Minister of Health's overview of Health & future plans

NCOP Health and Social Services

15 May 2018
Chairperson: Ms L Dlamini (ANC) (Mpumalanga)
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Meeting Summary

The Minister of Health, Dr Aaron Motsoaledi, provided a detailed overview which clearly defined the four critical challenges of Human Resources, Financial Management, Procurement and Maintenance of Infrastructure and Equipment. If you master the human resources, financial management, procurement and infrastructure, the health system will operate well. It does not require expertise in Health. The Ministerial Task Team found that these problems did not originate from the Health system but from the provincial governments. Ministers are given the responsibility but not the authority in Departments that have concurrent national and provincial competences such as Health and Education. Premiers appoint HODs and the President appoints Directors General.

Most crucial was the inability of the Minister of Health to intervene in provinces, due to national government’s lack of legislative authority in provinces. He only had ‘post-mortem’ powers to intervene after the problem and had no authority to prevent it from happening. All the powers, and in some instances the delegation too, is with the MECs and Premiers, in provinces, who have authority over budget allocations and the approval of appointments. Life Esidimeni happened because MECs, legally, have all the power. The health review boards which exercise oversight functions on public health facilities and have the powers to overturn the Minister and MEC decisions, were also appointed by the MECs. The Minister is responsible for performance in the provinces without the authority to realise that responsibility. The South African Law Reform Commission has started to review current legislation. There are 108 laws operating in Health, 39 must undergo extensive changes and divided into three groups to be amended, repealed, or consolidated. The amendments will solve all the challenges about concurrent responsibility and authority raised today.

A Chief Financial Officer (CFO) forum had been formed and chaired by the NDoH CFO who got the South African Institute of Charted Accountants (SAICA) involved. Treasury was so impressed with SAICA’s involvement and improvement in the provinces, it gave R8 million towards the SAICA programme. “Audits are not only about skills”, said the Minister, “it is also about stability”. If a Province was unstable, where people were changed all the time, it was not possible to get a clean audit. ‘A clean audit is something that is planned over time it may take two to three years to get, it is something that is planned deliberately. The Eastern Cape stabilised because it went from having a new HOD every six months to having the same CEO, Chief-Director, and HOD for five years.

NDoH presented its strategic objectives and interventions to address all the pressing challenges. It was committed to improving audit outcomes in the provinces. Most of the provinces had improved especially Mpumalanga and he was confident they would get an unqualified audit.

To start implementing the NHI, NDoH had identified five vulnerable groups and had allocated money towards the roll-out. The groups are mental health patients, people with disabilities, oncology patients, and hearing, dental and eyesight programmes for children. A number of community health centres and hospital have been constructed or revitalised and more facilities had been maintained, repaired, and/or refurbished in NHI districts. It had also assigned its three Deputy Directors General to adopt a province (Gauteng, KwaZulu-Natal and Limpopo) and work with them to improve performance and efficiency.

The Committee assured the Minister that the Committee would call a meeting with the Premiers if time permitted. It resolved in future to invite the national department together with provincial departments and their MECs to account on concurrent matters affecting the two levels of government. It welcomed the progress and work done in ensuring that supply of medicines is no longer a crisis, and appreciated the improvement in infrastructure and the delivery of oncology equipment in Kwa-Zulu Natal. There was no contention about the R47 billion NDoH budget and the proposed changes to Health legislation.

Meeting report

The Chairperson indicated she received written apologies from both the Minister and Deputy Minister of Health who had to attend a cabinet committee meeting to present the National Health Institute Bill at the same time as this meeting.  The Director-General and the rest of the NDoH delegation were acknowledged. The Chairperson requested guidance from Members on how to proceed, given the non-attendance of the Ministry. According to a decision taken by the Committee, last year, the Minister and/or the Deputy Minister had to be present to respond about the Annual Performance Plan and Budget. This is the final year of the Fifth Parliament and there are several issues that need to be addressed directly to the political leaders.

Ms P Samka-Mququ (ANC, Eastern Cape) said it was not right that both the Minster and the Deputy Minister had to attend the cabinet meeting. At least one of them should have been here. We will be discussing the budget and she agreed with the Chairperson that this is the last year of the Fifth Parliament. She did not have a solution but it was not justifiable that neither was present. What could be so important that both had to be there? All they are required to do here is give a political overview and then the Director-General could take over on the administrative issues. The address by the Minister or Deputy Minister is important. This discussion will be on their budget and their annual performance plan that the Committee must present to the National Assembly. It will be difficult to do so without the Minister’s policy inputs. 

