The Compensation Commissioner for Occupational Diseases (CCOD) and the National Department of Health (NDOH) presented their annual performance plans, while the Professional Association of Clinical Associates of South Africa (PACASA) introduced the profession to the Committee.
The main highlights of the presentations related to possible legislation being passed to hold mines accountable for the finding on the compensation of the ex-mineworkers, the employment of inspectors, the training of health professionals, the benefits to the health profession of clinical associates, provincial departments’ lack of competence, and the oncology crisis.
Members commented that although the CCOD had produced a good report, more could be done to hold the different stakeholders accountable. It had made progress in establishing one-stop service centres and mobile clinics for the beneficiaries. However, it appeared that the CCOD’s funds were not adequate to fund everyone affected by diseases as a result of the mines, but only those who worked at the mines. Members suggested that mining companies should be taxed in order to increase the budget for the CCOD and that they should possibly legislate this act. They emphasised the importance of using unemployed graduates in CCOD’s processes as inspectors, especially the unemployed youth in the specific areas that they were working in.
Members welcomed the presentation by the Professional Association of Clinical Associates of South Africa, and agreed that the profession would be useful in the health sector. Members had noted their challenges and would engage with PACASA in future.
The National Department of Health said their aim was to prioritise the vulnerable. Members felt strongly about the conditions of health care centres in the provinces, especially in Limpopo. They suggested that provincial health departments should be held accountable for management failures and be more transparent in how their funds were spent. The mental health care services were a concern, since there were no fully functional mental health facilities in South Africa, and Members warned that something must be done to avoid a situation like that of Life Esidimeni. The oncology issue was raised, and Members said the NDOH should take extra measures to fix it, since it seemed that what had been presented in the plan was not a true reflection of what was really happening in the health care centres.
They were also concerned, in light of the listeriosis crisis, that there were still retail stores selling cold meats. The Department assured the Committee that inspectors had been put in place to monitor the listeriosis situation, and investigations were being done on countries from which cold meats were imported. It was suggested that provincial health departments should perhaps be called to Parliament to present their own performance plans and be taken to task on their mismanagement.
Compensation Commissioner for Occupational Diseases (CCOD): Annual Performance Plan.
Dr Barry Kistnasamy, Compensation Commissioner, provided the highlights for the 2017/18 financial year. One-stop service centres had been opened as per mandate, there had been a decline in benefit medical examinations, certification had dropped, the payments had doubled and they were able to get support from the Banking Association of South Africa to assist with access to financial services
The focus areas for the 2018/19 financial year for the CCOD were amendments to the Occupational Diseases in Mines and Works Act of 1973, the utilisation of decentralised one-stop service centres, and to submit the annual reports and financial statements of the 2014/15 and 2015/16 financial years. The actuarial valuation report had been approved by various parties, including the Auditor General’s (AG’s) office, and a new updated valuation was to be compiled on 31 March 2018. There was approximately R45 billion in unclaimed pension funds in South Africa, and of this there was about R4 billion in unclaimed funds for mine workers. There were 231 controlled mines and 21 controlled works, and the register had been updated through gazettes, with help from the gold mining groups and the Department of Mineral Resources (DMR).
Mr Sam Mulaudzi, Deputy Commissioner: CCOD, presented the budgets for the CCOD for the medium term. The Compensation Fund for the mid-term budget was to increase overall in the year 2018/19 from just over R190 million to R200 million. The Eastern Cape project, which was an old project that had been taken over by the CCOD, was projected to decrease, as most of the claims had been paid. The unadjusted projected total revenue for the financial year 2017/18 was R594 million, and the expenditure was projected to be R194 million. The financial position consisted of total assets that were projected to be R4.2 million, and an accumulated surplus of about R594 million. It was also projected that the total equity and liabilities for the year 2017/18 were about R4.2 billion.
Partnerships that the CCOD had made with different stakeholders had been beneficial and had contributed about R150 million which was not necessarily cash, but had helped with other things such as seconded doctors and outreach programmes. The class action settlement fund, which was a programme that would help with the funding for CCOD and the Medical Bureau for Occupational Diseases (MBOD) by the gold mining companies, was still to be finalised and more information would be sent to the Committee once it was finalised. The CCOD would continue with the mobile clinic project in the Eastern Cape and had also included other provinces, was working as well with the constituency offices. However, there was unfortunately limited funding for this outreach programme.
Mr Mishaick Maswangaye, Director of Finance: CCOD, presented on the voted funds budget for the medium term. These were the administration costs allocated to the MBOD and CCOD by the National Department of Health (NDOH). For 2017/18, the budget was R61.1 million and of this, R58 million had been spent. The voted fund budget for 2018/19 was R65.5 million, of which R35 million had been allocated to the compensation of employees.
