The Department of Health presented its Annual Performance Plan (APP) highlighting the Department made a lot of improvement regarding life expectancy, infant mortality rate and other programmes. Life expectancy increased from 57.1 to 63.3 years as of 2015, there was a significant decrease in Under Five Mortality Rate- reportedly 56 deaths per 1 000 live births in 2009 to 37 deaths per 1 000 live births in 2015.
The decrease in the Infant Mortality Rate was moderate, with just 39 deaths per 1 000 live births in 2009 to 27 deaths in 2015. The Department reported a significant decrease in mother-to-child HIV transmission, from 8.5% in 2008 to just only 3.5% in 2010, and 1.5% in 2015 - the Department was certainly moving towards and eliminating this epidemic. The number of people initiated on Anti-Retroviral Treatment (ART) increased nearly threefold and the number of people dying from AIDS reduced significantly from 41.9% to 27.9%. The TB treatment success rate was slowly moving towards a 100%, currently at 84%.
The Department’s financials reported Programme 5 (Hospitals, Tertiary Health Services and Human Resource Development) absorbed the largest portion of the expenditure budget amounting to R21.1 billion. Programme 3 (HIV & AIDS, TB, Maternal and Child Health) followed at R18.2 billion. Growth over the Medium Term Expenditure Framework (MTEF) period reported the Department’s compensation of employees’ budget had been reduced by R9.7 million for 2017/18, R10.7 million for 2018/19 and R11.3 million for 2019/20. The goods and services budget had been reduced by R22 million over the MTEF period. A new component had been added to the National Health Insurance indirect grant for an integrated patient based information system and an electronic stock management system which included an early warning system for stock-outs of medicine in primary health care facilities, R166 million, R390 million and R411.8 million was allocated, respectively, over the MTEF period. R600 million had been re-prioritised for the operation of the Nelson Mandela Children’s Hospital (R100 million, R200 million and R300 million).
Members asked questions about how the Department intended to reduce deaths through injuries, when the global health security was scheduled to happen, total spending on primary health and a consolidated figure on what the provinces spent. There was discussion on how the Department intended to respond to Non-Communicable Diseases (NCDs), resources required to implement the National Mental Health Policy Framework strategic plan, and assessments required for it, budget allocation for infrastructure and maintenance in clinics and hospitals.
The Committee wanted to know more about the School Health Programme, how the Department planned to reduce teenage pregnancy, measuring HIV/AIDS campaigns and consequences for provinces that did not respond to letters coming from the DG’s office. Members asked why a national approach to malnutrition was not developed so that it could be implemented by provinces, instead of focusing on two provinces, whether the 2 000 functional WBHPCOTs were actually functioning, why certain indicators had been removed from the APP and an update on all infrastructure revitalised.
Briefing by Department of Health on its Annual Performance Plan 2017/18 – 2019/20
Ms Malebone Matsoso, DG, Department of Health, took the Committee through the presentation stating there was alignment between the National Department of Health, provincial and district departments in terms of annual plans. Under outcome number two of the National Development Plan (long and healthy lives for all South Africans), reflected gains from 2009 to 2014 included:
- increase in overall life expectancy from 57.1 years in 2009 to 63.6 years in 2015
- decrease in the Under-5 mortality rate (U5MR) from 56 deaths per 1 000 live births in 2009, to 37 deaths per 1 000 live births in 2015
- decrease in Infant Mortality Rate (IMR) from 39 deaths per 1 000 live births in 2009, to 27 deaths per 1 000 live births in 2015
- decrease in mother-to-child transmissions of HIV from 8.5% in 2008, 3.5% in 2010 and1.5% in 2015
- increase in the number of people initiated on Anti-Retroviral Therapy (ART) increased nearly threefold (1.4 million in 2011 to 3.7 million in 2016) in the past five years
- decrease in the total number of people dying from AIDS – the percentage of AIDS deaths reduced from 41.9% to 27.9% (2016)
- TB treatment success rate increased from 74% in 2009 to 84% in 2015.
