Department of Health 2019/20 Annual Performance Plan; with Minister

Meeting report

Department of Health Annual Performance Plan

Dr Zwelini Mkhize, Minister of Health, said that the annual performance plan of the Department was based on the National Development Plan (NDP) as adopted in 2012 and the Sustainable Development Goals (SDGs) as adopted in 2015. The Department had to align its targets to achieve the NDP and SDG goals, which included advocacy for the reduction of maternal and neonatal mortality as well as under-five mortality. and of epidemics such as AIDS, tuberculosis (TB), malaria and the reduction of non-communicable diseases.

The targets were premised on universal health coverage, which dealt with an improvement in access to essential medicines and quality health care. Surveys showed that the Department of Health (DoH) was in line with some of the SDG and NDP targets. Life expectancy should be 64.2 years in 2024 and 70 years in 2030. The DoH would develop measures to reduce maternal and under-five mortality.

Access to quality health care was a fundamental human right. The Department would achieve universal health coverage through progressive realisation. It would also improve the quality of the health system and infrastructure. It was important to collaborate with provinces to ensure good financial management. The DoH sought to minimise waste through a reduction of medical-legal claims.

The Department and the President were keen to see an acceleration of the National Health Insurance (NHI) scheme. The Bill had gone through the necessary Cabinet processes and would be presented to the Committee at the right time. The Department had made significant progress in the reduction of TB and HIV. However, it needed to focus on people that required attention. Surveys revealed that the Department had 4.6 million people on treatment, representing a reduction of 36% between 2011/12 and 2017/18, with a 50% reduction in mortality being associated with the programme. The Departments aims to identify two million additional people before the end of 2020. The Department would need to increase the number of personnel and those that got treatment.

He commented that young women had the highest level of HIV infection. The Department sought to reduce TB infection by improving its follow-up programme. The DoH was focusing on the elimination of malaria, in collaboration with neighbouring countries, but observed that malaria could be spread through cross-border migration of vectors. The DoH had also prioritised Primary Health Care.

The Department had been restructured to improve the dissemination of health information, promotion and socio-economic development, which formed the basis of a quality health system. It sought to strengthen governance in hospitals and improve engagement with communities, which were encouraged to provide feedback. There was more to achieve in the employment of qualified health personnel. The Department expected to gain a number of doctors from the Cuban programme. The Deputy Minister had dealt with the graduation of some of the doctors recently, and he was managing the return of an additional 45 doctors. The Department would strengthen medical institutions to provide adequate training for nurses. It would build on the achievement of previous administrations to achieve the SDG and NDP goals.

Ms Malebona Matsoso, Director-General: DoH, told the Committee about the tools and framework that guide the training of employees. These include the Public Finance Management Act (PFMA) and Treasury regulations that outlined how the strategic plans and APP must be presented. The integrated planning framework specified the operation of the DoH and its interaction within the various spheres of government. The National Health Act specifically made provision for the development of national health plans and the integration of these plans with those of the provinces, districts and the metropolitan health services. It also made provision for the National Health Council, chaired by the Minister, whose members were the Deputy Minister, Members of Executive Councils (MECs) of provinces, the DG, provincial heads of the Health Department, and the Deputy Directors General. There were performance indicators to determine the extent of the achievement of quality health services in 2024.

The DoH had not achieved its target on the reduction of both maternal and neonatal mortalities. The two were related, as they involved the mother-child relationship. The maternal mortality rate was currently 134 per 100 000 live births, and it should reduce to less than 100 by 2024. The neonatal mortality rate was currently 12 per 1 000 live births, and it should reduce to less than ten by 2024.

The Department was currently undergoing restructuring, especially in preparation for the full implementation of the NHI. The DoH’s overall budget for 2019/ 20 financial year was R51.46 billion, and a significant portion -- R47 billion -- was transferred to the provinces as conditional grants.

For Programme 1 (Administration), funding was allocated to the offices of the Minister, Deputy Minister, DG and the DDGs for corporate services. The programme provides financial management support to provinces to achieve unqualified audits. Five provinces had achieved unqualified audit outcomes in the 2018/ 19 financial year, and the Department aimed to achieve seven provinces in the current financial year. It also sought to reduce contingent liabilities linked to medico-legal claims, which currently sat at R98 billion. The money saved could be used for fruitful projects.

