Department of Health 2019/20 Annual Report; with Deputy Minister

Meeting report

Department of Health 2019/20 Annual Report

Dr Gail Andrews, Chief Operating Officer (COO), National Department of Health (NDOH), presented to the Committees on the Department’s 2019/20 Annual Report. She commented on the overall performance, and explained the term “achieved”. If work was not 100 percent completed, then it was counted by the Auditor-General of South Africa (AGSA) as not achieved. Very rarely would there be a non-delivery of a target against the Department’s indicators. Challenges were being addressed, and plans for relocation were under way.

In the 2019/20 financial year, 3 381 731 patients were registered in the Centralised Chronic Medicines Dispensing and Distribution (CCMDD) programme to receive prescribed medicines at their pick-up points, against the annual target of 3 000 000.

A total of 3 059 primary health care (PHC) facilities implemented the health patient registration system (HPRS). Registered National Health Insurance (NHI) beneficiaries reached a total of 45 286 288, against a target of 40 million in 2019/20.

The NDoH would attend the 2020/21 public hearings on the NHI Bill that would be arranged by the respective committees of Parliament.

The proposed organogram of the NDoH, including an NHI office, was prepared and submitted to the Department of Public Service and Administration (DPSA). Discussions on the filling of posts for the NHI office would continue between the Department of Health and the DPSA during the 2020/21 financial year.

22 000 patients with mental health problems consulted by a contracted psychiatrist or a psychologist was the planned target, and the actual achievement was zero patients.

A total of 1 906 PHC facilities obtained ideal status against the annual target of 1 800, after conducting both peer reviews and peer review updates. Based on the success of the ideal clinic programme, the Department also introduced the ideal hospital framework, which was fully aligned to the regulated national core standards.

The planned target for 2019/20 was to have 45 facilities maintained, repaired and/or refurbished, and this had been achieved at 39 facilities. 16 hospital revitalisation projects were not completed.

A total of 646 Cuban-trained medical students were placed at South African universities for their final year’s training.

100 percent of South African medical Interns and community service personnel who studied at SA universities were allocated for placement by October 2019.

The main reasons for the vacancy rates were budget cuts.

Mr Ian van der Merwe, Chief Financial Officer (CFO), NDOH, said the Department had maintained an unqualified audit opinion for the past nine years. Particular attention was put on COVID-19 and its impact on the Department’s performance and ability to meet its targets.

No opinion was raised in the audit report, only in the management report. This showed the huge improvement year on year. There were two programmes unqualified and one qualified – the Forensic Chemistry Laboratories.

The Department had spent almost 99 percent of its budget in each programme.

Discussion

Ms N Chirwa (EFF) expressed dissatisfaction on her part because of the NDOH’s regression. This regression was not noted properly in the report, and the Committee would not have known that the Department had regressed if it were not for AGSA. There was a consistent regression in the Department’s finances, management and human resources (HR), and nothing was being done about it. Its public relations, management and communications were very good at making the Department appear to be doing the work, but on paper it indicated a different reality.

She had an issue with the information that the Department presented to the Committee. The AG had informed the Portfolio Committee about this issue, and said that the reliability of the reports that were brought to this Committee must be questioned. On the point of the 100 percent achievement of the six refurbishments of the targeted hospital and clinic facilities, could the Department provide the names of these facilities so that the Committee could do oversight that this was representative of what was stated in the report? There could be more health facilities that did not represent what was reflected in the report, such as the BJ Vorster Hospital in the Eastern Cape. The Department had approved the budget for this facility to be refurbished and to increase its capacity, but when she did oversight at this hospital, the staff were still waiting for the Department to deliver on its promises. She claimed that the ceilings were falling, doctors did not have office space, and had to share space with patients in the corridors. She stressed the importance of getting the names of the six facilities stated in the report so that the Committee could do oversight itself.

Ms Chirwa requested an update on the placement of interns. The Department had met with the interns and their representations on Sunday, and had indicated that it would have completed the placements by 17 November. This was not the case, and it was still not the case at this moment. Could the Committee get an update on the plans for this matter, and indicated if it would be resolved by the end of today? The Department could not keep making promises and not fulfilling them, especially when there were HR issues and unemployment in this country. The Department continued to take students out of this country to China and Cuba to get a proper education, and then it was unable to place these students when they returned. This means that there was less time to grow the specialist industry, because the Department was unable to perform a simple administrative issue. The administration was poor in the Department, and was failing in the hospitals.