According to its annual performance plan (APP), CCOD’s objective in the 2018/19 period was to submit amendments to policy and the legislation framework to the Director-General. There were to be six meetings of the audit and risk committee and four meetings of the advisory committee to manage governance and management. The database would be extended by five mining companies. The training of health professionals was a priority, as occupational health was a scarce profession.
Ms R Adams (ANC) asked if the benefits were only for ex-mineworkers. What happened to those who had died due to environmental exposure as a result of living in mining areas and not necessarily working in the mines? She asked whether outreach programmes had been set up to give information to the people who lived far away from the one-stop centres.
Dr P Maesela (ANC) said it was actually the mines’ responsibility to find the beneficiaries of these grants and give them what was due to them. He asked why mining companies were not taxed, necause the mobile clinics were for the labour that was working for them. He suggested that the taxing for mines could even be done through legislation. Were unemployed graduates utilised in CCOD processes?
Ms L James (DA) enquired about the number of mines that the CCOD had registered on the database and how it reconciled with the number of inspectors in order to get accurate data. She commended CCOD on the mobile clinics, but said the information on these mobile clinics should be distributed to the Committee so that it could be conveyed to different constituencies. She stressed the importance of training more health professionals to assist in these programmes, especially unemployed graduates.
Ms Adams asked for clarity on the number of people using one-stop centres.
The Chairperson asked about the criteria that were used to employ the inspectors, and what was expected from them. She also asked about the mobile clinics and who they actually catered for. Did the CCOD actively look for medical graduates or students who actually wanted to specialise in occupational health?
Dr Kistnasamy responded that the social protection fund was a shared fund, and there were multiple links to these funds that the CCOD was busy working on.
There were five unemployed graduates who had been in employed in Welkom. He stated that CCOD welcomed any suggestions from the Committee on how to tackle some of the issues, especially in terms of youth employment. The work that was done by the CCOD also covered migrant workers and it was a straight forward process, in collaboration with the different provinces.
Regarding the effects of environmental exposure, there was a gap in the legislation and the CCOD could not cover it all
The CCOD’s one-stop service centres could not get to every place, and it was working with various provincial departments to provide other services to the people. Responsibility for mines was with the Department of Mineral Resources, and he suggested that different committees should work together to fast track these processes. There was an extensive programme on tuberculosis (TB) and mining.
To cover 352 controlled mines across South Africa, there were only three finance inspectors and nine health inspectors.
Dr Mpho Rabada, Director: MBOD, commented that they were working with hospitals to ensure that doctors were involved. Regarding the mobile clinics, the CCOD collaborated with the National Department of Health (NDOH) to ensure efficiency, and that nobody left without being attended to. These people came with documents in order to be helped. The mobile clinics were worker=based and could not be family based, and were restricted to only ex-mineworkers.
The finance inspectors stated that people from different backgrounds were needed. There were also different inspection levels that needed people with different education levels.
Dr Kistnasamy said that the CCOD was working with Wits University on outreach programmes for the occupational health profession.
Ms E Wilson (DA) suggested that the Departments of Health and Education should work together to mitigate the health risks that were faced by different schools, as the conditions were often bad.
The Chairperson welcomed the suggestion that the Committee should work in collaboration with other departments and be more involved in CCOD processes. She said that CCOD processes were prone to fraud and that it should look into this when recruiting inspectors.
Professional Association of Clinical Associates of South Africa (PACASA): APP
Ms Zikisa Tshabalala, Chairperson: PACASA, defined a clinical associate as mid-level trained health professionals who had earned a Bachelor of Clinical Medical Practice. Clinical associates were initially intended to be placed in the district health sectors. The clinical associate was a generalist who could perform professional health assessments. The advantage of clinical associates was that they were cost effective, preventative and curative. Young people from disadvantaged areas were recruited and trained with no fees, and were required to work back in their communities. However, a salary review had not been done, and over the years clinical Associates had not been able to move up the salary scale. The universities of Pretoria, Witwatersrand and Walter Sisulu trained clinical associates in South Africa, and they were able to study further along this career pathway.
Mr Edwin Leballo, Deputy Chairperson: PACASA, emphasised that there were not enough posts for clinical Associates, and he urged government departments to employ them where health professionals were needed.
Mr Sanele Ngcobo, Secretary General: PACASA, said that training for clinical associates was more practically based. They were trained in rural areas and were able to work back as a result.
Mr A Shaik Emam (NFP) asked PACASA about the challenges they faced in finding common ground with other medical professionals.
The Chairperson said that the challenges had been reflected on in the presentation and fortunately in the presence of the Department of Health. She asked whether clinical associates were supervised when performing their medical tasks.
Ms Tshabalala responded that there was supervision, and that the level of supervision changed with the continuous practical involvement of these clinical associates. A limiting factor on how many of them got hired was that there might not be adequate supervisors at medical centres.