Ms L Zwane (ANC, KwaZulu-Natal) agreed. This meeting was more important than all other meetings as the discussion was on the Department of Health’s financial plans for the year. There will be political issues that the Committee will want to raise in the presence of the Minister or Deputy Minister. She cannot understand what is so important that needs both their attendance. The Deputy Minister has usually been of service to the Committee when the Minister cannot be here. What was different today? The difficulty with not proceeding was the Committee’s tight schedule. If there is no certain date to postpone the meeting, it must proceed.

Mr D Stock (ANC, Northern Cape) agreed. The Committee had been consistent, and insistent, on the attendance of ministers at meetings. His concern was if the Department delegation is sent away, they would have to debate the Annual Plan and Budget, in the National Assembly, without having had the opportunity to discuss it with them. Given time constraints, the meeting should continue since the Department is present.

[The Chairperson suspended the meeting for five minutes for the Director-General to return and begin the presentation. The Director-General returned to the meeting room with the Minister]

The Chairperson apologised to the Minister and said his written apology had been received noting he had to attend to an important matter but the Committee felt that this was a very important meeting about the financial plans of his Department for the year. There are issues that the Members would like him to specifically address. She apologised for disturbing the Minister and appreciated his attendance. She highlighted a number of issues the Committee had dealt with since it took office in the Fifth Parliament.  Some improvements had been noted in some areas and there were concerns in others. The biggest problem previously was the availability of medication. The Committee had been to almost all provinces besides North West and Gauteng which it would visit this year. The Committee felt that the problem of medication availability had been dealt with and they appreciated the work done. It was no longer a crisis.

Audit outcomes were also an issue that the Committee insisted the Ministry address. Seven Provincial Departments had received qualified audits. Today, it is only Limpopo and North West who had regressed. Most of the issues the Committee emphasised then had improved. They were appreciative and acknowledged how difficult it had been, considering the Minister had previously raised his frustrations that he was not fully responsible for the provinces.

During the Committee oversight visits three key challenges were evident in the provinces. The biggest is human resources. There is shortage of staff. The Committee’s position is that personnel can be cut from all other departments but not from the Department of Health. A message was relayed, during the visits, to all the provinces to tell Premiers that if there are any budget shortages the Department of Health should not be affected. The question is whose child must die? What is more important than life? This must be addressed. Doctors want to leave because of the pressure. The Committee suggested that the provinces, with the Premiers, have a meeting and address the matter.

The second challenge is the infrastructure and maintenance of public clinics and hospitals in all the provinces visited. There were some provinces which had done a lot of work, such as Mpumalanga, but other provinces, such as the Free State, were not doing well. Some clinics are still four-roomed houses.

Lack of equipment was a third challenge. The Chairperson was under the impression that the oncology machines had been delivered to Kwa-Zulu Natal, but now some problems had been raised. There are also serious issues in the Western Cape. She had received three separate petitions from Khayelitsha Hospital which she had not yet shared with the Committee about the mismanagement, corruption, and appointment of unqualified personnel resulting in infant deaths. A good specialist from Nigeria had to leave the facility because he was threatened by one of the other doctors. She raised the selective targeting of provinces due to their audit outcomes. Sometimes five provinces were targeted for interventions and others were left out. Why only five provinces? The Committee is aware that the Department cannot do everything but it must at least target all of them equitably. Mpumalanga and the other provinces that have had qualified audits consistently, the situation must improve.

The Chairperson asked the Minister to give a political overview and to allow the Members to respond.

Minister of Health overview
Minister Aaron Motsoaledi clarified that he does not undermine the Committee and was going to join the meeting after he had presented the National Health Institute Bill and Medical Schemes Amendment Bill to Cabinet. He had always been there when the Committee invited him but unfortunately today was a challenge. He expressed his happiness that the Chairperson had raised the same challenges that he had repeatedly raised to Cabinet. To start off, he was not say that he was not responsible for the provinces because he is the Minister of Health. What he was complaining about was having responsibility without authority. He was responsible for the performance of provinces but he had no authority on who gets appointed to senior positions. Some of the appointments made were wrong. He boldly stated that, ‘North West is in a crisis because the Head of Department (HOD) that was hired was also a mediocre Director at the Department of Health. It is no secret he was mediocre’. The Minister discovered that the Premiers appoint HODs and the President appoints Directors General. This is the reason the Minister of Home Affairs could not fire the DG because ministers had no powers. He had personally gone to the North West Premier and warned him on three occasions but he still went ahead with the appointment of the HOD. When things go wrong everyone turns to the Minister but he could not prevent the situation from happening, that was what he meant by responsibility without authority.

