Nursing Strategy: Chief Nursing Officer progress report; Nigerian delegation meeting

Meeting report

Meeting with Nigerian parliamentary delegation
The Chairperson welcomed members of the Nigerian Parliament.

Senator Tejuosho Olarenwaju led the delegation of Parliamentarians from Nigeria. He said that the current Assembly in Nigeria is the eighth Assembly post 1999, when the current democratic dispensation began, and this Assembly is just 18 months old. 70% of the current senators in the National Assembly are a first time senator which makes it important for them to learn as quickly as possible. The purpose of this visit was for senators to interact with members of the South African Parliament to observe and learn.

He noted that the Nigerian Assembly is a bi-cameral Assembly, with the upper house being the Senate and the lower called the House of Representatives.

Mr A Mahlalela (ANC) welcomed members of the delegation and proceeded to give an overview of the South African Health sector. He said that the South African health system is divided into the public health sector and private sector. The public sector caters for about 85% of the populace and has inadequate resources, while the private health sector caters for a very small percentage. The mandate of the Minister of Health is enshrined in Section 27 of the Constitution of South Africa, the National Health Act of 2003 and other pieces of legislation. 

The main strategic objectives relating to health are to increase life expectancy, to decrease maternal and child maternity, to combat HIV and AIDS and Tuberculosis and to strengthen the effectiveness of the health systems.

The national government and provinces are given certain constitutional competencies to perform certain health functions at their spheres. In some cases there are concurrent functions, where more than one sphere of government has constitutional competency.

South Africa faces a quadruple of burden of diseases - HIV and AIDS, Communicable diseases, non-communicable diseases and violence and injuries. Priorities of the health system in South Africa include overhauling the health care system and improving quality of health care services, fast tracking the implementation of a National Health Insurance (NHI), revitalising the infrastructure and strengthening HIV response, improving human resources for health at state hospitals and deploying primary health care teams to communities and schools.

He explained that the Portfolio Committee on Health is responsible for considering bills, considering and approving departmental budget votes, conducting oversight to the Department of Health (DoH or the Department) and its entities, facilitating public participation in its processes, enquiring and making recommendations about any aspect of the Department. Government has introduced a new system which is looking at national core health issues. 

The National Department of Health has its own budget and also has a conditional grant which is used to address issues that are beyond the provinces' financial capacity. The Committee has powers to determine its own procedure, conduct public hearings, and summon any person to appear before it to give evidence on oath or affirmation or to produce documents. The budget review and recommendation process recognises the State of the Nation Address, strategic plans and annual performance plans,  the Department’s quarterly expenditure reports, the Department’s annual report, the budget vote and the entities' financial performance.

Discussion
Senator Olarenwaju Tejuosho asked if the Abuja Declaration, which specifies that 15% of the national budget should be dedicated to health, was being implemented in South Africa. He asked about the state of malaria in South Africa, asking what was being done to try to eradicate it, and, if it had been eradicated already, how that was achieved. He noted the attempts to implement the NHI and said that only about 4% of the Nigerian population was covered by health insurance. He asked about the geographical spread of the primary health centres and who was responsible for these centres.

Hon. Muhammad Umar Jega asked about the relationship between the public and private health sector and whether and how they were being integrated. He also asked for more clarification on which body was responsible for monitoring the health sector in South Africa.

Senator T Orji wanted to know if health was a priority in South Africa and if there was adequate provision for funding of the health sector in the budget. He also asked if the funds were released in a timely manner.

Dr John Dyegh asked what the government was doing to make medication affordable to the citizens,  and the relationship between South Africa and its neighbouring countries in terms of drug provision. He asked if there were any legislative enactments that regulated medical products.

Dr W James (DA) lauded the eradication of polio in Nigeria and asked for more information. He appreciated the cordial discussions and confirmed that a lot of money was being put into health in South Africa. There was still a problem of under-funding of the public health sector but another major problem was mismanagement. Speaking on the national health insurance model, he talked about the White Paper that has being developed by the DA on national insurance, which was somewhat different from the model being proposed by the ANC, the ruling party. He noted that there is a health gap in South Africa and the current health care system needs to be reformed. He also said that there is no minimum set of standards, and this is affecting the relationship between the sectors.

Dr P Maesela (ANC) said that the NHI remains a top priority of the ANC and it has always been rooted in the ANC policy, since the ANC Manifesto says that the party intends to provide equitable health care for everyone, funded by the State, in alignment with section 27 of the Constitution. The NHI scheme is already being piloted in certain areas, and primary health care is being redefined. She said that there is a need to revisit legislation backing the implementation of the healthcare system, and the funding. There has been an increase in the funding of health in South Africa.

Mr H Volmink (DA), speaking on medical products, told the delegation that legislation has been put in place to address the issues and it will make the registration of medicine easier and quicker. Food and medical devices were also included in this legislation. 8.5% of the GDP is being spent on health, but there has being no corresponding outcome.

