Department Budget: briefing

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Health

08 April 2003
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Meeting report

HEALTH PORTFOLIO COMMITTEE
9 April 2003
DEPARTMENT BUDGET: BRIEFING

Chairperson: Mr. L. Ngculu (ANC)

Documents handed out:
Department's Strategic Plan
Vote 16: Department of Health (link to Treasury website)
Responses to Questions Posed by Health Committee

SUMMARY
The Committee was informed that the overall prevalence rate for HIV/Aids was 22.4% in 1999, 24.5% in 2000 and 24.8% in 2001. This development was attributable mainly to the prevalence rate in women under twenty years old remaining stable for the last few years.This was the best indicator of the uptake of the prevention messages since it implied that it was possible to curb new infections. The Committee heard that the licensing policy would be reviewed so that this mandate would move from the Pharmacies Council to the Department so that non-pharmacist could be licensed to dispense drugs. However, provision for non-pharmacist to dispense drugs would be confined to people registered under the Health Profession Act which in order to improve public access to affordable drugs.

The Department had been inundated with calls from various companies some as far away as Europe seeking information on the licensing requirement for parallel importation of medicines. The Department could not currently predict how many companies would be involved in the parallel importation program and that an amendment to Act 101 made provision for this activity. The transition from Hospital Reconstruction and Rehabilitation to the Revitalization Programme had been agreed upon with the provinces. It was explained to the Committee that this programme combined the area of physical infrastructure, management strengthening, organizational development, quality of care, equipment, information and monitoring systems and that the implementation of the programme started towards the end of 2001.

MINUTES
The Chair stressed the need to for qualitative changes arising from budgetary allocations.

Briefing by Dr. E Mhlonga - Chief Director, Maternal, Child, Women's Health & Nutrition
Dr. Mhlonga informed the Committee that the Department was implementing the school health policy. Although the program had been taken over by the Department of education, his Department monitored to ensure that the content of the food supplement was right. The Department was committed to the program to ensure that the country was polio free by 2004 noting that many activities occurred at the provincial level and that explained the limited operational budget at the National level. Prenatal causes of death was one area of major concern and the Department was moving to strengthen its integrated programme. Integrated nutrition programme was a National effort, which brought together all Departments to ensure that child related issues were adequately addressed.

Dr. Mhlonga revealed that the baby friendly initiative had resulted in 58 out of 480 maternity units being declared as baby friendly and that the program was being implemented slowly in the Gauteng, North-West and the Western Cape provinces. There was an ongoing programme for staff training on HIV and infant feeding. The biggest problem was the challenge posed by the provision of free infant formula to mothers on the PMTCT program. A draft feeding guideline had been developed and the same would be presented to MINMEC early in 2003.

Briefing by Ms N Matsau - Deputy Director General- International Health Liaison
Ms Matsau informed the Committee that issues regarding South Africa's international co-operation and regional development emanate directly from the Presidency. South Africa was inundated by many requests for co-operation agreements by friendly countries but that this venture was prioritized to ensure that only those partnerships that benefitted the country were signed. These Agreements helped the country gain international status noting that whereas many agreements solicit for money there was another category of agreements that brought in development. So far the Department had signed five to six agreements this financial year and explained that the south-south partnerships helped strengthen co-operation between developing countries. The Nepad initiative encompassed four major programs and this included South Africa's contribution to SADC noting that although the later relocated to Botswana its activities were still running within the Department.

Briefing by Dr. S. Khotu - Director, National Health Systems, Health Monitoring and Evaluation
Dr. Khotu informed the house that the National Policy on Quality in Health Care had been adopted and the same was being operationalised both by the national and provincial departments of health. Most of the provincial departments had appointed quality of care (QA) co-ordinates and that all of them either had or were in the process of developing provincial QA policies based on the national policy. Provinces like the Eastern Cape, Kwazulu Natal, North West and the Free State had employed the services of the Council for Health Service Accreditation in Southern Africa (COHSASA) to assist them to improve the quality of care rendered in public hospitals. Other provinces such as Gauteng had decided against external accreditation in favour of internally developed standards and assessment of compliance.

Dr. Khotu reported that most health programs have produced clinical guidelines to assist health workers to better manage their patients adding that the national Department was in the process of establishing peer review mechanisms to assess clinical care. Mechanisms to report and investigate adverse reactions were currently being explored. Most facilities had established clinic and community health centre committees, ward committees and hospital wards. Most provinces had also established provincial level structures in the form of Provincial Health Councils (PHCs) noting that these structures had been established as a mechanism for involvement of local government in the spirit of co-operative governance.

