Health Budget: Treasury; National Health, Eastern Cape, Mpumalanga, Free State Input

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15 April 2003
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Meeting Summary

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Meeting report

15 April 2003

Mr. L. Ngculu (ANC)

Relevant Documents:
Treasury on Health Budget & Inter-Governmental Fiscal Review 2003
National Health's Report on Inter-provincial Inequity
Eastern Cape Presentation
Free State Presentation
Mpumalanga Presentation
Department of Health budget: Vote 16 (link to Treasury website)

Treasury noted that the Hospital Revitalisation Grant had seen a significant rise and that the HIV/AIDS financing has been enhanced - which development has been attributed to the budgeting strategy that was started in 2002/3. On equitable share amongst provinces, National Health stated that there were massive inequities in public health and that this feature remains even where conditional grants are removed. There was no comprehensive assessment that had been done to determine the best way to address these inter-provincial inequities. It was suggested that a definition of basic health care services and the development of both quantitative and qualitative norms and standards be instituted to address the problem. The Committee was challenged to partner with the Department and influence policy in this regard.

Mpumalanga, Eastern Cape and Free State Provincial Departments of Health reported on the manner in which budgets had been spent over the past year. As part of their submissions, it was expected of them to provide the Committee with information on their future plans, with particular emphasis on the financial implications of those plans and projections. The three provinces who presented were Mpumalanga, Eastern Cape, and Free State.

The Chair welcomed members to the continuation of provincial budget hearings. He directed that the National Treasury and the National Departments briefly explain the fundamentals around the nagging question inter-provincial inequities as it relates to conditional grants before the provinces can commence their respective address. He listed the provinces present as the Eastern Cape, Mpumalanga and the Free State.

National Treasury on Health Budget and Intergovermental Fiscal Review
Dr M Blecher, Director Public Finance National Treasury, noted that the provincial share on personnel component was well controlled but that the health personnel financing shows clear signs of inequities and areas of scarcity. Equity in health professions distribution was a most critical challenge. The hospital revitalisation grant had seen a significant rise as well as capital expenditure. The HIV/AIDS financing had been enhanced which was a direct response to the strategy that was started in the 2002/03 budget.

Dr. Blecher pointed out that the Integrated Nutrition Programme had also witnessed an increase of R 1 billion which was quite impressive. For the first time there was a clear distinction between clinics, PHCs, HIV/AIDS and the Nutrition programme as separate components for budgetary allocation purposes. He regretted that there was a serious crises of efficiency since many health facilities were not functional. However, this situation was being addressed through the accreditation program that would ensure proper quality was maintained in all institutions. Trends in conditional grants had shown an upward mobility which were predicted to continue for the foreseeable future.

National Health on Provincial Inequities
Mr Muller, Chief Financial Officer: Health Department, stated that there were massive inequities in the public health system noting that even if conditional grants were removed these inequities were not significantly reduced. Some provinces had made remarkable progress but that the main source of concern was the pace at which change was taking place noting that overall the impact on reducing inequities had been very small. Regarding the inter-provincial inequities, no comprehensive assessment had been done and limited studies showed similar trends. He observed that rural and less advantaged areas had less access to resources noting that the district health expenditure reviews helped in the assessment of the level of inequities upon which informed decisions could be made. Guidelines had been developed to help the province roll-out these assessments.

Mr. Muller identified obstacles to the drive to achieve equity namely that global budgets were allocated to provinces instead of being allocated specific sectors and that equity needs were therefore not properly assessed in the light of other social spending on services. He recommended that norms and standards be set up and that a definition be provided for basic help care, which would be much broader than the primary health care.

Mr. Muller further recommended that the way forward would entail a review of the budgeting system and the use of fiscal federalism to improve inter-provincial equity noting that it was necessary to conduct an incident analysis of financing and the benefits of health care in the country. He also called for the development of a definition of basic health care services and the development of both quantitative and quantitative norms and standards. It would be necessary to develop minimum funding requirements for health care provision. There were clearly a number of areas where the Committee could intervene to influence the promotion of greater equity in health care spending. He challenged the house to partner with the Department in this regard.

