Health Budget: Kwazulu-Natal, Western Cape, Gauteng Input: submission

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Health

13 April 2003
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Meeting report

HEALTH PORTFOLIO COMMITTEE

HEALTH PORTFOLIO COMMITTEE
14 April 2003
HEALTH BUDGET: KWAZULU-NATAL, WESTERN CAPE, GAUTENG INPUT: SUBMISSION


Chairperson: Mr L V Ngculu

Relevant documents:
Kwazulu-Natal Responses to Questions on Budget
Kwazulu-Natal Budgeting Process
Kwazulu-Natal Comments on the Health Budget
Western Cape Department of Health Presentation
Gauteng Department of Health Presentation

SUMMARY
Kwazulu-Natal's Department of Health presented the Department's answers to the Committee's questions prepared in advance. The discussion focused on the Department's budget decisions, the need for better medical services in rural areas, the funding received from the HIV Global Fund, and issues concerning building contractors.

The Department of Health in the Western Cape presented their budget to the Committee and outlined their plans for Healthcare 2010 for a more equitable distribution of medical service facilities and the building of a new hospital that will service Mitchell's Plain and Khayelitsha. The discussion focused on the location of medical services, the decrease in beds for psychiatric patients, mother to child HIV transmission rates, and the provision of primary healthcare.

The Department of Health in Gauteng presentation focused on the Department's strategic goals and key priorities, the alignment of the ten point plan, the five biggest expenses, financial management, budget allocation, and budget issues. The discussion looked at the programme to reduce transmission rates of HIV from mother to child, the expenses of antibiotics, electricity and water, , prescription drug thefts, the hospital laundry situation, and the availability of laboratory tests.

MINUTES
Kwazulu-Natal submission

Prof R W Green-Thompson from the Department of Health in Kwazulu-Natal presented the Department's answers to the Committee's questions on their department (see document). Prof Thompson's presentation focused on the inequities of funding among the provinces, the Department's reasons for overspending, the change in spending for the Department's programmes, the supervision of building contractors, and the HIV/AIDS budget allocation.

Discussion
Ms M Malumise (ANC) asked about the time frame for implementing the rural incentives scheme.

Prof Thompson responded that he was unaware what the time frame was for implementing the rural incentives scheme.

Dr A Luthuli (ANC) asked why the Department under-spent on the health facilities management budget.

Mr H Conradie, Chief Financial Officer, answered that the under-spending was a result of the slow process of the Public Works Department. The money spent on facilities has to go through the Works Department. If a tender cannot be processed by them in that financial year, then the money cannot be spent.

Ms S Baloyi (ANC) asked about the HIV Global Fund. She also was concerned about the inequity between primary and tertiary healthcare services.

Concerning the HIV Global Fund, Prof Thompson answered that the money Kwazulu-Natal received from that fund was an add-on. The money was used across the spectrum of HIV/AIDS spending, from supporting home based care and hospice to prevention and treatment of the disease to sustaining behavioural change in order to prevent the spread of HIV. He reiterated that the Global Fund money was an add-on and could not be viewed with the budget.

Mr Conradie answered the question relating to the inequity between spending on primary and tertiary healthcare. He stated that the percentage of funds spent on primary healthcare has risen from 16% in 1998 to 22% of the total budget.

Dr Luthuli asked what specific plans the Department had to address inequities among districts.

Prof Thompson answered that the Department has been working out problems and inequities that exist among the districts. The problem cannot be solved by simply allocating more pay to medical professionals who work in rural areas. Infrastructure in these areas must be upgraded to attract the people necessary to improve the medical treatment in rural areas. He stated that all clinics have water, almost all have electricity, and most have telephones. By continuing to improve infrastructure, the Department will be able to recruit more medical professionals to rural areas that need them.

Dr E Jasaat (ANC) asked about the public/private initiative to combat STDs and about the correlation between HIV and tuberculosis.

Prof Thompson stated that there is a correlation between HIV/AIDS and tuberculosis. He stated that the relationship between the public and private sector has been improving.

Dr Cachalia wanted clarification about the building of medical facilities and who was given the contracts.

Mr Conradie explained that unfortunately most of the tenders went to the most established contractors. Smaller, emerging contractors could not perform the jobs because of the structure of the contracts as required by the Public Works Department. The contractors must perform three months of work before receiving any payment, which is an impossibility for small, emerging contractors.

