The Department of Health (DoH) told the Select Committee on Social Services that it had made a positive impact on the health sector, such as increasing South Africans’ average life expectancy from 57.1 years to 63.3 years in the space of six years. In addition, there had been a decrease in mortality rate for children under the age of five, as well as the infant mortality rate. HIV/AIDS statistics had also declined through measures to prevent mother-to-child infection. While there had been a decrease in HIV infections among the youth, there was still concern about the vulnerability to the infection among young women.
The Department described six programmes that it plans to implement in the current financial year. The first programme was focused on administration, whose main aim was to provide support services to the Department. This includes effective management of funds, to enable accountability. This was implemented in the 2016/17 financial year, and the outcome was positive, the Department got an unqualified audit opinion. Programme two was focused on the National Health Insurance development and implementation, and systems enablement, thus there would be a patients’ register information system that would capture patients’ health information to enable them to go to any health facility in any geographical area, as long as it was still within the South African boundaries. Programme three focused on measures to further decrease under-5 mortality rate, infant mortality rate, morbidity, HI/AIDS, TB, etc. in all nine provinces. Programme four focused on primary healthcare services, which would improve nutrition and the accessibility of healthcare to the public, particularly people with disabilities. For instance last year only 25% of PHC health facilities were accessible to people with disabilities, and this year the Department was looking to increase the proportion to 35%, and up to 70% in 2019/20. Programme five focused on hospital, tertiary health services and human resource development, where policies and delivery models would be developed. In addition, the capacity of staff would also be increased through HR health systems. Moreover, health infrastructure would be improved through maintenance, repairing and refurbishing the existing infrastructure. Lastly, programme six focused on health regulation and compliance, where regulations of food would be established in order to improve the life expectancy of South Africans through the establishment of state entities.
Overall, the Department was applauded for the work that it had done thus far, and the work that it continues to do. As a result, there would be an investigation that would be conducted because some doctors who work for public hospitals sign the register while they were secretly moonlighting in private hospitals whereas they were on duty, stealing government’s time and still getting paid. The public suffers in the process because they do not get the help that they need from doctors, due to their absenteeism and moonlighting, and this affects service delivery and hinders the progressive work and quality services that the Department hopes to render. Moreover, student doctors suffer too because they were not getting the adequate training they were supposed to be getting. The latter was of importance too because there would be Cuban final year medicine students that would be coming to South Africa next year in August for their training in public hospitals.
In terms of the budget, it had increased but the percentage growth would be slow over the coming years. The budget for compensation of employees had been reduced by R9.7 million for 2017/18, R10.7 million for 2018/19, and R11.3 million for 2019/20. The overall budget for the programmes would fluctuate over the years, there would be a general increase in most programmes, however, some of them would have slow percentage growth.
Annual Performance Plan 2017/18 – 2019/20
Dr Gail Andrews, Chief Operating Officer, Department of Health (DoH) said the Department had a number of positive outcomes from 2009 to 2014. For instance, overall life expectancy increased from 57.1 years in 2009, to 63.3 years in 2015. There was a decrease in the under five mortality rate, the numbers dropping from 56 deaths per 1 000 live births in 2009, to 37 per 1 000 live deaths in 2015. The infant mortality rate declined from 39 deaths per 1 000 live births, to 27 deaths per 1 000 live births in 2015. Mother-to-child transmission of HIV fell from 8.5% to 1.5%, antiretroviral therapy (ART) intake increased nearly threefold, from 1.4m to 3.7m, there was a decrease in AIDS-related deaths, and the TB treatment success rate increased from 74% in 2009 to 84% in 2015.
This Annual Performance Plan was built around six programmes.
Programme 1: Administration
The aim of this programme was to provide support services to the National Department of Health, and included human resources development and management, labour relations services, information communication technology services, property management services, security services, legal services, supply chain management and financial management services.
The Department aims to ensure financial management and accountability by improving audit outcomes. Indeed, there were improved audits, as in the 2016/17 financial year the Department had received an unqualified audit opinion, and the plan for the current financial year was to get an unqualified audit opinion again, and a clean audit opinion for the next two financial years. Four provinces had shown improvements in audit outcomes r, and this year the aim was to have five provinces that showed audit improvements, and by 2019/2020 the aim was to have all nine provinces showing improvements in audits.
The Department wanted effective human resource services in order for employees to access health and wellness programmes. Currently, only 30% of National Department of Health employees accessed these programmes, and this year the aim was to have 35% accessing them, rising to 45% by the 2019/2020 financial year.