Briefing by Dr. R. Mulumba, Director, HIV/AIDS

Dr. Mulumba reported that the 1999, 2000 and 2001 results of the annual HIV sero-positive prevalence surveys of pregnant women attending public antenatal clinics suggested that prevalence rates were stabilizing. Overall prevalence rate was 22.4% in 1999, 24.5% in 2000 and 24.8% in 2001. She attributed these developments mainly to the prevalence rate in women under 20 years old remaining stable for the last few years. This was the best indicator of the uptake of the prevention messages since it implied that it is possible to curb new infections.

Dr. Mulumba informed the Committee that there was a further strengthening of expenditure on the HIV/Aids and Tuberculosis sub-program with the result that it was projected to grow from a modest R75 million in 1999/00 to R903 million by 2005/5. The budgetary increase related to the raised allocations in the conditional grant to provinces - primarily to fund the roll-out of prevention of mother to child transmission - and for the national program. The national program related to the procurement of male and female condoms, contributions to the Global Fund for HIV/ Aids and partnerships with love-life and other related NGOs. Payments to the South African Aids Vaccine initiative doubled to R10 million in 2002/03 and this would be maintained over the MTEF period.

Dr. Mulumba reported that the HIV/Aids, STI and TB cluster allocated much of the conditional grant to provinces and non-governmental organizations and that in order to ensure good financial management, these transfers were closely monitored. Besides the requirement for a business plan, regular expenditure reports must be submitted. Hospital Services cluster also provided funds from the conditional grants to provinces, which were also closely monitored in similar fashion.

Briefing by Dr. H Zokufa - Chief Director, Pharmaceutical Policy and Planning
Dr. Zukufa addressed the issue of pharmaceutical policy and noted that there had been a significant increase in budgetary allocation due to the expected legislative program that started from 2 May 2003. He appealed to the Committee to play its rightful role in ensuring that there were affordable drugs for the general populace. Licensing policy would be reviewed so that this mandate would move from the Pharmacies Council to the Department so that non-pharmacist could be licensed to dispense drugs. Provision for non-pharmacist to dispense drugs would be confined to people registered under the Health Profession Act. This measure was intended to expand opportunity for members of the public to access affordable drugs.

Briefing by Ms J Gous -Director: Inspectorate & Law Enforcement: Medicines Regulatory Authority
Ms Gous noted that budgetary allocations in this area was clearly an extensive increase and reported that the Department would improve systems and processes to ensure provision of safe drugs and at the same time improve procedures for registration of drugs.
The Department would seek membership to the International Pharmaceutical Inspection Scheme with a view to rationalize the registration of drugs. Centres of excellence for GMP and quality systems for the SADC and Nepad would be developed. South Africa was currently training the SADC inspectorate. The Department would periodically review the list of essential drugs to ensure relevance and availability and at the same time establish a pricing committee, which was provided for in the Medicines Act.

Ms Gous reported that the Department had been inundated with calls from various companies some as far away as Europe seeking information on the licensing requirement for parallel importation of medicines. At this point in time it was not easy to tell how many companies would be involved in the parallel importation program noting that the amendment to Act 101 makes provision for this activity. There was no provision for the registration of medical devices but that registration was required for devices with active ingredients. The provision as it stood was problematic since it did not offer clear guidance and that the only solution was to go back to Parliament and write provisions in the Act to supply the necessary clarity.

Entry points for drugs at the border would be much stricter and that only four border controls would be made available. More enforcement officers would be employed to enhance capacity on the policing front. The Cosmetic Control Act, which was written in 1972, would be updated to bring it in line with current developments on the international scene. In an effort to ensure the supply of safe drugs, the (Medicines Regulatory Authority) MRA would acquire its own laboratory, which in any event is a directive from the WHO noting that this would also be in pursuance of provisions of the Quality Control Act.

Briefing by Dr. T Sibeko - Chief Director, Hospital Services and EMS
Dr. Sibeko informed the Committee that as a result of hard lobbying the hospital services programme had witnessed a significant budgetary increment adding that indeed an additional R120 had been allocated in this regard. The first draft of the Integrated Health Planning Framework document was completed in January 2001. Since this exercise was conducted using limited information, it was deemed necessary to review the process as and when the quality of information flow increased. All provinces used this draft to produce their first draft Strategic Position Statement (SPSs) which he explained was a costed long-term vision for the delivery of sustainable health services.

