SA Military Health Service MTEF Plan; with Minister

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Defence and Military Veterans

19 August 2020
Chairperson: Mr V Xaba (ANC)
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Meeting Summary

In its virtual address to the Committee, the South African Military Health Service (SAMHS) outlined the challenges it is facing and suggested comprehensive plans on how to address these challenges.  SAMHS was to brief the Committee on the maintenance and repair programme (RAMP) for military hospitals and sickbays. However, detailed information would be provided later by the Logistics Division of the SANDF.

The inadequate budget made available to the SAMHS was recognised as an overarching challenge. It is not capable of covering the cost of stocking medicines within all three hospitals, offering a competitive salary required to retain specialised staff, and to operate at a high level of service provision simultaneously. These challenges were exacerbated by the increasing patient population travelling large distances to seek medical attention from the three military hospitals. Since SAMHS cannot increase its budget it is unlikely further military hospitals can be erected. Therefore, the only alternative for patients outside the reach of the military hospitals is through outsourcing health services.

Members recalled that the challenges raised by SAMHS had been raised in the Fifth Parliament but were still not resolved. Since the budget is not available to increase SAMHS allocated funds, the Committee asked what practical strategies will be implemented to resolve the challenges. It was suggested that its facilities should become part of the Department of Health. Members said the estimated SAMHS R2 billion deficit over the MTEF was alarming. They asked what strategies were in place to recruit and retain specialised staff since it is unaffordable to outsource treatment to specialists. Due to time constraints the discussion had to be cut short. As questions still remained, especially on the budget, a follow up meeting will be scheduled.

Meeting report

Minister of Defence and Military Veterans comments
Minister Nosiviwe Mapisa-Nqakula introduced Deputy Surgeon-General, Dr Noel Ndlovu, who would be leading the SAMHS presentation and its alignment to the South African National Defence Force (SANDF). The objective of the presentation was to discuss service delivery challenges, the Medium Term Expenditure Framework (MTEF) plan, and the proposed way forward. The SAMHS is at the forefront of delivering health services to members of the South African National Defence Force, their dependents, and military veterans. SAMHS total patient population amassed to an estimated 176 000 people within the country, including the President, Deputy President and foreign armed forces on request and against payment. The numbers include: Regular Force (61 218) and their dependants (71 884) and Military Veterans and dependents (17 457). SAMHS will need to extend their services due to the COVID-19 pandemic. This is an ongoing discussion with the South African National Defence Force. 

The Minister highlighted that during the COVID-19 pandemic SAMHS had been integral in supporting the National Department of Health in the national fight against the pandemic, especially in the Eastern Cape. SAMHS has been able to do this despite a reduction in the Department of Defence’s budget. Reference was made to the need for improvement in a specific hospital, addressed in the previous budget. With the funds given to SAMHS during the COVID-19 pandemic the Minister made the decision to use the funds to secure the medical supply stock required to provide quality healthcare, in addition to allocating a portion of the funds to the maintenance of one of the military hospitals.  

The Minister said that there was an inadequate number of health care professionals within the South African National Defence Force. The presentation will outline the numbers of doctors, epidemiologists, nurses and other expertise within SAMHS. She emphasised that the mandate of SAMHS was to ensure the health of the soldiers, as they are the last line of defence for the safety of the people of South Africa. The Minister referred to the Ministerial Task Team (MTT) she appointed to establish why numbers of doctors were leaving SAMHS to join the Department of Health (DOH). Following the investigation SAMHS has been able to address some of these contributing factors. However, doctors are still required. The Occupational Specific Dispensation (OSD) had contributed to doctors leaving SAMHS. New doctors coming into the system do receive OSD as part of their package right from the beginning, but for those who have been in the Defence Force prior to that were in fact not receiving OSD so this is a matter that DoD had to correct immediately. The Ministerial Task Team report revealed this, along with a portion of doctors not being paid for their committed overtime. Grievances still remain among the doctors on how overtime is paid.   

