The meeting involved the presentation of the National Department of Health’s (NDoH’s) performance report for the first quarter of the 2017/18 financial year, using the benchmarks of its strategic and action plan and focusing on the achievements and the challenges that the Department had experienced during this period.
The major talking points of the report were the wider systemic problems affecting the operations of the Department and hospitals. It had become clear that the decentralisation of funding of hospitals to the provinces had created problems for the NDoH, as it had little control over four main areas of its operations: (a) procurement/supply chain management, (b) human resources training and recruitment, (c) financial management and (d) maintenance of infrastructure and equipment. Many health facilities were under-funded, because the provincial executives were the ones who had the power to allocate funding, and they were often not meeting the budgetary requirements of the hospitals. In some cases, even where funds were available, the health facilities were not being allowed to use the money. Consequently, there was a shortage of medical staff, medicines, equipment and other medical necessities.
The provinces also had centralised procurement, leading to delays in procurement as hospitals were not allowed to undertake their own procurements. Provincial governments were disbursing less than the required minimum threshold of 30% of their budgets. Some provinces were even abolishing important medical positions so that they could balance their books, and had even implicitly frozen the recruitment of new health personnel. The under-funding also meant that most facilities were going beyond the recommended 60% budgetary allocation for personnel – in some instances, reaching 75% for staff costs and only 25% for health services.
The Minister of Health also addressed the Committee on the findings and recommendations of a Ministerial task team that had been mandated to carry out investigations into service delivery at selected hospitals. The team’s 25 recommendations were adopted at the meeting. Many of the team’s findings echoed those presented by the National Department of Health. There were also resolutions to engage the provincial executives on the matters that were of concern, especially regarding funding and procurement.
The Minister lamented that the responsibility of looking after the affairs of the ministry fell squarely on his shoulders, yet he had little authority to effect any real changes, as power was decentralised. The Committee resolved to look at the possibility of making changes to the constitution, with a view to addressing the challenges in the areas mentioned. The constitution empowered Members of Executive Committees (MECs) to have authority over medical budgets in their provinces, rendering the Departments weak in ensuring that health facilities had sufficient funds to effect good service delivery.
Department of Health (DoH) Quarterly Performance Report
Ms Precious Matsoso, Director-General (DG): National Department of Health, presented the report on the first quarter of 2017/18 financial year, indicating that the average achievement against the targets in its six programmes had been 83%. However, none of the targets in the health regulation and compliance programme had been achieved.
Each programme had quarterly targets with the Administration Programme achieving all its three targets and the next best performing programme being the Health Planning and Systems Enablement Programme achieving 24 out of 25 targets. The worst performing programme was the Health Regulation and Compliance Management which achieved none of its targets. On average, the achievement rate was 83%.
Programme 1: Administration
The main concern was that four provincial Departments of Health (DoHs) obtained unqualified audit opinions for the 2016/17 financial year. It was reported that all senior managers had entered into performance agreements with their supervisors. The National Department of Health (NDoH) vacancy rate was 10%.
Programme 2: National Health Insurance Health Planning and Systems Enablement
The main strategic objective was to achieve universal health coverage through the phased implementation of National Health Insurance (NHI) scheme. The White Paper on the NHI had been finalised and gazetted as a policy document on 30 June 2017. On the establishment of the NHI Fund, Treasury had developed a funding modality for budget allocation. There were plans to further regulate the traditional medicine health sector, so an amendment to the Traditional Health Practitioners Act had been drafted. A national electronic system to monitor the supply of medicines had been developed, which would monitor the performance of all contracted pharmaceutical suppliers. The Department had already started domesticating international treaties to which South Africa was a party, and so far one international treaty and convention had been implemented. Plans were also under way to align provincial Annual Performance Plans (APPs) to the national health systems priorities, and nine provincial APPs had been reviewed and aligned.
Programme 3: HIV/AIDS, TB and Maternal, Child & Women's Health (MCWH)
The cervical cancer control policy was being implemented and the guidelines had already been circulated to the provincial DoHs. Plans to eliminate mother to child transmission of HIV had been developed and were being monitored in selected districts. Guidelines for the breast cancer policy had also been developed and provincial DoHs were being supported in their implementation. The strategic objective of reducing the mortality rates of children under five was being pursued vigorously through the implementation of child health programmes that were aimed at reducing severe acute malnutrition. Surveillance systems for polio, measles and neonatal tetanus were also being reviewed. The health needs of adolescents and the youth were being addressed through the implementation of the adolescent and youth health policy. District implementation plans had been developed for the prevention and treatment of HIV, Sexually Transmitted Infections (STIs) and tuberculosis (TB).