Dr. Sibeko pointed out that the transition from Hospital Reconstruction and Rehabilitation to the Revitalization Program had been agreed upon with the provinces. This programme combined areas of physical infrastructure, management strengthening, organizational development, quality of care, equipment, information and monitoring systems noting that implementation of the program started towards the end of 2001. A set of delegations for hospital managers had now been drafted and was pending discussion and approval by the Provincial Health Restructuring Committee (PHRC) in 2003. Considerable amount of training had been provided for hospital general managers, specifically on strategic and business planning, performance management and change management.

Dr. Sibeko pointed out that the standard job description and performance plans for hospital CEOs had been developed in collaboration with the Department of Public Service and Administration, and that particular progress has been made in the appointment of CEO/SEO and the implementation of management structures. Financial management systems in hospitals were being strengthened and that the National support to the cost centre management program had significantly been improved. This development had seen the expansion of the program from the original fifteen to 46 hospitals.

Discussion
Dr Cachalia (ANC) asked if the Department had plans to license parallel importation of anti-retroviral drugs.

Dr Zokufa replied that the generic version of the drugs was already available in the country but that patent holders sold these drugs. The law provided for compulsory licensing but the process of securing a license was riddled with insurmountable obstacles. Parallel importation was provided for under section 76 of the Medicines control Act that would come into effect from the 2 May 2003.

Ms Baloyi (ANC) commended the Department for the clarity it had put to programmes, which clearly showed where it was coming from and where it was going. Which provinces were experiencing problems in implementing the mother to child HIV/AIDS prevention programme.

Dr. Mulumba replied that provinces that were behind in implementation were Mpumalanga, Limpopo, the Eastern Cape and North West in that order.

Ms Malumise (ANC) asked the Department to outline tangible projects it had rolled out in the provision of the Home Based Care programme.

Dr. Mulumba reported that there were 665 HBC projects running throughout the country noting that in fact the Department has superceded the initial target of 500. She added that the Department has compiled its targets, which are placed under rigorous monitoring mechanisms to ensure that they do not only function but also undergo continuous assessment and improvement.

Dr. Rabinowitz (IFP) asked if plans had been made to include saliva testing as an alternative means of detecting the sero-positive status of a patient.

Dr. Mulumba pointed out that blood testing was by far preferred becomes it was more sensitive and specific than saliva and that the latter was much more difficult to predict. There was on-going research on the issue and that this information would be made available once the research findings are tabled.

Ms Tshwete (ANC) asked if the Department had any plans to extend the training programs to the rural areas noting that most initiatives like love life were urban based.

Dr. Mulumba concurred with Ms Tshwete that indeed most training programs were urban based but assured the Committee that the Department was expanding to the rural outposts noting that one such centre that had been ear-marked up at the University of the Transkei in place of Port Elizabeth.

The Chair noted that most provinces lacked capacity to put together credible business plans in order to make a persuasive case for extra budgetary allocation and asked what the Department was doing to help such hapless provinces.

Dr Zokufu replied that new posts had been created at the national level, which would become part of the provincial manpower and that this new edifice would form strong linkages to the provincial structure to facilitate collaborative work.

Dr Luthuli (ANC) sought an explanation as to how the PMTCT program was being rolled out and whether there were benchmarks upon which the Department measures progress in this regard.

Dr Mulumba acknowledged that there had indeed been deficiencies in monitoring but that the Department had now set up an operational plan dealing with indicators and targets. There had been a tremendous improvement in the roll-out of the PMTCT program and that the Department was going out of its way to assist provinces in strengthening mechanisms.

Ms Baloyi asked how the Department collaborated with the Department of Social Development in the roll-out exercise of the Home Based Care program.

Dr. Mulumba explained that her Department has entered an understanding with the Department of Social Development that they carry out the work in terms of the Home Based Care (HBC) and administer the programme while Health carried out follow-up and treatment regimen. It was the National Treasury edict for the HBC program to be unified instead of having several packages.

Ms Tshwete enquired why HIV/Aids patients did not qualify for the social grant supplement.

Dr. Ntsaluba replied that it was government policy not to make a specific provision for HIV/AIDS patients in terms of access to social grant. The Department of Social Development in the Eastern Cape tried to implement such a policy and it ran into deep problems and was forced to abandon it.