SA Military Health Service MTEF Plan
The Deputy Surgeon-General, Dr Noel Ndlovu, said that the Surgeon General is assisted by five formations within the military health service: Area Military Health Formations responsible for all military based hospitals including 83 sickbays; the Tertiary Military Health Formation which is responsible for the three hospitals at Pretoria, Cape Town and Bloemfontein and four institutions: Institution of Aviation Medicine, Institute of Maritime Medicine, Military Veterinary Institute and Military Psychology Institute. The Mobile Military Health formation is characterised by two Regular Force Medical Battalion groups and three Reserve Force Battalions. The fundamental capabilities of SAMHS is supported by the Support Formation and the Training Formation.

Prior to 1994, SAMHS was designed to be located at military bases. Currently SAMHS supports 176 483 patients. The regular force makes up the majority of the patient population. However, due to the limited facilities patients have to cover large distances to receive service. This makes it difficult for SAMHS to estimate the future number of expected patients in each hospital.  

The aim of the programme is to provide quality health services for the full range of military operations and members of the South African National Defence, their families and others eligible for healthcare provided by SAMHS. The expected outcomes for SAMHS include an increase in combat readiness, population health improvement, and affordable best-quality military healthcare.  

The structural deficiencies such as recruiting specialist personal is continually being addressed. The plan to improve infrastructure, refurbish equipment, and ensure maintenance has been submitted to the Logistics Division. This programme will include building facilities in Bluff, Port Elizabeth, Polokwane and Nelspruit. More details will be provided by the Logistics Division at a later stage. COVID-19 has shown that South Africa does not have an adequate humanitarian strategic national reserve, the proposed facilities would try to amend this national issue. The inability to retain specialists as a result of the lack of incentive to work at SAMHS still remains and urgently needs to be addressed. SAMHS has initiated the training of Operational Emergency Care Practitioners (OECPs) for the Reserve Force.  

MTEF priorities are:
• Organisational Renewal: Commenced several work studies to address SAMHS structural deficiencies. 
• Renovation of DOD Facilities: SAMHS Facilities Maintenance and Development Plan is being implemented
• Strategic Resource Direction: Funding challenges to maintain medical stock levels and critical reserves. COVID-19 has re-emphasized the necessity of national humanitarian crisis relief reserves – SAMHS intends to lobby the National Disaster Coordination Centre for such reserves.

Service Delivery Challenges
SAMHS has recently experienced a perceived decline in quality and responsiveness. This perception is endemic amongst patients and to the SANDF Command Cadre. However, this account does not consider that prior to 1994 SAMHS had greater resources than what is currently available. This has caused sub-optimal operating and capital budget ratios, increased medico-legal claims and expenditure, patient dissatisfaction and the inability to improve. These issues are exacerbated by the uneven distribution of the healthcare facilities, sub-optimal supply chain management, inadequate healthcare monitoring system and tools, sub-optimal knowledge management, and budgetary constraints.

SAMHS does not have the capability to manage its role as a funder of outsourced healthcare services because it has not been structured for that role. However, it is estimated that SAMHS will continue outsourcing as it is not cost effective for SAMHS to have the capability to deliver all needed health interventions such as heart transplant capability in all three hospitals.

SAMHS members who do not have direct interaction with the patient constitute 43% of the total workforce, and the operational frontline healthcare providers such as medical officers, nursing officers and operational emergency care practitioners constitute 21% of the total workforce. There is no international standard to consider in order to understand if this is an optimal workforce composition.

It is apparent that the service facilities are not easily accessible to the majority of the SAMHS patient population. This is because the facilities established prior to 1994 were disproportionately placed in urban areas. This means that distances between facilities and the patients increases the patient's cost of access to treatment and hospital facilities. Alternatively, healthcare services have been outsourced to other providers at an additional cost.

