Health Budget: Treasury; Northern Cape; North West Province; Eastern Cape; Mpumalanga

Meeting report

SOCIAL SERVICES SELECT COMMITTEE
21 May 2003
HEALTH BUDGET: TREASURY; NORTHERN CAPE; NORTH WEST PROVINCE; EASTERN CAPE; MPUMALANGA

Chairperson: Ms. L Jacobus (ANC)

Documents handed out:
Treasury on Health Budget & Inter-Governmental Fiscal Review 2003
National Health's Report on Inter-provincial Inequity
Northern Cape Presentation
North-West Province Presentation
Eastern Cape Presentation
Mpumalanga Presentation
Department of Health budget: Vote 16 (link to Treasury website)
Kwazulu-Natal Presentation

SUMMARY
The Committee was informed that data on under-spending was annually released. The Committee heard that language was a general problem, which was not unique to Cuban doctors. In the Northern Cape, however it was revealed, some Cuban doctors were very fluent in Afrikaans whilst some of the local medics were not. The Committee was informed that the high HIV/AIDS prevalent rate in Botswana affected the North West province in the same pattern it did in any other area in the country especially on track routes and in the mines. The termination of pregnancy programme was inadequate in that most sites were poorly staffed due to a shortage of skilled staff and there was urgent need to improve on the provision of equipment.

The Committee heard that the only measures available to the Department to monitor usage of female condoms was the number of condoms that had been distributed. Health workers had been designated to demonstrate safe usage of the condoms. It was reported that no study had been carried out to determine how widespread the female condoms were used except that there had been a notable increase in its demand. The Department was critisized for completely neglecting the western side of the province in its drive to shift services to the eastern region. However the Department defended its action pointing out that the government was keen to address historical inequities so focussing on the eastern side of the province when allocating the scarce resources.

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 showed 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, Primary Health Care Clinics (PHCs), HIV/AIDS and the Nutrition programme as separate components for budgetary allocation purposes. 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.

Discussion
The Chair asked what informed per capita expenditure, which she noted was very high.

Dr Blecher replied that the per capita figures reflected the trend in government policy to deal with issues of equity noting that the incidence of inequity was still a big problem. The restructuring of the conditional grants was meant to address the vexing issue of inequities. He pointed out that the biggest winner in the alleviation of poverty programmes had been the social welfare system and this explained the significant gains that had been made in the health sector.

Dr Niel (NNP) noted that there was a of 10.9% growth in the overall budget and sought clarity on how this margin of growth compares in real terms when the incidence of inflation is factored into the equation.

Dr Blecher explained that health inflation was a very important factor but regretted the fact that the country had never come around to compile data on this aspect noting that policy makers were still finding a solution to this otherwise developmental problem

Mr Tlhagale (ACDP) asked what measures, if any, the National Department had put in place to deal with provinces that frequently under-spent on their budgetary allocation.

Dr Blecher said that data on under-spending was annually released into the public domain noting that it was a very common feature in the local dailies and therefore this helped to bring pressure on provinces to put their house in order. The National Treasury engages in forums with provincial departments to understand their problems and work out solutions.

Briefing by Dr. M H Hendricks HOD - Northern Cape
Dr. Hendricks informed the Committee that the Department's vision was to achieve excellent, historic, people-centred and affordable health care in the Northern Cape. This would be achieved through a decentralized, accountable, accessible and constantly improving health care system within available resources. The Department's caring, multi-skilled, effective personnel would use evidence-based, informative health care and maturing partnerships for the benefit of its clients and patients.

Emphasis would be put on accelerated service delivery noting that one of the major areas of concern to be addressed rates through integrated strategic interventions was the decreasing morbidity and mortality. Other key areas were namely: revitalization of hospital services, improving human resource development and management, reorganization of support services, legal reform programme and improving resource mobilization and management of resources without neglecting the attainment of equity in resource allocation among other targets.

Dr. Hendricks reported that the equitable allocation to the Department of Health was increased from R488, 062 million to R564, 818 million, an increase of 15.73% while the conditional grants allocation was increased from R110, 152 million to R171, 694 million an increase of 55.9%. This large increase in conditional grants was attributed to the substantial increase in the allocation of two conditional grants, namely the Integrated Nutritional Programme and the Hospital Revitalization Grant. This grant increased by more than 100% each in the 2003/04 financial year as compared to the previous year. Capital allocation received a substantial 51.6% increase in the current financial year as compared to the previous years' adjusted budget bringing the total capital allocation to R79,523 million. This allocation represented 11% of the budget and was funding mainly the construction of Colesberg and Calvinia Hospitals.