Programme 2 (NHI) was mainly to improve access to quality health services for all South Africans irrespective of their socio-economic status. The Minister and the Deputy Minister would table the Bill to the Committee for proper deliberation and approval. Apart from the Bill, the Department was also undergoing restructuring to develop capacity to implement the NHI at both national and provincial levels. It was important to prioritise areas of focus and have adequate information systems. The Department targeted primary health care facilities in particular. The hospital systems were far more complex than those of the clinics. It had registered approximately about 40 million people on the system in preparation for the NHI. It was important to know the beneficiaries who were South Africans, and those who were migrants. Beneficiaries would have to present either their national identity documents (ID) or passport before they were attended to.

The Department would work with the provinces in this financial year to address the challenge of stock outs in hospitals. It had installed systems in clinics and hospitals, but the systems alone were not enough. Patients' feedback on the quality of service delivery was important. It was also important to establish early warning systems. The Department aimed to establish a system that eliminates the need to queue for medicines at medical facilities. For instance, it would be possible for people to collect their medicines at the nearest pharmacy, church or mosque. R2.1 billion had been allocated for this programme in the current financial year, of which R1.3 billion was transferred to provinces. The focus of this programme was stock management. It also targeted specific areas like oncology and mental health. The Department would collaborate with the provinces to achieve success in these areas, to reduce backlogs and improve the quality of service.

Programme 3 aimed at reducing communicable and non-communicable diseases. Its focus was on reducing mortality associated with HIV, tuberculosis (TB), malaria, mental health and cancer.

The Department had identified interventions that would help to achieve success in reducing maternal and child mortalities. For instance, with HIV it considered testing more people and placing them on treatment. An additional two million people had been placed on treatment in the current financial year. It was important to identify the missing cases in order to reduce the transmission rate of TB. The Department targeted 40 000 people in the current financial year. It aimed to reduce the mortality rate of children under five years, and would focus on illnesses associated with diarrhoea and malnutrition. The country would receive a certificate after achieving the complete eradication of malaria.

Ms Matsoso said the Department needed to implement international health regulations to ensure epidemic preparedness and response. It focused on disease outbreaks, chemical spills, and nuclear and natural disasters. The Department would collaborate with other departments and entities to ensure implementation of the international regulations. Mental health would also receive priority. It would work with psychiatrists, psychologists and social workers, who would facilitate effective service delivery at the provincial level. It would also improve rehabilitation services and ensure that rehabilitation teams were appointed and available. The teams would work at provincial facilities to ensure adequate treatment of cerebral palsy, which was one of the leading contributors to medico-legal claims. It would strengthen community-based primarily health care services by ensuring the availability of community health workers.

 A budget of R33 billion had been allocated for this programme. A significant amount of the budget was dedicated to HIV and AIDS grants. Almost R20 billion in conditional grants was allocated to provinces for HIV and AIDS treatment. The DoH gives a R1.5 billion grant to community outreach services. Of the R23 billion that was allocated to Programme 3, R22.2 billion was transferred to the provinces.

Programme 4 (Primary health care) aimed to strengthen the district health system, emergency services and environmental services. The Department would strengthen district health management teams and ensure adequate training. Each clinic should have a Committee and each hospital must have a hospital board. A specific handbook would guide health workers on their duties and responsibilities. The workers would be trained and given adequate support. The Department would attempt to enhance user experiences at hospitals and clinics. Currently, it determines the quality of user experiences from annual surveys. It aimed to raise the standard, as surveys did not give a total reflection of user experiences.

The DoH would work with traditional health practitioners (THPs), as most people in rural communities patronised their services. It would table the THP Amendment Bill before the Committee for consideration and approval. It would establish the THP Council that outlined the functions of various practitioners, based on different categories. The Department prioritised improved access to services for people living with disabilities.

It aimed to establish and implement environmental health standards, and would work with the 52 districts to ensure compliance. It assesses and audits district facilities to identify areas that need improvement. Implementation of environmental standards would help to comply with international health regulations, which was a global legal instrument.

It had the capacity to respond to disease outbreaks. It was important to adopt contact tracing in cases of communicable diseases. This helped to identify all the people that the infected person had contacted, and would help to prevent the spread of diseases and manage outbreaks in the most favourable way.

The DoH was working on specific sections of the National Health Act that required review. Environmental health services would evolve in municipalities. There were still capacity constraints in compliance monitoring in municipalities. The municipalities must be adequately trained as the nation prepared for the implementation of the NHI. The Department encouraged municipalities to perform regulatory functions. For instance, they should inspect shops that sell meat products to assess the quality of products being sold. This could reduce the outbreak of listeriosis.

The Department prioritises emergency medical services, and had regulations that provinces must comply with. However, there were still constraints that limited compliance. It was concerned about the emerging risks that emergency medical personnel face, and sought measures to protect them as they performed their duties.

