Minister of Health on his Department 3rd Quarter 2015/16 performance

Standing Committee on Appropriations

03 May 2016
Chairperson: Mr N Gcwabaza (ANC)
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Meeting Summary

Minister of Health Aaron Motsoaledi said maintenance of infrastructure was very important. He suggested the current ratio of 25% spent on maintenance and 25% on refurbishment should be further changed to 30% for maintenance and 20% for refurbishment to cover the maintenance backlogs. It had been a battle dealing with the Department of Public Works (DPW) over the delivery of new infrastructure such as hospitals. He noted that there was no law that said DPW had to be used, however the provincial DPW felt that the DPW had to be used. He questioned why other capable state agents who had the capacity could not be used.

The Minister said that the number of doctors required at hospitals was drawn from the World Health Organisation (WHO) doctor per population ratios. However, WHO had found the formula to be meaningless as it did not reflect the needs of people. WHO had formulated a new method to determine requirements, the Workload Indicator of Staffing Needs (WISN). Differing communities had different needs such as the difference between rural and urban areas, however provincial organograms were still based on the old ratio approach. WISN was being implemented and had been completed in all primary heath care facilities. It was not implemented yet at central hospitals and was very complex.

The Minister said expenditure was low on the National Health Insurance (NHI) because the budget was for a pilot project where people had access to GPs via a clinic. Initial contracting of GPs had been slow due to their reluctance to contract as they questioned repayment times. Also many GPs were contracted at hospitals and were reluctant to go to clinics and because the NHI contract monies were regarded as too little. Contracting had since picked up.

The Minister said that Cabinet had decided that late payment of invoices would be a punishable offence, and there would be consequences. The National Department was not guilty of this practice but it was not easy to monitor where money was transferred to other tiers to pay service providers. In one instance NDOH had even paid the service provider directly, circumventing the province. NDOH had written letters to explain why it had done so, yet the Auditor-General had reported it as R300m in irregular expenditure. Treasury said that the Department, in addition to writing the letters, had to gazette the matter.

 

On whether to focus on the basics as opposed to state of the art technology, the Minister said that it was not an either/or type question. The issue had been discussed at Davos. One could not build developing countries without good health systems so there was a need to leapfrog by using technology, new business and services systems and influencing behavioural change. Preventative medicine was better than curative medicine. Technology was not to be regarded as something fancy but as a basic necessity.

The Minister said Mahatma Ghandi Hospital had an outbreak of Klebsiella which is a hospital borne infection which occurred naturally. The problem was when it breached the barriers and entered into the bloodstream. There had been a breakout in 2005 and babies had died. The infection at Mahatma Ghandi Hospital had been successfully treated but some politicians had sought to use the matter to their advantage in the media.

The Department briefing covered the spending performance on all conditional grants, the service delivery implications of slow spending, the challenges and remedial actions for health care waste management and health care information systems and its response to the Committee’s previous recommendations.

Members appreciated the progress of the NHI but were concerned by the low expenditure rate. What were the key drivers of the low expenditure rate and which provinces contributed towards the low expenditure rate? What was the expenditure at the end of the 4th quarter? Why was the Health Facility Revitalisation Component (HFRC) at 40.8% expenditure, so low? Late payments were still an issue despite the President saying many times that payments must be made timeously. Were there consequences for those who did not make the payments on time? Members noted that there was low expenditure on TB and HIV programmes. Members said that outsourcing of work could be expensive and the issue of job creation had to be taken into account.

Members said there was a need to consider and review conditional grants because the Financial and Fiscal Commission (FFC) had raised this in its report. Members noted that the Department had met with Treasury, but that it needed to meet with the FFC. Did the Department meet with the Minister of Public Works? On vacant posts, members asked if there was a time frame for the completion of the Workload Indicator of Staffing Needs (WISN). Members asked if the matter regarding the Auditor-General report and its concerns around the distribution of ARVs had been sorted out. How far was the Department in linking healthcare facilities through IT infrastructure.

Members said the financial figures were a matter of concern as all the spending appeared to occur in the last quarter. Members wanted verification that it was actual spend and not a forecast. Members said it was scary to see that one of the challenges of late payment was that late payment of services could be life threatening such as the late payment for Healthcare Waste disposal. When would the patient registry process be completed. When would the broadband challenges be resolved? What was the progress on appointing inspectors to hospitals as previously announced by the Minister and could the Committee get a report if there were any reports by the inspectors? Members said the hospitals in the country were in a poor state, especially in the Eastern Cape where people were sleeping on the floor.

