Department of Health 2017/18 Annual Report; South African Health Products Regulatory Authority (SAHPRA) update; with Minister and Deputy Minister

Meeting report

Opening remarks

The Chairperson welcomed the Minister, Dr Aaron Motsoaledi, and Deputy Minister, Dr Joe Phaahla, and the entire delegation from the Department of Health (DoH), and the Committee would be briefed on the performance of the Department over the past financial year, as aligned to the goals and objectives that were set out. This was an also an opportunity for the DoH to report on what the corrective plans were to resolve targets that were not optimally achieved.

The Chairperson thanked the Minister for his hard work and achievements regarding tuberculosis (TB) treatment and prevention. The Minister had received an award for the caucus he started in 2014, with just five Members of Parliament. The caucus now had over 2 000 international members. He had also received an award for the work that was done as a country to combat TB. The impact on South Africans from the work he was doing was huge and also respected by other countries. South Africa was leading globally in terms of fighting TB. The Committee had submitted names of Members who would be joining this TB caucus.

DoH annual report       

Ms Malebona Matsoso, Director General: DoH, said the health sector derived its vision and mandate from the National Development Plan (NDP) Vision for 2030.  By then, South Africa should have:

• Raised the life expectancy of South Africans to at least 70 years;
• Progressively improved TB prevention and cure;
• Reduced maternal, infant and child mortality;
• Significantly reduced prevalence of non-communicable diseases;
• Reduced injury, accidents and violence by 50 percent from 2010 levels;
• Completed health system reforms;
• Established primary healthcare teams to provide care to families and communities;
• Implemented universal health coverage; and
• Filled posts with skilled, committed and competent individuals.

Programme One: Administration

The vacancy rate was 12.5%, which exceeded the Department of Public Service and Administration’s (DPSA) target of 10%, due to budget cuts on the cost of employment (CoE) by Treasury. The National Department of Health (NDoH) had embarked on a robust reprioritisation process to ensure that critical posts were filled. The turn-around time for the recruitment process was within four months, which exceeded the DPSA benchmark of six months. The NDoH had obtained an “unqualified audit opinion” from the Auditor-General (AG) for consecutive years since 2011/12, including the financial year under review.

A planned target was that five provincial DoHs had to demonstrate improvements in audit outcomes or opinions. Four provinces - the Eastern Cape, Free State, Gauteng and the Western Cape – had obtained unqualified audit outcomes or opinions. Another target was that 35% of NDoH employees should access the health and wellness programmes, and 60.9% (961 of 1 504) had accessed the health and wellness programmes.  56 communication interventions were planned, and 82 were implemented.

Programme Two: Health Planning and Systems Enablement

The final White Paper policy on the National Health Insurance (NHI) scheme was submitted to Cabinet for consideration before the end of March 2017 and published in the Government Gazette on 30 June 2017. At the same time, the Minister announced the establishment of seven NHI implementation structures, which were published in a Government Gazette Notice on 7 July 2017. The NHI implementation structures were the Committees on Tertiary Services, Human Resources for Health, and Health Care Benefits for NHI, the National Health Pricing Advisory Committee, the Committees on Consolidation of Financing Arrangements and on Health Technology Assessment for NHI, and the National Health Commission.  The NHI Bill and Medical Schemes Amendment Bill were submitted and approved by Cabinet.

The Centralised Chronic Medicines Dispensing and Distribution (CCMDD) programme continued to enrol new patients. Patients enrolled to receive their prescribed medicines through CCMDD had increased from 1 252 000 in 2015/16 to 2 166 973 in 2017/18. Patients received their prescribed medicines from over 855 pick-up points, including occupational health sites, general practitioners and private pharmacies. Use of the stock visibility system (SVS) had increased to 3 168 primary health care (PHC) facilities. The SVS allowed the back code on the package or bottle to be scanned using a specially supplied cellphone and application. When a nurse scans at a clinic, the stock level is reported automatically and in real time to an electronic map of all clinics at the central tower in Pretoria. Hospitals using the electronic stock management systems in order to strengthen demand, planning and governance, increased from 228 hospitals in 2016/17 to 324 hospitals in 2017/18.