The budget for the primary health care (PHC) programme was R221 million, and was allocated to the national Department, not to the provinces. Provinces had their own PHC programmes. The role of the Department was to support the provinces and ensure quality service delivery. It gave conditional grants to provinces to implement certain projects, provided certain standards were met. For instance, a theatre must be well-lit and have controlled access. She cited an example of a medical facility in the Northern Cape that had been built for mental health treatment. All structural challenges had been fixed and the facility should be able to service all the provinces.

Programme 5 (Hospital System) was where the DoH supported provinces to accelerate the implementation of the infrastructure plan. It transfers R19 billion out of the total R20 billion to provinces. The fund was for building hospitals and medical schools that met the requirements of the training programme. There was a programme for governance and human resource development and training. The programme dealt with the development of health policy, the alignment of academic centres with the programmes, and the development of strategy.

Ms Matsoso commented nursing was now a responsibility of the Department of Higher Education and Training (DHET). All colleges had been assessed and would undergo accreditation. Accredited colleges must have adequate infrastructure and academic staff that would facilitate the implementation of the new curriculum. The Department works closely with the DHET.

The DoH funds forensic laboratory-related activities for blood alcohol tests and toxicology. The budget was about R5 billion, of which R4.7 billion was transferred to various entities. The entities include the Office of Health Standard Compliance, which was responsible for assessing quality in hospitals and clinics, the National Health Laboratory Service (NHLS), the Medical Research Council (MRC), the Traditional Medicine Interim Council, and so on. Each entity presents its annual report to Parliament.

Mr Ian van der Merwe, Chief Finance Officer (CFO): DoH, said that nearly R45 million was budgeted as direct grants. This covered areas such as the health professionals development, National Tertiary Services, comprehensive HIV & AIDS, TB and community outreach services (COS), health facility rehabilitation, and human resource capacitation. An indirect grant of R2 533 699 was given for NHI programmes, non-personal and personal services. The total indirect grants for the 2019/ 20 and 2020/ 21 financial years were R2 533 699 and R3 210 816, respectively.

Ms Matsoso said that the DoH's APP was founded on the government's 2030 vision, as outlined in the NDP. The Department would continue to work towards equity, quality and access to health care through the implementation of NHI policy, which would commence in the 2019/ 20 financial year.

Discussion

Mr M Bara (DA, Gauteng) asked about provinces that had not achieved unqualified audit outcomes. What were the reasons for the poor performance? What could the provinces do to achieve unqualified audit? Why did the DoH fail to record an improvement in the neonatal mortality rate? What steps did it take to remedy the situation?

Mr M Nchabeleng (ANC, Limpopo) wanted to know the type of support team that the DoH sent to assist at the provincial level. Did it comprise consultants, or employees of the Department? Were provincial officials able to transfer skills to the health workers in municipalities? In reaction to the Department's plan on oncology, radiation and the mental health programme, he asked if the DoH was ready to face the challenge and provide effective service. He expressed concern about the outbreak of malaria in Mozambique, Zimbabwe and Limpopo. The government must work with neighbouring countries to prevent the migration of the malaria vector into South Africa. What was the financial contribution of neighbouring countries to malaria eradication?

Ms N Ndongeni (ANC, Eastern Cape) was concerned about the marked increase in the amount of medico-legal claims, which had increased from R28.6 billion in 2015, to R80.4 billion in 2019. What were the reasons for the increase? Did the Department have measures to reduce the claims? She said the Department must ease the budgetary constraints on provinces. The amount of under-spending must be reduced drastically. What criteria informed the allocation of funds to the provinces?

A Member asked about the origin of HIV and AIDS, as well as the controversy that surrounded the disease. Were there measures to prevent people living with HIV and AIDS from transmitting the diseases to partners during unprotected sex? Could infected parents give birth to children that were HIV negative? He urged the Department to test the efficacy and side effects of anti-retroviral drugs and vaccines, commenting that the health of certain individuals got worse after vaccination. Did the research institute and laboratories funded by the DoH have the capacity to validate most of the drugs?

Mr Nchabeleng asked about the medical facility built in the Northern Cape. When had the facility been built? If the initial structure lacked foundations, had it been demolished and rebuilt? Was reconstruction at the cost of the DoH or the contractors? What was the nature of consequence management, based on the Public Finance Management Act (PFMA)? What was the current status of the facility? He urged the Department to discuss the terms of the contract with the Committee.

The Chairperson was concerned about the amount of under-spending in various programmes. What was the Department doing to remedy this problem? She specifically cited an example of forensic chemistry laboratories, which was characterised by complaints from the public. What was the plan of the Department to solve the problems associated with delays in the procurement of security systems, maintenance services and other supplies? She said that the Muslim communities were the most affected.