Ms L Dlamini (ANC) responded to the question of health being a priority in South Africa. She also told the Nigerian delegation that it was a top priority of the ruling party, and this could be seen in the provision of the budget. She maintained that malaria was not a significant problem in South Africa as the disease has been kept under control. The South African democratic government inherited a health system where only a privileged few had access to good health facilities. She noted that in relation to the NHI, the ruling party was to present a Paper that would be submitted to Parliament a a Bill, and once finalised, this would cater for the entire country.

Ms D Senokoanyane (ANC) also spoke about access to health services, and spoke about the history of South Africa, where health services were provided according to skin colour. She said the present government is striving to address this and make affordable health care within the reach of all. There were some challenges with the public-private partnerships in health care, but a lot of progress had been made in the health sector post 1994.

Mr A Mahlalela (ANC) talked about the majority of South Africans who had been excluded from proper health services as a result of the issues pre-1994. He spoke about the model being developed by the DA on health, and accused the DA of trying to protect the interests of a white minority population. This fundamental problem was what the ANC was attempting to tackle, by the introduction of the NHI scheme. He disagreed totally with the position of Dr W James on the NHI. He agreed that malaria had, for the most part, been successfully tackled in South Africa, but there are still some regions close to the borders where there were small incidences of this disease. The health facilities in South Africa are providing services not only to South Africa, but also to all the countries sharing borders with South Africa, free of charge.
Dr W James responded and took exception to Mr Mahlalela calling him names.

The Chairperson reiterated the position of earlier MPs who talked about the NHI being introduced as an ANC policy, and reiterated that health services had been provided according to skin colour in the past. This was currently being addressed by the health policy introduced by the ANC.

Senator Tejuosho Olarenwaju gave a vote of thanks on behalf of the Nigerian delegation and noted that some questions which were raised had not been answered. He looked forward to a further round table discussion with the Committee where these questions could be deliberated.

Nursing Services: Chief Nursing Officer's progress report to the Portfolio Committee on Health
Dr Nohlanhla Makhanya, Government Chief Nursing and Midwifery Officer, took the Committee through her report to the Committee on the launch of the Nursing Strategy. She noted that the key strategic partners are the National Department of Health, South African Nursing Council (SANC)  and the Department of Higher Education and Training (DHET). The 2011 Nursing Summit was a result of the Ministerial intervention which produced the compact, and which resulted in a Ministerial Task Team. In 2012 the National Strategic Plan for Nurse Education Training and Practice 2012/13 – 2016/17 was developed. It was launched in 2013. In March 2014 the Government Chief Nursing and Midwifery Officer was appointed.

She noted that the nursing strategy is broadly classified into three main aims: develop, reconstruct and revitalise. The Development strives to develop the national nursing education policy, and to develop nursing programmes for the new nursing qualifications in line with the Higher Education Qualifications Framework and new scopes of practice. Reconstructing aims to reconstruct the Nursing Education system by supporting the three colleges to implement the new college based National Qualification Framework (NQF)-aligned education programmes and thus model a new system of educating and training nurses. The National Strategic Plan for Nurse Education, Training and Practice is aligned within seven strategic pillars of  Nursing education and training, resources in nursing, professional ethos, governance, leadership, legislation and policy, and promotion of a positive practice environment, compensation, benefits and conditions of Service and human resources for health. There is an alignment with the health sector policy framework and education sector policy framework, where relevant. She emphasised that nursing education and training must be harmonised with the service needs of the health service, to ensure that qualifications are commensurate with scope of practice.

A critical review of what has been done is important and there is a need to foster strategic partnerships with both internal and external partners who are lead agencies in each of the strategic focal areas of the strategy. The implementation of the nursing strategy hinges on both legislative and legal factors.

There are three main recommendations in relation to nursing education. Firstly, nursing education is to be developed as a national competency, which will address provincial inequalities, standardising clinical practice and funding for nursing education. There are currently 252 colleges and 23 universities offering courses related to nursing education. There are 17 public colleges of nursing but they subscribe to the provincial standards and not the national requirements. The universities subscribe to both the national and provincial requirements. This is the reason for the establishment of a national nursing strategy, which will create uniformity in nursing education and make all qualifications on par with other national qualifications.

The second recommendation speaks to the status of public sector colleges.  It is recommended that there should be an engagement between the Departments of Health and Higher Education and Training, to facilitate the incorporation of public sector colleges and their programmes to the higher education sector. The role of the South African Nursing Council’s (the Council) is based on governance, leadership, legislation and policy. The Council’s role is to develop a regulatory framework which provides regulations for implementing the provisions of the Nursing Act 2005, and the creation of specialist categories with competencies. The Council is also responsible for the development of a framework for creation of post registration categories. The Department of Higher Education has a legislative mandate to support a function shift, share quality assurance responsibilities and the preparation of colleges.