In 2015, the Department came up with the concept of ‘non-negotiables’. There are some things that can never be negotiated – if they were not there it could not be said that there is a functioning health system in the country. This included medicines and vaccinations (for chronic illnesses), infrastructure, and laboratory services. These should be budgeted for in advance to pay within 30 days in accordance with the law. There was an instance in Durban where the HOD could not provide an itemised budget. Everything fell under ‘good and services’ without specifying how much had been spent on HIV, TB so they would have to guess how much was spent on vaccines. Together with the CFO, the Minister and the HOD worked on improving budgeting. It took a long time but eventually it was done properly. The CFO consistently followed up on the non-negotiables with the provinces. However the MECs would say the Premiers are the ones who decided on budget allocation. He said, ‘Premiers do not believe that they report to Ministers’. When the Minister of Health visited North West, he was even called out for visiting the province without permission. When the Minister realised that the ‘non-negotiables’ were not working, he chose a Ministerial Task Team (MTT). He selected five members based on expertise and institutional memory to visit one hundred hospitals within six months to diagnose the problems. The hundred hospitals were chosen because they were always in the news due to insufficient resources. After visiting only 25 hospitals in six provinces (not including Gauteng, North West and Western Cape), the MTT called a meeting with the Minister and said they felt that they would be wasting tax-payers’ money if they continued with the hospital visits. No number of visits would solve the problem, which they already know as the problem was not inside the hospitals. All the problems came from the provincial governments. The hospitals should be left alone and the MTT project must start by looking into the provinces. It was observed that HODs do not even have the delegation to change a diffused light bulb. The delegation is with the Department of Public Works in the province who has the budget. Even the Chief Executive Officer (CEO) at Baragwanath could not change a light bulb as the budget to do so was held by another department in Gauteng.

The Ministerial Task Team identified the following four problems in the provinces: Human Resources, Financial Management, Procurement and Maintenance of Infrastructure and Equipment. Health and Education are concurrent competences but these four problems are not concurrent. Even the budget, the equitable share, is transferred directly from National Treasury to the Provincial Treasury to the Executive Members who then take over the rights and responsibilities to distribute it to the Departments. Previously, the National Department of Health would be involved in budgeting and deciding how much each Province is allocated. Unfortunately, this was the old legislation under apartheid which did not recognise provinces as governments. Now the Minister is not able to participate in the budget allocation of provinces. The National Health Act which came into force in 2003 recognised provinces as governments and not as administrative centres as they were previously recognised. The Public Financial Management Act (PFMA) recognised the HODs as Accounting Officers and the Public Service Act recognises the MEC as the executive authority. The MEC has all the authority to decide who must be hired. The Public Service Commission no longer does so and the chapter which decided the number of Directors and Chief Directors to be appointed according to population per province was taken away.

Life Esidimeni happened because MECs, legally, have all the power. The National Health Act of 1973, which did not have human rights provisions as an apartheid legislation, provided that the President, the Minister of Health and Magistrates were the custodians of mental health patients. Those three people had the responsibility and authority over the state of mentally ill patients, without either of their signatures and approval nothing could happen to the patients.  After 2002, the new Act then included human rights provisions and all those powers were packaged in one and given to the MEC. Checks and balances were provided to protect mentally ill patients as the Act provides for a health review board as a quasi-judicial structure whose decisions can be overturned only by a court of law. The decisions of the MEC on the state and movement of mentally ill patients can be overturned by the health review board. However, the problem is the health review board is appointed by the MEC and reports to the MEC. Many of its members fear the MEC as was the case in Gauteng. This is painful as prominent members of society – senior advocates, magistrates and other professionals – are appointed as members of health review board. When the ombudsman said these powers must be given to the Minister this is what he was referring to. In the National Health Insurance Bill, which the Minister is going to present to Cabinet, provision is made for the Minister to be given the necessary authority to exercise those responsibilities.

Human Resources
It was found out that provinces have changed delegations. Many people running the facilities do not have the delegation to effectively do so. A special meeting about delegations was called in Pretoria with MECs, HODs and the Department of Health who advised them exactly who and what to delegate. However, nothing was done further. It seems as if provinces need to be guarded all the time meanwhile they have politicians leading them. The general expectation appears to be that Ministers and National are there to clean up every time the provinces mess up yet the provinces hold so much political power. This is what the new Act is intended to change.