When would community healthcare workers be permanently employed by the Department? This was a major issue that was constantly overlooked. Ms Chirwa explained that the Department had emphasised the issue of training, even though it did not pay these workers well, and these were temporary posts. In some hospitals, some of the workers were given contracts until March 2020 because of COVID-19. The increase noted in the report had not indicated that this increase was given because the Department was preparing for the pandemic, and that most of these workers would be dismissed in March 2021. Was there a date when community healthcare workers in hospitals and clinics would be permanently employed?

There was an issue with the regression of entities. The Department was not doing enough to ensure that most of the problems noted in the entities were resolved, especially because there was no accountability strategy in the Department or in the Ministry to ensure that people were held accountable. There was an issue at the Council for Medical Schemes (CMS), where a young black woman was told that she could not be nominated to run for the CMS Board because she had received a bouquet of flowers. Ms Chirwa had written to the Minister to investigate this issue, because there could not be ongoing issues regarding the representation of black women. Young black women were not adequately represented on these boards, and secondly, there was the ostracisation and abuse of the same people that were spoken about when it came to representation. The Department did not do anything to address these issues, and fuelled these matters further, as it did not hold these people accountable. She requested an update on this letter, as she had not received a report from the Minister’s office on this issue.

She referred to the Commission for Gender Equality’s (CGE’s) report on the forced sterilisation of HIV positive black women, and asked the Department to provide an update on this because it had been over nine months that the CGE released the report with recommendations for the Department to implement within a matter of three months. Nothing had been done by the Department over the past nine months because it “does not value the lives of black women and HIV positive black women.” The Department taught communities about stigma, yet it “suffers from stigma and tortures black women by forcefully sterilising them and then not accounting for it.” She requested a proper and detailed update on what the Department had done since the release of the CGE report to date.

The Committee had noted the issue of security systems in hospitals and clinics, but there had been no attempt to fix this situation. On the refurbishment of the six hospitals that was mentioned in the report, the Department did not indicate which security systems it had employed to ensure that security issues were dealt with. The health workers’ safety was not ensured in public facilities, including patient safety. Ms Chirwa said that there was a patient and a young two-year old boy who was raped in hospital in Gauteng, and “many other cases of rape and violence in our own hospitals,” but there was no accountability from the Department. What new interventions and innovation systems had the Department employed? The South African Medical Association (SAMA) had recommended a biometric system for pharmacies several times, but the Department had not employed this recommendation. Ms Chirwa said that this recommendation was not implemented because “it benefits some of the people in power that medication goes missing, that clinics are broken into, and that facilities are not safe enough.” The Department had a responsibility to respond to these issues because it had not responded to the issue of the safety of its own workers and the patients that it cared for.

Ms Chirwa said that access to services for sexual violence victims was “dismally inadequate.” She said that there was a situation in Port Elizabeth of a young girl who was raped on Friday but could not access a clinic until Monday. This meant that the chances of this victim getting justice were “thwarted by the very National Department of Health.” What were the strategies to ensure that this did not happen? This was happening today in South Africa “under the guidance of (Deputy Minister) Joe Phaala and Minister Zweli Mkhize,” and that more must be done to ensure that this did not happen under their watch. Rape victims could not get justice because DNA laboratories were not functional, even in mainstream provinces such as Gauteng. In Hatfield, the laboratories for DNA services were not working, and some of them had not been working for months. What was the Department doing about this, and how would it take accountability for such issues?  

Ms E Wilson (DA) said that “no amount of sweet-talk or excuses” changed the reality of the situation. The biggest concern in the AG’s report, which was “particularly damning,” was that he had said “the NDoH had no regard for compliance with legislation on financial statements.” This was the third year in a row that the Committee had heard this statement from the AG, and “it was a damning statement.” There was a serious problem when there was no regard for compliance with legislation. With the current state of affairs in South Africa, where the day-to-day talk was about state capture, corruption, and these kinds of issues, Ms Wilson said that such statements made her question if this was also what was happening in the Department. There could not be such statements that could not be corroborated in the report.

The under-spending of budget was a big concern. A total of R422 million under-spent was a big problem when public health facilities were “a bloody disaster,” and the situation in clinics and hospitals in this country was terribly depressing. Programmes 3 and 4 indicated under-spending because of COVID-19, but whether the Department’s financial year ended at the end of February or March, South Africa had gone into lockdown only at the end of March. Trying to justify this kind of under-spending with sudden cancellations of days was like the TB day – could the Department inform the Committee when this TB day was supposed to happen? This was right at the end of the Department’s financial year, so sudden under-spending and blaming this under-spending on COVID-19 was concerning, because it was dealing with an entire year before the country went into lockdown.