Mr Bara said that it was not sufficient to transfer R47 billion to the provinces. The Department had to monitor how each province spent the funds in order to get value for money and effective service delivery to the public. He complained about the poor attitude of DoH’s employees towards the public. This could have negative impacts on the implementation of the NHI. The Department must train its workers to treat members of the public with compassion and dignity. He commended its decision to prioritise the safety of Emergency Medical Service (EMS) personnel, who needed protection from criminals. It had to ensure that its funds were used for the intended purposes.

Ms D Christians (DA, Northern Cape) expressed concern about women's health in the country. It was unfortunate that young women had the highest prevalence of HIV and AIDS, despite the huge funding allocated to treatment and awareness. How did the Department intend to solve this problem? How effective were the various programmes? She sought clarity on the treatment of the Human Papilloma Virus (HPV) in women. How was the money rolled out? Were young women advised on where to get treatment and injections? Was the fund allocated to HPV treatment sufficient? She expressed displeasure about the infrastructure in the Northern Cape which was intended to provide mental health services. She said that the building had been under construction for ten to 15 years. When would the Department commission the infrastructure? The facility should have the capacity to treat drug-related illnesses and should be able to serve all the provinces. The Department should try to improve the quality of ambulance services, especially in the Northern Cape. The DoH should assist provinces with poor audit outcome to improve their performance.

Ms Ndongeni sought clarity on the eight mega infrastructure projects envisaged by the Department. She urged it to advise the Committee on the newly proposed Limpopo Academy Hospital. Where exactly did the Department intend to locate the infrastructure?

A Member asked when the DoH would present the NHI Bill to the Committee. When did it intend to complete the first phase of the NHI?

The Chairperson asked why the lowest increase in budgetary allocation was to primary health care, as it was one of the pressing needs in the country and required the attention of the government. The DoH should monitor and evaluate the money sent to provinces. She observed that the plans and policies of Pprovincial governments sometimes differed from those of the national government. She asserted that the challenges faced with the infrastructure in the Northern Cape was a result of poor monitoring and evaluation. She commended the DoH's expenditure on medical supplies, but wondered why it had hired more contractors. Why had it increased the money spent on consultants and business advisory services? It must inform the Committee on its proposed head office due to the public interest. It should evaluate the NHI pilot programme.

She expressed concern about the budget allocation to women’s health. Women had the largest population and were the most vulnerable group in the country. She briefly remarked on the oncology service and the challenges people faced when they needed medical assistance. The Department should train its employees to ensure effective service delivery to recipients. On what basis were patients treated?

The Department must update the Committee on the school health programme. It had to ensure that its programmes got to the rural areas. She expressed concern that the DoH might not be able to roll out all the projects it had for primary health care due to the budgetary constraints. How far had the Department fared in the roll out of ideal clinics? It must prioritise the training of its staff in the restructuring programme, as this would facilitate effective service delivery to recipients. She urged the Department to exercise caution during budget allocation to provinces, as allocation based on equitable share would not address the backlogs in the rural areas. It must attach a time-frame to the implementation of projects by provinces.

She commended the Department for its transparency.

Department’s response

Minister Mkhize asked the Committee to give the Department ample time to consider the concerns raised by Members. This would enable it to treat each question appropriately and give precise answers to each question. It would also give Members the opportunity to critique the NHI Bill and budget.

He said economically buoyant provinces like the Western Cape and Gauteng had been advantaged by the current democratic order at the expense of other provinces. Those two provinces should provide support to surrounding provinces. The Sixth Administration aimed to achieve equity for all provinces in the country. He acknowledged the budgetary constraints the Department faced, It was important to acknowledge the existence of HIV/ AIDS and to formulate an effective programme to reduce the infection. The administration of anti-retroviral drugs helped to reduce viral load and enable some HIV-positive patients to procreate, without infecting the unborn child.

Ms Matsoso said that a dedicated team from the DoH was sent to provinces to improve their financial management, which led to improved audit outcomes. She said the leading causes of neonatal mortality were sepsis, premature birth and overcrowding at medical facilities. Sepsis-related infections could be treated with active antibiotics. Infection control through hand washing and disinfection was also important. The Department had interventions that help babies breathe. It aimed to boost its infrastructure to reduce overcrowding in medical facilities.

The Traditional Health Practitioners Bill was still with the state law advisers. It would be tabled to the Committee at the right time for deliberation and approval. It had to be subjected to a socio-economic impact analysis, as stipulated by government regulations.