In the 2017 Budget Speech, then Finance Minister Pravin Gordhan, at the plea from Minister Aaron Motsoaledi, mentioned in his that staff can be cut elsewhere but not in the Department of Health. He clearly specified the moratorium on compensation of employees should not apply to the coalface of delivery. By this he was referring to doctors, nurses and teachers but he could not specifically mention them by name at the risk of discrimination between professions. Subsequently, the MTT reported back that there was a moratorium in the provincial health departments. Although it was subtle, it could be recognised as one because it still had the same effect. In most of the provinces, the Premier’s Office had taken over the human resources function. Before any appointments are made it must approve. The Office of the Premier argued there was no moratorium but appointments must be approved by it. However, this never happens as doctors do not get feedback even months after interviews. The Premier always states to NDoH that it is waiting for Treasury to approve. This is happening in several provinces where new appointments must be approved by the Premier or Treasury and the approval never comes.

Interns were also a contention as this is another human resource function that sits fully with the province. Doctors do not get internships. The Health Professions Council must approve an institution before it can take on interns. The hospitals are accredited to take a specific number of interns. Western Cape only filled 56 percent out of the 100 posts that were accredited. It meant 44 posts were not created and could not be taken up because no money was put aside for the posts. The Western Cape province said all the budget had been allocated to the drought crisis. In Gauteng also, not all the accredited posts were filled. All the other provinces filled all their accredited posts but these are small in comparison to Gauteng and Western Cape. If these two provinces and Kwa-Zulu Natal push back on taking interns, there will be a problem because internships were only supposed to happen where there is specialist supervision which is only in these three provinces. 

Another problem was that when people were unfairly or irregularly dismissed from their posts, the law provides that they must appeal the dismissal to the MEC, then to the CCMA, and then the Labour Court to adjudicate on the matter. The Minister has no power to intervene, at any stage, on the matter. The unions were also not aware of this and often called upon the Minister to assist with unfair dismissals. All the Minister can do is cooperate but has no further powers.

Financial Management
A CFO’s forum was formed and chaired by the National Department of Health CFO, Mr I van der Merwe, who also got the South African Institute of Charted Accountants (SAICA) involved. Five provinces were chosen instead of all of them because progress needed to be assessed first before roll-out to all provinces. From 2009 it was always Western Cape and North West who were getting unqualified audits. The Minister could not understand why Kwa-Zulu Natal and Gauteng did not have unqualified audits. When other provinces started to improve on their audits, the North West drastically regressed because of the appointment of the HOD. This is a fact, which can be verified, that the North West received a qualified audit after the appointment. Limpopo received an unqualified audit after it was under section 100 administration, immediately after the Department of Health left they regressed and got a qualified audit.

Treasury was so impressed with SAICA’s involvement and the improvement in the provinces, it gave R8 million towards the SAICA programme but unfortunately, ‘you can only take the horse to the river, you can only do that’, said the Minister. The MECs of Finance denied that the control they had over Health Departments was potentially making them corrupt. When the MECs for Health were called to account they said all the powers were taken from them and given to the Premiers. This was why the Minister of Health advised the Committee to summon all the Premiers and take up the matter with them. The National Assembly said it does not have the powers to call the Premiers, only the National Council of Provinces can do so. For as long as the Select Committee called on the Minister and MECs to account it was only holding those responsible and not those with the authority. He cannot do anything about the financial irregularities in the provinces because he does not have the authority.

‘Audits are not only about skills, said the Minister, it is also about stability. If a Province was unstable, where people were changed all the time, it was not possible to get a clean audit. ‘A clean audit is something that is planned over time it may take two to three years to get; it is something that is planned deliberately. The problems of Health are not in Health. The previous MEC for Health in North West was not a health ‘expert’ but because he mastered the four things: human resources, financial management, procurement and infrastructure he did very well’. If you master those four things the health system will operate well. The Eastern Cape stabilised because it went from having a new HOD every six months to having the same CEO, Chief Director and HOD for five years; that was why they improved. It is difficult because you cannot instruct Premiers to keep certain people in key positions.