The Ministerial Advisory Committee on eHealth was appointed by the Minister of Health on 25 April 2017.  The Committee completed a rapid review of the implementation of eHealth Strategy 2012-2016, and produced a report with recommendations in November 2017. The Department migrated routine data from the stand-alone District Health Information System (DHIS) 1.4, to Web-DHIS. As at 31 March 2018, 1 759 of 3 955 facilities were able to capture data at the facility level, whilst the remainder of the facilities were capturing data at sub-district or district levels because they did not have internet connectivity at facilities. The implementation of the Health Patient Registration System (HPRS) was expanded from 1 854 PHC facilities in 2016/17 to 2 968 PHC facilities in 2017/18. As at 31 March 2018, 20 700 149 people were registered on the HPRS and linked to a Master Patient Index.

A national survey to measure patient experience of care at selected PHC facilities and hospitals had been conducted. Three guidelines were finalised:  

• Patient experience of care survey guideline,
• National guideline to manage complaints, compliments and suggestions for the public health sector of South Africa; and
• National guideline to manage patient safety incident reporting and learning in the public health sector.

Norms and standards regulations applicable to different categories of health establishments were finalised and gazetted in February 2018, and implementation by all health establishments will be expected from 1 March 2019.

South Africa was participating in the Global Lancet Commission, and had also established the Lancet National Commission consisting of 15 members from the public sector, universities, the private sector, and non-governmental and quality institutions. The Lancet National Commission was launched in May 2017, and together with the Lancet Global Commission, had hosted the Global Lancet Commission meeting from 11 -13 December 2017, attended by the chairperson of the Commission and national commissioners from South Africa, Mexico, Ethiopia, Senegal, Philippines, Argentina, Nepal and Tanzania.

Minister Motsoaledi said that when quality of care was spoken about in terms of global health coverage, the measurement of quality was often not well understood. When speaking of quality of care, clinics in rural and distant villages in Africa were unfairly compared to clinics in well-developed cities with major resources, like New York. The Global Lancet Commission aimed to set up what quality care would be in every country respectively. It would be linked to the countries’ level of development, the gross domestic product, household incomes, the human development index, and so on. When clinics would next be assessed, they would be compared to the quality of care within the country, and not to different country.

Ms Matsoso said that a depot manager had recently been appointed, and a revised project plan had been developed to support the Provincial Medicine Procurement Unit (PMPU) functionality in the Mpumalanga Department of Health. The NHI Phase 1 evaluation was currently under way.

Programme Three: HIV and AIDS, Tuberculosis, Maternal, Child and Women’s Health

The MomConnect programme launched in August 2014 to improve access to early antenatal services and empower pregnant women, had reached a cumulative total of 1 888 918 pregnant women and mothers at the end of March 2018. The Integrated School Health Programme (ISHP) services had contributed to the health and wellbeing of learners, as they were screened for health barriers to learning. A total of 387 574 Grade 1 learners and 193 438 Grade 8 learners had been screened between April 2017 and March 2018. A cumulative total of 4 339 875 learners had been screened since inception of the programme, and 504 803 learners had been identified with various health barriers to learning and referred for intervention. The human papilloma virus (HPV) coverage for the eligible girls in 2017/18 was at 82.6% for the first dose, and 61.3% for the second dose.

Since the HIV counselling and testing (HCT) campaign was introduced in 2010, over 44 million people had been tested. A total of 13 872 315 people were tested for HIV, exceeding the annual target of 10 million for the 2017/18 financial year. At the end of March 2018, the total number of clients remaining on anti-retroviral (ARV) therapy (TROA) reached 4 189 070. Fewer infants were being infected with HIV. In 2017/18, a polymerase chain reaction (PCR) test done at around 10 weeks showed a 0.95% positivity rate for all babies born to HIV-positive women. The goal for this was to reach 0% of infants to be born with HIV from mothers who had the virus. A new TB client treatment success rate reached 84.4%, while the TB client death rate was at 3.9% in 2017/18, the same as the rate in the previous financial year.

Minister Motsoaledi said that by 2004, South Africa had 70 000 babies born HIV positive every year. This number had fallen to below 4 000 because of the prevention of mother-to-child transmission. South Africa was moving towards a period in which no more babies would be born HIV positive. This had already been achieved in Cuba three years ago.