Lastly, the percentage of senior managers who had entered into performance agreements with their supervisors was 98% in 2016/17. This year the aim was 100%, as well as the next two years.
Programme 2: National Health Insurance, Health Planning and Systems Enablement
This programme aimed to improve access to quality health services through the development and implementation of policies to achieve universal health coverage, health financing reform, integrated health systems planning, monitoring and evaluation, and research.
The Department aimed to achieve universal health coverage through the implementation of the National Health Insurance (NHI) scheme, which had been conceptualised as a Bill In the previous year. In the current financial year, the draft NHI Bill would be Gazetted for public comments, and the revised NHI Bill would be submitted to Parliament, with the aim of it being approved in 2019/20 by the National Assembly and the National Council of Provinces.
Another objective was to be able to manage medical stock for availability purposes, through making the national surveillance centre aware of the stock. In 2016 there had been a total of 3 200 health facilities reporting stock at the national surveillance centre. The target was to raise this to 3 450 by 2019/20.
The Department also aimed to regulate traditional health practices in South Africa through an amendment of the Traditional Health Practitioners Act, which would be drafted in the current financial year. In the next financial year, it would be Gazetted for public comments, and implemented in 2019/20.
Revenue collection would be strengthened by incentivising hospitals to maximise revenue generation. All nine provinces would be expected to use the revenue retention model in 2018/19, and the effectiveness of this model would be evaluated in 2019/20.
The Department also planned to implement a web-based patients’ registration system that contained information about patients, to enable them to go to the clinics or hospitals of their choice in any geographical area, and access medical care easily.
The monitoring of supplier performance would be developed, and this would done through performance reports on all contracted pharmaceutical suppliers on a quarterly basis.
Lastly, the Department planned to conduct a survey on patients’ experience of care. In essence, this was a survey that would be implemented to generate feedback from patients in order to improve healthcare in hospitals and clinics. Provinces would be trained on how to manage and use the feedback in order to manage patient safety incidents.
Programme 3: HIV/AIDS, TB, and Maternal and Child Health
The purpose of the HIV/AIDS, TB, and Maternal and Child Health Programme was to develop and monitor implementation of national policies, guidelines, norms and standards, and targets for the national responses needed to decrease the burden of disease associated with HIV and TB epidemics, to reduce the rate of maternal and child mortality and morbidity, optimise good health for children, adolescents and women, and to monitor and evaluate the outcomes and impact of these.
The objective was to reduce neonatal morbidity and mortality rates through standardised dashboard reports. In addition, the mother-to-child transmission in South Africa needed to be eliminated. Implementation of the standardised dashboard reports would be monitored.
Another strategic objective was to improve access to cervical and breast cancer treatment through policy development.
There would be a reduction in the under five mortality rate, which would be done through monitoring child health programmes, and a reduction in severe, acute malnutrition in all provinces by 2019/20. In addition, the under five mortality rate would further be fought against through a review of the surveillance system for polio, measles and neonatal tetanus.
The programme would also improve access to adolescent and youth health services in South Africa.
The prevention and treatment interventions to reduce HIV, sexually transmitted infections (STIs) and TB infections would be combined and implemented in 52 districts. Furthermore, the treatment and care for TB would be strengthened.
Programme 4: Primary Health Care Services (PHC)
The purpose of the Primary Health Care Services Programme was to develop and oversee the implementation of legislation, policies, systems, and norms and standards for a uniform well-functioning district health system, environmental health services, communicable disease control, non-communicable disease control, as well as health promotion and nutrition programmes.
This programme aimed to improve district leadership and governance of the health system, in order to check whether district health systems were in line with national guidelines.
Another aim was to improve the quality of services at primary healthcare facilities. The number of primary healthcare facilities that qualified as “ideal” clinics in the 52 districts was 811 in 2016/17, and the Department aimed to increase this to 2 823 in 2019/20.
Access to healthcare services for people with disabilities would be improved. In 2016/17, the proportion of PHC facilities accessible to this sector was 25%, and the aim was to increase it to 35% of 2 823 facilities in 2017/18, and 70% of 2 823 in 2019/20. In addition to this, the Department aimed to improve the quality of district hospitals through the Ideal District Hospitals Programme.