The Minister expressed his confusion with the criteria the Chairperson was using because his records showed it was the other way around. The Free State was doing very well in infrastructure. It stopped using the Department of Public Works. In the past financial year, the highest expenditure for infrastructure was the Free State. Mpumalanga was problematic because they had an underspend because there was nobody in the Public Works Department in the Province, there were only three people with technical skills the rest were managers. How do they build schools and roads with so few people working in the Department? The Province which had more technical people than managers in Public Works, was Western Cape. In the Free State the biggest problem was the size of the clinics but these were built for Qwaqwa which had a small population. They agreed with the MEC to consider increasing the size of the buildings.

For medicines, there is an essential drugs list but only recently has there been an essential equipment list. It outlines the level of equipment a facility must have. All the equipment must be bought by one office, the Chief Procurement Officer in National Treasury. Unfortunately, a few problems have been encountered throughout the country. They have not delivered on the list provided by the NDoH. In Kwa-Zulu Natal, it is the Ministry of Health which bought the equipment after asking Treasury for special compensation. It had also brought in oncologists from University of Witwatersrand who will see 450 patients per month. The KZN MEC for Health had indicated that the equipment had arrived and all that was left to do was to obtain the accreditation to operate the machines. The KZN Department of Health had repaired one of the old machines.

The Minister disclosed what he was going to mention during his budget speech later that afternoon. A special decision had been taken to assist Kwa-Zulu Natal and Gauteng to deal with their current backlog. Gauteng does not have a problem as it is the neighbour provinces (Limpopo, North West and Mpumalanga) which do not have the skills to deal with radiation oncology and transfer all their patients to Gauteng. The machines are not coping with the demand.

He said that he will get further details on Khayelitsha Hospital so the matter can be attended to.

In summary, the Minister said, ‘(1) Call the people who have the authority and (2) Support the National Institute of Health Bill to change the laws’. The Law Reform Commission has started to review current legislation. There are 108 laws operating in Health, 39 must undergo extensive change and are divided into three groups to be amended, repealed or consolidated. The amendments will solve all the problems raised today.

Ms L Zwane (ANC) thanked the Minister for attending and applauded his elaborate overview. When discussing Annual Performance Plans, the Committee appreciated the presence of either the Minister or the Deputy Minister. Expecting Ministers to answer on the issues emanating from the provinces is due to the nature of the National Council of Provinces whose interest is the provinces. It is understood that the powers are vested in the provinces with the MECs and Premiers because they are concurrent structures. However, the fact of the matter, as the Minister himself said, when things goes wrong in any Department, people tend to look to the National Minister more than the MEC.  On the powers of the Minister, this was a constitutional issue that needed to be taken up. She expressed her appreciation to the Minister for the oncology equipment and attending to the backlog. The Committee also appreciated that after having visited seven provinces, there is a turnaround for the better and there are a few challenges’. There will always be rotten apples who are intent on destroying the system’. When you hear people say they would rather be taken to a public hospital (Port Shepstone Hospital) instead of a public hospital (Margate Hospital) it means you are turning around the health system and changing the lives of people. She was not referring to poor people but people on medical aid. On standardisation of the structures of the clinics, in KZN you can recognise that a certain building is a clinic. It was not the case in the other provinces where the sizes and structure are not the same. This needs to be looked at. She asked if the challenge with the absorption of the ‘Cuban’ doctors had been resolved. Has the Life Esidimeni matter been resolved? She was aware that the Minister was not directly responsible but it was a troubling issue and a burden on all of government. She assured the Minister that if time permitted the Committee will call a meeting with the Premiers.

Mr M Khawula (IFP; Kwa-Zulu Natal) remarked that it was always good engaging with the Minister. He had also sent a message to the KZN MEC, Dr S Dhlomo, to confirm that the oncology equipment was delivered. He thanked the Minister for providing responses to the concerns the Committee had raised last year. Even though the responses took time, the Committee is grateful and will further engage.

Mr Stock also welcomed the political review. He wanted clarity on the MTT. The Minister indicated when the Task Team started they were given 100 hospitals to visit in 6 months and came back after visiting 25 and report that the real problem is the Provincial Departments. He wanted to know whether the mandate of the MTT had changed and if there had been any progress since their visits and going out to the Provincial Departments? Is it necessary for SAICA to remain in the piloted provinces that had improved their financial management? Gauteng has now improved, is SAICA still need to ‘babysit’ them or can they now go on to assist in another province?

