Department of Health on its 2018/19 Annual Report; with Deputy Minister

NCOP Health and Social Services

05 November 2019
Chairperson: Mr M Nchabeleng – Acting (ANC; Limpopo)
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Meeting Summary

The NCOP Select Committee on Health and Social Services was briefed by the Department of Health on their 2018/19 Annual Report.

For the period 2011/12 – 2018/19; the National Department of Health received an unqualified audit.The National Department of Health (NDoH) had 1456 out of 1694 posts filled with a vacancy rate of 13.3%. HIV & AIDS, TB, Maternal & Child Health spent 100% of their allocated budget. Hospitals, Tertiary Health Services & HR Development; along with Health Regulations & Compliance Management spent 99% of their allocated budget. Administration spent 90% of their allocated budget. Primary Health Care Services spent 89% of their allocated budget. NHI, Health Planning & System Enablement spent not only 70% of their allocated budget but also the least of all the programmes. Accumulatively, 98% of the total allocated budget was spent across its six programmes.

The Chairperson asked which institution gave certification of recognition to Traditional Healers. He asked NDoH to enlighten Members on the National Public Health Institute of South Africa (NAPHISA) Bill which had been revived from the Fifth Parliament. Members noted HIV infection continues to increase in young women – this needed to be fixed. An alarm bell for the future generations is the increase in mother-child transmission rates – literally affecting the future of South Africa. A complaint was made about the ZK Matthews Hospital in Barkley West, Northern Cape. Members asked how much the Department has spent on consultancy services; how many interns had been employed by the Department; about irregular expenditure; about lack of capacity at clinics; about medicine stock-outs; and about the TB death rate.

Meeting report

Mr M Nchabeleng (ANC; Limpopo) was Acting Chairperson as the Chairperson was unable to attend due to obligations relating party business in the Western Cape. The Chairperson welcomed the Deputy Minister of Health, Dr Joe Phaahla.

Department of Health 2018/19 Annual Report
Deputy Minister Joe Phaahla thanked the Chairperson for the warm welcome and invitation to present the 2018/19 Annual Report of the Department of Health. He apologized on behalf of the Minister of Health who could not attend due to being on assignment.

Deputy Minister Phaahla spoke to the vision and mission of the Department of Health which derived its vision and mandate from the National Development Plan Vision 2030 where by 2030:
- 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.
- Filled posts with skilled, committed and competent individuals.

Dr Anban Pillay, NDoH Acting Director General, gave the presentation and Mr Ian van der Merwe, NDoH Chief Financial Officer, gave the financial management report.

Programme 1: Administration
Financial management and accountability was measured by improving audit outcomes with the performance indicator being the audit opinion of the Auditor-General. NDoH had achieved an unqualified audit since 2011/12. Four Provincial Departments of Health (Free-State, Gauteng, Eastern Cape and Western Cape) obtained unqualified audit opinions for 2017/18.

Programme 2: Health Planning and Systems Enablement
The strategic objective was to achieve universal health coverage through the phased implementation of the National Health Insurance (NHI). The planned target was to have the NHI Bill submitted to Parliament and; to get private health providers contracted to purchases health services on behalf of population. These targets were achieved.    The National Health Insurance (NHI) Bill was presented in Cabinet in January 2019 and approved for tabling in Parliament. President Ramaphosa was awarded a Universal Health Care Award, recognizing his leadership for NHI in September 2019.

The new National Digital Strategy for South Africa (2019-2024) was developed and approved in 2018/19 and published and disseminated in 2019/20. The process of involvement included strategy review workshops and consultative meetings. The NDoH, in partnership with the CSIR, developed the Health Patient Registration System (HPRS) with a goal to provide a single, authoritative national source of patient demographic information and to standardise patient registration across all health facilities in the country. The HPRS uses the South African Identification Document and all other legal person identification documentation such as a passport as the unique identity verifier of the patient. A National Patient Registry has been created by the HPRS, and it will be the source of the NHI beneficiary registry. As at 31 March 2019, 2 955 primary healthcare (PHC) facilities and additional 6 hospitals implemented HPRS in 2018/19.