Eastern Cape submission
Dr Mike Fraser, HOD, outlined the vision of their provincial department, which aimed at providing health care services to the people in the Eastern Cape Province that promote a better quality of life for all. The mission of the Department was to provide and ensure accessible comprehensive integrated services in the Eastern Cape. This strategy emphasised the primary health care approach that utilised and developed all necessary resources that would enable all its present and future generations to enjoy health and quality of life. The Department internalised the values of equity, service excellence, fair labour practices, good work ethics, accountability and transparency all for purposes of ensuring that residents had access to essential health services.

Dr. Fraser reported that the provincial hospital maternal death rate was calculated at 133 deaths per 100,000 hospital deliveries and that in the year 2000, 108 deaths were reported 53% of which were from the eastern regions of the province. There had been a dramatic rise in TB cases from mid 1980s. This was seen to be HIV/AIDS related. There had been a significant improvement in the hospital revitalisation and rehabilitation programme. The Nelson Mandela Hospital had been completed and the first batch of patients would be admitted on 1 September 2003. There had been an increase in the utilisation of primary health care services annually and the management and administration of the Department had been improved significantly through filling of critical posts, recruitment and appointment of suitably qualified personnel in all fields.

Dr. Fraser informed the committee that ante-natal care was being offered five days a week in 80% of the clinics since 1999 which was a remarkable increase from the baseline survey when only half of all clinics were providing the service for the five working days. The Department was in the habit of conducting quarterly budget reviews with all institutions and this had improved the critical monitoring process.

Turning to major health challenges, the main issue was the escalating HIV/AIDS and TB cases noting that statistics in this regard had been enhanced by the improved reportage. He also identified the brain drain of health professionals especially doctors and nurses to countries like the UK and Saudi Arabia as a major stumbling block to the provision of improved health care services. Currently the province had a doctor patient ratio of 1 per 3000. He also sited the low immunisation coverage and the legislative reform that had been influenced by cultural factors such as circumcision and the recognition of alternative medicines including traditional healing as another challenge. The escalating crime rate was a major impediment to the expansion of the primary health care program and called for more security to protect staff working in these critical facilities.

Addressing priorities the Department would manage and improve health outcomes for HIV/AIDS, Sexually Transmitted Diseases and TB. Efforts would be doubled to reduce infant and child mortality rates among other undertakings. He proposed an improved access to VCT by increasing the number of testing sites by 30% and the involvement of communities in the HIV/AIDS management through AIDS councils. The Department's strategy for the retention of health professions entailed the provision of accommodation and induction programmes for community services staff and interns among other lucrative packages.

Ms Malumise (ANC) asked how many baby-friendly clinics the Department had been set up so far.

Dr Fraser replied that baby-friendly facilities were available at most level one clinics and that efforts were underway to develop more centres.

Ms Malumise noted that the rate of maternal death was unacceptably high. Why was this was the case.

Dr. Mjekevu said that the Department recognized the issue of communicable diseases. The major issue was the incidence of perennial cholera out-breaks which was caused by lack of clean water and a proper sanitation. These were issues falling under another Department but nonetheless the Department of health tried to help where it can.

Ms Malumise asked what experience the province had with the roll-out of the PMCTCT program.

Dr. Fraser explained that the Department had rolled-out the PMCT programme in twelve hospitals including eight clinics. The Department's facilities in this area offered a comprehensive service unlike other provinces. Traditional healers were involved to ensure the success of the programme. Sanitation and other traditional practices were a huge challenge to success of the program.

Ms Tshwete (ANC) noted with concern that TB cases were on the increase in the provinces yet the Department sought to opt for the curative rather than the preventive intervention.

Dr. Mjekevu noted that with regard to TB the Department had developed a business case that would overhaul the service that was currently offered to patients in order to focus on cross-cutting issues which would encompass information, education, provision of drugs and laboratory services.

Ms. Baloyi (ANC) was glad to note that mobile services for the PHC roll-out were up and running. This was a major achievement on the part of the Department in view of the poor infrastructure in the province. Infant mortality and maternal death rates were too high. What intervention plans did the Department have to arrest this unhappy situation?

Dr. Fraser explained that to address the mortality issue the Department had improved the immunization program by a coverage of 20%. Key areas that caused death had been identified and intervention mechanisms utilized.

Dr. Luthuli (ANC) said expressed concern on the high infant mortality rates which must be arrested. She noted with understanding that the region had poor infrastructure lay-out and urged for a greater use of the mobile clinic facility. She called for an intensified educational program to ensure that the message on the availability of the PHC through the mobile clinics reached the people on the ground.

