National Health Insurance (NHI) Pilot Evaluation; Coronavirus response; with Minister & Deputy Minister

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04 March 2020
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Watch: Minister’s briefing on coronavirus 

NHI: Tracking the Billthrough Parliament

The Minister spoke about the Coronavirus and noted that the common influenza caused more deaths than the Coronavirus.  Currently 81 countries are exposed to the virus. Preparations are currently in place to return 151 South Africans who are in China and want to return home. Steps have been taken to manage the virus such as having temperature screening at ports of entry. An emergency hotline has been launched for the public and clinicians. The Minister confirmed that previous reports about South Africans being infected with the virus was fake news.

The Department presented the Evaluation Report of Phase 1 of National Health Insurance pilot districts aimed at health systems strengthening interventions. These interventions dealt with: Ward Based Primary Healthcare Outreach Teams; Integrated School Health Programme; General Practitioner contracting; Ideal Clinic Realisation and Maintenance Model; District Clinical Specialist Teams; Centralised Chronic Medicine Dispensing and Distribution; Health Patient Registration System; Stock Visibility System; Infrastructure projects; Workload Indicator for Staffing Needs.

The evaluation concluded that all the projects were successful but some required amendment due to challenges of implementation. The findings and recommendations were presented.

A myriad of concerns were raised by committee members such as the NHI lacking clarity of vision, budgetary constraints, a lack of referrals and follow-up care of screened learners and poor communication and coordination between stakeholders.


Meeting report

The Chairperson welcomed the Minister and Deputy Minister. He noted that there would not be an official presentation document by the Health Department on the Coronavirus as the figures frequently changed. 

Minister of Health on Coronavirus response
Minister of Health, Dr Zweli Mkhize, stated that the Coronavirus originated in a Wuhan city market in China and after spreading to other countries it was declared an emergency. He noted that the common influenza caused more deaths and said that currently 81 countries are exposed to the virus. The symptoms of the virus include a sore throat, coughing and flu-like symptoms. China reported that it had over 186 000 people under observation and 80 000 cases have been confirmed. Italy and Iran are reported to have the second highest death rate from the Coronavirus as well as the Diamond Princess cruise ship. Senegal, Morocco, Tunisia and Algeria have also reported cases of the virus where there was a history of contact with Italy. A large number of South Africans who are in China were contacted and asked if they would return home and many were not interested. Those wanting to return home had increased to 151 and preparations are being made for their return. We have implemented measures such as screening gadgets in ports of entry which indicate one's temperature to manage the virus and an emergency hotline has been launched for the public and clinicians. He confirmed that previous reports about South Africans being infected with the virus was fake news. The two South Africans found to test positive for the Coronavirus were on the Diamond Princess Ship. They have been moved to Japan for treatment and are in quarantine. Once those infected test negative, they will be allowed to return on commercial flights after 14 days. Protective gear has also been given to those officials who require it.

Ms S Gwarube (DA) commended the work which has already been done by the Department of Health (DoH) and said the reality of the situation was that the virus had already rocked some of the strongest health systems in the world. For South Africa to have a chance at beating it, very solid strategies need to be put into place. She asked about travel bans and if this was something the executive was considering, if so, what would trigger this? Is there a strategy in place by DoH to involve the private sector? Can we have a sense of how far along the resilience strategies are?

Mr Anban Pillay, DOH Acting Director General, replied that there is a committee which manages the policy-type responses and it is activated immediately when an infectious disease has been identified. General practitioners also participate in this process and they link up with their representatives and through this an agreement is reached on how to manage the disease. Thus from a clinical management perspective, the private sector is on board and we have been doing training with private GPs to ensure that everyone is aligned with how to manage the disease and what to do when there is a shortage of something. Laboratories are being trained to improve the capacity for testing for the virus.

Ms H Ismail (DA) noted that in other countries videos were going out to residents as part of a campaign and asked if South Africa would have a campaign in place to remind South Africans what, why and when. Ms Ismail asked about the hotline and said most South Africans were not aware of this and wanted to know if anything was constructed to create awareness of this? She was concerned that some public health facilities did not have running water and asked how the hospitals would cope if presented with the virus. She asked if all public facilities had masks to protect the professional staff?