Members said the Auditor-General’s report noted a lack of consequence for poor performance and transgressions, a slow response by political leadership and senior management in addressing the root causes of poor audit outcomes and vacancies in key positions. The Minister had said the Department would contract these positions. What has been put in place to address these root causes and how would the Department contract regarding male circumcisions? Which provinces were responsible for the slow spending on HIV/AIDS, TB, the NHI and on hospitals. People could not get condoms because of the delay in the rollout of condoms because the specifications had changed and this was infringing on peoples rights to have safe sex. What actions had been put in place about the slow spending? Members wanted timeframes to be assigned to the remedial actions in slide 7. When would the waste cages be sorted out, for example?

Could the difference between what was considered the norm and what was low spending, be explained? How effective was the spending? Members were alarmed to hear of the lack of HCW officers and late payment of Health Care Waste (HCW) service providers. What had been done about this? Did the Department have HCW officers? Whose responsibility was it to segregate hospital waste? The Health Patient Registration System (HPRS) was said to be completed in 657 of the targeted 700 institutions in the NHI pilot districts. In terms of the bigger picture how far had the Department got? Why could the Western Cape system not be used in all the other provinces? Could the Department not get to do the basics first before doing the nice-to-have computer systems?

Members asked the Minister to discuss the case of Mahatma Ghandi Hospital which had recently been in the news. Was the Department in touch with the Department of Trade and Industry on the condom issue. What was the vacancy rate within the Department? Was there an abundance of nursing staff in one province compared to another province?

 

Meeting report

Briefing
Mr Ian van der Merwe, DOH CFO, spoke to the spending on conditional grants and said that there was low spending on the National Heath Insurance (NHI) Grant and the National Tertiary Service Grant (NTSG). At the time of preparing this presentation, the numbers were still preliminary. He said that while the numbers for the third quarter were low, by the fourth quarter the percentages were in the nineties because of budget reductions.

Mr Aaron Motsoaledi, Minister of Health, explained that the reason the numbers were still preliminary was because the Human Papilloma Virus (HPV) vaccinations occurred in March and October for the cervical cancer immunization programme at primary schools. He emphasized that the work was done but the bookkeeping had to catch up.

Mr van der Merwe then spoke to the implications of slow spending on service delivery. He noted the late payment of service providers resulting in problems at project level and said that transfers to provinces were being tracked and that planning for health technology equipment was extremely poor. The late payment also resulted in an inability to recruit and retain health professionals in rural tertiary hospitals. In the area of Health Care Waste (HCW) management, the challenges were the lack of resources in the form of equipment and HCW officers, late payment of service providers, the lack of central and temporary storage facilities and the poor segregation of waste material.

In the Department’s response to the Committee’s previous recommendations, Mr van der Merwe said that the NHI conditional grant would end in 2017/18 and would then be consolidated as part of the NHI indirect grant. Grant frameworks were assessed annually. The Department was implementing the ePHC project which was a patient and web based patient information system and had completed 657 out of 700 facilities in the pilot districts.

The Minister said there were teams on the ground to install computers because all the facilities did not have computers. However a part of the problem was the country’sbroadband connectivity. 1500 facilities would be completed in the following financial year. This would allow files to be accessed within 45 seconds, not minutes. It would also allow clinics to know that a patient had visited a facility the previous day for example. Nurses had been required to complete 52 registers but this had been rationalised down to six registers.

Mr van der Merwe said the Department, in conjunction with the CSIR, was identifying gaps in existing information systems and rationalising data collection tools. The medical male circumcision was being expanded to traditional sites through contracted GPs.

 

He said that the current focus of the Health Facility Revitalisation Grant (HFRG) should be on maintenance and business plans would only be approved if it had a bias towards maintenance rather than new infrastructure spend. Interventions were done through the Infrastructure Unit Support Systems. In the past the Department had not monitored properly resulting in irregular expenditure, especially in the provinces.

The Minister said he felt the current ratio of 25% on maintenance and 25% on refurbishment could be further changed to reflect 30% for maintenance and 20% on refurbishment to cover the maintenance backlogs. Maintenance was very important. It had been a battle dealing with the Department of Public Works over the delivery of hospitals. There was no law that said the DPW had to be used, however the provincial DPW felt that the DPW had to be used. He asked why other capable state agents who had the capacity could not be used.

On the irregular expenditure, the Minister said that the Auditor-General said that the national department was responsible for financials regardless of who did the work.

Mr van der Merwe said the Department had introduced a four month turnaround time in its Annual Performance Plan (APP) for the filling of vacancies, as opposed to the six month period allowed for by the Department of Public Service and Administration (DPSA).