A major concern was the achievement of 46.5% of the target and the spending of 99% of the budget, which was alarming. There could not be an achievement of under 50% of the target and 99% of the budget was being spent, as this was unbalanced and concerning. The concern was programme 2: the National Health Insurance (NHI). The previous financial year’s target was 27%, and for the financial year in question this had been reduced to 12%, which was less than half -- and the Department still managed to meet only eight, and spent 92% of its budget. This was “imbalanced and does not make sense.” She was concerned about rollovers because last year there was a virement of about R89 million for the Department of Health in Limpopo for medicines, and she questioned how it could not budget for medicines, and this year for medical equipment again in Limpopo, as this did not come up in any of the other provinces.

Irregular expenditure of R166 million was currently accrued, with R54 million in this year. The Committee had to put a stop to this and get this reduced, because it was astronomically high, and no amount of justification could explain R54 million in irregular expenditure. Vacancy rates were a huge concern. The issue of vacancy rates because of budget cuts, the cost of employment (COE) part of the budget being moved to the NHI, and the 99% of the budget being spent while achieving under 50% of the target, was hugely concerning. One of the biggest problems in public health was the shortage of staff -- nurses, cleaners, specialists and doctors -- yet budgets were being cut in a very important line item. Without these people, the NHI could not work because the NHI could not work if medical facilities were inadequate, and if there was no staff to treat the people that it was supposed to be caring for.

Ms Wilson said she was “terribly disturbed” that the Committee did not have provincial reports yet. The fact that they were late and delayed was concerning, because the NDoH was claiming that it had transferred all the money, but the Committee did not have a sense of where the money was being spent at a provincial level. She said that the “Minister, the Deputy Minister, and the people in the Department of Health were still responsible or accountable for what happens in the provinces.” It was alarming that this information was not available to the Committee, because this report meant very little until the Committee could see where the grants and transfers to the provinces were spent. She questioned if the Department had monitored, controlled, observed, or were being accountable for these kinds of transfers.

Mr P van Staden (FF+) expressed his disappointment at the reports presented today, because it did not reflect the reality of the current situation. The Committee had heard from the AG last week that this Department’s irregular expenditure of R69 million for 2019/20 financial year was because of non-compliance. In 2018/19, it was R37 million because of procurement processes not being followed. This was an increase of R32 million in one financial year, which was totally unacceptable, and it was descending into a disaster. He agreed that the Committee needed a detailed breakdown of every department’s irregular expenditure for the 2019/20 financial year. The Committee urgently needed every report of every provincial department in this country.

He was concerned at the comments of the AG last week that there had been no response with the required urgency to its message about addressing risks and improving internal controls. This was totally unacceptable, and there had to be consequences. This problem was getting bigger, and there was the same issue last year where there had been under-spending of a budget of nearly R1 billion. He said that officials who deliberately or negligently ignored their duties and contravened legislation were not held accountable for their actions, and these employees and officials must be named and shamed and there must be consequences.

There was concern that people were not complying with the legislation process in the Department. This was a serious problem, and it could not continue. This was the reason why children were getting raped in hospitals, and the reason for the current situation in the Eastern Cape where workers were on strike because of the problems in this Department. This was also the reason why there were bodies decomposed in broken mortuary fridges in Mafikeng Hospital in North West. He said that “this Department will never come out of a swamp of corruption and maladministration unless dramatic measures are put in place to hold people and officials accountable, and to face the consequences to the full extent of the law.”

Peoples’ lives were at stake and it was unacceptable that this Department was gambling with the lives of South Africans and the healthcare workers. The deaths from COVID-19 were the highest in the world among the healthcare workers, as South Africa was ranked in the top five in the world. Why was this happening? He asserted that this was because the country’s hospitals and clinics were “in a terrible state”. This was evident in the situation of the state hospitals during COVID-19, and the Eastern Cape was still experiencing major problems. This sort of practice must be stopped.

Mr Van Staden referred to the one new hospital that had been built in KwaZulu-Natal (KZN) during this financial year. This meant that only one new hospital had been built in the whole of South Africa for the current population of people who were in dire need of medical care and attention. The issue was that it was not a complete hospital, but rather a half-hospital to cater for all those people who needed medical assistance in South Africa.