With regards to the neonatal mortality rate, the baseline year (2009) targeted 14 neonatal deaths per 1 000 live births - the current performance reported 11 neonatal deaths per 1 000 live births. Further detailed information on the programme performance of the Department can be found in the document attached.
With regards to expenditure per programme, programme 5 (Hospitals, Tertiary Health Services and Human Resource Development) absorbed the largest portion of the expenditure budget amounting to R21.1 billion, followed by programme 3 (HIV & AIDS, TB, Maternal and Child Health) at R18.2 billion. Lastly, the programme 6 (Health Regulation and Compliance Management) absorbed R1.7 billion of the budget. Budget allocation for sub-programmes 2, 4 and 6 was expected to grow in the 2018/19 financial year or Medium Term Expenditure Framework (MTEF) period. Growth over the MTEF period reported the Department’s compensation of employees’ budget had been reduced by R9.7 million for 2017/18, R10.7 million for 2018/19 and R11.3 million for 2019/20 respectively. The goods and services budget had been reduced by R22 million over the MTEF period. A new component had been added to the National Health Insurance indirect grant for an integrated patient based information system and an electronic stock management system which included an early warning system for stock-outs of medicine in primary health care facilities - R166 million, R390 million and R411.8 million was allocated over the MTEF period. R600 million had been reprioritised for the operationalisation of the Nelson Mandela Children’s Hospital (R100 million, R200 million and R300 million over the MTEF).
In conclusion, the Department’s 2017/18 – 2019/20 APP was founded on government’s 2030 vision outlined in the NDP. It reflected interventions to improve the health system and health outcomes for all South Africans. The Department will continue to work towards improving equity, quality and access to healthcare through the introduction of the National Health Insurance and other Health Sector reforms through various initiatives.
Dr P Maesela (ANC) noted that with grants given to the provinces by the National Department, the Committee had been suggesting the funds could be used for infrastructure revitalisation – this would help a lot. In the next two to three years all tertiary institutions could be revitalised and there would be progress. How much infrastructure had been revitalised thus far. He requested the Committee be updated as to why there were problems with SAHPRA (South African Product Regulatory Authority), and when will the CEO get appointed.
The lack of visibility of the school health programmes was worrying because if the children were not caught at an early stage they became part of the bigger problem at a later stage. Catching them at that age was part of prevention which was better than cure. There were supposed to be teams doing this but they were invisible – the Member said he had never met any of the teams although they were supposed to be around.
He was concerned by the lack of progress in implementing the Global TB Caucus Strategy – was it still in the pipeline? When would the Committee hear about it? How did the Department intend to reduce deaths through injury? The focus was not about reducing accidents but rather injuries sustained through accidents that then lead to death. Perhaps the Department should engage the RAF (Road Accident Fund) and come up with strategies on how this can be reduced or prevented. Environmental health was very worrying as well as mining related health problems - there were good programmes in terms of compensation for people who were damaged instead of inventing plans that prevented people from being damaged. The strategy needed to be tweaked and people needed to be compensated as soon as possible so that they were able to receive treatment.
Dr W James (DA) welcomed the development of a National Health Commission which had been a long time coming. Joint evaluation for the global health security was also very welcomed – when was this scheduled to happen? Support for the Nelson Mandela Children Hospital seemed to be in good shape and this was also very welcomed.
He asked about total spending on primary health - the budget was a national one and it did not reflect expenditure on provinces. He asked for a consolidated figure on provincial expenditure. It seemed as if there was enough infrastructure but the problems of staffing continued to be persistent – this was where the expenditure budget focus should be. He suggested that perhaps there should be a 24/7 operation in the institutions - although this may be a challenge and strain the budget, it was something that should definitely be considered.
The Medical Council, in its presentation to the Committee, reported that non-communicable diseases were increasing – how did the Department intend to respond to that? Funding on the basis of disease burden should be the approach in terms of allocating adequate funding to mitigate these diseases. With regards to the National Mental Health Policy Framework strategic plan, he wanted the Department to disclose how much resources would be required to implement the plan. What assessment was required?