The demand mismanagement has manifest itself in SAMHS as patients believing  their medical “wants” are equivalent to their medical “needs”, over-stocking of medical materiel in some facilities whilst other facilities remain under-stocked, over-servicing of patients, and the unplanned rationing of healthcare services increasing long waiting lists of patients seeking medical attention.

Organisational knowledge is lost when members of the facilities leave or retire and do not relay knowledge to the new recruits and this creates a deficiency of knowledge within the facilities. This process has contributed to the sub-optimal healthcare.

Mr Anton du Pisani, SAMHS Budget Manager, said there is a Containment Work Group working toward estimating the possibility of SAMHS being able to finance the proposed programme. However, COVID-19 has caused delays for the Group. There is a possibility that finance can be generated by capitalising on the Department of Defence’s collateral utility. SAMHS primary challenge to the National Agenda is that it does not participate in the National Health budget vote, therefore it is not entitled to conditional grants.

Service Delivery Improvement (SDI) programme
Dr Ndlovu outlined that to contain the cost of outsourcing and ensure an affordable quality service, SAMHS must implement Managed Health Care (MHC) to enable the SAMHS to develop administrative capability; define “comprehensive services”; and determine services that should be provided in-house, insourced or outsourced. The restructuring of the healthcare delivery model would be necessary. COVID-19 showed SAMHS that any gaps in their capability need to be closed. The failure of control is a major factor in monitoring and evaluation.

The MTEF Military Health Plan is to ensure:
• A health support capability of five medical groups, including one specialist medical battalion group, for deployed and contingency forces.
• A comprehensive, multi-disciplinary military health service to a projected patient population of 302 000 members per year.

The six Military Health sub-programmes are: Strategic Direction, Mobile Military Health Support, Specialist/Tertiary Military Health Service, Area Military Health Service, New Military Health Support Capability, Military Health Training Capability.

Situation Analysis
SAMHS is burdened by a host of diseases such as HIV/AIDS and TB, which is combined with high maternal and child mortality, injuries and non-communicable diseases. The level of over-expenditure is expected to increase year-on-year. Human resource expenditure is difficult to contain as specialised skills are required to decrease cost of medical outsourcing.

Strategic Issues
In preparation for the future Defence Review, SAMHS must address the following strategic issues:
• acquire and retain health care practitioners,
• upgrade military health facilities,
• adaptation of the main medical equipment to meet envisaged battle space so intra-operability is achieved.
A further seven strategic issues were identified (see presentation).

Financial Report
Mr du Pisani said the R2bn budget shortfall projected for each year of the MTEF was lower than the predicted deficit had all services been outsourced. In the next financial year, roughly three quarters of the funds allocated to paying for outsourced services will not change. SAMHS budget allocation was not aligned with increased health costs. SAMHS has to procure equipment and pay specialists and the negligible 2% increase was not in line with the increase in the cost of health care outsourcing which was 9% per annum The limited budget allocation to SAMHS had slowed down the rate at which its 88 facilities could provide services, which is what caused patients to perceive a reduction in the quality of service. It is difficult to finance a large stock of medicine while simultaneously increasing the salaries of specialists.

Although the cost of outsourcing was substantial, it will be unlikely that this process will not continue. Human resources, medical outsourcing, pharmaceuticals, fuels and rations are the main cost drivers.

Conclusion
The performance of SAMHS was satisfactory despite the financial risk. However, the continuous increase in its footprint resulting in an increased demand for healthcare services, will impact negatively on the budget and on service delivery. The compulsory budget baseline reductions over the three financial years from FY2020/21 to 2022/23 will exacerbate this. The challenges have exacerbated the operational readiness and the sustainment of healthcare service delivery.

Discussion
The Chairperson thanked Dr Ndlovu for his comprehensive presentation on the SAMHS, the MTEF plan, and national repairs and maintenance programme. However, the presentation exceeded the provided time allocation. Consequently, a subsequent meeting with Dr Ndlovu will be arranged in this term to engage in an in-depth discussion of the presentation. He allowed Committee members to raise questions.