Programme 3: HIV and AIDS, Tuberculosis, Maternal, Child and Women’s Health
• 692 397 new HIV/AIDS patients that started on ART in 2018/19 and a total of 4 629 831 patients on ART remained in care at the end of 2018/19.
• 14 874 879 clients tested for HIV (including antenatal) against the MTSF target of 10 million tests per year.
• 1 385 of 187 879 (0.74%) of infants born to HIV positive mothers were HIV positive at 10 weeks PCR test
• 79% TB client treatment success rate; and TB death rate of 3.9%.
• 20 530 adherence clubs and 601 605 patients participating in adherence clubs.
The strategic objective was to implement a combination of prevention and treatment interventions to reduce burden of HIV, STI and TB infections. The performance indicators were made up of four factors:
• Total Remaining on ART (TROA) – out of a goal of 5 million, they manage to exceed that by lowering the amount to 4 629 831.
• Number of people reached in the National Health Screening and Testing campaign annually – out of a goal of 14 million, they achieved 14 874 879.
• Medical male circumcisions (MMC) – goal of 600 000, they just fell short of it by achieving 595 006.
• Number of undiagnosed TB Infected persons (new cases) found – goal was 80 000; they achieved 42 734.

Performance Improvement Strategies: The implementation of 90-90-90 Treatment and Retention Acceleration Plan has been strengthened through daily reporting and monitoring of 328 high burden facilities. Health facilities are required on a daily basis to trace patients who miss appointments and are lost to follow-up. Additional data capturers have been appointed in some facilities. Data capturers have also been given daily capturing targets. Health promotion through radio talk shows and the print media covering MMC will be intensified and the winter campaigns on MMC will also be continued during 2019/20. The fieldwork for the immunisation coverage survey commenced in April 2019 and will be completed within 2019/20. NDoH officials will be deployed to work directly with provinces, districts and health facilities that are under-performing to ensure that undiagnosed persons with TB are found and initiated on treatment.

Child, Adolescent and Maternal Health: New guidelines were developed to emphasise a rights-based approach to sexual and reproductive health services. The maternal mortality ratio (MMR) continued to decline reaching the lowest ratio of 102/100 000 deliveries as a result of implementation of quality improvement plans. A nationwide immunisation coverage survey currently underway will estimate the proportion of children in South Africa at national and district levels who are fully immunised up to 18 months of age. The human papilloma virus (HPV) coverage for eligible girls in 2018/19 was at 83.1% for 1st dose, and 61.2% for 2nd dose.  86.7% of schools with grade four girls was reached by the HPV vaccination team.

Programme 4: Primary Health Care (PHC) Services
The functionality of PHC governance structures assessed and intervention plans developed to ensure that the crucial link between communities and health facilities remain intact. The Ideal Hospital Framework was introduced for implementation at hospital level. A cumulative total of 1 920 facilities qualified as Ideal Clinics. 22 municipalities and 110 Public Health Facilities assessed for compliance with the National Environmental Health Norms and Standards. Trainings on Norms and Standards conducted in three provinces. 12 of the assessed 18 Points of Entry were compliant with the International Health Regulations (2005).

A strategic objective was to eliminate malaria with zero local cases of malaria in South Africa. Publishing of the National Malaria Elimination Strategic Plan for South Africa served as a performance indicator and this was finalised.

Another strategic objective was to improve quality of services at Primary Health Care (PHC) facilities through the Ideal Clinic initiative. The number of primary health care clinics in the 52 districts that qualify as Ideal Clinics served as a performance indicator. With a planned target of 1400, 1920 PHC facilities in the 52 districts qualified as Ideal Clinics in 2018/19.

Programme 5: Hospitals, Tertiary Services and Workforce Development
There are currently 1 928 students in Cuba, of which 647 arrived back in South Africa in July 2019. In July 2018, 713 South African medical students participating in the Nelson Mandela Fidel Castro Programme (NMFC) from Cuba returned. On Fri 6 July 2019, 87 South African medical doctors who were trained in Cuba graduated at the Walter Sisulu University in Mthatha, Eastern Cape.