The Chairperson in closing commended the presentation by PACASA. She said this was an introduction and further presentations would be arranged, and that it had fortunately been done in the presence of the National Department of Health.
National Department of Health (NDOH): APP
Ms Malebona Matsotso, Director General: National Department of Health, gave an overview of the priorities for the medium-term commencing in 2018/19. The Department aimed to prioritise the vulnerable groups and work on the management of health centres in order to provide efficient health care. In doing so, they had developed different programmes.
Programme 1 was an administration programme that had been put together to support other services and to ensure effective financial management and accountability by improving audit outcomes. Over the years, progress had been made. Unfortunately two provinces had regressed, but four provinces had improved. There were also only three provinces that had not achieved an unqualified audit. The target for 2018/19 was that five provincial Departments of Health demonstrate improvements in audit, with no significant matters.
Programme 2 focused on the National Health Insurance (NHI). The programme was being implemented to improve access to quality health services through development and to implement policies to achieve better health care services. This was being done through implementing the e-Health strategy of South Africa; by developing the patient information system; establishing a transparent national stock management surveillance centre to improve medicine availability; regulating traditional health practitioners and having the Amendment Bill published for comment in 2018/19; and implementing an integrated monitoring and evaluation plan aligned to health outcomes in the health sector strategy. Phase 1 of the NHI evaluation report should be published in 2018/19.
Programme 3 was the HIV/AIDS, TB and Maternal and Child Health programme. This programme was disease-based and aimed to develop and monitor implementation of national policies, guidelines, norms and standards, and targets for the national responses needed to decrease the burden of diseases associated with the burden of HIV, TB and other non-communicable diseases, to minimise maternal and child mortality and morbidity, and to optimise good health for the vulnerable.
Programme 4 was for primary health care services, and aimed 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 and non-communicable disease control, as well as health promotion and nutrition programmes. South Africa was also one of the countries that had committed to malaria elimination by 2020. In 2018/19, the Department aimed to have functional facility committees to strengthen district governance and improve leadership of the district health system. Currently no province had fully functional mental health facilities, so the Department planned to have about 15 district mental health teams established to strengthen these services.
Programme 5 was for hospital, tertiary health services and human resources development. The purpose of the 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 to ensure the planning of the health infrastructure to meet the health needs of the country. For 2018/19, oncology and obstetric services improvement plans needed to be developed. Nine provincial departments of health would be monitored for compliance with the Emergency Medical Services (EMS). All students returning from Cuba during 2018/19 were to be placed for clinical training in local medical schools, and this would be done with all nine medical schools across the provinces. The nursing qualification programme would be integrated for both young and old nurses. Approximately 60% of the backlog on alcohol and toxicology tests would be eliminated.
Programme 6 was for health regulation and compliance management, and aimed 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 National Public Health Institute of South Africa (NAPHISA) Act was targeted to be promulgated in to law in 2018/19. A handbook for departmental representatives serving on entities’ boards would be developed to ensure integrated and coordinated governance and management oversight of public entities and statutory professional councils.
Mr Ian van der Merwe, Chief Financial Officer, NDOH, highlighted that the ear-marked funds had been allocated by Treasury, and indicated the following key changes in the programmes from the year 2017/18 to the year 2018/19:
- Programme 1: Information Technology (IT) had been developed and centralised.
- Programme 2: Most of the NHI grants had been broken down into different sub-headings.
- Programme 3: The earmarked funds and community health workers had been added.
- Programme 4: A reduction in capital, by centralised IT services.
- Programme 5: Improvements mainly because of the movements in programme 2.
- Programme 6: Southern African Pharmaceutical Regulatory Affairs Association (SAPRAA) would be noted under public enterprise.
Ms Wilson said that in terms of programme 1, Limpopo had completely fallen off the bus, and that the conditions there were horrendous. She asked why the Limpopo health department was not under administration.
Ms Ndaba commented on the performance of provincial health facilities, and asked the NDOH if there had really been progress in these facilities because it seemed that health in provincial departments was worsening. She asked if the Department had any plan and framework to improve mental health facilities to avoid another case of Life Esidimeni. She further commented on the environmental inspectors, and why cold meats were still being sold in retail stores.
Mr Mahlalela asked how the removal of the 37 indicators would streamline the NHI, and where the removed indicators had been placed in the process of streamlining. He said that having R16 billion worth of accruals was a problem and should be looked into. Special focus needed to be applied to the issue of irregular expenditure because there was lot of fruitless and wasteful expenditure. However, there seemed to be business as usual, but if this behaviour continued provinces may even collapse. The NHI bill also had to be tabled before government. The bulk of the budget was on phase three, but there were only two indicators. He asked why the big campaign on cancer that had been presented by the President in his State of the Nation Address was not in the Department’s budget plan for this financial period.