Mr M Sokathsha (ANC) said that during the presentation, the Minister mentioned that South Africa did not have any signs of the virus yet. He was concerned about the stigmatisation of those individuals who are coming into the country from China and how will this be managed?

The Deputy Minister, Dr Joe Phaahla, replied that stigmatization was a concern and that this was due to ignorance and people having limited information. The Department agrees that the public need to be more educated about this. The evacuation plan the Minister spoke about and which we have established is being undertaken is for the evacuation of South Africans who are trapped in the centre of an epidemic and who have been in lockdown for almost two months. They have become frustrated and anxious and this is the reason the evacuation has increased. This evacuation is so that these people can be moved to their home country and be quarantined for the required period and only once it has been confirmed that the virus cannot be detected the person is sent home. Thus we hope dispel the myth that we are creating a risk by evacuating them and bringing them home to South Africans who have not been exposed to the virus.

Ms M Hlengwa (IFP) thanked the Ministers and Department for their work over the past few days. Ms Hlengwa said she shared Ms Ismail’s sentiments and concerns on hygiene in particular.

Mr P Van Staden (FF+) asked if the measures which the Minister announced would be well managed and administrated? Each day more countries were being affected by the virus and South Africa should not be too relaxed about it. It should be taken very seriously. France had placed a temporary ban on events of more than 5 000 people to prevent the virus from spreading. He asked if South Africa would do this as well. The Olympic Games seemed to be cancelled and he asked about national and international sporting events and if it was not time to place a ban on sporting events to protect South Africa’s athletes? He asked if South Africa’s borders should not be closed. He mentioned that security was efficient at airports, but he was still concerned about the weakened security at the borders and if solutions to this were being considered? He asked about hospitals which have been designated to deal with Coronavirus and if they had the capacity to manage the virus as some of the staff at these hospitals have reported to the media that they did not know how to handle this crisis. Have hospital staff been briefed on this? The press conference held by the Minister had mentioned quarantine areas and he said South Africans should be given more information about this. He noted the fake news on the virus and asked how this would be dealt with as many individuals were resorting to taking certain remedies believed to protect them from the virus. He asked about the hotline operating between 8am and 4pm and when it would be run on a 24-hour basis as it was clearly time for this. He hoped more money would be allocated to assist South Africa’s scientists in developing a cure for the virus.

Mr Pillay replied that travel bans have been considered and need to be weighed up against other matters. The US had stopped flights directly from China, however in doing so, those who wanted to travel to the US from China could simply use alternative airlines to connect them via another route which posed a risk.

Mr T Munyai (ANC) welcomed the report by the Minister and the work that has already been done to prevent the Coronavirus. He had more faith in government as opposed to the private sector. South Africa was the first country to combat the Ebola virus and therefore he had confidence in South Africa, its capabilities and its scientific research development. The designated hospitals or areas which those infected with the virus will be treated at should be declared isolated and not be flooded with journalists or family members as this could potentially be dangerous. Fake news began amongst ourselves. He proposed a collective visit by the Committee to points of entry in the country.

Mr Pillay replied that 13 public hospitals have been identified to manage the virus and the staff have been trained by the NICD and World Health Organization (WHO), and have protective gear in place. The clinicians at these hospitals are familiar with managing highly infectious diseases. One News24 journalist reported that a particular hospital was not prepared to manage the virus, however when DoH contacted the hospital the manager there was very surprised about this claim as they were prepared. Mr Pillay said he thought personal hygiene was critical and what needed to be done was to place hand sanitizers all over.

Ms N Chirwa (EFF) thanked the Minister and asked what criteria were considered in declaring that South Africa was in a state of readiness to deal with Coronavirus. She pointed out that there have been cases of individuals admitted to hospital after car accidents, having left the hospital infected by TB due to overcrowding and infrastructure challenges. She referred to local public transport, particularly in townships and rural areas, where people were unable to simply take leave from work if infected by Coronavirus. She asked if there was a strategy to prevent the spread of the virus in buses, taxis and trains.