Ms C Ndaba (ANC) noticed that indicators relating to CCOD, had been removed from the APP – she asked if this was an oversight on the part of the Department or not. In terms of reducing maternal mortality in Africa, had the strategy ever been evaluated on whether there was improved or not? With regards to the maintenance budget for infrastructure, she was uncertain of whether the budget allocated for infrastructure included maintenance. Did this budget set aside funds for all the clinics and hospitals across the country because in some clinics and hospitals the infrastructure was ageing? Perhaps, the Department can consider having a maintenance team that dealt strictly with maintenance issues in the institutions – it was critical and important there was budget for maintenance. Training for nurses had been an ongoing process for a long time but the Department did not seem ready. The Chief Nurse came to the Committee and explained but it was still unclear whether there was progress or not – she was concerned by uncertainty on what exactly was going on in this regard.
Ms L James (DA) asked for an update and feedback on the School Health Programme. Last year there was a steep increase in teenage pregnancy – what was the Department doing to ensure this was reduced? Was the Department measuring HIV/TB campaigns? If so, how? It seemed the campaigns were not visible enough and she was not sure where they were happening. Had roadside blood or alcohol testing happened ever happened anywhere in the world? Was there even capacity to carry this programme, as spoken of by the DG, through? Some clinics and hospitals were not in good conditions – did the Department ensure the provinces budgeted for infrastructure and maintenance?
Ms S Thembekwayo (EFF) stated the Department wrote letters to the provinces but there was no response. Beyond this, the DG said nothing could be done about it – this was problematic because the content of the letters were important. What were the consequences of such insubordination and lack of response? Perhaps the Department can set up a team that did follow ups on the contents of the letters because it cannot be left alone and not attended. With regards to the complaints port from hospitals and clinics specifically from the patients, it would be better if there would be campaigns that promoted and created awareness of the existing complaints channels instead of hearing about these complaints from the media.
Mr A Mahlalela (ANC) observed the challenge of multiplicity in relation to the Department’s plans which made it difficult to have proper alignment between the Department’s APP and budget – this challenge of multiplicity in the Department’s planning might explain the reason for the lack of correlation between the Department’s performance and expenditure. It seemed to be a challenge not addressed. The budget did not link with performance indicators because of the stance the Department had taken that most of these functions were carried out by provinces and this then somehow exempted the Department from any responsibility because the provinces were carrying out the work. This was not ideal because it was the Department that dished out conditional grants – this explained the lack of correlation between the APP and budget.
Statistics SA reflected, in its research, there was a rise in non-communicable diseases – what was the Department’s stance on this because nothing much was said in the presentation. This was similar to the issue of the mental health programme where there was no monitoring system in terms of implementation. Even in the APP no mention was made about assisting provinces in the implementation of mental health. A framework on mental health was adopted but there was no activity and implementation of that framework in provinces- there was no clear plan on what the Department expected from provinces. Another general observation was the issue of social determinants of health and working together with various government institutions on what can be done about the determinants – the Medium Term Strategic Framework (MTSF) was not clear at all on what it was that needed to be done.
With regards to the APP and the issue of malnutrition, it seemed the focus will only be on two provinces (Eastern Cape and North West) – why did the Department not develop a national approach on the matter for all provinces to implement? There should be a national approach so that a national framework can be developed in a broader sense. In relation to programme 4, Primary Health Care, and the 2000 functional WBHPCOTs, was the Department talking about the current WBHPCOTs? Were they functioning? When the Committee did its oversight in Gauteng, these WBHPCOTs were not functioning and it was a disaster. What did the Department mean by 2 000 functional WBHCOTs? Community health workers were part of these but province were implementing these differently so there was no consistency in the implementation. He then asked why certain indicators had been removed and why others, implemented by provinces, were included in the APP.