Speaking to the progress on the legal, administrative and regulatory frameworks to date, Dr Makhanya said that there had been a harmonisation in the legal framework which supports nursing education, so that showed legal shift. Nursing education will remain within the portfolio of the Department of Health, with the Department of Higher Education coordinating that education. DHET had also obtained a positive legal opinion and recommendation that nursing education has to move from the provincial to the national level.

Ms Sizeni Mchunu, Acting Registrar, SA Nursing Council, talked about the progress made on the regulatory framework. The mandate of the SANC is to create a register for learners and practitioners, and to coordinate the practice and conduct of practitioners, as well as the education and training of nurses and midwives. Learners must be registered with the South African Nursing Council. This is a big challenge because some of these institutions responsible for this fail to live up to their responsibility and the unfortunate implication is that their learners may then not be able to write the exams to get their qualifications. Another core function of the Council is to set the standard for practitioners, with a broader function of being responsible for the accreditation of all the nursing institutions within the country. The Council is phasing out the old qualifications, and introducing a new qualification. Most of the institutions which have applied to the Council for accreditation fall short of the minimum requirements. This new qualification will not affect the institutions offering nursing education as long as they do not fall short of the requirements. Communication with the relevant stakeholders in this regard is ongoing. In addition, there has been the creation of specialist categories and the development of a framework for continuing professional development and competencies for nurses and midwife specialists.

Dr Makhanya highlighted that there would be no gap between the phasing out of the old qualifications and the phasing in of the new qualifications. She assured the Committee that the current standards will be maintained and government will ensure that quality is not compromised. She noted that there is a national policy for nursing education and training and the unique and complementary role of stakeholders is also defined.

Discussion
Dr James asked about the shortage of nurses, wanted to know how those figures and statistics were arrived at and whether they were calculated according to budget or need.

Mr Volmink noted that nursing is not just a profession, but a calling. He feared that there were some obvious potential gaps in the various steps set out for phasing out old qualifications and phasing in the new ones, and wanted an assurance that these gaps would not in fact become apparent and that nothing would affect the phasing in process of the new qualifications.

Mr Volmink also talked about the Scope of Practice document, which was tabled on 15 October 2012, and asked what had happened to the comments from that document. He wanted to know what happened to the comments from the document.

Mr Volmink also asked about the current status on the licensing of nursing agencies. He said there was a need to maintain proper communication channels with the relevant stakeholders.

Ms Senokoanyane appreciated the fact that nursing education will remain in the public sector. She expressed her concern at the lack of practice opportunities by nursing students in the course of their studies, and wanted to know if there was any plan by the SANC to consider the number of hours devoted to practical training. She asked if there was uniformity on the admission criteria,  between the colleges and the universities.

Ms L James (ANC) said the presentation was very informative. She noted that alcohol and drug abuse are major problems in South Africa currently and asked if there was specialist training for nurses to assist the communities in dealing with this problems.

The Chairperson spoke of her own experience in a private hospital and how she was treated by the nurses, pointing out that some of the private hospitals do not act correctly and wondered if there was capacity to have these private hospitals checked also. Speaking about primary health care and the change in curriculum, she asked if there was any campaign to emphasise that primary health care starts in women's kitchens. She wondered if enough was done to instil in the trainee nurses and to emphasise at Council level that bedside nursing was also a vital part of their clinical training.

Ms Mchunu stated there were some accredited institutions doing well, and some not. Providers did train both nurses and non-nurses, and the communities find it difficult sometimes to differentiate between them. The SANC does carry out a lot of impromptu inspections and any institution which is non-compliant will be closed down. She confirmed that there is both capability and capacity to deal with accreditation matters, but the real challenge is getting information about any non-compliant institutions.

In relation to the suggestion that more nurses should be equipped to deal with drug and alcohol abuse, she admitted this was a problem because the current curriculum does not address this; however, the new curriculum under development will look at these specific areas. In relation to the admission criteria for nurses, she stated this will differ slightly but there is a need for a Senior National Certificate to be the minimum requirement for admission. She accepted the caution to avoid any gaps between the various phases of the new qualification scheme. In relation to the suggestions around practical training for nurses, she said it is almost impossible to have a blanket structure for all nursing institutions, because of the regulations. The phasing out of the old qualifications was not targeted at the private nursing education institutions. She agreed that there was a communication shortfall between the Council and its stakeholders at one point but said that it had been addressed and everything was now on track. She admitted that nursing agencies were a problem, and the necessary action is being taken to address this legislation.

Dr Makhanya added that, in the absence of a current legislative framework, the nursing agencies are being managed under an interim framework which will monitor the quality of care being provided by nurses deployed by the nursing agencies. The challenges associated with the nursing agencies will be addressed by a legislative framework. In relation to the admission criteria, she emphasised that the matric certificate is the minimum requirement. She noted that there are minimum standards also around the amount of clinical practice, and all institutions have to meet these standards.

The meeting was adjourned.