Ms Chirwa referred to the racial stereotyping that was taking place and how this affects the people of Africa. She said there is a misconception about the Coronavirus – while it was serious, the fatality rate was only at 2% thus far. The seasonal flu was worse than Coronavirus as the fatality rate currently stood at 10%. She asked how the stigmatisation and false propaganda can be corrected. When she had visited Mamelodi hospital a healthcare worker said that the hospital had already dealt with a case of Ebola – this had never been reported by DoH. If South Africans were to be informed of this, a xenophobic reaction could be anticipated. She asked how people should be informed about current events yet at the same time prevent a triggering situation. She asked how DoH was disseminating information on the emergency call centre and if there was screening of a person's temperature?

Mr Pillay replied that about Ebola, that there is a committee which works together with the Emergency Operations Centre at the National Institute for Communicable Diseases and when there is an outbreak, assuming that we have identified someone who has tested positive, this team will then identify who this person had contact with and immediately identify and isolate them. The WHO provides guidance to every country about the disease and what needs to be done to combat it. WHO also produces a guideline and a checklist which DoH has gone through. At the time of the meeting, no outbreak of the virus had been reported in South Africa. Mr Pillay added that the guideline changed all the time as certain things needed to be changed or amended depending on how people responded and this is constantly monitored.

On education campaigns, Mr Pillay replied that DoH has put out a lot of material in the media and on television for people to understand.  If one looks at the DoH website, there is a video about contact, symptoms, personal hygiene, treatment, Frequently Asked Questions and how the disease is diagnosed. DoH needed to reach people differently through different communication channels. There are two hotlines, one is for doctors and another for the general public as well as an email address to which the public can send any questions they have. DoH will monitor whether this needs to be expanded.

On the screening process, Mr Pillay replied that the guidelines at this stage indicate that temperature screening is the best thing to do as anyone who presents with a temperature will within the first two days show signs of a high temperature even if they are asymptomatic in the sense of not having a cough and other known symptoms. Having a temperature is the earliest indicator. The diagnosis of this virus is getting a pharyngeal swab and sometimes the organism looked for to identify the virus is not always found at an early stage even though the virus is present in the cells and is able to replicate. DoH has been working with airport officials and there is an isolation area at the airport to manage the virus. Protective gear has also been distributed to customs and Home Affairs officials.

Ms A Gela (ANC) welcomed the report by the Minister and commended DoH for their work. Another mechanism to spread information was through campaigns. There were environmental practitioners who went to schools and educated scholars about hygiene and preventative measures as well as volunteers from the Department of Health who go door to door to educate people. She noticed that people have already begun to wear gloves and masks at the airport and said that airport staff should also be doing this. She asked if there was an injection or equivalent that could assist people in preventing infection?

The Deputy Minister, Dr Joe Phaahla, replied that if South Africa’s public health facilities become overburdened, DoH will engage to ascertain where resources can be accessed in the private sector. He noted the scepticism on whether South Africa is ready to manage the virus and the concern about water not being available in some public health facilities and said one should not conflate the normal capacity of our public health facilities to handle the burden of disease and demand for services which is an ongoing matter. When a specific emergency is being dealt with such as the Coronavirus, there are very specific guidelines on what to provide. This does not mean that the usual challenges disappear, but infrastructure challenges already present cannot be translated to mean that South Africa is not ready to manage the virus. As the Minister suggested, it is possible that the Corona Virus could morph into an endemic virus. This means that the virus could become regularly found among particular people or in a certain area, such as Influenza. He noted that in the event that the Corona Virus becomes endemic, the virus could be managed more simply, and not through a state of emergency procedure. The Minister made a similar comparison to how the HIV/Aids virus was managed during its initial outbreak, and how it is currently managed, through awareness, screening or testing and education of the virus. He said that similar processes would be followed if the virus becomes endemic. 

The Minister thanked the Committee for the clarity seeking questions and said that these questions were indicators of which areas need to be given attention as DoH deals with the public. The travel ban has been raised and he asked Members to share their views on this. The hospitality industry was extremely concerned that decisions may be taken by the Health Department which would adversely affect them. We need to engage to figure out what exactly these concerns are. Right now, there is a platform for collaboration and we only test for Coronavirus in the public sector and we will follow-up on cases of private doctors who have been reported to provide this testing service.