She said there had been numerous lapses in the initial construction of the facility in the Northern Cape. The project had started in 2003. The DoH and National Treasury had conducted a forensic investigation under the leadership of the Accountant General, to establish the real cause of the challenge and had taken steps to achieve the intended purpose of the project. The restructuring ensured that the facilities accommodate other Provinces and serve other purposes, especially rehabilitation. The provincial authority had told the Department that the construction was complete. However, the DoH had to evaluate the facility, based on the provisions of the Mental Health Act, before granting approval. Other factors that would determine approval were human resources and budget.

The forensic laboratories performed blood alcohol test, and also analyse food and cosmetics.

In response to the question on women's health, the DG said the DoH had various interventions to help women and adolescents have better lives. A programme called "She Conquers", for example, aimed to prevent unwanted pregnancy and sexually transmitted infections (STIs) through contraceptive health services. The DoH also had a programme on the HPV, which was in schools and specifically for girls. The Department collaborated with other government departments to achieve its targets. It also funds research into cervical and breast cancer. It had conducted an audit of all oncology centres in the provinces to assess the state of the equipment. About 3 000 had been recently screened and women who were undergoing treatment had been adequately attended to. She spoke briefly about the oncology programme the DoH currently runs in the Eastern Cape. It ensures proper training of employees and ensures that they operate with competence, care and compassion. It works with non-governmental organisations (NGOs) and other entities that have capacity to implement its programmes.

Mr Van der Merwe said the Department works with provincial officials to improve financial management, which leads to improved audit outcomes. Consistency in leadership and management played important roles in effective finance management. This was especially true for the Eastern Cape and Mpumalanga. Limpopo had managed to improve its audit outcome in the last financial year. The Department was taking steps to improve collaboration with provinces in order to progressively increase the number of provinces with unqualified audits.

The Department gets additional funding from various sources to augment its budgetary allocation. The National Treasury had given additional funds over the medium term expenditure framework (MTEF) period, which was withheld till the audit processes were completed. It had monitoring mechanisms to ensure that provinces utilised grants for their intended purposes, and monitors the implementation of projects, by province, on a quarterly basis. The DoH also had grant managers that monitor how Provinces spend their funds. Funds were sometimes withheld by the Treasury, while provinces sometimes use funds for unintended purposes. The Department had mechanisms to recover unspent funds from provinces and monthly monitoring was sometimes performed to ensure sound financial management. The DoH would ensure a continuous and consistent monitoring programme.

In response to Ms Christians' concern about the inadequacy of ambulance services in the Northern Cape, Ms Matsoso said the DoH had a challenge with accessibility due to the unfavourable geographical locations of certain areas. It was trying to find ways to reduce the travel time from main accident spots to medical facilities in the Free State and Northern Cape to alleviate the plight of recipients. It also envisaged additional facilities to handle trauma in order to ease the burden on existing facilities. Provinces that collaborated in this programme would a sign memorandum of understanding to formalise the agreements. The DoH would become more aggressive in its monitoring programme going forward.

Ms Valerie Rennie, DDG: Corporate Services, referred to the relocation of the head office, and said that the Department was undergoing two parallel processes. The Department of Public Works (DPW), which was the implementing agent, maintained the building based on the requirements of the DoH. The DoH had decided to vacate the building. The DPW had already advertised the call for proposals for relocation, based on the specifications of the DoH. The advert went out on July 6, 2019, and proposals close on August 30. The DoH should vacate the building by December 2019.

Regarding Ms Ndongeni's concern on soaring legal claims, the DG said the Department had set up a team comprising lawyers and other experts to analyse the claims in provinces in order to prioritise them. She commented that some of the claims were frivolous and fictitious. The team and the DoH would seek to develop measures to reduce legal claims. She promised to present detailed responses to all the concerns raised by Members at a subsequent meeting.

Further comments

Mr Bara expressed dissatisfaction with some of the responses from the DoH. He urged the Department to provide answers to the questions raised on poor audit outcome and the monitoring of funds given to Provinces. This would allow sound financial management and optimise service delivery to the recipients. He said that adequate responses to the questions would equip Members to have a productive engagement on the Department's budget.

The Chairperson said that it was necessary to give the Department ample time to consider Members' concerns. The Committee could organise a workshop where specific answers could be provided to areas identified for improvement. Members could also critique the budget at the workshop. She sought clarity on the nature of collaboration between the DoH and the Department of Social Development in relation to the activities of Community Social Workers.

Minister’s Response

Minister Mkhize said the proposed workshop had nothing to do with capacity building. The workshop was proposed to address concerns raised by Members within an acceptable time frame.

The meeting was adjourned.