Hospital services had been overhauled in line with Departmental Strategic Position Statement recommendations, which outlined measures on Human Resources Development and Redistribution of Tertiary Services Grants. There had been and equitable distribution of limited resources through the largest geographic area in the country. In an attempt to curb the uncontrolled migration of nurses, the Department had introduced a nurse scholarship program in conjunction with the Oxford Radcliffe Hospital in the United Kingdom. The programme which was jointly funded by the EU had already trained its first batch of fourteen nurses who left Kimberly Hospital Complex for the course that lasted six months and the group returned to the country at the end of January 2003. The increase of tertiary services at the Kimberly hospital, the Department had drastically reduced its reliance on other provinces and the private sector for specialised services.

Discussion
Ms Sono (NNP) noted that the Department claimed to have purchased a warehouse for the storage of pharmaceuticals and asked how far this facility was from laboratories.

Dr Hendricks replied that the warehouse was at the Kimberly hospital but that it only acts as a storehouse from where medical provisions were distributed to the rest of the province.

Ms Gouws (DP) noted that the Cuban doctors were not conversant with the local language and wondered how the Department dealt with this barrier that presented a real obstacle to service delivery.

Dr Hendricks pointed out that language was a general problem, which affected locally trained medics as well. He noted that in fact some Cuban doctors were very fluent in Afrikaans whilst some of the local medics are not.

An ANC member asked if the Department had a gender focal point and if so whether this item was budgeted for and the level of the gender focal person.

Dr Hendricks replied in the affirmative noting that the Department had a gender focussed person to mainstream gender sensitivities and that this drive was not confined here but that it permeated the entire Departmental programmes. The gender focossed person holds the rank of an assistant director and that indeed the budgetary allocation deliberately inclined towards gender preferences.

Mr Tlhagale asked if the recent demarcation of provincial borders had had any effect services delivery.

Dr Hendricks pointed out that provincial borders did not in any way dictate the provision of health care services noting that services were rendered to anyone irrespective of their home provinces.

Mr Tlhagale noted that some condoms were manufactured overseas while others were locally sourced and asked how the Department ensured that quality was not compromised.

Dr Hendricks pointed out that the Department had so far not received any complaint regarding the quality of the condoms it distributed and to that extent it was satisfied with the quality of those it distributed.

The Chair asked what the Department's staff component looks like and what challenges it has had to grapple with in this respect.

Dr Hendricks revealed that the Department had only recently compiled a human resource plan where the vacancy rate was noted at 30%. He pointed out that this rate had improved at the Kimberly hospital owing to the increase in tertiary services where many specialists had been hired. He added that the Upington hospital was still a problem noting that the vacancy rate in this facility was still unacceptably high.

Briefing by Dr. Gosnell - Head of Department North-West Province
Dr. Gosnell stated that the Department's vision was to offer an optimum health service for all individuals and communities in the North West Province. The Department would ensure access to affordable, equitable, quality, caring health services for all in the North West Province. This goal would be achieved through: Community involvement and partnerships; Batho Pele Principles and the Patients' Rights Charter; Innovation driven performance; and by valuing people and their diversity. The Department envisaged a well-managed and effective District Health System that was driven by a competent, empowered and performance focused employees. The Department endeavoured to put in place appropriate and effective organizational systems that would strive to deliver quality health services to its inhabitants.

Dr. Gosnell reported that so far the Department had established 322 VCT and that a total of 1310 Nurses had been trained in rapid testing while another 664 nurses had been trained in counselling. The PMTCT facility was district based and that these sites had increased from 2 to 89. More than 1333 care givers were trained in HBC Department and that in addition 24 private doctors had been trained in the management of STI, as well as 320 traditional healers. So far the Department had distributed 2,080 condom at designated points and these included 22,208,331 male condoms and 210 837 female condoms.

Dr. Gosnell informed the Committee that twenty new fully equipped surgeries with state of the art equipment were opened between 2000 and 2002 out of which 80% were based in rural areas. The number of out reach clinic visits had witnessed an increase of 30% and that preventive services on the other hand had increased by 35%. He continued that conservative dentistry services had also increased by 30 % while curative services in areas where there was no such service had increased by 100 % as new more clinics where opened. The quality of services for the management and prevention of HIV/Aids & TB cases had significantly improved noting that clinic supervision and hospital accreditation had been established.