The Minister said he was unsure about the claim of some clinics still not having running water. At present, of the 3 467 clinics, 3 128 of these clinics have a constant and reliable water supply. Such areas must be dealt with but that they are not the majority of cases. He emphasised that Members needed to stand together to dispel fake news and stigmatization. The Minister mentioned that he was looking at the US and a lot of cases would have originated from Italy and the Diamond Princess Cruise. The number of cases that originated from Wuhan in China is 3 and 45 cases of infection came from the Diamond Princess Cruise.

The Minister said the issue of public transport has not come up yet.

National Health Insurance (NHI) pilot districts: Evaluation of Phase 1 implementation
The Minister said that the Department wanted to go through this information on the pilot districts with the Committee so that when it is debated, it is debated from the same set of information. The Minister said an evaluation of the NHI Phase 1 (2012-2017) was done from November 2017 to December 2018. Phase 1 was about health systems strengthening and not personalised service delivery. The barriers to health system performance were considered. The presentation highlights the recommendations and how DoH has responded to these. The evaluation established that there were both challenges and successes during Phase 1 of the NHI implementation and the lessons learned will strengthen the interventions of Phase 2 (2018-2022). Additional resources will also be mobilised. Phase 3 (2023-2026) is about expanding health systems and strengthening activities to full scale. The success of the interventions was identified as being due to strong political will, adequate resources for implementation, good communication, coordination  and monitoring systems in place at the time of implementation.

Most of the successful interventions at the time were expanded to reach non-pilot districts and these successes include over 3 million learners who were screened through the Integrated School Health Programme and where necessary, cases were directed to health centres for treatment. A total of 330 GPs were contracted,12 million households were covered, 45 of 52 districts in nine provinces had fully functional district specialist teams and 2.1 million patients enrolled on the Chronic Medication Delivery system collecting medicines from over 855 pick-up points. There were 3 167 clinics and community health centres which gave a 92% coverage. The programme has established an electronic system called SyNCH which generates an electronic prescription which allows greater visibility and collaboration in the movement of stock between manufacturers and hospitals and clinics. Twenty million people were also registered on the out-patient registration systems at 2 900 public healthcare facilities.

The challenges faced include inadequate planning and lack of communication. The lessons found to be most useful was that the organizational culture was found to be overly bureaucratic and not often supportive of problem solving which left little room for creativity and innovation. The Minister stated that none of the challenges experienced indicated that Department could not continue with the implementation of NHI.

Mr Anban Pillay, DOH Acting Director General, stated that the evaluation was done on Phase 1 of the NHI pilot districts implementation of interventions. One of the areas of confusion was that people thought this was the NHI delivery but Phase 1 was rather on health systems strengthening of delivery to prepare for the NHI. Before the NHI can be delivered, the country has to be ready from an NHI health systems strengthening perspective, thus the first phase is the strengthening phase. In terms of methodology, a total of 416 interviews were done at provincial, district and national levels to understand how people viewed the project and their perception of the successes and failures. The Department also conducted a facilities management survey. Phase 2 was about identifying those interventions that worked and expanding them across provinces and facilities. Phase 2 will also focus on the development of legislation which is currently in process. Phase 3 is more about continuing with the health systems strengthening as it is a continual process of improving service delivery, mobilization of additional resources as well as allocation of finances to the NHI Fund.

There were ten objectives in the Phase 1 health systems strengthening interventions:
(1) Ward Based Primary Healthcare Outreach Teams (WBPHCOTS), which were responsible for the provision of promotive and preventative health care to households
(2) The Integrated School Health Programme (ISHP), which aimed to provide a range of health promotion and preventative services to school going children at their place of learning
(3) General Practitioner (GP) contracting, which aimed to increase the number of GPs at primary healthcare (PHC) facilities to improve the quality and acceptability of care
(4) The Ideal Clinic Realisation and Maintenance Model (ICRM), which aimed to increase quality of services through the establishment of minimum standards
(5) District Clinical Specialist Teams (DCST) responsible for supporting clinical governance, undertaking clinical work and undertaking research and training
(6) Centralised Chronic Medicine Dispensing and Distribution (CCMDD), which aimed to improve distribution of medicines to patients through the provision of chronic medication at designated pick up points closer to the communities
(7) The Health Patient Registration System (HPRS), which has the ultimate goal of a fully electronic patient record keeping system, but has started with data capturing of patients and generation of electronic files
(8) Stock Visibility System (SVS) aimed to improve oversight of stock through an electronic stock monitoring system, and thereby reduce stockouts by allowing for appropriate and timely ordering
(9) Infrastructure projects, implemented to improve health infrastructure to ensure increased access and quality of care and lastly
(10) Workload Indicator for Staffing Needs (WISN), which is a WHO planning tool conducted to help facility managers make more efficient staffing decisions