In relation to legislation mentioned in the APP, it was not clear when some of the legislation would be tabled – clarity was required thereon so the Committee could plan ahead notwithstanding that some of legislative processes may be outside the control of the Department. What infrastructure and institutions had been revitalised and refurbished and where? The Committee had asked this question before and the Department promised to deliver this information but this was to no avail. Which were the 42 clinics and eight hospitals to be revitalised and where were they located? Also required were the timeframes for design and construction.
Ms Ndaba highlighted that during Committee oversight visits in the provinces, there was a consistent issue of staff shortages - were there any plans in place set by the national Department to mitigate this issue? This was something raised several times before. This issue was affecting the existing staff because they ended up faced with a lot of work.
The Chairperson asked whether the Department had any intention to have an integrated programme with the Department of Social Development regarding mental health as a silo mentality will deter the progress of the Department. The Department had a programme called Wising - where was it now given shortage of staff and bloated structures in provinces? What was the impact of Mom-Connect? The programme was developed precisely to deal with neonatal maternity.
The DG responded that in the joint-sitting with the Standing Committee on Appropriations, the Department presented an analysis on the allocation of grants. The grants were created for a specific purpose and were not meant to be there forever. There was a grant as a form of control kept at national level. The only allocation at national level will be R5.1 billion and the Department would account for every cent. The overall budget allocated to provinces was not a linear process – when the funds were allocated by Treasury to provinces, through the equitable share, it could take different forms and shapes. The Department accompanied the Appropriations Committee to provinces, such as the Free State, when there was a crisis.
Members needed to refer to the National Health Act because what the Department was doing was in terms of general functions of provincial departments and then what was to be done at national level. The Intergovernmental Relations Act was also very specific on what must be done and how far the Department could go in terms of taking decisive interventions – one could not act contrary to the Act. The Department had gone as far as requesting legal opinion on the matter. The reality was that if interventions were to be radical, laws needed to be amended but there must be consensus as to the extent of the intervention. Some powers must be removed from provinces and given to districts but then districts were simply administrative offices and an extension of the province. There was need for a change and different structures – the Department had ideas on how the districts should look.
With regards to SACRA, this was a sequencing issue. There was a hanging legal issue where one stakeholder group said regulations could not be published without proclamation of the Act while other stakeholders were saying the opposite. The Minister must make regulations in consultation with the board but the board was not yet established so there were two contrary opinions. The Department, however, decided to go ahead with publishing of the regulations while the Act would be proclaimed at a later stage. The advert for the board would soon be out. Proclamation would be awaited as the regulations were ready. Appointment of the CEO could then begin.
Since the programme of school health started, the Department assessed 4.5 million learners and information can be provided by school and by learner - the Department could also communicate what was wrong with those learners. There were 298 community workers on the database and although they had finished their work, provinces refused to absorb them citing lack of funding. The Department had since come up with a programme on how those workers can be utilised to assist learners with barriers to learning. The Department also used donor funding to deal with certain problems.
Ms Matsoso then looked at reducing death through injuries noting that the RAF did not disclose the information in full regarding the results of the injuries, only the number of people who died. The Department only made evaluations based on incomplete information so while death was not prevented, the emphasis was on ensuring those who survived were assisted. The Department will not perform functions of other departments but it was willing to work in partnership - the Department could only assist as far as the law allowed.
On the National Health Commission, the Department was waiting on it but it was finally going to happen. It was difficult for the Department to play a facilitating role without the Commission as implementation needed to be monitored. With NCDs (Non-Communicable Diseases), tobacco was a risk factor in terms of whether it should be written each time in the Health Act and APP. It did however need to be monitored. It was an issue that did not include health alone but various other departments too, such as Treasury. These matters were behaviour related issues and had to begin in schools for the behaviour to change. For example, the salt regulation was amalgamated but people still went on to put more salt on their food – this explained the underlying factor of behaviour.
Ms Matsoso said the 24hour service was an important discussion to have but she was of the opinion that the Department could not have such a service or operation at this moment across the country. At the moment there were workshops done in provinces and so the provinces should assist the workers.