Ms Baloyi asked if the Department had a revenue retention system.

Mr Conradie answered that the Department does not have a revenue retention system, but rather a revenue incentive system. A hospital will keep some of the revenue that they have received that is over their targeted amount.

Dr Luthuli asked if the demographic balance in medical school was working in favour of doctors working in rural areas. She also noted that tuberculosis cure rates are low.

Prof Thompson agreed that the cure rate for tuberculosis is low and stated that the Department was working toward alleviating this problem. District and provincial co-ordinators have been appointed to work on the problem. Community health workers are also helping with this problem. More home based care is important in improving the situation.

With regard to the changing demographics of medical school students, Prof Thompson stated that the incoming student body was moving toward demographic representation. Rural black students are being recruited. The problem was coming up with adequate incentives to persuade medical students to return to rural areas to work.

Western Cape submission
The Department of Health and the MEC from the Western Cape attended the Committee meeting. Prof K Househam, Head of the Department of Health, made the presentation to the Committee (see document). The presentation detailed Healthcare 2010, a departmental plan that focuses on guaranteeing equal access to quality care by 2010. The presentation also focused on the provision of primary healthcare, the inequitable distribution of medical facilities, HIV/AIDS testing, and the decrease in beds for psychiatric wards.

Discussion
Dr Cachalia asked about the projected budget from 2004 to 2006. He asked if the Department expected inflation to decrease during that period. Additionally, he noted the drop in beds for psychiatric patients to 1 300. He asked if the Department expected a decrease in psychiatric problems. He was also unclear about who was responsible for feeding children in schools as he thought the Education Department was supposed to assume responsibility.

Prof Househam stated that inflation is a national adjustment, suggesting that the Department's budgetary estimates for future years are in today's dollars.

He stated that the Department did not expect a decrease in psychiatric problems, but that the decrease in beds could be justified by increasing home care and community based initiatives. The same amount of money will be spent, but it will go to things other than beds for psychiatric patients.

He answered that the Department of Education will be responsible for feeding school children, but not this year.

Ms Baloyi asked if the Department was taking staff on board for the Healthcare 2010. She noted that the Committee was placing a lot of emphasis on tertiary health delivery. She asked what the Department was doing to improve primary healthcare. She explained that most hospitals are in white areas and asked what the timeline was for the hospital the Department said it would build on the Cape Flats. She also asked the Department to address problems concerning cross-border patients and inequities between the districts.

Prof Househam explained that there has been a shift from health services to primary care. The cost of service at the primary level is much less than that at the tertiary level. 88% of patients go to primary care, while 8% go to secondary care and only 3% go to tertiary care. Yet tertiary care consumes 35% of the budget.

The Department's Chief Financial Officer explained that primary healthcare has seen a 14,3% growth in funding while tertiary care has received a 4,9% growth in funding.

The Western Cape MEC, Mr P Marais, noted that all of the staff will have their role in Healthcare 2010 explained. The major focus is on home care, community care, and primary care. A more appropriate level of service will be provided in these areas.

With regard to the location of hospitals, he noted that a map will be made available relating the location of the hospitals and clinics, as well as their function and the number of beds. The Healthcare 2010 plan makes provisions for a better and more equitable distribution of medical service facilities. This includes the expansion of current facilities that service areas of the Flats and the building of a new hospital that will service Mitchell's Plain and Khayelitsha. There is no time frame for this new hospital, as it is in the planning stage, but money should be able to be freed up for the project.

With regard to the medical services provided to those from outside the Western Cape, Prof Househam stated that the Department had an obligation to offer services to all South Africans. That being said, 15-20% of the people offered medical assistance in the Western Cape are from other provinces. This is not taken into account in the appropriation of conditional grants.

Hospitals in most rural areas of the Western Cape are under-utilised. They need proper staff and equipment. In some areas, bed occupancy is under 40%. He admitted that there are major inequities between the districts, but stated that expectations for medical care are much higher in the city.

Dr Chalachia asked if community based care would be able to address the needs of mentally-ill patients.