Discussion
Ms Mashangoane noted that due to the sheer vastness of the province and given the expanse of the farming community provision of health care must be a big challenge. Had the Department made provision for mobile clinics in order to ensure that health services were accessible to the wide farming communities?

Dr Gosnell concurred with Ms Mashangoane that access to medical care by the farming community in the province was a matter of serious concern. The Department was well aware of this problem and that is why provision has been made for several mobile clinics.

Dr Gosnell added that the Department was in constant consultation with the farmers to explore ways of increasing the frequency of this clinics noting that the number of visits was not satisfactory but it was nonetheless much higher than the previous years. The Department was in the process of negotiating with farmers to create central areas from where health services could be accessed by a greater number of patients.

Ms Mashngoane noted that the home based care program had not produced satisfactory results in some areas and asked if the Department had put in place some form of monitoring mechanisms to ensure proper delivery of services takes place in this area.

Dr Gosnell acknowledged the fact that the home based care program was not adequate noting that most of the work around this program was handled by NGOs some of whom, he observed, were doing an excellent job while others were not. The Department was trying to improve monitoring and assessment measures to ensure that the program achieved acceptable standards.

Mr Tlhagale asked if the Department was satisfied that with the current budget it would be able to deliver medical stores to the deep rural areas.

Dr Gosnell clarified that delivery of medical stores was out-sourced and that what the Department did was to record all the medicines that was dispensed to patients then take an audit to check whether proper delivery was made. The Department hoped to achieve a 90% delivery of essential drugs by end of next year.

Mr Tlhagale pointed out that Botsawana had one of the highest HIV/AIDS prevalent rates in the world and wanted to know whether its proximity to the province had influenced the spread of the pandemic in the region.

Dr Gosnell concurred with the observation that Botswana had a very high HIV/AIDS prevalent rate but noted that the effect of transmission was not unlike any other area in the country especially on track routes and in the mines.

An ANC member noted that there were huge resources that were channelled through the NGO sector and asked if the sector was periodically called upon to account for the utility of the allocated funds.

Dr Gosnell explained that NGOs were independently funded and that the Department had no competence to call them to account save that it monitored their work to see to it that they were fulfilling their respective mandate.

Dr Niel noted that the Minister had alluded to a severe shortage of ambulance services yet there was a marked budgetary increase for this item. He asked if theDepartment maintained an ambulance college.

Dr Gosnell agreed that the budget for EMS had significantly increased by 57% to twenty million which would enable the Department to acquire some twenty more ambulances and noted that possibilities of introducing the tracking system was being explored. The Department had hired one ambulance trainer but that it, for the most part, relied on other provinces for its training needs.

Mr Sogoni noted with appreciation that about 500 women were benefiting from the nutrition program but pointed out that there had been widespread allegations of looting of funds. He asked how the Department ensured quality of work and whether there were any monitoring and control measures in place.

Dr Gosnell explained that the main concern around nutrition had been the quality of care and not misdirection of funds. He pointed out that a number of SMMEs had been contracted to distribute food and that the Department was addressing areas of inadequacy. He pointed out that nutrition inspectors regularly monitor service quality offered by the NGOs and that for them to get back the re-investment they must compile and file a report on service delivery.

Ms Gouws noted that the Department employed youth as peer educators and asked if these people were students.

Dr Gosnell replied that the Department ordinarily recruited youth that were out of school through youth centres.

The Chair noted that there had been a marked increase in the female condom distribution and asked if the Department had a way of determining whether they were utilised at all. She pointed out that there have been numerous complaints around the usage of these condoms.

Dr Gosnell replied that the only measure available to the Department was the number of condoms that had been distributed. Health workers had been designated to demonstrate safe usage of the condoms. No study had been carried out to determine how widespread its usage was noting that, in spite of complaints there has been a notable increase in its demand.

The Chair asked if the Termination of Pregnancy (TOP) sites were well equipped and staffed

Dr Gosnell admitted that it was very difficult to say that the TOP sites were 100% operational but explained that the first measure was to equip and staff the facility before it could be up and running. He expressed frustration at the difficulty of keeping these facilities operational noting that it was often very difficult to replace personnel who frequently vacate the facility.

The Chair sought to know the ratio of doctor to patient in the province.

Dr Gosnell pointed out that the ratio of doctor to patient now stood at 1: 3300 noting that the province did not experience a debilitating shortage of doctors like other provinces save for specialist support where the real challenge lies. The ratio of nurses to patients is 1: 726 noting that there were marked shortages in some areas.