With the National Mental Health Policy Framework, Ms Matsoso agreed there was governance problem. At national level there was a ministerial advisory committee and at provincial level there were Mental Health Review Boards. The Department could provide a report about the performance of every single Mental Health Review Board and training provided in every province and workshops conducted. The question was if there was a problem in the manner the Mental Health Act was amended in 2012. If this was the issue, the Act should be revisited/reviewed. There were four pieces of legislation if de-institutionalisation happened with which provinces would have to comply. The first was the provision for licensing of a health establishment – it was the responsibility of the province to determine whether there was a health establishment or not. The second provision was in terms of the Mental Health Act. For an NGO, there was a provision for it to be registered with the Department of Social Development. A provision for municipalities centred on the appropriateness of infrastructure. When all 27 had been assessed, it came to the fore that 20 did not meet the requirements while seven met the requirements but did not comply with municipal laws. The department then went back for follow up inspections. Only one out of the seven met the requirements and the municipal laws were implemented by national. NGOs needing to be registered with the Department of Social Development and then questions of Department of Health oversight in this regard, concerned the matter of mandate. While laws of the Department had been reviewed, the Department aimed to return to review the legislation for purposes of alignment. This review was completed by the legal team and the Department was ready with the guidelines. These were however “soft” laws which could not be enforced although they would eb gazetted.
With regards to the district health system, it has to change and the department has proposals on how it should change, and if this is possible the department would like to start as soon as possible with implementation. If the department can find expression in regulation, it would really help.
With reduction of the neonatal maternity health, because SA was chair of the African Union, the Department prepared a report on what it had achieved as a country and to share what other countries had done. The report the Department relied on was the one of the World Health Organisation Africa region because it was a systematic and rigorous report. With maintenance of infrastructure, the Department had presented a detailed document to a joint Committee meeting – to refresh the minds of Members in terms of planned infrastructure maintenance, the report could be provided to the Committee again. The Department could show that out of the 1 037 ideal clinics with infrastructure issues, which ones were solved, and the link between that and Wising. All data in this regard could be provided to the Committee.
Ms Matsoso said that with nursing training, the Department was indeed moving at a slow pace but it could provide brief the Committee on issues experienced in this environment. The Department did reviews on each and every programme and information thereon can be extracted. There were also formal reports on the information which could be shared.
With regards to letters written, the DG stated that she followed up, monitored and demanded reports on the service providers not paid and each and every letter that her office sent to the provinces. The Department started a process with the medical device industry because the industry complained it had not been paid - Ms Matsoso monitored this to check which province had not been paid. Each Head of Department (HOD) was an accounting officer according to the Public Finance Management Act (PFMA). The HODs were to ensure payments were made to providers within 30 days – while the DG was under no obligation to write letters regarding payments to providers, her office did so anyway. Some providers responded that they were paid while others did not bother. The reality was that every HOD was under obligation, in terms of the PFMA, to pay service providers within 30 days.
Provisions of Treasury were included in the APPs but not included were the Department’s operational plans – if this were included the APP would be a very thick document. The operation plans could however be provided to the Committee should it so request. The APP reflected everything the Department did. Provinces had their own indicators, for example, Mpumalanga, Limpopo and KZN had malaria endemics so it would make sense for those provinces to have plans and indicators for malaria. Not all provinces had a malaria problem so malaria indicators were there for the provinces with the problem. There was a national indicator for malaria because SA was part of the countries globally appointed as a malaria-eliminating country. Provincial indicators were no included in the Department’s APP because provinces had their unique indicators and not because the Department was trying to paint a good picture of itself nationally. With the indicators in the APP there was a system to collect the data related to them.
Ms Matsoso then spoke to the NCDs noting that SA had risk factors and with these factors came regulations. She would not mislead Parliament and develop regulations on the Alcohol Bill because the Bill was not yet law – regulations could only be developed when implementation was being on done on the legislation. Equally with tobacco, the legal issues had already been outlined. With the risk factors of inactivity, the Department was working with others departments. If another department already took the lead on a certain programme, this did not necessarily mean it must be reflected in the APP.