In terms of successes, the evaluation concluded that all the projects were successful and some required amendment due to challenges of implementation. The Department identified that 4.3 million learners were screened and 504 000 were referred for treatment and 12.8 million households were visited. 25 Districts had clinical specialist teams. 2.1 million people were on the programme to collect their medication at the various pick-up points. 20.7 million people are registered on the out-patient system.

The Department provided a progress report on each recommendation for the interventions (see document). For example, the use of pick-up points for medication collection has increased from 2.1 million to 3.1 million patients who are enrolled in the programme. In the Integrated School Health Programme 4.3 million learners have increased to 5.1 million learners screened and 651 000 referred to the health system to access services for hearing and speech concerns.

Key findings and recommendations included:
• The district clinical specialist team model should be reviewed in the context of its cost-effectiveness. It was recommended that these teams be responsible for clinical work and not only its support which may be more effective. GP contracting worked well, but there were some GPs that wanted to be contracted but wanted to work from their own premises, and it was therefore proposed that DoH develop a capitation system for that. Salary differences also caused tensions in the environment. Since then DOH has developed a capitation model for GP contracting and we have used the public sector salaries to benchmark the contracting where GPs are working in the facilities to ensure that there are no disparities.
• For Chronic Medicine Dispensing and Distribution, it was recommended that costs be reduced and systems need to be in place to coordinate pick-up points to ensure patients do not get lost if they need to change facilities. The programme has established Sync which is an electronic system where prescriptions can be recorded electronically to prevent scripts from getting lost and assist with the dosage of medicines.
• High schools need to have contact with a clinical nurse ensure that there are reproductive health services. Transport and equipment was identified as sometimes being a challenge and appropriate budgeting needs to happen for this. Weakness in design also needs to be addressed before this school programme can be expanded. The programme is being reviewed and in the 2020 it will require schools to provide feedback on whether the children have received the appropriate referral services.
• Maintenance needs to have a dedicated budget and managers in facilities need to have power over maintenance budgets and a project management information system has been implemented to track facilities.

Ms E Wilson (DA) said the report was extensive and required much analysis. The NHI project put in place interventions to uplift the state of healthcare in the country but the GP contracting concerned her as at one pilot project in Limpopo it was realised that 30 extra doctors needed to be contracted but there was no funding for this. This caused some doctors to be disillusioned with the heath system and this was not reported on. Ms Wilson referred to NHI training which has commenced and said that the MECs, HODs and officials have been sent on international study tours to Turkey, Thailand and the UK and asked about this cost as the NHI Bill has not been passed yet. She asked why people were being sent for training overseas when South Africa was not in a position to implement the Bill. A continual problem was noted in the NHI evaluation report from pilot districts upwards about the lack of clarity of vision. Most facility managers do not feel that district officers are responsive to facility maintenance requests and have simply been told that there is no budget.

Mr Pillay replied on the GP contracting that there was a change in approach post evaluation. The Limpopo department indicated that they had a backlog in surgical and other cases and they would like to contract specialists for this as opposed to GPs. This is the reason the doctors were not kept on.

Ms Gwarube said that Phase 1 emphasised strengthening the health system more than the piloting of the NHI system. While there are demonstrable positive successes, there are some damning reports such as the the GPs mentioned by Ms Wilson and the report showed that at some points there was inconclusive information which was crucial in confirming if Phase 1 was successful or not. She highlighted that there was inadequate planning and a lack of communication as well as poor coordination between the different stakeholders. She asked how these challenges would be fixed before a system of universal healthcare could be implemented in the country. A lack of funding remained a challenge so how can it be said that one would have ideal clinical status regardless of this? Workload indictors did not work due to massive vacancy rates and in a financially constrained environment, how would this be fixed?