The reduction of risk factors and improvement of management of non-communicable diseases would take place by implementing the 2012-2017 strategic plan for non-communicable diseases. This would be done through guidelines on nutrition for early childhood, the development of regulations relating to labelling and packaging of tobacco products, and smoking in indoor and outdoor public spaces, and random monitoring of salt content in foodstuffs.
A new public entity -- the National Health Commission -- would be established to address the social determinants of health. Access to quality mental health services in South Africa would be improved. In addition to this, rehabilitation services in SA would be expanded. Malaria would also be eliminated up to a point where there were no local cases of malaria in SA by 2020.
Another area that would be improved was the response with regard to influenza prevention and control. In the previous year, 800 000 high risk individuals had been covered with seasonal influenza vaccination. The Department wanted this number to decrease to 630 000 for the next three years.
Regulations on organ transplantation and dialysis had been drafted, and would be published for public comment. In 2018/19, these regulations would be promulgated. In addition, the national policy framework and strategy on eye health was being developed in 2016/17, and would be presented to the National Health Council in the current financial year. These would be promulgated and implemented in 2018/19. Lastly, the oral health policy and strategy would be drafted in 2017/18, approved in 2018/19, and implemented in 2019/20.
Programme 5: Hospitals, Tertiary Health Services and Human Resource Development
The purpose of this programme was to develop policies, delivery models and clinical protocols for hospitals and emergency medical services. It was also to ensure alignment of academic medical centres with health workforce programmes, the training of health professionals, and the planning of health professionals and health infrastructure to meet the health needs of the country. This programme would also assist the government to achieve the population health goals through nursing and midwifery, by the provision of expert policy, technical advice and recommendations on the role of nurses in the attainment of desired health outputs.
This programme would ensure quality healthcare by improving compliance with national core standards at all central, tertiary, regional and specialised hospitals. It would also increase the capacity of central hospitals to strengthen local decision-making and accountability, to facilitate the semi-autonomy of ten central hospitals.
Another aim was to develop and implement health workforce staffing norms and standards. This would be done by the human resources department, and by doing so, the capacity of staff would increase. Furthermore, nursing education training and practice needed to be strengthened through implementation of the objectives of the nursing strategy. This would be strengthened through new basic nursing qualification programmes and the drafting of curricula.
Health infrastructure would also be improved. Last year, 178 facilities had been maintained, repaired, and/or refurbished in NHI districts, while this year the Department was planning to maintain, repair and/or refurbish 197 facilities in NHI districts.
This programme would also ensure that there was access to an efficient and effective delivery of quality Emergency Medical Services (EMS). EMS regulations had been revised in the previous year, and a compliance checklist had been drafted and presented to the national committee on emergency services. In the current financial year, the checklist would be finalised and presented to the National Health Council (NHC) for approval.
Another new strategic objective that would be developed in the current financial year was roadside testing to monitor driving under the influence of alcohol. The Department would sign a Memorandum of Understanding with the Department of Transport to implement the programme.
There would also be policy on the education and training of EMS personnel monitoring. This had been developed in the previous financial year, and this year the Department would have quarterly monitoring reports produced to determine compliance with policy on education and training. In addition to this, there would be regulations for emergency care centres at hospitals, including EMS in mass gatherings, forensic pathology services, and scope of practice for the rendering of the forensic pathology services.
Programme 6: Health Regulation and Compliance
The purpose of this programme was to regulate the sale of food and to ensure accountability and compliance by public entities and statutory health professional councils in accordance with applicable legislative prescripts.
The Department would establish a public entity called the South African Health Products Regulatory Authority (SAHPRA). It had been listed as a public entity in the previous year, and a Memorandum of Understanding would be signed by the Department and SAHPRA, and a chief executive officer (CEO), executive management and committees appointed. In the following year, it would be fully functional.
Another entity that had been partially established was the National Public Health Institute of South Africa (NAPHISA) for disease and injury surveillance. In the previous year, the comments on draft NAPHISA legislation had been considered and revised, and the Bill had been submitted to Cabinet. The Bill would be tabled for consideration by the Parliamentary Portfolio Committee on Health in the current year, and it would be promulgated into law in the following year, and fully operational in the following year as a public entity.
The Department would improve oversight and corporate governance practices by establishing effective governance structures, policies and tools.
Lastly, a number of newly-appointed boards had been inducted and trained. In the previous year, there had been three new boards at the South African Medical Research Council, the Office of Health Standards Compliance and the Allied Health Professions Council of SA. In the current year, two boards had been appointed -- the South African Health Products Regulatory Authority and the Council for Medical Schemes – and four new boards would be appointed in the following year, and two others in 2019/20.