Prof Houseman argued that the Department would not de-institutionalise mental illnesses. He explained that the Department may be cutting down the number of beds for the mentally-ill, but it was simultaneously building up the ability to treat these patients in other ways.

Dr Luthuli asked how patients get services despite their inability to pay. She also asked about the decrease in conditional grant funding and the difference in funding between district and central hospitals.

Prof Houseman answered that no one would be turned down because of his or her inability to pay. The decrease in the conditional grant was necessary so that services could be built up in other provinces. A significant amount of money is necessary to upgrade and build infrastructure in other provinces.

Ms Malumise asked about treatment for babies born of mothers who have HIV. She also asked about the training and retaining of medical professionals with regards to foreign countries.

With regard to mother to child HIV transmission, the Western Cape is aiming for 100% coverage for anti-transmission. 344 clinics and 60 mobile clinics are providing this treatment. Currently, 80% of women who come for their first antenatal test are tested for HIV/AIDS. The transmission rate of the disease, mother to child, is roughly 12%. The expected rate is between 25 and 30 percent.

On a question about the targeting of overseas students, Prof Househam answered that the Department was targeting overseas students to come and work in South Africa. The concern is that young medical professionals are being recruited to leave South Africa. This is not a problem as long as they come back. The Department must look at its strategies for many young medical professionals who want to stay in South Africa but leave because they get frustrated. They are unable to do their work and research because of a lack of funding and they are concerned about their personal safety, so they leave.

Mr Ngculu asked Prof Househam to give his assessment of the current process of the conditional grants. Did he believe the government is currently taking the correct approach in providing conditional grants? He also asked for his view on the tendering process and the accounting process.

Prof Househam replied that conditional grants are not a problem with hospital revitalisation programs. The Department required more money for restructuring, but that it could make due with the money it had. The Department may also look at other ways of raising revenue from its property holdings. With regard to money for equipment, the R40 million designated will not be enough, but the Department will maximise the benefit from that money in addressing the equipment backlog.

Gauteng submission
Dr G Ramokgopa of the Gauteng Department of Health delivered the Department's presentation to the Committee (see document). She focused on the Department's strategic goals, key priorities, the alignment of the ten point plan, the five biggest expenses, financial management, budget allocation, and budget issues.

Discussion
Ms Baloyi asked about the roll out of the programme to test mother to child HIV transmission rates. She asked if there was a follow up mechanism for gathering the information. Additionally, the Department did not indicate how it would deal with the five biggest expenses that it had identified. She asked if there were standards for the prescription of antibiotics, which is the fifth biggest expense.

Dr Ramokgopa answered that the programme was being rolled out quickly because Gauteng is privileged with greater access to resources. All public hospitals provide the transmission testing programmes. The challenge for the Department is following up. Once the mother has been diagnosed with HIV, the Department must follow up to find out if the baby contracted the disease. The way to overcome the challenge is to have an individualised follow up system that suits every person.

With respect to the five biggest expenses, she answered that electricity and water are necessities and there is nothing the Department can do to reduce those expenses. There is a protocol for the prescription of antibiotics in the public sector. Antibiotics constitutes such a great expense because of the great need for antibiotics, not because doctors over-prescribe them.

Ms Malumise asked if the facts reported in the media concerning theft are correct. She wanted clarification on the laundry situation. Additionally, she asked if the National Health Bill will help the Department in Gauteng.

Dr Ramokgopa replied that the Department has identified areas to deal with theft of prescription drugs. Theft of medication is a criminal matter. When theft is reported, the accused staff member is suspended pending an investigation. The Department is currently working to follow up leads concerning theft.

She noted that the Department would welcome the National Health Bill. The current national health bill was passed in 1977 and is clearly outdated. The Bill will help alleviate the funding gap presently in the system, especially the ones between local and national government.

The laundry situation has been improved but that there is room for further improvement. The Department needs to separate laundry services from hospital costs.

Ms Baloyi asked what the Department was doing so that people in informal settlements have access to medical services.

Dr Cachalia understood that the Department had a policy of providing laboratory services only between the hours of 8am and 5pm. What happened if a patient needed these services at other times?

Dr Ramokgopa replied that laboratory tests are available 24 hours per day. The Department does, however, attempt to limit laboratory tests outside the working day as those tests often cost double the amount.

The meeting was adjourned.

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