The Chair was happy with the DG's point of clarification noting that the Western Cape government made similar announcements which was a contradiction of the stated government policy. He pointed out that at times provincial governments were pushed into making rush decisions when they were under immense public pressure without first assessing the impact of their policy pronouncements.

Dr. Cachalia asked what, if any, monitoring mechanism the Department had put in place to check on the drugs manufacturing cost in view of the fact that the pricing committee only determined exit prices.

Dr. Zokufa acknowledged the fact that a single exit price was a huge challenge for the Department and that a working group had been constituted by the Minster to look into this issue. He lamented the lack of general support from manufacturers noting that the challenge the government was faced with was how to gather sufficient intelligence with which to engage companies on the sourcing, acquisition, rate of exchange and a feel of the production costs. The Department was committed to the introduction of the economies of value for money.

Ms Baloyi asked how Department would deal with the issue of setting up the pricing committee. Would the private sector be represented on the committee?

Dr. Zokufa replied that consultations were carried out from among the provinces and various medical groups but that the private sector had no membership on the committee.

Dr. Luthuli asked how the Department could reach out to SANAC and other related organizations to assist with policy formulation.

Dr. Zokufa said that once one has engaged the medical fraternity in a comprehensive manner as was the case here, it is possible to come up with credible guidelines on the way forward for the implementation and getting non-members to buy into the package.

Dr. Luthuli asked when the pricing Committee would be up and running.

Dr. Zokufa replied that the Department had received more than 60 plus applications from people seeking representation on the Committee which needed organising. There were deep-seated tensions between the pharmacists and medical doctors and therefore not all stakeholders were buying into the project as yet.

Dr. Ntsaluba said that indeed dispensing doctors were clearly unhappy about this new development which they feared would eat into their incomes.

Dr. Jassat noted that there were too many backlogs in the process of drug registration and wondered why this was the case.

Ms Gous attributed delayed registration process to resource scarcity noting that her section had many resignations and that most of the vacant posts had just been re-advertised for filling.

Dr. Jassat asked how long, on average, it took for a drug to conclude the registration process.

Ms Gous explained that it took many years for a new drug to gain the evaluation competence noting that on average it took eleven to twelve years for a generic drug to be registered while a new drug would take on average two years.

Dr. Jassat asked how the inspection process was carried out before a drug was registered.

Ms Gous explained that there were various levels of inspection but that the most crucial ones were at the manufacturing and processing level.

Dr. Cachalia (ANC) asked if the Department conducted quality verification before a drug was registered.

Ms Gous noted that the evaluation process looked at three main ingredients before recommending a drug for registration and these were: quality, safety and efficacy noting that if the imported substance fell below the required standards then it must be withdrawn.

Dr. Cachalia referred to the outlined registration process and asked what happened in cases of compulsory registration.

Ms Gous pointed out that in such cases the law provides for an expedited registration process, which in the end would ensure that all the essential ingredients in the evaluation process were covered.

Dr. Jassat asked what an ideal South African hospital should be. What standards was the Department aiming at in its revitalization programme?

Dr. Sibeko admitted that it is quite tricky to determine at this point in time what an ideal South African hospital should look like noting that it was a question that should concern people at policy making level.

Dr. Cachalia noted with appreciation the significant increase in the budgetary allocation for the hospital revitalization programme. He asked what plans, if any, the Department had or was putting in place to attract private patients to the improved state facilities so that these hospitals could generate income from the medical aid scheme.

Dr. Sibeko pointed out that the Department had put in place many initiatives to appropriately position state facilities so that they can compete fairly with private service providers. Some of the initiatives included the differentiation of service provision within the state facilities.

The Chair cautioned that the Department should tread carefully in its ambitious plans to set up state of the art facilities, which might turn out to be nothing but white elephants. There was no point in setting up such facilities if there is no provision for equipment, personal and other necessary facilities to improve the quality of service on a sustainable basis.

Dr. Sibeko explained that the revitalization program did not entail doing everything at once noting that the National Treasury had complained that huge resources had been allocated to the Department yet the health infrastructure was in a state of a shambles. The Department then decided to impact on a programme to improve the physical facilities before moving to other areas of concern.

Ms Chetty, Deputy Director General said that the real change was not only the upgrading of physical facilities but rather the whole question of re-engineering of the entire health infrastructure to keep with the changing times.

Ms Baloyi lamented that most hospital facilities were urban based. Were there plans to expand these facilities to the rural areas?

The Chair felt that the Department's strategic plan had reflected a qualitative change. However, there was still room for improvement.

The meeting was adjourned.











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