Dr. Fraser pointed out that the Department had rolled-out some mobile clinics in some parts of the province but that due to resource constraints not many areas had so far benefited from this facility.

Dr. Jassat (ANC) pointed out that the Western Cape had often complained that it took a big chunk of the patient burden from the Eastern Cape. Did the Department makes savings from this relief?

Dr. Fraser observed that KZN made the very same allegation yet the government fully funded tertiary services in these provinces through conditional grants noting that this funding envisages such influx of referral patients from other provinces. The best way forward was to work together with neighboring provinces in order to improve provision of quality health services,certainly not through fighting each other.

Dr. Jassat asked if there was any training for traditional surgeons who preside at circumcision ceremonies.

Dr. Mjekevu explained that an Act had been passed to ensure that health standards are maintained throughout the circumcisions exercise but that the Department would not be drown into making decisions as to who became the surgeon. The Department also involved the traditional surgeons in AIDS awareness campaigns to sensitize them on dangers of infection.

The Chair was concerned about the number of vacant posts and was very pleased to see that most of them had been filled. Almost all posts for CEO were now in permanent employment unlike in the past when about all office bearers were there in an acting capacity. He applauded the Department for its efforts at decentralization of facilities in, which would no doubt improve service delivery noting that measures to address the biting TB situation were equally commendable. He pointed out that the Committee would continue to engage the Department on these issues in future in order to help them improve the provision of health care service in the province.

Mpumalanga submission
Ms Riena Charles, Head of Department, stated the vision of the Department was that of being a caring and humane society in which all the inhabitants of Mpumalanga had access to affordable, good quality health services. The mission of the Department was essentially to provide and improve access to health care for all, and reduce inequity. The Department would focus on working in partnership with other stakeholders to improve the quality of care at all levels of the health system especially preventive health and to improve the overall efficiency of the health care delivery system.

Ms Riena Charles tabulated the Department's Legislative Reform programme and pointed out that the Draft Provincial Health Bill had been developed and that a business case was already prepared for the process of consultation. The Department intended to pass the provincial Health Bill by the end of 2003 and that with respect to colleges, the Department hoped to align pieces of legislation touching on the former homelands. The promulgation of the Mental Health Act would enable the Department to train of Health Workers in this field.

As a pointer to the excellent services the province had rendered so far, Ms Riena Charles drew members' attention to the three prizes that the Department won in the Cecilia Makiwane Awards. She singled out the Premier Service Excellence Awards, which received six trophies for service excellence of which the Mpumalanga Department of Health received three. The National Department of health had awarded the National Disability Trophy to the Provincial Rehabilitation Program.

Turning to the critical area of the PHC Service provision Ms Riena Charles noted that the District Health System had witnessed a decreasing morbidity and mortality through strategic interventions. Treatment guidelines for sexual assault was implemented in all health facilities. Sexual assault support rooms had been established in ten Hospitals. There was an on-going monitoring of skills implementation amongst those trained in this discipline. The Victim Empowerment project had been opened at the Othandweni Violence Referral Centre. She reported that the project was progressing well in counselling and supporting an average of 80 clients per month noting that the clients that had been seen so far presented with rape, other sexual offences and domestic violence.

Ms Riena Charles outlined the Department's priorities for the next eigtheen months namely that a basic package of secondary hospital services would be established including an increase in district hospital services and PHC services. The Department would provide health support services while at the same time developing the workforce to ensure fully functional health facilities. The Department would strive to improve the management of pharmaceutical services and establish and maintain information management and research. Information technologies would be incorporated and developed in addition to the Reconstruction and Rehabilitation of health facilities.

Dr. Luthuli (ANC) noted that there was a substantial roll-over on the HIV/Aids allocation and inquired on what became of this roll-over. The new director would take some time to acclimatize with the office and asked how the Department would move to ensure that spending in this area was accelerated.

Ms Riena Charles replied that it had taken long to fill the directors' post due to the fact that the Department wanted to identify the most qualified person to fill the job and that it was not easy to attract the right calibre of skills in that part of the country.

Ms Baloyi noted with concern that quite a substantial sum of money remained unspent in spite of HIV/AIDS in the province. She asked why the Department had taken so long to set up the necessary units for the past three years? Precisely how did the Department plan to spent its budgetary share? What monitoring mechanisms had been put in place together with the necessary training programme?