The 16 hospital revitalisation projects not completed was totally unacceptable. It was time for this Portfolio Committee and the Select Committee of Health to undertake oversight at every single state hospital, provincial hospital and clinic in the country, to assess what was happening in these facilities. This situation in South Africa could not continue in this current manner.  

Mr Van Staden asked for the reasons for the failure of four Cuban-trained South African students to pass their final exams in Cuba, while there were many South African medical practitioners and healthcare workers who were currently unemployed, and were already trained to do this work in state hospitals and clinics.

Ms N Ndongeni (ANC, Eastern Cape) referred to the AG’s report that the Department must provide a comprehensive report on irregular expenditure, which was extremely high -- up to R151 million from R112.1 million in the previous year. What were the reasons for the irregular expenditure and what was being done to address and prevent this in the Department? Had anyone been held accountable for this?

The AG had referred to the low response by management to improving key controls and addressing risk areas. How was the Department addressing this? What role was it playing in addressing the high level of irregular expenditure within the provincial Departments of Health, which had increased over the past few years? The Department must provide an explanation on the fruitless and wasteful expenditure incurred. Who permitted fruitless and wasteful expenditure? What was being done to prevent this in future? How was the Department dealing with the accruals, which was a major issue in the health sector as the Department assisted provinces in dealing with the accruals?

Ms A Maleka (ANC, Mpumalanga) asked the Department to provide a detailed report on the challenges with the reimbursement model for the contracting Ccapitation model. Had any general practitioners, pharmacy assistants and other health professionals been contracted to work in the NHI pilot sites? How had this affected service delivery? How was the Department implementing the lessons identified in the NHI evaluation reports? On the issue of the Centralised Chronic Medicines Dispensing and Distribution (CCMDD) programme, it was important for patients’ demands to be registered. Was the programme standardised across the country? In which provinces were home deliveries provided, and which required patients to come to facilities such as churches etc?  

Ms S Luthuli (EFF, KZN) said it seemed that the Department used too many consultants. She asked what role the consultants played in the Department -- did they perform routine tasks, or did they provide specialised services? Could the Department provide details on the number of unemployed graduates or interns that it hired in each province?

Ms D Christians (DA, Northern Cape) agreed with the concerns over the targets achieved that did not correspond with the expenditure. Most of the expenditures from the finance report indicated a 99% expenditure, or just below this, which did not correspond with the work done on the ground. This was of huge concern -- that money had been spent, but the Committee could not see what this money had been spent on.

On the mental health issue, it was quite disturbing to see that zero targets were achieved. This was extremely disturbing, considering that the country had just come through a pandemic and was perhaps in the throes of a second wave, yet mental health had taken a backseat in the country. How would the Department roll out a programme to ensure that the mental health of South Africans did not lag, especially during the pandemic, since people had lost jobs and had been ill. The country was really in need of assistance in this regard.

On the human papillomavirus (HPV) grant, it was extremely concerning that targets were not achieved, and budgets were significantly cut, yet young girls were hugely exposed to HPV. Were there any plans to further rollout awareness campaigns on HPV? Where would additional funding come from for the HPV grant? How could the Department ensure that young girls had the option to take this vaccine? Would this be rolled out in schools? Were communities aware? On the budget cuts, how would the Department ensure that this was back on track? On community healthcare and primary healthcare, only 12.8% of the targets were achieved.

It was concerning that currently in the Northern Cape, primary healthcare and community healthcare facilities were on strike because of dilapidated clinic infrastructure. Caregivers had not received stipends, and there were promises of increases and permanent positions that the Department had not delivered on. These clinics had been closed for several days, and it was concerning that they were closed because of issues such as dilapidated infrastructure and lack of mobile units. A large group of patients were forfeiting chronic medication, which was extremely concerning. She emphasised the point that the targets achieved did not correspond with the expenditure presented to this Committee by the finance department.  

Ms S Gwarube (DA) noted concerns about some of the issues raised by Dr Andrews. On the NHI programme, the Department was very proud of its target of registering 45 million South Africans on the patient beneficiary registry, but she wanted to know how this worked. Was this simply the population of a system by essentially taking what was publicly available, or from Home Affairs records, and simply just inserting it into a health record system, or was it actually a substantive system that allowed patients to be truly recorded on an online system so that there was one single paperless patient registration system, where patients were able to go to any facility in the country and have their folders pulled up from an electronic system? In 2020, this was where the Department should be headed, and not just simply a listing of people. She asked Dr Andrews to provide clarity on this issue, because if the Department was stating that 45 million South Africans were now able to walk into any facility and have their details on an online system, this was a wonderful feat.