Mr Ian van der Merwe, Chief Financial Officer (CFO): DoH, said the budgeted expenditure for the years 2017/18 to 2019/20 showed a number of decreases in Programme One, but there would generally be increases in the other five programmes. (See attached document)
Mr C Hattingh (DA, North-West) commented that he understood there was a new system coming for medicine registration, but what he did not understand was why there was an increasing backlog of critical medicines that could not be registered by the Medicines Control Council.
With regard to infrastructure planning, in the Free State there was a hospital that had been built and was partially open, and yet there were clinics that had shortages of staff. Where was the rationale in this?
What would be the status of the qualified Cuban doctors who were coming to South Africa? Would they practice only in hospitals? Did they need more training?
Ms D Ngwenya (EFF, Gauteng) commented that in light of what had happened in the past few months, she thought that mental illness would be featured in the Department’s APP, and that it would concentrate mainly on dealing with mental health challenges faced by the country, with a special indicator for it. Mental illness could be viewed as a non-communicable disease, and she had hoped that there would an analysis and a plan on the social burden of dealing with the bio-social factors that contributed to mental health, and an attempt to close the gap of inequality that was experienced in the country’s health system with regard to mental illness. She had also hoped that there would be a plan to reduce the burden faced by mentally challenged people, together with their families. She was not sure if mental illness could be viewed as a non-communicable disease, but it should have had a special indicator in the plan. In essence, she wanted to be corrected if she was wrong on this, and wanted to know what the Department could do to help with this issue.
Mr M Khawula (IFP, KwaZulu-Natal) said the Department had been reporting on the NHI since 2014, and asked what the time frame for the pilot in the original plan was. Looking at the figures of how much was going to be spent, was the Department on target? Looking at it countrywide, the figures were not convincing, considering the country was piloting the NHI over the ten districts. There needed to be a report of what had been done so far, and what the phases were going forward, to compare and make sense of what was said. The departments were doing the planning, but the execution was being done by the provinces, and thus there was a gap in terms of theory and what happened on the ground. How would this gap be closed?
Ms P Samka-Mququ (ANC, Eastern Cape) commented that three hospital boards would be appointed in the current financial year. What would happen at the other hospitals? Could the Department update the Committee on the school health programme? Had it been rolled out in all the provinces? What progress had been made with the contracting of general practitioners?
Ms M Moshodi (ANC, Free State) said she and the Chairperson had visited the Free State two weeks ago, where they had managed to visit four or six clinics in three days. None of the clinics had blood pressure machines, and when this issue was raised, the clinics’ response had been that they had been ordered, and would be delivered in two months. The expiry date for medications had been checked, but there were no air conditioners at those clinics. Furthermore, there was only one clinic in the rural area where she comes from, and it had no doctor. The clinic opened between 07:00 and 16:00. There were no ARVs, and patients had to travel long distances of up to 280 km.
The Chairperson said since the Department had indicated it was increasing the number of people accessing ARVs, what was the basis for this? Was the Department winning the battle against HIV/AIDS? Were people being made aware of how to obtain access to ARVs? There were syndicates that stole ARV medication -- what were the Department’s plans to address this challenge?
The rolling out of healthcare services was dependent on other departments as well. This required a collaborative effort, meaning that other departments needed to be involved. Was the DoH winning in this regard? Were the other departments willing to work with this Department?
Was there a budget for the testing of blood at the roadside? Would there be enough staff to perform this function?
There was a concern about cutbacks in the baseline for compensation of employees, but it had been mentioned that there were 800 doctors coming into the country next year. How would this be balanced?
In the Free State, doctors were available once a month, and a survey should be conducted because doctors from other countries were said to “moonlight” in private hospitals, even though they signed the registers in public hospitals. There was no intention to be xenophobic in the statement, but the Department had been asked to go to public hospitals and look at registers and investigate. There had been a direct complaint from a doctor that some doctors were not doing what they were supposed to be doing.
Dr Joe Phaahla, Deputy Minister of Health, said part of the problem regarding the backlog of medicine registrations was that there was more vigilance about safety and quality for whatever medication that needed authorising. There was a backlog in approvals because most of the work was done on a part-time basis, and the assessments were taken at certain times only, and the documents on each product had to be analysed carefully, and therefore this caused a backlog. The solution to this was having a public entity that would employ full-time people to do the analyses.