NDoH introduced the HR Capacitation Grant in 2018 to:
- Supplement resources for appointment of personnel required to fulfill Statutory obligations (i.e. Medical Internship and Community Service Posts)
- Support the appointment of personnel into 2 638 prioritised critical posts across provinces.

The Internship and Community Service Placement (ICSP) online system was developed and implemented, to manage medical internship and the pipeline for 18 categories health professionals entering the work environment after completing their qualifications.

New Human Resources for Health (HRH) Strategy is being developed. It will provide guidance on the number of health workers required for effective service delivery in the public and private sectors, as well as strategies for dealing with key HRH challenges. All nursing programmes were aligned with the Higher Education Qualification Sub-Framework (HEQSF). All colleges have prioritised a three-year Diploma in General Nursing, and these have been approved by accrediting bodies for implementation in 2020. All provinces have also developed and costed three-year infrastructure improvement.

The strategic objective was to strengthen local decision making and accountability of central hospitals to facilitate semi-autonomy. The number of central hospitals organisational structures aligned with Guidelines on Organisational Structures for Central Hospitals served as a performance indicator. The planned target for 2018/19 was to establish guidelines on Organisational Structures for Central Hospitals approved by Tech NHC. The actual achievement was the Draft Guidelines were developed.

Another strategic objective was to ensure access to an efficient and effective delivery of quality Emergency Medical Services. The number of provinces monitored for Compliance with EMS regulations was a performance indicator. They achieved their goal of nine Provincial Departments were monitored for compliance with EMS regulations using the approved checklist. 9 EMS improvement plans were revised accordingly.

Programme 6: Health Regulation and Compliance Management
The strategic objective was to establish the National Public Health Institute of South Africa (NAPHISA) for coordinated and integrated disease and injury surveillance. The planned target for 2018/19 was to get the NAPHISA Act promulgated into law. The actual achievement was that the NAPHISA Bill was processed and finalised by the parliamentary committees. The Bill had been passed by NCOP and returned to National Assembly only for concurrence when the Fifth Parliament ended.  The Bill has now been revived.

Human Resource Management
NDoH Administration had 407 out of 473 posts filled and has a vacancy rate of 13.5%. NHI, Health Planning and Systems Enablement had 154 out of 178 posts filled – with a vacancy rate of 10.1%. Hospital, Tertiary Services & HR Development had 255 out of 301 posts filled – with the highest vacancy rate of 15%. In overall, 1456 out of 1694 posts were filled in the NDoH – with the vacancy rate being 13.3%.

Financial Management
HIV & AIDS, TB, Maternal & Child Health spent 100% of their allocated budget. Hospitals, Tertiary Health Services & HR Development; along with Health Regulations & Compliance Management spent 99% of their allocated budget. Administration spent 90% of their allocated budget. Primary Health Care Services spent 89% of their allocated budget. NHI, Health Planning & System Enablement spent not only 70% of their allocated budget but also the least of all the programmes. Accumulatively, 98% of the total allocated budget was spent across the six programmes.

Conditional Grants Expenditure
Health Professions Development Training Grant: Overall spending on the grant has improved from 94.8% (2017/18) to 98.6%. KZN and NW are overspent whilst LP, MP, NC & WC spent within the acceptable norm. EC, FS & GP are under spending and this is due to:
EC: delays in the assumption of duty by registrars and delays in the delivery of medical equipment.
FS: non-delivery of procured medical equipment
GP: slow supply chain management process in procurement and payment of training and medical equipment, unpaid invoices to the value of R1.7  million.

National Tertiary Services Grant: Overall spending is within the acceptable norm. NC, MP & WC are spending within the acceptable norm. All other provinces are under spending due to: 
EC: Persal and BAS interface misallocations between regional and tertiary/central facilities – a process of correction in place.
GP: delays in sourcing of quotations and finalisation of tenders for Tertiary Services equipment.
NW: delays in the payment of invoices and delivery of machinery and equipment.