Programme 4: Primary Health Care (PHC)
The Department had set a target of establishing 1 000 PHC facilities as ideal clinics in 52 districts, and had managed to go even beyond the target, with 1 037 facilities qualifying. A priority of the programme was the improvement of the accessibility of primary health services for people with disabilities, and it was revealed that 35% of PHC facilities were accessible to people with physical disabilities. On the need to improve access to quality mental health services, district mental health teams had been established in eight districts. Regarding the objective of eliminating malaria by 2018, the indicators were showing a reduction which was above the target that had been set. The oral health policy had been drafted, and the regulations on dialysis and organ transplant had been developed and published for public comments.
Programme 5: Hospitals, Tertiary Services and Workforce Development
This programme saw hospitals achieve 75% compliance with the national core standards. There had been a drive to increase the capacity of central hospitals in decision-making and accountability. Organisational structures for the hospitals had been designed and approved. Health workforce staffing norms had been developed and a number of hospitals had been benchmarked against staffing normative guides. The capacity building of staff was continuing, with a number of managers accessing the mentoring programme. The target was to train 80 hospital managers and 800 facility managers. The targets were already being exceeded in this area. There were also plans to develop business plans approved by the National Tertiary Service Grant for hospitals, and 17 tertiary hospitals had already had their plans approved. Regulations for emergency care services had been drafted and published for comments. A monitoring system had been developed to measure compliance with pathology services scope of practice. A memorandum of understanding (MoU) had been signed with the Department of Transport (DoT) facilitating a programme of roadside testing to detect drivers driving under the influence of alcohol.
Programme 6: Health Regulation and Compliance Management
This programme was meant to improve oversight and corporate governance in the health sector. There were plans to establish the National Public Health Institute of South Africa (NAPHISA), and a bill had been tabled to the Parliamentary Portfolio Committee on Health for consideration. A number of newly appointed boards had been inducted and trained.
A financial expenditure report was also presented.
Ms C Ndaba (ANC) observed that in the programme on HIV/AIDS/TB, some NGOs had not received their funding. She expressed concern that NGOs who worked with the poorest of the poor were not being funded timeously. She wanted the DG to explain how they were managing the impact of this lack of funding. She also expressed worry that the National Treasury had recommended that there should not be any more recruitment of health staff. She attributed the poor service delivery at some health facilities to poor staffing levels, and wanted an explanation on this matter. Was there any follow up on the screening that was being done by health personnel in the schools, as screening without any follow up would not produce the desired results in combating HIV/AIDS/TB and other diseases. On the governance of health facilities, she said there was a need to have functional committees. Members of Parliament had received numerous complaints on the failure of the health facilities to pay stipends to the members of these clinic committees.
Ms L James (DA) expressed satisfaction at the progress made in regulating traditional healers. However, she was concerned at the under-funding of many health facilities. She wanted to know whether the Department was having consultations with the National Treasury on this matter. She also recalled that blood, alcohol and toxicology had been presented as a problem at the previous presentation, and wanted to know what progress had been made. She was also interested to know whether all provinces had plans on malnutrition. Lastly, she wanted to know why some provinces were having challenges in submitting invoices for their expenditure.
Dr S Thembekwayo (EFF) drew attention to information that had been presented by the DG, that the “Road to Health” booklet had been revised, published and distributed to 52 districts. She wondered how effective printed literature would be in a country with such high levels of illiteracy, with over five million people being unable to read or write. She asked for alternative media campaigns to supplement the printing of materials for health educational purposes. She also wanted to find out why there had been under-expenditure in Programme 4.
Mr A Mahlalela (ANC) asked how many provinces had demonstrated improvements on audit outcomes. Was the NHD monitoring the provinces on a quarterly basis, rather than waiting until the end of the year? He was concerned that provinces ran out of money towards the end of the year because of unauthorised expenditure. He observed that most plans of provinces did not correlate with their budgets. If monitoring was done more frequently, some of the challenges being experienced could have been avoided. If monitoring was not done on a quarterly basis, it would be difficult to ascertain whether maintenance or refurbishment of infrastructure, for instance, was moving according to schedule. In the North West (NW) province, there were challenges regarding payments, and he had never found a fully functional clinical committee. He wanted to know the standards against which the performance of these committees was measured. He sought clarification on the R83 million that had been allocated in the budget for vacancies. Was the under-performance of provinces like the Eastern Cape, KwaZulu-Natal (KZN) and the Free State, related to poor infrastructure? He recalled that there were complaints about poor infrastructure in the Free State, but the province was under-spending.