Mr Pillay replied that workload based assessments were done through observation of how healthcare workers manage a particular patient and disease and this means that the healthcare worker knows that they are being studied and thus will not perform the task in the way that they normally would.

Ms Gela welcomed the report and said the work is being done. Rome was not built in a day and she appreciated the NHI initiative. The communities have spoken and they said that dirty politics needs to stop and they want the NHI to be implemented.

Mr Sokatsha said he was part of the implementation of the Phase 1 piloting which was vigorously implemented and he can attest to the fact that the groundwork has been laid for Phase 2 to be implemented.

Ms Ismail welcomed the report and said she viewed the report as one that showed how to improve the present health system rather than working toward the NHI. It could be deduced from the NHI Bill public hearings that the existing public health system needed to be improved, however the report was a far cry from the NHI system. She pointed out that the same monitoring systems were not used for each pilot project in the report and the staffing challenges and vacancies concerned her as this affected service delivery.

Mr Munyai said that the pilot project should be used as a noun so that people could comprehend this. He said the negative and positive findings should indicate what must be avoided when implementing the bigger project. He welcomed the recommendations and said he felt relieved after being briefed on the evaluation report and again welcomed the hard work by DoH.

Ms Chirwa said she was concerned about bias projected from DoH in carrying out interviews and public hearings. She was concerned about the integrity of the report and people wanting to save themselves which compromised the real status of the health system. She asked about sub districts and healthcare at high schools saying that she did not see this information in the report. She was concerned about the lack of a feedback system on referrals for school children. She asked what exactly DoH was alluding to when they referred to the need for good communication systems. She asked for the differences in implementation across provinces as she noted the implementation process varied. She was concerned about communication mechanisms between the stakeholders and this impacted on the report. She asked about monitoring systems implemented in Phase 1 as these disappeared with time. She asked who benefitted from the medication collection system. She was concerned that the obligation would always be to make a profit on what needed to be delivered. She pointed out that the pilot projects did not include the private sector and one had to consider how it would impact funding, infrastructure and government relations with the private sector.

Mr Pillay replied that they identified that there was no system for referral for a patient and this would now be managed electronically. This did not mean patients were not previously assisted but it simply meant there was no paper trail of these referrals. On the bias in the case where a quantitative research methodology was used in what we call a qualitative method, this meant that the number of people was not as important as was the themes which the evaluation study showed.

Mr Pillay replied that if a district manager did not agree with a certain intervention, it did not progress. Thus district managers need to be trained and given constant feedback to take corrective measures. There was never a record of how long people waited to access medicines at the pharmacy and the collection points for medication were introduced to ensure that there was access to medication and to reduce waiting times as DoH was aware of the long waiting times. Some patients with a chronic condition simply collected medication as they are chronic-stable and have a repeat six-month script and only see the doctor for a check-up if necessary.

Mr Ramphelane Morewane, DoH Chief Director: District and Development Cluster, emphasised that it was about improving facilities rather than achieving the ideal clinic status. He said the same clinics were assessed every year.

Ms Lesley Bamford, Acting DoH Chief Director: Child Health Cluster, replied that the referral of learners was being dealt with and that it was agreed that educators should provide more feedback on learners as they see the children every day and nurses only see them on an intermittent basis. It has been agreed that sexual reproductive health services can now be provided in schools albeit within a particular framework.

The Chairperson said that clinics in all provinces should be visited and compared. He referred to slide 7 and said that innovative indicators were introduced and of the 2.1 million patients, 1 million patients collected their medication from pick-up points and this was not expensive and worked well. [He spoke in Zulu]. He noted slide 8 and said for the first time educators were aware of the challenges children were faced with.

The Deputy Minister acknowledged that the Committee has emphasised budgetary concerns and pointed out that there would never be a utopia without an abundance of money. The huge divide between those who can afford healthcare and those who depend on the public healthcare system needs to be remedied and how infrastructure is managed should be reconsidered.

The Minister said that human resource strategies need to be revised so DoH ensures that the NHI framework can be implemented. The Department would strive to create ideal clinics and deal with all the challenges as a part of building into the implementation of the NHI.

Meeting adjourned.

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