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.

Discussion
The Chair asked to what extent, if at all, the Department had succeeded in its efforts to integrate health care services both in terms of resources and personnel in the province.

Dr Fraser replied that all municipal and local authorities had set up a task team with the national Department to try and address the nagging question of integration of services. He added that there had been a gradual change in management model in district hospitals in the provinces especially where this touches on the allocation of scarce resources.

The Chair asked about the spread of VCT sites and whether these facilities were accessible in the deep rural areas.

Dr Fraser pointed out that due to the problem of accessibility most of the VCT sites were located in the eastern part of the province noting that the population demographics show that these areas were mostly rural.

The Chair asked what, if any, interventions the Department had put in place to stabilise the nutrition programme at the community level in order to prevent re-admission.

Dr Fraser informed the Committee that the Department had introduced a vitamin supplement which had proved very successful noting that all the clinics monitor the children that were discharged from hospitals to ensure proper follow-up management.

Ms Gouws pointed out that she appreciated the fact that the eastern side of the province was in dire need for health services but faulted the Department's approach that tended to neglect the western side of the province.

Dr Fraser observed that there were more clinics in the province than anywhere else in the country but that most of these facilities were saturated in the western side of the province. He pointed out that the government was keen to address the glaring historical inequities and therefore it was in this spirit that priority was given to the eastern side of the province while allocating the scarce resources.

Mr Sogoni (UDM) acknowledged the fact that the province was beset with many daunting challenges.The new legislation that was meant to check the death of initiates had not been supported by all communities and asked how the Department was dealing with this general resentment.

Dr Fraser concurred with member Sogoni that indeed the circumcision bill had not gone down well with a segment of the community. He said that the Department was dealing with the problem through a collaborative approach and education. The Department's main concern was to try and promote hygienic methods for conducting the operation noting that in this respect all traditional surgeons were required to be registered under the Act.

Mr Sogoni noted that the main cause of the exodus of medical personnel from the province revolved around service environment and general demoralisation. What was the Department doing to address these twin maladies.

Dr Fraser pointed out that in fact the Department had managed to reduce the attrition rate by introducing a rural allowance scheme. He noted that the question of brain drain in the health profession was a national problem and that is why the government had set aside R 500 million budget for rural incentives.

Mr Sogoni asked to which the Department had addressed the question of reportage of HIV/AIDS in rural areas.

Dr Fraser replied that the Department had finalised a tender worth R3.5 million for media advertising and to run regular radio and TV programs around the HIV/AIDS issue.

An ANC member asked if the Department had a gender focal point with a separate budget and the designation of the gender focal person.

Dr Fraser replied in the affirmative noting that the director of special programmess managed the gender focal point and that this program was monitored by the premier's office.

The Chair asked when a new head of department would assume office.

Dr Fraser replied that the recruitment process started last year but that the same would only be concluded after completion of the on-going restructuring process.

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. 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 Primary Healthcare 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.

Discussion
An ANC member asked if the Department had a gender focal point complete with its own budget and the designation of the focal person.

Ms Charles confirmed that the Department has a gender focal point that is managed at the level of an administrative officer but that there are plans to upgrade this function to the level of deputy director general. She said that this office does not have a specific budget but that the officer reports to the head of the department from where its budget accrues.

An ANC member asked if there were any mechanisms in place to ensure proper accountability by NGOs.

Ms Charles noted that the NGOs business was a tricky one but concurred that there was need to improve on financial accountability. She pointed out that the Department monitored NGOs activities through its unit managers as a matter of priority and that at present monitoring took place through business plans that were submitted by NGOs.

The Chair enquired if TOP sites were fully staffed and equipped.

Ms Charles reported with regret that all was not well with the TOP sites noting that most were poorly staffed due to a shortage of skilled staff and that there was urgent need to improve on the provision of equipment.

The Chair asked about the capacity of ambulances that were maintained by the Department.

Ms Charles replied that the provinces has 60 fully equipped ambulances out of the original 90 noting that the remaining 30 had exceeded the recommended life-span.

Dr Niel noted that malaria prevalence was endemic in the province and asked about the measures the Department had put in place to address this.

Ms Charles concurred that the province was the worst hit in malaria out-breaks in the country and more so on its eastern border. She however assured members that the Department's malaria control programs were well managed noting that it had abandoned the spraying intervention in preference for Kwazulu Natal's method of combination drugs.

Meeting adjourned.