He said that in 2006, there had been between 69 000 and 70 000 deaths annually due to TB. In present times, that figure had dropped to below 28 000. On a global basis, 4 000 people died every day because of TB. Also on a global basis, it was estimated that there were ten million people who had TB, making it the biggest infectious disease killer of our time. Out of that global ten million, only six million were on treatment for the infection. This meant that there were four million TB-infected people, dubbed “the missing four million”, who each had the capacity to infect 15 other people in their lifetimes. The quarter of South Africa’s population in the “missing four million” was estimated to amount to 160 000 people. The Department aimed to find half (80 000 people) of its “missing” TB-infected people over the next 24 months.

Referring to performance improvement strategies, Ms Matsoso said that the development of the HIV strategic plan outlining key actions and strategies for the public health system would be done during the 2018/19 financial year. The district implementation plans to reach 90-90-90 targets for HIV and TB would be developed as part of these plans.

It had been planned for 18 Multi-Drug Resistant (MDR) TB treatment initiation facilities with clinical audits to be conducted, and 22 had been achieved.

Minister Motsoaledi said that the world was highly technologically developed in these times, but the way that TB was treated was neglected. Throughout history there had never been paediatric formulations for TB, which meant that children and infants were forced to consume adult-specific medications. Recently, a liquid and a sprinkle form of the medication for children had come on to the market.

Programme Four: Primary Health Care Services

As at the end of March 2018, a cumulative total of 1 507 facilities qualified as ideal clinics. This achievement had been enabled by collaboration between the NDoH and National Treasury in resolving supply chain management (SCM) challenges faced by clinics, especially with regard to equipment, essential supplies and infrastructure. A total of 20 district and metropolitan municipalities rendering municipal health services were audited, and 13 of the 20 reached 51% and above. Ten ports of entry (PoEs) were assessed and found to be compliant with the International Health Regulations, 2005. Orientation workshops for government departments on the national guide for healthy meal provision in the workplace were conducted in all nine provinces to assist employees to adopt healthy eating habits. 36% of PHC facilities were accessible to people with physical disabilities. It had to be ensured that all facilities were accessible.

Among performance improvement strategies, malaria indoor residual spraying (IRS) would be increased, and would commence earlier than usual in the endemic provinces. The killing of larva (where appropriate) would be strengthened and rolled out in the winter. Collaboration with neighbouring countries affected by malaria would also be strengthened and scaled up.

Programme Five: Hospitals, Tertiary Services and Workforce Development

A national core curriculum had been finalised for the new three-year diploma in general nursing and a one-year diploma in midwifery. The three-year diploma programme aimed to enable graduates to function as clinically focused, service-oriented, general nurses, able to manage low-risk health problems along the continuum of care. Eight of the 17 public nursing colleges were supported to develop customised curricula in preparation for programme accreditation. In the 2017/18 financial year, staffing norms were implemented for the PHC levels. More than 2 000 PHC facility managers in seven provinces were trained on the concept and methodology for determining staffing needs based on workload.

Staffing norms at the higher levels of care -- regional, tertiary and central hospitals -- would be developed following completion of the process at the district hospital level. Forensic chemistry laboratories would implement a targeted approach to analysis, in particular toxicology analysis, which would significantly reduce the toxicology backlog.  Blood alcohol and food analysis turnaround time, and the repair and maintenance of equipment, would be enhanced to improve output.  All outstanding activities in the area of forensic pathology mortuaries would be facilitated through quarterly engagements with forensic pathology managers in all provinces. The 793 infrastructure projects that failed to reach practical completion by end of March 2018 would form part of planned projects in the 2018/19 financial year. Provincial workshops were scheduled for 2018/19 to ensure that all managers accessed the already established knowledge hub, coaching and mentoring programme.

Programme Six: Health Regulation and Compliance Management

The first Board of South African Health Products Regulatory Authority (SAHPRA) had been appointed by the Minister for a three-year term of office. The Acting Chief Executive Officer of the Authority had been appointed following the first meeting of the Board.  The National Public Health Institute of South Africa (NAPHISA) Bill was also tabled for consideration at the Parliamentary Portfolio Committee on Health. The Compensation Commissioner for Occupational Diseases and Occupational Health had paid about R254 million to 10 409 claimants, of which R110 million went to neighbouring countries. One-stop service centres had been opened in Burgersfort and Kuruman, one in Botswana, two in Lesotho, two in Mozambique and two in Swaziland, to give ex-mineworkers increased access to decentralised services.