HIV/AIDS & TB Grant: Overall spending for on the grant has declined from 100% (2017/18) to 98.5%. EC, FS, KZN, MP, NW &WC are spending within the acceptable norm. Other provinces under spending due to:
GP: late submission of claims for MMC and delays in the deliveries of condoms by the suppliers
LP: non-delivery of quantities ordered and unavailability of male condoms stock.

Health Facility Revitalisation Grant: Overall spending has improved from 92.9% (2017/18) to 96.4%. All provinces are spending within acceptable norm except FS, GP and NW due to:
FS: outstanding invoices of R129 million that could not be paid due to disputes with service providers.
GP: delays in the starting of various projects.
NW: delays in delivery of health technology equipment and late submission of invoices by service providers.

Human Papillomavirus Grant:
Overall spending is 89.7%. FS, NC, NW & WC are spending within the acceptable norm. All other provinces are under spending due to:
EC and GP: outstanding invoices still to be processed for vaccine
KZN: committed vaccine fridges not yet paid.
MP: late submission of service provider invoices or car hire / accommodation after payment cut-off date.

National Health Insurance Indirect Grant:
Infrastructure Component – Under spending is due to Limpopo allocation received during Quarter 3 however rollover requested.
Personal Services – Under spending due to delays in arranging a contract for mental health and oncology and subsequent cancellation.
Non-Personal Services – Delays in payment of suppliers for Central Chronic Medicine Dispensing and Distribution (CCMDD) and delays in implementation of projects as well as implementation by State Information Technology Agency (SITA).

Way forward on Conditional Grants:
- Monitoring of grant business plans in line with NDoH interventions – reprioritization of activities.
- Reforming of grants in their entirety
- Strengthen monitoring to ensure spending efficacy.

The Chairperson asked why slide 15 (Patient Experience of Care Surveys) gave no mention to the Western Cape. He asked which institution gave the certification of recognition to traditional healers. The Chairperson explained that many Members were new to Parliament and were not aware of the NAPHISA Bill – he wished for the Department to give more clarity on the Bill and how far along it was in the parliamentary process.

Ms D Christians (DA; Northern Cape) thanked the Department for their presentation. When the Annual Performance Plan was presented, NDoH indicated that the HIV rates in young women and the youth in general were still on the rise, despite the countless programmes in place. It was going the contrary to what was intended. The Department had many NGOs such as LoveLife and many others. However, what was exactly being done by the Department to ensure that those programmes were doing what they were intended to do, as well as what other programmes were being implemented to decrease the currently high HIV rate. She explained that it was particularly alarming that the HIV mother child transfer rate was enormously high. What was being done to educate pregnant mothers? Many programmes had been on the ground for many years and instead of decreasing the HIV rate – there had been an escalation.

She expressed her concern that the Department had received an unqualified audit, yet, there were provinces that were not doing well – she emphasised the Northern Cape. Health services in the country were a concern regardless of NDoH receiving an unqualified audit. NDoH expressed happiness that money allocated to provinces had been spent accordingly, however, in the Northern Cape there had been no significant improvements – in fact according to her, the Northern Cape health system was on the brink of collapse. The Professor ZK Matthews Hospital in Barkley West was one such example – a brand new state of the art facility opened in 2008 had become a dysfunctional facility. The roof had blown off two years ago and if the Northern Cape was to receive rain, the roof that remained would not be able to hold it. There was practically no staff capacity there, and if patients needed to be operated on or transported to a bigger facility they needed to be transported to the Kimberley Hospital or even Upington Hospital – almost 400km away. Northern Cape roads were not suitable for transporting of sick patients – especially such long distances.

Despite the countless years of receiving unqualified audits, there had still not been a single primary healthcare facility or hospital treating human beings in a respectable and clean environment. She asked what NDoH was doing to assist Northern Cape. What was being done to hold the Northern Cape DoH accountable for the terrible state the health system was in?