The Minister said that the number of doctors required was drawn from the World Health Organisation (WHO) doctor per population ratios. However WHO had found the formula to be meaningless as it did not reflect the needs of people. WHO had formulated a new method to determine requirements, the Workload Indicator of Staffing Needs (WISN). Differing communities had different needs, for example the difference between rural and urban areas. However provincial organograms were still based on the old ratio approach. WISN was being implemented and had been completed in all primary heath care facilities. It was not implemented yet at central hospitals and was very complex.

Discussion
Ms C Madlopha (ANC) said she appreciated the progress of the NHI but was concerned by the low expenditure rate. What were the key drivers of the low expenditure rate and which provinces contributed towards the low expenditure rate? What was the expenditure at the end of the 4th quarter? Why was the Health Facility Revitalisation Component (HFRC) at 40.8% expenditure, so low? Late payments were still an issue despite the President saying many times that payments had to be made timeously. Were there consequences for those who did not make the payments on time? She noted that there was low expenditure on TB and HIV programmes. She commented that outsourcing of work could be expensive and the issue of job creation had to be taken into account.

Ms M Manana (ANC) said there was a need to consider and review conditional grants because the Financial and Fiscal Commission (FFC) had raised this in its report. She noted that the Department had met with Treasury, but that it needed to meet with the FFC. While it was not necessary to do work through the Department of Public Works (DPW), did the Department meet with the Minister of Public Works on the matter, because the DPW thought it was entitled to do the work and the matter needed to be resolved. On vacant posts, she asked if there was a timeframe for the completion of the WISN. She asked if the matter in the Auditor-General report on ARV distribution concerns had been sorted out. How far the Department was in linking healthcare facilities through IT infrastructure?

Dr M Figg (DA) said the financial figures were a matter of concern as all the spending appeared to occur in the last quarter. He wanted verification that it was actual spend and not a forecast. It was scary to see that one of the challenges of late payment of services could be life threatening such as that of Healthcare Waste disposal. He asked when the patient registry process would be completed. When would the broadband challenges be resolved? What was the progress on appointing inspectors to hospitals as previously outlined by the Minister and could the Committee get a report if there was any report by the inspectors? The hospitals in the country were in a poor state, especially in the Eastern Cape where people were sleeping on the floor.

Ms E Louw (EFF) said the Auditor-General’s report noted a lack of consequence for poor performance and transgressions, a slow response by political leadership and senior management in addressing the root causes of poor audit outcomes and vacancies in key positions. The Minister had said the Department would contract these positions. What has been put in place to address these root causes and how would the Department contract regarding the male circumcision issue? Which provinces were responsible for the slow spending on HIV/AIDS, TB, the NHI and the hospitals. People could not get condoms because of the delay in the rollout of condoms because the specifications had changed and this was infringing on peoples rights to have safe sex. What actions had been put in place regarding the slow spending situation? She wanted timeframes to be put on the remedial actions noted in slide 7. When would the waste cages be sorted out for example?

Mr A McLoughlin (DA) said that the Department had noted low spending on the NTSG conditional grant at 70%  while the Health Professional Training and Development Grant (HPTDG) grant spending, at 72.5% was regarded as the norm. Could this difference as to what was considered the norm and what was low spending be explained? The Department did not indicate whether the 80% overall spend had achieved 80% of the targets. How effective was the spending? He was alarmed to hear of a lack of HCW officers and late payment of HCW service providers. What had been done about this? Did the Department have HCW officers? Whose responsibility was it to segregate hospital waste? HPRS was said to be completed in 657 of the targeted 700 institutions in the NHI pilot districts. In terms of the bigger picture how far had the Department got? Why could the Western Cape system not be used in all the other provinces? He could add his voice to those that had discussed the condition of hospitals and the conditions facing patients. Could the Department not get to do the basics first before doing the nice-to-have computer systems? The Department of Public Works challenge needed to be sorted out for the benefit of all departments, not just that of Health.

Mr A Shaik-Emam (NFP) asked the Minister to discuss the case of Mahatma Ghandi Hospital which had recently been in the news. He asked if the Department had been in touch with the Department of Trade and Industry on the condom issue. What was the vacancy rate within the Department? Was there an abundance of nursing staff in one province compared to another province?
 
The Minister said that the HPV vaccine was not linked to the NHI programme. It had started in 2014 and was a vaccination programme for girls in grade 4 to prevent cervical cancer. The first dose was given in March at all public schools and the second in October. Private schools were excluded. The programme had a budget of R200m and the work had been completed. The Department, for example, did not have enough cars to cover all the schools and cars were hired hence the final cost could not be tallied until all invoices were handed in. He added that because this was not an infectious disease, some parents did not give consent and the Department could not overrule the parents' decision.