The Committees had to take the mental health target seriously. Ms Gwarube proposed that the Minister and the Deputy Minister had to have a separate session with these Committees where they could account for this dismal performance by the Department in this programme. She commented that “it was absolutely shocking,” considering the fact that they had come from the biggest blight in democratic South Africa, which was what had happened at Life Esidimeni. This matter had not yet been concluded, yet the Department had set targets that were extremely low. One of the targets had been putting 22 000 people in touch with mental healthcare professionals, which was “absolutely pathetic,” and yet zero targets had been met. She asked how 99% of the budget had been spent on the mental health services programme, yet not a single target was met. Mental health services had essentially been the stepchild in this Department for many years, and this was not a new issue.

Ms Gwarube agreed with Ms Wilson’s caution of using the pandemic as a scapegoat when dealing with mental health, since this was not a new issue. The targets for mental health services had been lagging for many years, but the targets for this past financial year were truly pathetic and made her ashamed. How could the Members of this House hold the Department accountable when it could not meet a single target in one programme?

The presentation had indicated that 1 906 primary health care facilities were awarded “Ideal Clinic” status. Was this simply a listing of PHC facilities that had achieved Ideal Clinic status, and how did this correlate with what the Office of Health Standards had essentially stated -- that a fraction of care facilities that it had looked at were compliant with the standards that it set? Was there a difference between the Ideal Clinic status and the Office of Health Standards, and if so, why? Why was there not one standard which every facility had to meet? This was misleading. If 1 906 PHC facilities were awarded Ideal Clinic status but the Office of Health Standards stated that a fraction of these clinics were meeting these standards, what metric was being looked at, and why was it not uniform? She asked for clarity on this matter.

An issue that was unrelated to this year was the infrastructure that had been built for COVID-19. Did the Department have a plan to repurpose some of this infrastructure? It was important to ensure that this was not wasted, because billions were spent on this. The Committees must ensure that what was spent was somehow repurposed and brought back into the health system to ensure seamless healthcare services. This could be used as an opportunity to improve access and infrastructure in many of the areas that were lacking these facilities.

Dr P Dyanti (ANC) was concerned about the fruitless and wasteful expenditure. The main concern in the AG’s report was that “the data given by the Department had weaknesses, and performance information may not be reliable or accurate”. How would the Department address this in the long term? Did it have a plan to assist provinces as well?

On the poor spending in Programme 3 and the achievement of 56.3% of the target despite the budget being used, did the Department analyse these targets and assess what was being done wrongly on the costing and activities that were supposed to be completed? COVID-19 had affected the targets, but there were areas and programmes that had been brought to the Department to improve on, such as mental health, before COVID-19. Why was it a challenge for the Department to establish more district mental health teams?

She said the CCMDD was the best programme that the Department had embarked on, but it needed to continuously update the Committee on whether the communities still received their medications closer to them. A regular update with these statistics would be useful when the Committee did oversight.

The Committee was aware that the entities were not doing well. How was the Department assisting these entities and provinces to get a clean audit? It was a major concern that the provinces were not doing well.

On the issue of patients being raped in hospitals, could the Department inform the Committee what role it was playing in fighting gender-based violence (GBV)?

Dr S Thembekwayo (EFF) said that the Committee did not need an explanation from the presenter about how the AG did its audit. The Committee believed in the report and it did not need the presenter to tell it what to believe, especially since the presentation had not addressed any findings of the AG’s report. It stated that the vision of the Department was to fill posts with skilled, committed and competent individuals, yet the AG’s report indicated irregular expenditure. Irregular expenditure of millions of Rands was a major concern, and the report did not inform the Committee on this crucial matter because there was nothing that was supposed to be accounted for in this Department. Under Programme 1 (administration), it stated that this was to “ensure effective financial management and accountability by improving audit outcomes.” The presenter’s report on the provinces repeatedly told the Committee that it had heard this before, which meant that there was no urge for improvement on the faults that could be observed.

Six provinces that did not implement the medico-legal claims management system showed ineffective and unaccounted responsibility. What were the measures to curb this occurrence? Under non-compliance on the status of internal controls, the AG’s report stated that the figure of 67% ran through the NDoH on matters of proper record-keeping, daily and monthly contract reviews, and monitoring compliance contract. This meant that there was no compliance under these three aspects specifically by this Department, so how did it expect other provinces that reported to it to be compliant on such matters? The same applied to assurance provided. The assurance provided by the senior management stood at 100% rate of accountability, while the accounting authority officers’ rating stood at 33% percent. This meant that as long as the NDoH could provide 67% assurance, it was expected that such percentages would come down to the other committees.