An ANC Member wanted to find out how the recruitment of health professionals was progressing. He also wanted to know how effective the female condom was. He encouraged the Department to invest in sanitary towels as he believed they could also help in reducing infections. On the rollout of new clinics, he wanted confirmation that the process had been finalised. Was the random testing of salt in foodstuffs working well, as well as the training of medical students?
Mr T Nkonzo (ANC) asked whether the four provinces that had received unqualified audit reports were the same as those from the previous financial year. He referred to the nine provinces’ APPs that had been reviewed and aligned to the National Health System priorities, and asked what this actually meant. Lastly, he wanted to know how much had been budgeted for legal costs, as there were so many claims for compensation for occupational diseases.
The Chairperson asked how boards and committees were monitored. She was especially interested in knowing whether there was system that monitored their financial expenditure. She was worried about the reported freezing of the recruitment of health personnel, and asked whether the Department had made clear to the National Treasury the negative impact this would have on health service delivery. Members of Parliament were always bombarded with questions in their constituencies about the shortage of staff. She complained that people seeking medical attention often had to wait for hours or even days before being attended to, because of this critical shortage of health staff. Infrastructure and machines alone could not offer care and services to the sick. She recalled a clinic that was closed because all the staff were on study leave, and said such a situation was unacceptable.
Ms Matsoso said the DoH was presenting to the Portfolio Committee on Health, as they would to the Appropriations Committee, that health was under-funded, and that only Gauteng and KZN were on the threshold of 30% of budgetary allocations. If one did not have laboratory services, medical personnel and medicines, then one did not have a health service.
Regarding vacancy rates, provincial health departments were being forced to cut down on the number of health positions because they were being under-funded. Each time KZN had a vacancy, they abolished the position. On the financial books it looked good, but the medical situation on the ground was critical because they did not have essential staff to provide the much needed health services.
About the failure to release funds for NGOs, the Department explained that several requirements needed to be met before they could release money to civil society:
- There was an assessment whether the projects being undertaken added value to the mission of the HoD;
- The NGOs needed to spend the money they were given; and
- The NGOs needed to have audited financial reports before being eligible for further funding.
If these requirements were not met, then the Department would not disburse funds.
Regarding screening for HIV/AIDS, three million people had been screened and the Department believed that securing a grant for this process would be the right way to proceed. There was a need to continue with the process and the follow-ups.
Inspections were carried out regularly on the clinic committees, and detailed reports were written after each inspection.
The DG said that the former Auditor-General had offered to help with the audit plans of provinces with unqualified audit reports, and an agreement had been signed with the South African Institute of Chartered Accountants (SAICA).
About the performance of provincial health departments, the DG disclosed that NW had previously been doing well, but had recently slipped up. Limpopo had regressed and the Northern Cape was struggling. Gauteng was under-funded, as there was a concern that the province might be paying for foreigners.
The DG said that the Department had been discussing the issue of accruals and allocations with provincial officials who approved the health budgets for hospitals in their respective provinces, but that nothing had changed. In Gauteng, the provincial officials were refusing to release funds for health services. The NHoD lamented that it had no power over provincial health budgets, as this was the responsibility of Members of the Executive Committee (MECs). The Department did do an analysis of the financial situation and health requirements and shared the information, but it was often disregarded.
Ms Matsoso expressed the need to have a sustainable recruitment structure for the training of medical students, especially as there were big numbers of students that were due to arrive back from Cuba.
The Department was still supplying condoms and sanitary towels, with the most popular condom being the Maximum flavoured condoms.
Regarding toxicology tests, the Department was satisfied with the progress that had been made since the last report. The drunken driving tests had surpassed the targets that the Department had set for itself. A breathalyser and pathology pilot project was also being conducted in order to improve the testing.
The department had only a small budget for legal fees, which did not include medical claims. R50 million was still owed in medical fees, and KZN had monthly medical claims of R30 million.
About the use of mass media to disseminate health information, the Department had taken steps to be visible and had adopted a multi-faceted approach which involved more than the circulation of printed literature.
On provinces that were under-spending, the Department also attributed this to provincial executives, as in the case of the Free State, which had money but the Premier had stopped them from spending it. The Free State was also reluctant to support the revenue retention policies being implemented by the NDoH.
Minister’s report on investigation into service delivery at selected hospitals
Dr Aaron Motsoaledi, Minister of Health, said he had appointed a five-member task team on 14 July 2015 to investigate the state of affairs at identified hospitals. The team was comprised of Prof R Green, Dr R Mgijima, Prof K Househam, Ms Nomvula Marawa and Mr A Karim.
