indicators. In writing the MTEF and strategic plan, outcome indicators – such as those for mortality - cannot be considered on a quarterly basis, because they measured health and economic development and must be annualised. However, the discussion was around the milestones. Structural and process indicators could be quarterly.

The Chairperson, referred to page 17, Programme 2, on monitoring supplier performance. She had been told that  the Gauteng Department of Health owed suppliers a large sum of money, and she asked what was being done about this. She also asked about the problem of antibiotic resistance caused by the large volume of antibiotics being consumed in South Africa. She asked about the side effects of the drug Ritalin that was prescribed to children with attention deficit disorders.

The Minister responded that Ritalin was necessary at times. He acknowledged the possibility of side effects, but stated that doctors only prescribed medication after considering that the potential benefits outweigh the potential risks of taking the medication.

Ms Matsoso replied that the Department had developed a tool on monitoring supplier performance. She had taken it upon herself to write to different heads of department to notify them about not paying suppliers within 30 days, as this was unfair and negatively affected the cash flow, causing some to close down.  The technical NHC was also being used for heads of department to account for payments to suppliers. She urged the Committee to champion the cause for antimicrobial resistance to antibiotics. In other countries, the issue was taken so seriously that Heads of State dealt with it. The issue will also be discussed at the UN General Assembly.

The meeting was adjourned.

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