Under the common findings by the AG on supply chain management, the procurement processes were not followed. It was a major concern for the Committee to discover that the procurement processes were also not followed under the NDoH. Why was this tendency also present in this Department? The KZN Department of Health, which was part of the NDoH, had funded four groups of students that were studying to become orthotists and prosthetists. While group A and B had been placed in 2017/18 respectively in Wentworth Hospital, group C and D were not placed to date. Various meetings with the Department had yielded no possibility of them being placed, since they were told that their posts were frozen. Was the Department aware of this? If yes, how would it intervene in this matter?

Ms H Ismail (DA) said that the non-placement of South African interns that had studied outside of South Africa and met the Health Professions Council of South Africa (HPCSA) standards was concerning when there were vacant posts, a pandemic, the NDoH and provinces not functioning properly, and staff shortages at hospitals and clinics, yet the Department was not placing these interns that were ready and willing to assist. Could the Department give the Committee a date when these interns would be placed at the various healthcare facilities? All hands on deck were essential right now, and the Department’s delays were causing further delays in essential service delivery to communities.

On the issue of mental health targets not reached, it seems that when there were targets that were not achieved, the Department was not concerned in really addressing them. There were allegations of sexual assault on mental health patients due to a lack of security in hospitals. Mental health was going to be one of the key areas of healthcare because of the consequences and impact of COVID-19. If Department was already not meeting targets and not informing the Committee of its plans to really address mental health targets, this country would face major consequences, because most communities in this country were already on the back foot. Many people were now needing counselling, and this was going to get worse. Could the Department provide a full report on all these matters, especially the rape crisis at each and every public healthcare facility?

What was the NDoH doing to ensure that provinces were compliant? This question was always raised about the accountability measures employed by the Department to ensure that the provinces were indeed compliant. The report stated that some public healthcare facilities were not operational for various reasons, yet primary healthcare was a key and optimal arena of service delivery. How could this Committee be proud of a presentation when service delivery was the key, and these targets were not being met on the ground?

The under-spending of the budget was shocking, and there was really nothing more that the Committee could say, as this was totally unacceptable. Wasteful and irregular expenditure did not seem to be improving each time this was reported on, because there were no accountability measures in place. What consequence management programmes were in place, and what accountability was going to be done to ensure this type of report did not come back to the Committee?

The AG’s report was quite damning -- there were serious problems in the NDoH. The issues of provinces not complying, entities not achieving, refurbishments of healthcare facilities not taking place or delayed -- these were all serious issues that were affecting service delivery on the ground. What was causing the delays with the refurbishment of healthcare facilities,? Several site visits to hospitals were done, but these refurbishments were not completed on time and wards could not be used. The Department was paying contractors to do these jobs. What was it doing to ensure that things were done properly and systematically, with accountability?

A matter of concern on communicable and non-communicable diseases was that many of the tuberculosis (TB) patients had not received their medication on time during the lockdown period of COVID-19. The fact that there were already delays, and these were further delays, was making things worse on the ground. These were patients that needed care, and nothing was being done to really address these issues.

Mr T Munyai (ANC) commented that COVID-19 had caused havoc in the country and the international community. This had brought an unprecedented crisis which had implications for the work of the Department. Referring to the entities, he said that it would be worth the Committees’ time to note, appreciate and welcome the good results from the Medical Research Council (MRC) under these circumstances. He pointed out that the Department had had to move out of its headquarters at the old Civitas building, and under these circumstances, it had done its best. The Committee had to note that this was not a normal situation. The Department would turn the tide with all the entities, and he rejected the stance that sought to condemn it for not doing well, even though the Committee was aware was aware of the circumstances requiring a balance with the material conditions of COVID-19. In his view, the Committee should welcome and support this report, as well as the government’s efforts to try and do better in dealing with the COVID-19 consequences. It must not condemn the Department and the workers for working hard under difficult conditions. These workers were bearing the brunt and had been most affected by COVID-19. The DG and the administration must be supported in general, as well as the Department.