Ms Riena Charles replied that a director had been appointed to monitor all development programmes and that so far there had been no problem in the disbursement of funds to various projects.

Ms Baloyi faulted the Department for allotting scarce resources to the all-important PHC program and yet more money had been channeled to the district health facilities. This, she lamented, was contrary to government policy to promote the PHC as the focal point of basic health delivery.

Ms Riena Charles referred to the Department's strategic plan, which outlined an elaborate plan to roll-out the PHC program.

Ms Baloyi said that the Department's pharmaceutical program had been problematic and asked what intervention the Department had put in place to address this malady. What was the Department doing around the roll-out of the nutritional program.

Ms Riena Charles explained that the subsisting pharmaceutical contract had been terminated and that in its place the Department had developed service level agreements, which were being finalized for implementation.

The Chair noted that the main problems with the Department's presentation stem from the fact that it had not incorporated the responses that were given to queries raised by members into its strategic plan. It was not clear from the its report what its strategic vision was and what its strategic plans for the year 2003/04 would be. There must be a correlation between the strategic plans and the budget. The Department had displayed similar deficiencies like the one afflicting the KZN report.

The Chair pointed out that one would have expected the Department to address what business plans it had developed to absorb the increased HIV/AIDS allocation. Mpumalanga was essentially a rural province so what plans had the Department made to attract professionals?

Ms Manana - MEC Health - defended the Department from accusations of deficiencies noting that the Department had responded to the issues addressed in the letter of invitation. She called for clarity of communication in future to avoid this kind of misunderstanding.

Ms Riena Charles referred the Committee to the Department's strategic plan, which comprehensively address all the issues that members had raised. She explained that the impression the Department had was that the queries raised by members were the main area the Department would be called upon to address.

The Chair insisted that the Committee had not diverted from its practice in the previous hearings, which required an elaborate layout of strategic plans in budget presentations. He noted that the same letter of invitation had been sent to other provinces and there was no misunderstanding of issues so far save for the case of Kwazulu Natal. He promised to liaise with the MEC so that the Department would be given another opportunity to tender a better report and to enable members to interface with relevant issues more meaningfully.

Free State submission
Dr V Litlakanyane, Head of Department, stated that the Department's mission was to provide quality, accessible and comprehensive Health Care Services to the Free State community.

The Department's goals included to:
- Reduce the burden of HIV/AIDS and TB
- provide a functional district health care system
- develop and empower personnel and stakeholders
- ensure an appropriate infrastructure

Dr Litlakanyane informed the Committee that the budget allocated for addressing HIV / AIDS in the Province, almost doubled from R18.5 million in 2002/3 to R30 million in 2003/4.

He stated that the Department's achievements were addressed at the back of the presentation document which the Department had distributed ("Summary of the achievements of the MEC deliverables for the Department of Health for 2002/3").

Some of the challenges he mentioned, were
- the provision and facilitation of the sustainable development of infrastructure
- the enhancement of economic development and job creation
- ensuring a safe, secure environment

In order to achieve these objectives, the Department seeks to:
- strengthen primary health care services
- deal decisively with HIV / AIDS and other communicable diseases
- efficiently and effectively manage resources, including personnel

The Chairperson commented that it appeared as though more finances were being allocated for health at district level, than at the primary health level.

Ms M Malumise (ANC) enquired about the progress of the Prevention of Mother to Child Transmission (PMTCT) programme.

The Chairperson requested to know the per capita expenditure in the Province.

Dr Blecher, Director Public Finance, National Treasury stated that the table showing expenditure within the District Health Services programme showed very peculiar trends. Was this due to an error based on the first year of implementation, or was there were some other explanation?

Dr Litlakanyane replied, with regard to progress on the PMTCT programme, that the Department had started with two sites, one in a rural area. They now have seven hospitals within the Province that provide these services. Neviropine was being was being provided by all the hospitals, with post-exposure prophylaxis (PEP) being provided for rape victims.

The per capita expenditure for the Province stood at R866.11.

Dr Litlakanyane replied to Dr Blecher's question on the strange expenditure trends, that he would first have a relook at the figures, in order to provide an appropriate response thereafter.

Meeting was adjourned.


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