Mr S Marais (DA) appreciated the comprehensive presentation. As a member of the previous Parliament and Portfolio Committee, he was disappointed that the challenges identified in the presentation coupled with the plans to address these were being reintroduced as if they were not raised in the Fifth Parliament. The Air Force, Navy, and Army leadership are more transparent about the worsening situation outlined in the presentation. Despite the leadership's increased desire to address these challenges, the only way to resolve these matters is to employ more capital budget. However, this is not possible.

Mr Marais asked what had become of the three military field hospitals that were expected to be erected in Thaba Tshwane and the one expected to be erected in the Bluff. No report on the progress or funding of these field hospitals had been made public. However, it was reported that the 7th floor of one of the military hospitals had been utilised as a COVID-19 facility rather than using a military field hospital.

Mr Marais recalled that at a presentation he attended at one of the military hospitals it was explained that SANHS difficulty in retaining specialist staff was a result of circumstance, budget facilities and lack of equipment, which had inhibited specialists from doing their job. As a consequence of these factors, specialist staff sought employment in provincial hospitals, in which they could provide and apply their medical knowledge. He then asked if graduate medical students doing their year of community service are employed in the military field hospitals.

Mr Marais was concerned that the cost of running the three military hospitals had not been disclosed. This alarmed him because the cost of running the hospitals in addition to providing health services was not affordable from his understanding. He referred to the occasion that the Chairperson and himself visiting one of these hospitals where they discovered the hospital was being underutilised. He requested the current utilisation of the three military hospitals. If the situation at these hospitals had not changed, these facilities should become part of the Department of Health. It was estimated that in the current year and the two following years, there would be a R2 billion deficit. This was an alarming figure.

Mr S Marais (DA) asked to what extent was the Presidential VVIP unit being utilised at the 1 and 2 Military Hospitals by the President and the Deputy President. The Deputy President had again cancelled his appearance at Parliament's plenary question session on Thursday 20 August 2020 due to his poor health. He asked if these facilities care for both the President and Deputy President. He was concerned that no reason was given why the Surgeon General was not present at the meeting, since he is responsible for the care of the President and the Deputy President.

Mr Marais emphasised the need for a comprehensive plan to improve services at the base level to provide for ex-servicemen and uniformed members. It was apparent to him that the hospitals were not affordable. In his opinion, it would be impossible to get back to the levels of funding prior to 1994. Therefore, it was important to have a strategic solution so that the challenges raised are appropriately addressed.

Mr W Mafanya (EFF) was discouraged to hear from Mr Marais that the Fifth Administration was aware of the issues outlined in the presentation but did not implement solutions. Specialists moving to public hospitals due to salary disparities and the disproportionate provision of services in urban compared to rural areas needed to be resolved. He suggested the establishment of hospitals in the rural areas. He asked what was the cost saved when service provision was outsourced, because he felt this was expensive. He suggested that the benefits of stopping outsourcing would be that professionals would be recruited and retained and that cost saving measures would be established.

Mr Mafanya said that resources had been spent disproportionately as 73% of the resources were spent on human resources and the remaining 27% on other items. Once the investigation into these matters had been conducted, they must be dealt with.  

Ms A Beukes (ANC) asked why doctors had left SAMHS for the Department of Health. She pointed out the importance of the Committee seeing the task team report, and the impact of the issues they have addressed thus far. She asked how the challenges raised in the presentation will be addressed in the long term. She referred to one of the outcomes being population health improvement and asked what programmes were in place to achieve this and what their impacts are on the encouragement of healthy behaviour. She asked what measures are employed by SAMHS to ensure members receive the service required.

Ms Beukes asked what research had be conducted to investigate the specific challenges faced by SAMHS and if it was possible to establish hospitals for those that did not have access to the existing hospitals. Is there a strategic plan in place to recruit and retain appropriate personnel?  