Regarding the Cuban training programmes, the 800 people coming would arrive only next year around August. These were final year students, not qualified doctors. After the fifth year of study in medicine, students get clinical training, and the Cuban students would get it in South Africa. This was because in Cuba there was a low incidence of HIV/AIDS, TB, motor vehicle injuries, gunshot wounds, etc, so this was a way of exposing them to these cases. This was an assessment for them, and thereafter they would write their final exams for their Cuban certificates. The DoH was working with different provinces and medical schools to facilitate this. They would do their internships after they graduated, and register with their medical council afterwards.
Mental health was indeed one of the non-communicable diseases. The Department had reflected on improving district mental health facilities, where each district would look at the key clinical priorities. However, there were limited people in the psychology profession, and these were highly sought after in the private sector, and as a result it was difficult to tackle this challenge in all 52 districts.
Regarding the NHI pilot and funding, the budget allocation was to complete the piloting and finalise the infrastructure, the information technology (IT), contracting, HR, etc. The final roll out would be when the White Paper had been revised and the Bill had been passed, and that was when NHI funding would be established.
The Department was looking at how to improve the capacity of hospital boards, and members of the public must be able to access and approach them.
He said it was shocking to learn that there was a shortage of blood pressure machines in the Free State, and this was unacceptable. The three spheres of government played a concurrent function, and this was a provincial competence, where the national department could only advise and comment. In essence, this situation depended on cooperative governance.
IT systems were used to monitor stocks of medication, but this too depended on compliance, and if the pharmaceuticals were not scanned, the Department would not be able to monitor the stock.
Awareness of access to ARV medication needed to be further increased for more people to feel comfortable about testing for HIV. The stigma was still there, but at least now it was being viewed like any other chronic disease. There were still challenges around the reduction of HIV, however, and this was especially worrying among young women. The only way the future generations could be HIV free was by having measures that would prevent it.
The roadside blood-testing intervention would be expensive to implement, and this had been put on hold for a while because there were also court cases stemming from the use of breathalysers.
It was not only fully employed foreign doctors who were moonlighting in private hospitals -- even South African doctors did it too. However, this was problematic because students in medical training did not get adequate teaching or training from doctors. The medical society was also working with the Department in this area.
Dr Yogan Pillay, Deputy Director-General, DoH, said that on average 15% of children had oral, sight, or speech health problems. The biggest challenge in children was oral health, because they consumed a lot of sugar. There were insufficient nurses to do the tests in schools, however, and the Department was working on having nurses sent to schools in the poorest areas. The programme was growing, and the budget was a problem, but it would be ensured that the poorest areas would be reached. Mental health would also be integrated into the programme, because it was also a problem.
Referring to ARVs, he said there were about seven million HIV positive people in South Africa, but the good news was that the majority of South Africans were HIV negative, and there needed to be measures in place to ensure that this stayed the same. Furthermore, there had to be change in attitude of sexual behaviour through education, and people needed to be educated about condomising. The level of infection among young people had decreased, which meant progress was being made, but the Department would like to see quicker progress.
Dr Gail Andrews, Chief Operating Officer, DoH, replied that the appointment of hospital boards was related to the organisational structure, rather than the benchmarking of hospitals. The boards were related to programme six, for public entities.
She gave an overview of the planned phases for the introduction of the NHI. The first phase, from 2012 to 2017, was meant to be a platform for strengthening service delivery for primary healthcare and health facilities. The second phase would be from 2017 to 2021, with the establishment of funds, a population register, the contracting of health professionals, and amendments to the Medical Schemes Act. The third phase, from 2021 to 2025, would be for four years, and the funds would be for the NHI, and the providers would be contracted through the fund. The patient register would be helpful for the NHI, as it would be become the NHI’s information system.
The Chairperson commented that the response from the Department had been adequate. However, it could not be avoided that the buck stopped at the national level, because when people protested, they focused on national government, even though they were aware of the provincial members of executive councils (MECs). She applauded the Department for providing good quality services compared to other African countries. As a result of this, life expectancy had improved, the mortality rate had decreased, and the Committee was happy that every structure would be used to make healthcare accessible.
With regard to moonlighting doctors, there could not be doctors and skills on paper, only to find out that there were no such skills in practice for the public. In essence, they had to choose where they wanted to be.
The meeting was adjourned.
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