Ms A Maleka (ANC; Mpumalanga) welcomed the presentation. Referring to page 25, the project was an important initiative. She asked whether the programme was standardised across the country and to which provinces were home deliveries provided.

Ms N Ndongeni (ANC; Eastern Cape) noted that that some Members were new to Parliament and as such would not understand everything mentioned. Secondly, Members represented Provinces and health concerns within their province would generally be raised when engaging with the presentation. She asked how many unemployed interns were hired by the Department. If they did not have the exact numbers, they could forward it in writing. How much had NDoH spent on consultants? Did it plan to fill the vacant positions? It was exceptionally important to visit the clinics and see the states they were in – especially rural clinics. She gave the example of her mother who had been referred to a clinic and received the same news month after month that there was no stock of the medication she needed. Had the Department adequately tried to capacitate staff in clinics – especially in rural areas? She emphasised that the shortage of staff and doctors in rural hospitals and clinics was of great concern.

The Chairperson asked for the supply chain management challenges to be elaborated on.

Ms S Luthuli (EFF; KwaZulu-Natal) thanked the Department of Health for their presentation. She was of great concern to her that the TB death rate was 3.9% as TB was curable. She asked if the death rate could be attributed to clinics not dispensing the medication due to stock-outs. The graphs on slide 21 indicated that KwaZulu-Natal and Gauteng had high HIV rates. Was enough being done to teach communities about HIV treatment but more so prevention? In KZN the HIV rate was increasing annually – what was NDoH doing to teach the youth and even kids from a young age about HIV?

The Chairperson said that while the Committee held an oversight role, the Department held one too. Money given to provinces was conditional and as such NDoH had to ensure that the money was being used for its intended purpose.

The Deputy Minister of Health replied about the NAPHISA Bill that the Department had drafted the legislation, tabled it to the National Assembly, once it was tabled it was the property of the National Assembly. They were currently awaiting the outcome of that and therefore they were out of scope to make any comment regarding that. He explained that they were hopeful to have a positive outcome of the hearing.

He explained that the Department was currently still recording the particulars of the population, stating that out of the 57 or 58 million citizens in South Africa, they needed to gain information on the basic planning that needed to be done with the technical support team to ensure effective service delivery – this included – where people stayed, personal information such as age and gender.  This was referred to as clinical information. The modernization of information was going to go a long way in helping efficiency. It needed to be dealt with properly and carefully to ensure correct information and secured access by authorities only. He explained that NDoH was trying to get more of a buy-in by provinces to national meetings to deal with challenges that arose and could be assisted with promptly.

Dr Anban Pillay, Acting Director General, explained that the Traditional Health Practitioners Bill made provision for the current interim Council for Traditional Health Practitioners. It is the Council’s role to define how an individual would be classified as being part of their sector. He explained that they were finding it difficult in agreeing on how to do that. What the Department was trying to do was to get the Council to agree on the classification followed by the definition of the scope of practice. The scope of practice would set the boundaries – what was allowed and what was not.

On the question of accountability by provinces, he explained that under the NHI there would be a centralized fund which would be used for the purchasing of services on behalf of all South Africans directly from public/private health providers. The current problem was that funds were transferred from National Treasury to Provincial Treasury to Provincial Department of Health; and the utilization and division of funds at provincial level was largely due to decisions made at local level. The financing of a central system such as the NHI proposed would likely alleviate those problems currently being faced. There would also be private providers participating in the NHI, allowing the option for when the public sector is not performing well, for patients to still be able to access services.

On the shortage of medicine, whilst linked to underspending, he explained that the difficulty was due to availability of funds linked to cash flow. Provinces had money but could not pay suppliers within the allocated 30-day period. This was the main reason for reluctance to supply by suppliers. To deal with that, NDoH along with the Chief Financial Officers of Provinces were determining an appropriate budget for medicines for an entire year for a province – those funds would be earmarked and secured from other expenditure – for money to be available every month to pay for the medicines and avoid defaulting on payment to suppliers.