Responses
Minister Nosiviwe Mapisa-Nqakula clarified that the Surgeon General was not present because he was not well. She requested that the Deputy Surgeon General and his team submit a report on the Ministerial Task Team findings and investigate the impacts of the recommendations implemented thus far.

The Minister assured the Committee that the VVIP unit in the hospitals is used when necessary. However, it would not be appropriate to discuss the health of the Deputy President.

Due to technical problems Ms A Beukes (ANC) became the acting Co-Chairperson.

Dr Ndlovu replied that SAMHS performance was not getting worse, and that there are attempts to resolve the issues raised on a yearly basis. In the next meeting, the improvements SAMHS has made will be presented. It had been difficult to solve the issues presented, due to the coordination required from agents outside of SAMHS. He expressed his hope that the Committee will engage with the relevant structures of Parliament to ensure the issues are addressed.   

Dr Ndlovu explained that the four military hospitals referred to an expansion of the capabilities in the three military hospitals and also Bluff, not four new hospitals or four field hospitals. This programme will be reported on as the programme continues. At this stage SAMHS is combat ready to deal with COVID-19 to an acceptable level, as well as being able to assist the National Department of Health.   

Dr Ndlovu replied that the reasons SAMHS has faced challenges in retaining specialists are multi-dimensional. The rigid nature of operating as a doctor in the military simply did not suit some individuals. Additionally people in South Africa are naturally disposed to changing their work environment. SAMHS lost specialised workers because the military did not offer a competitive advantage over others such as the Department of Health and the private sector.

Dr Ndlovu replied that the brief intervals when military hospitals are not utilised to full capacity should not cause the Committee to forget the necessity of having such hospitals. From the perspective of SAMHS the hospitals are affordable as long as they are used more efficiently. However, to establish a world class military health system, capital will need to be injected. However, the capital required to solve the disproportion of services between the urban and rural areas is not available. Therefore, in locations where SAMHS services are not provided, then the outsourced service provided must be monitored.  

Dr Ndlovu replied that SAMHS and the National Department of Health have programmes that are similarly aligned, therefore, SAMHS plan to deal with population health improvement is a military adaptation of the Department of National Health’s programme. He explained the reason the budget showed 73% spending on human resources was because of an increased demand for HR.  

Dr Ndlovu replied that his explanation of monitoring services was misunderstood. He clarified that what he meant was patients may not be able to be attended to by their preferred doctor. The report on the Ministerial Task Team findings would be submitted to the Committee upon its completion.

Minister Nosiviwe Mapisa-Nqakula was surprised that the necessity for military hospitals was questioned during the discussion. In light of the provinces that need their own military hospitals, she expressed her hope of building at least one military hospital in either KwaZulu-Natal, Limpopo or the Eastern Cape during the COVID-19 pandemic. The Minister told the Committee that she had received feedback from the Military Command Council on a possible project in Limpopo. When the report on the MTT findings is completed, it would be submitted to the Committee.

Deputy Minister Thabang Makwetla said that the outsourcing of provision of health services is a matter that must be readdressed as SAMHS has not been conclusive on which solution will provide the best service for the community. He requested information on how SAMHS prior to 1994 sourced the provision of services. The Deputy Minister criticised SAMHS for identifying that in the event of national humanitarian crisis such as COVID-19, the Department of Defence must be more prepared, yet SAMHS failed to outline how the Department intended to become more prepared.    

The Chairperson assured the Committee that another meeting will be held to discuss SAMHS presentation further and to address the concerns raised during this meeting.

The Minister assured the Committee that the Ministerial Task Team’s report will be presented and made available. The generals will compile a spreadsheet of their findings, recommendations, work done and work remaining to be done.

The Chairperson closed the meeting by noting that the presentation was a sign of progress and that it was clear improvements were being made.

The meeting was adjourned.
 

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