Ms A Gela (ANC) supported the Report that was tabled. She welcomed the implementation of the introduction of the ideal hospital framework. It was a good move from the Department, because these ideal clinics were working, and it was good that health standards were achieved at these clinics. The renovations in other areas of health should be appreciated, as the Committee was aware that it was also correcting the mistakes of the past. In the past, there used to be a four-roomed facility as a clinic in the townships, but there had been many changes in society through the ANC-led government, such as the renovations and building of clinics in rural areas. Members of this Committee must appreciate the good work that the Department was doing, despite the challenges that it faced. This had been a difficult year for all because of COVID-19, and the country had not been ready to handle these challenges. She commended the Minister and the Deputy Minister of Health on their work to ensure that the people of South Africa’s lives were protected during the pandemic.

She requested that the Chairperson assess the findings and recommendations of the AG’s report tabled last week on the issues in the Department so that the Committees could work together and assist the Department in rectifying these issues. She supported and appreciated the report tabled today.

Mr M Sokatsha (ANC) commended the Department for receiving an unqualified audit opinion for nine consecutive years. The presenter had explained the reasons for vacancy rate had been due to funding constraints and the shifting of funds. Going forward, was there any plans from the Department to ensure that the vacancy rate was reduced from 14%?

When the medical students returned from Cuba and were placed in South African universities, some of them had failed. When students failed, did the Department place them on a programme, because the transition from a Spanish programme to a South African university must be challenging for students. Were there any programmes to support these students if they failed the exams?  

Chairperson Gillion handed over to Co-Chairperson Dhlomo.

The Co-Chairperson said he had received three messages three days ago from some sixth-year medical students, and quoted the message that they had received from the Department, which stated “please note that the preliminary allocation results for group 2 annual cycle have been released.” He had called these students, and they had indicated their excitement about receiving confirmation from the Department on their placement and the process around this even before writing the exams. This was one space that he observed where the Department started briefing the students on their readiness to start. He commended the Department on this, and said that it had to continue and go beyond this so that it was not faced with the same problems that it faced in January, when the healthcare students did not know where to go.

He supported the mental health concerns raised by Ms Gwarube. Mental health was generally not focused on throughout the world. He proposed that the Committees find the space and time with the Department to investigate the mental health situation in the country, and asked that this be investigated, as mental health was lagging and was getting less attention in the health sector.

The AG had stated that if it had not written to the CFO to do some material adjustments, the Department would have moved from an unqualified audit outcome to a qualified audit outcome. Why should the Department not be able to make a once-off submission and get an unqualified, or even a clean, audit outcome? Why should it get an unqualified audit after it had been asked to make corrections?

How often did the Department get the reports on the ideal hospital status, and how often could they be shared with these Committees? This was one of the backbones of the NHI, because the more it did well in improving hospitals and health services, the better chances of restoring peoples’ hope in the NHI. The Committee must take a collective view on the delay in the NHI Bill, but COVID-19 had caused some delays which were currently being resuscitated by the Portfolio Committee. Colleagues in the National Council of Provinces (NCOP) were eagerly awaiting the outcome, which would be available only after it had been processed and delivered to the Speaker.

The CCMDD was commendable, and it had done well in assisting patients. Focus on this programme must not be lost, because it was almost a step in the right direction towards even improving the NHI.

It must be clear that the improvements in the area of Emergency Medical Services (EMS) had not really been on a level where South Africans were able to compare rural versus urban areas. In rural areas two years ago, patients would wait two hours for an ambulance, and now the wait was an hour or less. In urban areas, the wait would be 45 minutes, but now it was 15 minutes. Could the fleet and waiting times be improved? This was what mattered, because chances of survival in a car accident were heavily reduced when patients were not met with an ambulance within the first hour. EMS was the backbone of a successful health system in this country and in the world.

Chairperson Gillion welcomed the Annual Report and the Department’s positive presentation on the Civitas building. When would this move happen? What had the Department done to improve the TB indicators? What was the effect of COVID-19 on the TB services in the country? How had COVID-19 impacted on the work of this Department? What lessons had it learned in moving this country forward out of the pandemic?

NDOH’s responses

Deputy Minister (DM) Phaahla thanked the Committee for its questions.

In response to Ms Chirwa’s “sweeping statement” on the regression on HR and finance, and notwithstanding that this was indicated by the AG’s report, he observed that the Department had sustained an unqualified audit, and that the team would respond to the concern raised by the AG on the reliability of information.

He said Chairperson Dhlomo had dealt with the placement of interns.

The Department had faced several challenges mentioned by Dr Andrews, including difficulties with the Civitas building headquarters, various conflicts with the workforce and labour unions on the safety of the building, and the non-functionality of headquarters had affected many staff members.