Financial Management

Programme One:  Administration

Mr Ian van der Merwe, Chief Financial Officer (CFO): DoH, said that delays in receiving the invoice for the renewal of the software licence from the supplier has resulted in non-payment, and the lease contract for the forensic chemistry laboratory had not been signed.

Programme 2:  National Health Insurance, Health Planning and System Enablement

There was no expenditure for the drug-related group project during the 2017/18 year. The new in-kind grant for the medicine stock system was experiencing initial difficulties in spending funds.

Programme 4:  Primary Health Care Services

Invoices were delayed for ideal clinic realisation and maintenance (ICRM) feedback and planning meetings that were conducted in the provinces.

Mr Van der Merwe provided explanations for material variances per economic classification

For goods and services, there were delays in receiving the invoice for the renewal of the software licence from the supplier, which resulted in non-payment; and invoices were delayed for ICRM, feedback and planning meetings that were conducted in the provinces. With transfers and subsidies, not all non-profit institutions had applied for funding, and there was no capital expenditure for the Drug Related Group project during 2017/18 financial year.

He described the expenditure on the various conditional grants for 2017/18

Health Professions Training Grant

Overall spending was 98.1% in this financial year, which was a decline from the prior year’s spending of 99.6%. All provinces spent within the acceptable norm, with the exception of Mpumalanga and the Northern Cape. The under-spending was attributed to delays in the delivery of equipment. Rollovers had been requested and approved.

National Tertiary Services Grant

Overall spending was 99.6%, which was an increase compared to the last financial year, where the spending was at 98.3%, and was within the acceptable norm.  All provinces spent within the acceptable norm with the exception of Mpumalanga, the Northern Cape and the North West, which spent below the acceptable norm due to delays in the procurement of equipment and delays in the appointment of specialists, and challenges in attracting certain categories of specialists. Rollovers had been requested and approved.

Comprehensive HIV/AIDS & TB

Overall spending was 99.6%, and showed a slight decline from the previous year’s spending of 99.8%. All provinces spent within the acceptable norm. On unspent funds, rollovers were requested and approved.

Health Facility Revitalisation Grant

Overall spending was 94.1%, and had declined from the previous year’s spending of 94.7%.  Only three provinces -- the Eastern Cape, KwaZulu-Natal and the Northern Cape – had spent within the acceptable norm. All other province had under-spent and their under-spending was attributed to difficulty in attracting infrastructure technical skills (posts advertised, but applicants did not qualify), slow progress by contractors caused by delays in Eskom connections, delays in the conclusion of final accounts, late revision of the business plan (submitted during the last quarter) and delays in the awarding of tenders and implementation. However the rollovers had been requested and approved.

National Health Insurance Indirect Grant

• NHI component – spending was within the acceptable norm and the under-spending was attributable to CCMDD commitments at the year end. However, payment had already been made in this financial year.
• Health Facility Revite Component - component under-spent, and this was attributed to invoices that could not be processed at year-end as they were received very late for processing.
• Ideal Clinic component – under-spending due to delays in the delivery of equipment.
• HPV component – the component spent 100%, and the grant has been converted to a direct grant as from the 2018/19 financial year.
• Capitation funding was shifted to health practitioner (HP) contracting due to budgetary pressures within the component.
• HP contracting overspent due to budgetary pressures. The Department has scaled down on the number of HPs and the contracting process has been decentralised to the provinces. There was no projected overspending in future, and all accruals were settled.
• Health Information Systems component – the Health Patient Registrations System had spent full budget. The Medicine Stock Surveillance system under-spent due to supply chain management challenges – the migration from the Logical Information System (LOGIS) to G-commerce for the procurement of computer equipment.

Discussion deferred

The Chairperson thanked the Department for the presentation of the annual report.

She asked the Members for their input on how to handle the meeting, as the presentation given was an important one that could not be rushed. The Members agreed that the Department needed to be allowed to finish the presentation. They each had many questions of their own and decided to organise another Committee meeting for the following week in which they could put foward their questions to the Department. The details for the meeting would be confirmed and relayed to the Members and the DoH.

The meeting was adjourned.