With mental health, the Department used the incident management system. With provinces already shared, the Department could share what was done in this regard. The National Health Act was very specific with the board, or the National Health Council, which comprised all accounting officers, so when policies were agreed upon it, included every accounting officer. Responsibilities of the DG were also included in the Act. When the Department set an incident management system, it was set it up in such a manner so that it was user-friendly to the provinces.
In terms of the Social Determinants of Health, the Department was developing integrated planning within the concept of the district health system. In the past there was an MEC of Health and Social Development but this changed – perhaps this needed to be relooked because integration was necessary. With malnutrition data, there were two provinces which had the highest burden but this did not mean others did not have that problem - the Department picked the provinces with the highest burden.
Ms Matsoso said the Department had a legislative programme but this did not really help. For example with the Alcohol Bill, it went through Cabinet, Socio-Economic Impact Assessment System (SEIAS) and public comments. The Department can provide the Committee with its schedule on legislation but it had not even been invited to Parliament yet for a briefing and public hearing even though the Bills had been gazetted.
With shortage of staff, the Department presented budget issues to the Appropriations Committee in relation to provinces. There 298 allied workers (psychologists, audiologists, speech and hearing therapists, optometrist etc) in SA and while the DG had met them in person, they were unemployed. Of the R4.5 million assessed, the majority needed those services. The DG could share the names with the Committee. They could not be employed by the provinces due to budget constraints.
At district level the Department completed 24 district hospitals. The team working with the Department reported that at hospital level, it was a very complex exercise but, for now, the Department completed all primary health care facilities. All the data for this exercise could be reflected.
Dr Dlamini spoke on the school health programme noting that since it was launched, the programme focused on health barriers to learning. To date, there were 601 health teams which visited schools once a year and screened learners, from Grade R, Grade One and those repeating a year. For grade one, the teams assessed over 353 000 and 160 000 Grade Eights. With regards to teenage pregnancy, the Department was working with the Department of Basic Education and have come up with scripted lessons for Life Orientation, particularly those parts of the lessons deemed sensitive by teachers and therefore omitted. The Adolescent and Youth Health Policy had just been endorsed by the National Health Council. The Department adopted an approach that had been implemented in KZN called The Happy Hour - the name will soon be renamed due to issues of competition. The concept behind the approach was good - in the afternoon, when clinics had dealt with majority of the population and community, the clinics will be opened for youth people where there were young male and females nurses. The uptake was very good. The young people were then screened for Sexually Transmitted Diseases, HIV/AIDS and the provision of contraceptives. The Department was promoting the use of long term contraceptives instead of the injection. This instrument will be used to deal with adolescent youth health and there was a portal young people can use to ask any health related questions using their cellphones. There was also a campaign called “She Conquers Campaign” launched by the Deputy President last year which targeted women, from the age of 15 to 24, with four pillars:
- reduce teenage pregnancy
- reducing HIV/AIDS
- keeping the youth at school
- reducing gender violence.
Dr Dlamini said malnutrition was used as a generic term but included malnutrition wholly, severe acute malnutrition and stunting, where a child was too short for her/his age. There was a generic malnutrition plan but the provinces with the highest rates of malnutrition were intensely assisted by the Department and given extra attention. With Mom-Connect and the reduction of new born mortality, SA adopted the WHO recommendation of doubling anti-natal care visits from four to eight – all provinces adopted this approach.
Ms Matsoso said the Department requested budget allocation funding for mental health - for Gauteng it requested R200 million and R750 million for the rest of the provinces. In that process, whilst the request was submitted to Treasury, the Department of Health in Gauteng had allocated R893 million over the MTEF, but Treasury turned the request down. The Department will approach Treasury again in hopes that it might approve the second time around.
The meeting was adjourned.