The terms of reference had been to find out whether or not:
- The rights of any patients were violated;
- Any health professional had breached any ethical or other code of conduct;
- The conduct of the management of the hospital contributed in any manner to the state of affairs at the hospital;
- Support services were functioning optimally;
- Procurement procedures were in place and there was compliance;
- The oversight role of the provincial health department and district management was exercised adequately;
- The role supervisors played in highlighting the state of affairs in the hospital;
The team was to make recommendations on corrective measures to address challenges and shortcomings.
The Minister said it had been crucial that there was engagement with all necessary stakeholders if this project was to be successful, and the team had tried to engage as many people as possible, from directors, management, staff and even patients. There had been interviews with stakeholders on all aspects of health service delivery, such as health professional staffing, human resource training, funding, supply chain and logistics, infrastructure, equipment, and information communication technology (ICT). The Ministerial Task Team (MTT) had visited Limpopo, the Eastern Cape, Free State, KZN, Mpumalanga and Northern Cape.
The major findings of the MTT were as follows:
- Hospitals were operating under constrained financial, technical and human resources.
- The situation was worsened by unstable management, with role interference.
- There were vacancies in key managerial positions.
- There was no ownership of responsibility.
- There was a critical shortage of staff due to the freezing of posts.
- There was an inability to train and retain skilled staff in both the clinical and support areas.
- Moratoriums had been placed on all staff appointments in the provinces.
- Centralisation of appointments was hampering service delivery, as appointments took a long time.
- The poor financial position of provinces had impacted negatively on health services.
- Most of the hospital budgets went towards paying personnel, rather than equipment or medicines. Staff costs were as high as 75% in some instances.
- Hospital procurement was hampered by the provincial centralisation of procurement.
- Some hospitals suffered from infrastructural and design challenges.
- The challenges facing medical institutions had resulted in low staff morale.
Dr Motsoaledi said the findings pointed to four major areas which were connected to provincial functions: human resources, procurement, financial management and maintenance of infrastructure and equipment. He attributed the two major disasters experienced the previous year at Life Esidimeni in Gauteng, and oncology services problems in KZN, to procurement and human resources problems.
He reflected that as a Minister, he had huge responsibilities but very little authority to do anything about these major problems facing the health service. All he could do was to make appeals and engage with provincial authorities on these four major areas.
The recommendations were as follows:
- That the challenges facing health institutions should be acknowledged, and urgent and decisive action taken.
- That the separation of powers and functions between political players and health managers and professionals be clearly outlined and observed, especially those outlined in the Public Finance Management Act (PFMA) and the Public Service Act.
- That the problems facing the health sector were a reflection of broader systemic problems that were beyond the sector, and there was a need for broader collaboration.
- That the instability of management positions be addressed, as there were too many people in acting positions.
- That appropriate national human resource delegations be developed and approved by provincial executives.
- That the undertaking of the Workload Indicator of Staffing Needs (WISN) be expedited.
- That an approved list of funded posts within the allocated budget be developed and utilised to manage the appointment of staff.
- That the authority to fill posts be decentralised to hospitals.
- Monitoring and follow through by management was important.
- Quality care of, and respect for, patients’ rights was important to avoid litigation.
- That provincial treasuries and provincial DoHs should collaborate on budgets for rural areas, as they were highly dependent on government support.
- That health budget allocations should be around 38% of the provincial budget.
- That health budgets should not be made unrealistic by the subtraction of accruals.
- That financial budget plans should be made in cases where there were significant accruals.
- That once the health budget was settled, it should be accepted by the health department.
- That budget preparations should be undertaken in the provinces, where provincial health departments are consulted in order to come up with realistic budgets.
- That budget allocations to hospitals should be reviewed with a view to temporary relief of unmanageable budgetary allocations when this resulted in 75% of the total hospital allocation going towards servicing staff needs.
- That in exchange for this relief, investigations of the staff establishment be carried out within six months, with a gradual progression to the acceptable staff consumption level of 65% of the budget within a period of three years.
- That where this has happened, the decision to centralise procurement by the provincial department be reviewed, with necessary control measures put in place.
- That urgent attention be given to the implementation of provincial contracts to facilitate the procurement of essential goods and services by the hospitals in a cost-effective and efficient manner.
- That provincial goods and services expenditure be reviewed and prioritised according essential items.
- That systems be implemented that allow management at all levels to actively monitor and, where necessary, control levels of expenditure
- That urgent attention be given to the functionality of the primary and regional health service platforms.
- That once managerial stability is achieved, hospitals develop detailed, action-oriented and time-bound action plans.
- That corrective action be taken to repair the broken procurement system through three phases:
a) get the basic system working, with simple interventions and improved governance.
b) establish the foundational capabilities and infrastructure to ensure a fully functional procurement system.
c) systematically migrate all procurement operations on to the new system.
The recommendations were adopted.
The meeting was adjourned.