Dr Maesela commented on the HIV/AIDS pandemic, and said that if the conditions were not improving it meant something was not being done right. He commented that the Emergency Medical Services (EMS) could not say that they would comply in future, as compliance had to be performed now and drastic measures should be taken to ensure that they actually complied.
Ms James enquired about the amount of money that had been allocated to maintenance infrastructure and medical equipment. She also commented on the oncology problem in KwaZulu-Natal, saying that people were still not being helped. When questions were asked about the provincial department, nobody seemed to be taking the blame, and she suggested that maybe the Committee should invite the provincial departments to come to Parliament. She enquired about the state of the nurses and nursing colleges, because it seemed that there were not enough nurses in hospitals and clinics.
The Chairperson said there was a need to call things as they were and to shy away from generalisations. She agreed with Dr Maesele that maybe the National Health Act had to be amended to ensure competencies. She commented on the new curriculum for the nurses, and asked why it had not been implemented yet. The discussions seemed to be repetitive and maybe the Committee was barking up the wrong tree – perhaps the provinces should be called in to present on their APPs.
Ms Matsotso responded that their total budget of the year was R198 billion and of this budget, only R33 billion was being retained in the national department. She said that it was difficult to solve a facilitatory function with a political problem. The elephant in the room was that of the nine provinces, six were under administration. When a province was put under administration, every single transaction needed to be approved by the premier. There was only one province that had had stability over the years.
The Department had activated an emergency operating centre in order to track every single outbreak. They needed to have disease detectives out there in the field so that outbreaks were managed in time.
An analysis had been done on whether health was being under-funded, or if there was mismanagement, and it had been established that the bulk of the problem was that health was under-funded by about R9 billion. However, provinces needed to learn to work in constrained environments.
On the matter of the bill, she said that the bill had been subjected to three legal opinions.
The APP had been presented in the way it was because it was regulated, and they had to comply before they could present it to Parliament.
On the subject of oncology and mental health, they would try to deal with these issues at the national level as a test in the grant framework, and maybe it could be the basis for changing the whole system.
There were about 1 000 graduates, and the number kept on increasing and they would utilize them. She emphasised that R198 billion could do much more. On the issue of HIV/AIDS there had been a debate on whether the solution should be disease-based or health system-based. There were three provinces that had not been subjected to section 18.
Dr Gail Andrews, Chief Operating Officer (COO): NDOH, said interventions were currently being done in six provinces, in collaboration with the South African Institute of Chartered Accountants (SAICA) to deal with irregular expenditures. These irregularities were being dealt with according to SAICA regulations.
Ms Lamees Scholz said the reduced indicators were in keeping up with best practice to help with streamlining. In terms of the NHI evaluation, a copy of each individual report had been sent to Parliament. The final report was in progress and should be submitted by the end of September. Regarding the EMS, when provinces failed to comply with medical services, they needed to be held accountable to ensure consequence management.
Dr Danton Pillay, Director: Pharmaceuticals, NDOH, responded to the indicators and how they related to NHI policies. Committees and gazettes had been set up for the development of these policies. In order for NDOH to establish the funding, there had to be legislation in place.
Ms Ganile Buthelezi said that with regard to the oncology services in KwaZulu-Natal, the delay at a hospital in Addington had involved the disposal of the old machine and installation of the new machine. This was awaiting approval from Treasury, but was currently in progress and both these machines would be in full operation by the end of May. There were three functional machines at Albert Luthuli Hospital, but they had just had problems with oncologists which were being dealt with.
The Chairperson advised that the NDOH should visit these hospitals and check that the machines were actually operating well in terms of the oncology crisis.
Ms Wilson asked about the R28 billion in litigation against the Department, and wanted to know where the money would come from. Were the NHI pilot programmes still running, because Limpopo had just laid off the 30 doctors that were in the pilot project? It seemed the provinces did as they pleased and did not take orders from the NDOH.
Ms James said that what was in the oncology report was not a reflection of what was actually happening on the ground. She also commented that she did not think that it was fair for the Department to pose the question back to the Committee when asked about the issue of retailers still selling cold meat.
Ms Matsotso responded that if the issue was specifically on the cold meat imports from Brazil, then there were investigations being done. The oncology report had been presented for only KZN, but other provinces were also provided for in the APP.
To deal with the issue of litigation, they first needed to identify the fraudulent transactions, then there had to be an administrative audit, and finally there would be work with the Department of Justice to start with the legal reform.
The Chairperson said that progress reports on the NHI pilots had been given to Committee Members last year. At its next presentation, the NDOH needed to give detailed reports on the issues that had been being raised. Health was a very emotional topic and the Department should avoid giving general reports in future so that the Committee also knew exactly what was happening. The NDOH should refrain from saying that provinces were doing well because of their unqualified audit reports, whereas on the ground the state of the health services was bad.
The meeting was adjourned.
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