Ms T Sibhukwana (DA; Western Cape) commented that the Minister was silent on the shortage of nurses around the country. She requested a presentation on the shortage of nurses per province, and whether there had been any progress. She was pleased that the shortage of doctors and faulty equipment had been addressed as it was compromising the constitutional right to life. When it comes to Mpumalanga, how far is the infrastructure programme?

Mr C Hattingh (DA; North West) thanked the Minister for again highlighting the problem of having responsibility without authority. His questions were on the backlog in the North West. People had been without chronic medication for two months. ‘The people can do nothing about it, they are powerless’ he pleaded. Does the Minister have the authority to intervene when things are going terribly wrong? ‘When people’s lives are being threatened?’ It is well publicised in the media what is going wrong in the North West. People are being held to ransom and things are going devastatingly wrong. National Treasury has the authority to intervene on irregular tenders; can the Minister intervene when life threatening things are going wrong in the provinces?

The Chairperson allowed the Minister to only respond to one issue because of time and to respond in writing to the other questions. Not that the other issues are not important, but North West is being raised for the second time and it is well known the situation is getting worse. How soon after the intervention has started could change be expected? It is not a normal intervention. The Committee issued a statement that it was not undermining the intervention but medicinal supply cannot be stopped.  When patients are admitted to hospital it means their condition is worse. The Committee had received a letter from the Chairperson of the Council in North West, but she has not seen the letter.

Minister Aaron Motsoaledi clarified that there appeared to be confusion when has was talking about responsibility and authority. It does not mean that he is not allowed to intervene but that is where the problem lies, he can only intervene after things have gone wrong. He called this ‘post-mortem powers’. The Health Ombudsman said that in future the events that led up to Life Esidimeni should not happen without the Minister’s approval, meaning any MEC who wants to move a mentally ill patient somewhere cannot do so with the permission of the Minister. If they do not ask for permission, it will be an offence. The Health Ombudsman wrote in his report that the Act does not provide those powers. Section 103 of the National Health Act states the Minister can go and intervene but it is only after it has happened. Like the Auditor-General will only find out about irregular expenditure after it has occurred. The Chief Procurement Officer (CPO), as supported by the Ministry, requires any procurement of R10 million and above to be approved by the CPO in the strong efforts to prevent malpractice and mismanagement.

The Minister went on to say that there is no shortage of medicine in the North West. The medicine supplies had been cut off by the strike at the depot. Even the security company hired to guard the depot was part of the strike. The Army had to be brought in. Immediately after it was brought in, it took over the depot and discovered there were medicines. It was only that distribution was the problem. The Stock Visibility System (SVS) was launched with Vodacom and the Rx Solution system in the hospitals. Each clinic in the country uses the method except for Western Cape as the previous system is working well for them. The nurses are given cell phones and they scan bar codes of the medicines. The system then calculated the average consumption per drug at each hospital. When they scan, the information goes directly to Pretoria, at the NDoH head office. It will indicate, by different-colour flashing lights, when the amount is below normal and when the stock has run out. There is a big map at the head office that has all the clinics in the country on it. When the nurses do not scan, you can see on the map and this is followed up by the Department. However, in North West due to the strike, there are no nurses to scan. The Army delivers the medical supplies to the four district hospitals in North West. A message had been sent to all clinics to collect medicines from there. In order for the SVS to work well, nurses needed to be present which is why the strike in North West must be negotiated to an end. There is no shortage of medicines in North West. Even doctors have been to the depot and verified there is medicine.

National Department of Health (NDoH) 2018/2019 Annual Performance Plan
Ms Malebona Matsoso, Director General: NDoH, stated that NDoH had assigned its Deputy Directors General to adopt a Province to improve performance and efficiency. Dr Yogan Pillay was assigned to work with Gauteng due to qualified audit and concern about the significant accrual which reduces its present budget significantly. Dr Anban Pillay was assigned to work with Kwa-Zulu Natal. Limpopo will be revisited and Ms Valerie Rennie will go back there and assist. The adoption of the three provinces is intended to support and assist in improving the management of public facilities. NDoH wanted to make to make significant progress in these specific provinces.

The North West is currently under administration and NDoH had gone there to assist and has reported progress is being made. The Province used to be the leading performer in primary health care in the whole country, now it appears the whole system will need to be rebuilt. The labour issues in the North West were investigated, and the workers on strike gave them a memorandum of demands. The Department has gone through the memorandum and some of the problems were due to resolutions that had not yet been implemented. Amongst the demands are also sector-wide concerns. Community Health Workers (CHW) are not only a problem of concern in the North West but also in the other provinces. A CHW policy was approved by the Department of Health in December. It had subsequently informed Labour that sector-wide concerns not specific to North West must be removed from the agreement.  The agreement was ready, all that was left was for them to sign and go back to work. There are also broader concerns beyond the health sector, and the Department had involved the different communities, churches and community leaders to get involved and assist in addressing these.