Dr Pillay replied that the Departments of Home Affairs and Health had been in discussion about the information needed from Home Affairs for Health. The new Minister had provided linkages between the DoH current information system and the Home Affairs database so that DoH would be able to access it to check if a particular person was on the register. The plan was for an individual to be able to visit any health facility with their ID and biometrics and the facility would verify if an individual was a South African citizen. He compared it to the work done by banks currently.

Dr Pillay replied that the lack of medication at clinics informed the Committee that a huge problem was that facilities used the Stock Visibility System (SVS) which required that they record what medicine was available. When a medicine was not available it was to be flagged to the District Manager and the District Pharmacist – this was to be done a weekly basis, where the lack of medicine stock was to be fixed once flagged. The problem was that the system reported the lack of stock; however, it was the individuals who were not responsive to the system that had to fix the problem.

Ms Aneliswa Cele, Head of Environmental Health and Port Health Services, dealt with vacancies at national level and said if Members sought clarification at provincial level it could be made available to them. Referring to slide 43, at the end of 2018/19, NDoH had a vacancy rate of 13.3% – well above the expected limit of 10%. This was largely due to the Department undergoing a restructuring process to align itself to the anticipated NHI Bill. During 2019/20, NDoH had set aside R61 million to fill vacancies, however, the funds were reprioritized to deal with other priorities including the NHI Bill. At that point there had been 238 vacancies. Currently there were 25 critical positions vacant and DoH had a plan to deal with filling these. Adverts would be released this weekend to deal with prioritised critical posts – the intention was to fill all posts by the end of the financial year. The R61 million that had been reprioritized would be adjusted during the adjustment budget to allow funds to be made available again for the filling of the vacancies.

Mr Ian van der Merwe, Chief Financial Officer: NDoH, replied that NDoH had received so much information with regard to provincial support on finances. He explained that it was not necessarily a "silver bullet" to receive unqualified audit reports. In many instances, NDoH had only one resource to allocate per province. However, what they had found – such as in the case of Northern Cape and KZN – was that whenever resources were given to provinces, the province itself had to have strong leadership to manage those resources. Each financial year new challenges arose – this year it was the evaluation of illegal medical claims that had become a challenge. NDoH had earmarked funds to deal with programmes but in the current year they had to ask Provinces, despite paying for the services, to assist as far as possible.

He replied that R29 million was spent on consultants, however, while this fell under 'Consultants', many were service providers to the Department.

He did not have the exact figures for the irregular expenditure; however, he knew that some provinces had difficulty in quantifying irregular expenditure. Overall, irregular expenditure continued to be a big challenge in many provinces.

Ms Cele explained that the Department had an infrastructure plan. The way it was being funded was split into two – either via direct or indirect grant. To ensure infrastructure projects were implemented, NDoH developed a business plan on a yearly basis. There was a team in place that went throughout the country accessing facilities. There was also a team at national level that went out to identify key challenges within health facilities. From that feedback, NDoH was able to identify challenging areas and prioritise those – this was funded through their national fund.

Provinces had to develop their own business plan based on their needs. Their business plan would be sent to the NDoH to fund those projects. Mechanisms were in place to measure correct allocation of funds. NDoH tried their best to manage these. However, there were many cases where individuals were sent out to facilities to fix one item only to find other major problems which needed to be prioritised – the scope of work changed and as a result the original item was sometimes neglected to prioritise a more pressing problem.

She explained that DoH currently had several active projects in the Northern Cape. Further statistics could be forwarded on the active projects. The current funding model was being changed; a task team had been assigned by the Minister who was engaging with National Treasury because NDoH had to change the way projects were being funded. The new aim was to establish a funding model which allowed for a quick turnaround time on projects. Projects approved would then receive funding under the new funding model to be completed more quickly and efficiently.

As there were no more comments or questions, the Chairperson thanked the Department of Health and the Deputy Minister for their attendance. He stated that any additional information passed on by the Department would be forwarded to Members.

The meeting was adjourned.

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