On the low NHI expenditure patterns, the Minister replied that the expenditure was low on the NHI because the budget was for a pilot project where people had access to GPs via a clinic. Initial contracting of GPs had been slow because of the GPs' reluctance to contract because they questioned repayment times. Many GPs were contracted at hospitals and were reluctant to go to clinics and because the NHI contract monies were regarded as too little. Contracting had since picked up.

On the spending on TB, the Minister replied that South Africa had started new TB programmes and had won a prize internationally.

On the question of invoices not being paid on time, the Minister said that Cabinet had decided that this would be a punishable offence, that there would be consequences. The Department was not guilty of this practice but it was not easy to monitor, when money was transferred to other tiers to pay service providers. The CFO monitored and followed up on essential services. The Minister said that in one instance the Department had even paid the service provider directly, circumventing the province. It had written letters to explain why it had done so, yet the Auditor-General had reported it as R300m in irregular expenditure. Treasury said that the Department, in addition to writing the letters, should have gazetted the matter.

On the matter of the building of facilities and the role of the DPW and with regard to MECs, the Minister said that it had always been an emotional issue and in some meetings people had almost come to blows.

[The Minister left to do a radio interview on the outbreak of Klebsiella at Mahatma Ghandi Hospital.]

On the contracting of doctors for male circumcision, Ms Jeanette Hunter, DDG: Primary Healthcare, said there was no limitation on the male circumcision and that different districts had their own systems.

On healthcare waste, she said that the management of many hospitals was poor. The Auditor-General’s report had noted that the Eastern Cape had no problems in managing health care waste. Upon investigation it was found that this was because the Eastern Cape had retained some environmental health officers.She said the waste cages would be prioritised so that all hospitals were compliant. Hospital waste was the responsibility of the HCW officers who had to segregate it at the hospital. At the waste dump sites it became the responsibility of the Department of Environmental Affairs.

On nurses being qualified but unable to find a post, she said that the Northern Cape and the Western Cape had a MoU for excess people to be deployed in the Northern Cape. The Department had, in conjunction with Radio 702, done an exercise investigating people who had qualifications but who could not find a job. The result of the exercise was that it was found that most of the people were from foreign countries who had not received local accreditation.

On the roll out of the patient based information system, she said that all provinces had been requested to analyse its information systems in this regard. Apart from the Western Cape, where information systems were fully rolled out, other provinces also had systems but they were not fully rolled out.

Dr Gail Andrews, DOH COO, added that the Department did not want to start from scratch with the roll out of patient based information systems, but rather start with what they had especially with regard to the interoperability of the systems. She said patient based information systems had a global approach and were a necessity to effect the rollout of NHI.There was a need to invest in IT infrastructure like computers. The Department had started with a pilot project in areas where broadband connectivity was good because broadband connectivity was a problem countrywide. In conjunction with the information systems rollout, there had also been a rationalisation of the number of registers a nurse had to fill out.

Ms Valerie Rennie, DDG: Corporate Services, said the vacancy rate as at March 2016 was 3%. She said the challenge was filling critical posts in health infrastructure and the health workforce. There was a 14% vacancy rate at the provincial level where the total number of posts was 345 053. It was attributed to inadequate budgetary resources.

Mr van der Merwe said there had been a slow down in expenditure in the third quarter because some adjustments had been made to provincial budgets. The numbers for TB and HIV would be provided in a written reply. The Department would be meeting with the FFC. The preliminary figures for expenditure was the actual expenditure and not a forecast. He said that the Department used 72.5% as the norm on the Department’s dashboard.

The Chairperson asked to what extent human mobility was a factor when addressing the provision of services and facilities at a basic level versus the state of the art level.

The Minister replied that it was not an either/or type question. The issue had been discussed at Davos. One could not build developing countries without good health systems so there was a need to leapfrog by using technology, new business and services systems and influencing behavioural change. Preventative medicine was better than curative medicine. Cuba had had successful preventative medicine programmes but little was heard about these. He said initially 400 000 ARV doses had been dispensed, ten years later the country’s requirement was over 3 million doses and this could only be achieved by using technology. Technology was not to be regarded as something fancy but as a basic necessity. The Department was working with Vodacom to avoid stock-out situations.

On the question on circumcision, the Minister said that PEPFAR had provided R400m for voluntary circumcision, while the Department allocated R20m for each province where doctors of a certain culture could circumcise in an effort to reduce deaths at circumcision schools. However in the Eastern Cape there was still resistance to this.

On the Klebsiella outbreak at Mahatma Ghandi Hospital, the Minister said Klebsiella was a hospital borne infection which occurred naturally. The problem was when it breached the barriers and entered into the bloodstream. There had been a breakout in 2005 and babies had died. The infection at Mahatma Ghandi Hospital had been successfully treated but some politicians had sought to use the matter to their advantage in the media.

The meeting was adjourned

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