She outlined the targets and budget for each of the NDoH programmes:
Programme 1: Administration
NDoH was committed to improving audit outcomes in the provinces. Most of the provinces had improved especially Mpumalanga and it was confident it would get an unqualified audit.

There were some provinces that did not want the Administration programme which provides the following support services: 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. North West declined the support and said that they did not need it and then regressed. Those provinces that had agreed to the support have taken it up already and NDoH continues to provide support.

Budget for the programme is for the Offices of the Minister, Director-General and the Deputy-DGs. It is not a general administrative budget for the whole Department of Health.

Programme Two: National Health Insurance (NHI), Health Planning and Systems Enablement
The programme budget is R1.6 billion. The emphasis of this programme was on the NHI. The Bill had been sent to Cabinet, it needed to be finalised so it can be approved by Parliament. In the interim the Department had identified five vulnerable groups to start implementing the NHI and had allocated money towards the roll-out. The groups are mental health patients, people with disability, oncology patients, and hearing, dental and eyesight programmes for children. On an annual basis there are 8 000 community service professionals. When community service is completed they are not absorbed by the public sector. The NHI is intended to utilise those professionals, now unemployed, to master the programmes targeted at children instead of being absorbed by the private sector.

Three thousand facilities are on the Health Patient Registration System (HPRS) which tracks down patients when they move from one facility to another. 23 million patients have already been registered on the system and the target is to have 25 million registered in this financial year, to be ready for the NHI. 1.9 million patients have been enrolled to receive medication through the Centralised Chronic Medicine Dispensing & Distribution (CCMDD) programme. The Department targets to increase the number to 2.5 million in 2018/19.

Programme Three: HIV/AIDS, TB and Maternal and Child Health
Ms Matsoso highlighted the formalisation of CHW inclusion into the Comprehensive HIV/AIDS and TB Conditional Grant.  There are currently 49 000 CHWs having different contracts in different provinces. The policy approved in December states that all CHWs must have completed matric and have the tools of the trade, must be assigned to a facility to perform their functions, and must have a standard salary. Treasury had allocated within grant funding to formalise the appointment of CHW, in the public sector, to assist with disease prevention and major campaigns. The budget allocated for the programme is R20 billion.

Programme Four: Primary Health Care Services
This programme assessed South Africa’s capacity to respond to emergencies. Casualties from the listeriosis crisis had gone down tremendously since the manufacturers responsible were identified as the source of the outbreak.  National readiness to respond to emergencies and the plan developed to show level of readiness will be shared with the Committee.

The Committee’s assistance was required on the matter of a having both a functional clinic committee and a functional board to improve oversight functions. The board usually knows better than the chief executive officer what is going on in the facility. It helped to have a clinic committee, appointed by the MEC, as well as the board. NDoH has stressed the importance of appointing qualified, skilled personnel as board members.

On improvement of facilities to ensure constitutional compliance, NDoH has targeted 40% of facilities to be accessible to disabled persons in 2018/19. 50 public health facilities would be assessed for adherence to Health Care Risk Waste norms and standards. The aim was to improve environmental health services in all 52 districts and metropolitan municipalities in the country. The programme budget is R301 million.

Programme Five: Hospital, Tertiary Health Services and Human Resource Development
This programme prescribes hospitals must have centralised structures to function optimally. There were inconsistencies in most of the structures in hospitals. NDoH worked with the Department of Public Works to have generic structures for regional and provincial hospitals, the affordability of which was currently being reviewed. A number of clinics had been built and revitalised. The Department will provide a report to the Committee on the names of the public facilities and show pictures of the clinics to confirm.

An oncology services improvement plan had been developed, firstly, to target woman.

The nine provinces were monitored for compliance with the Emergency Medical Services (EMS) regulations using the approved checklist. Nine EMS improvement plans had been developed. The Department was also investigating privatising some of the services to ensure every person had access to EMS and personnel. It will report back its findings to the Committee.

There is a shortage of nurses. It is a ratio problem – there are more enrolled professional nurses then enrolled assistant nurses. ‘Too many commanders,’ she said. The unemployed enrolled professional nurses will be approached to take up assistant nurse positions.  Doctors who are coming back from Cuba in July will commence their final clinical training programme and will be allocated to medical schools in the universities. The 320 students have been allocated per province. Agreements will be signed with all HODs to ensure provinces will be ready when the students return. A new nursing diploma will be incorporated into Higher Education and will commence in 2019.  Nursing will now be part of Higher Education and Training. The Department had worked tirelessly to have the curriculum accredited. The programme budget is R22 billion.

Programme Six
This programme regulates and ensures accountability and compliance by public entities and statutory health professional councils with applicable legislative prescripts. There are currently two Bills proposed for adoption: the NHI Bill and the National Public Health Institute of South Africa (NAPHISA) Bill. A handbook for board members serving on public health entities and statutory professional councils had been developed. 

The total budget allocation for NDoH is R47 billion. The Department will continue working towards improving equity, quality and access to healthcare.

The Chairperson clarified the number of Bills the Committee had received so far. The NHI and NAPHISA Bills are still with the Portfolio Committee on Health. The Department of Health had completed its work on the Bills and was waiting for the other processes to conclude. She confirmed that the Committee will not be considering any new Bills after August 2018 and had informed the Chairperson of the Portfolio Committee.

Ms P Samka-Mququ sought clarity on the Ketlaphela project where HIV and TB and Malaria drugs were manufactured. What was the progress? Is it working? She asked the Department to provide a report. She asked if the Department is aware of recent media reports on the discovery of a new drug that cures AIDS. The pills were light blue in colour.  She respectfully asked if there was a drug to cure AIDS and whether it is available in public hospitals.

The Chairperson welcomed the initiative to create boards to oversee clinic committees. She was aware of the gross corruption and nepotism and appreciated the development of the handbook which is aimed at preventing this. It was the Committee’s anticipation that the Fifth Parliament would finalise the NHI but it is taking longer than expected. She asked if private schools received vaccinations or is it only public schools? Not all children who attend private school can afford private health care. The biggest problem in clinics is the waiting time. In some cases, patients had to stand in long queues from 3am only to be attended to at 11am and leave at 4pm, more than 12 hours later. It was important that this problem was addressed especially for those taking chronic medication. Are they assessed first before given medication? Or can other methods of distribution be explored, such as post boxes with numbers to go and collect the medication? Also, there was a problem with the staff’s attitude, they are understaffed and overworked and this pressure results in undesirable attitudes. Her final question was on event gatherings. There are many churches with large congregations. What is the role of the Department to assist in preventing disasters from happening?

The Director-General agreed that the long waiting period at the clinics was a problem and that where HPRS had been implemented, there was a reduction in the waiting time and it had been doing very well. It however needs to be supported by mass communication so patients know they do not have to go to the clinics only. There is a policy on mass gatherings on what should happen at these events and the Chairperson is correct it should be shared with the churches on what is expected from them so they are compliant.

Dr Anban Pillay, Deputy Director-General: Health Regulation and Compliance, responded that the Ketlaphela project falls under the Department of Science and Technology (DST) and NDoH is supporting it. The initial project plan is to make the active pharmaceutical ingredient which is the powder that goes into the tablet. The difficulty is that the business case to produce it, is not convincing and they have not been able to set up a plant to date. DST was exploring an alternative mechanism that will result in a more attractive business case. Many more patients could be on CCMD, however, the challenge is the allocation from National Treasury is limited. Other collection points for chronic medication had been utilised such as churches, schools and collecting from traditional leaders.

Dr Yogan Pillay, Deputy Director-General: HIV/Aids, TB, Maternal, Child and Women's Health, replied that the new HIV/AIDS drug was called Dolutegravir and had been registered with the Medicines Control Council (MCC). It is a better combination of the antiretroviral drug. There is no cure for HIV but the new drug was a better combination with less resistance and fewer side effects; it is more tolerable. The HPV vaccine is not made available to private school because there are not enough school staff nurses to cover them and not enough money to buy the vaccine. Only poor public schools were being targeted. It is hoped that the cost of the vaccines will decrease in the private sector, and the Integrated School Programme will roll out in private schools. The Department will relook at this and try to overcome the difficulties with the logistics of ensuring every learner was vaccinated.

The Chairperson requested that the Director-General provide the reports from the MTT and the Ombudsman to assist the Committee with oversight and to prepare for the debate. She noted that the Committee had no issues with the budget and will support it.

The meeting was adjourned.

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