Notwithstanding these issues, and the placement of interns, there had been considerable improvement, as noted by Chairperson Dhlomo. Despite a serious shortage of funds on an annual basis because of the continuous reduction in its financial allocation, the Department had made it a point that internship was a statutory requirement and required by law. Attempts had been made to ensure that South African graduates were specially prioritised, despite challenges with funding even in the current financial year, and these students were informed as early as possible.

On the CGE report on forced sterilisation, the DM agreed that this matter had to be finalised. The work had been done, but some matters needed to be wrapped up and many allegations needed to be investigated and finalised. The Department would update and provide the Portfolio Committee with a report on this issue. The DG and the team would ensure that this investigation on the Department’s part was concluded.

Ms Chirwa called a point of order.

Chairperson Gillion asked that no points of order be called so that the DM could respond to the questions and statements.

DM Phaahla thanked the Chairperson, and continued addressing the Committees.

On the issue raised by several Members of the non-correlation between the expenditure and the performance report, a large portion of the R51.195 billion allocation to the NDoH went as transfers to provinces, various non-governmental organisations (NGOs) and other providers of particular services. As reported in the presentation, of the R51.195 billion, R47.871 actually went as transfers, and only about R3 billion was essentially spent directly through the National Department. This was just the starting point. When reporting on the performance, it was on the direct functions which were largely in the NDoH, but some aspects of the performance also overlapped with the performance of provinces. He agreed with Ms Wilson’s point about the performance report being done as a composite with all the provinces, but unfortunately the NDoH’s system did not function this way. This was the first point, to remind Members that non-achievements of targets did not mean that nothing was done. In some cases, as indicated in infrastructure, it may just be that the project was not brought to completion in time for the completion of the financial year, but it was at 99%. What was left was a completion certificate which was not issued by the time of the audit. On the medico-legal issue and some of its functions, for example, the Department had developed the norms and standards and provided the template to provinces on which functions must be done. If these functions were not completed, it was a reflection on the NDoH, but it was impossible to take over these functions directly. Some functions were not properly structured -- for example, such as 650 students studying, and provision being made for all 650 to be given space. When only 646 passed, this was considered as a non-performance, but the Department could not write the exams for the students. The Department had a supervisory role, and must therefore be measured on this.

The DM said that the CFO and the team would respond to the issue on irregular expenditure, because this could not be a continuous issue. However, in some instances these things did happen where it was unavoidable that certain things had to be done in emergency situations.

In response to Mr Van Staden’s issue about Cuba, these were South Africans who got an opportunity to study medicine in Cuba and return to work in the country. For the Department, it was not contrasting these students with those who qualified in South African universities on opportunities for them to complete and be able to contribute to the health services of the country. This opportunity was given to students in local South African universities and to students who studied in Cuba. The Department, together with the Health Professions Council, ensured that South African youngsters who studied at other foreign universities were streamlined to be given an opportunity to enter the South African system, accredited through the Health Professions Council.  

Dr Phaala assured the Committees that the Department would come back and report on the concerns raised on mental health. He agreed with Chairperson Dhlomo that mental health had generally been neglected for various reasons, such as the pressure of communicable and non-communicable diseases, trauma, and so on, and had tended to be inadequately catered for. The challenge was around psychiatrists, as almost 90% of registered psychiatrists were in the private sector. There was the same issue with clinical psychologists and other professionals, and this was the reason for the idea to outsource and contract private providers to provide the service.

Dr Sandile Buthelezi, Director-General (DG), NDOH, commented that the Deputy Minister had addressed several issues that were cross-cutting. On the issue of the CGE, this was a matter that the Department was dealing with, and would provide an update to the Committee. The Department had had a meeting with the Commission and the Chairpersons last week to establish a joint way forward in concluding this matter. It would provide an update on this soon.

In response to Ms Gwarube’s question on the infrastructure provided with the use of COVID-19 funds, the Department had deliberately invested in the infrastructure in hospitals that would be one of the long-term investments in the health system, to ensure that it moved forward. Some of the equipment and ventilators that were bought -- some through the Solidarity Fund and some that were donated -- would improve the services in the health system in the future. The Department was aware that the investment would go a long way to ensure that it moved towards the NHI as a country as soon as possible.  

On the issue of the strikes of community healthcare workers and promises of permanent employment, the Minister had pronounced on this matter yesterday, that it was being addressed. The National Health Council (NHC) chaired by the Minister, would receive the report on the proposal at its next meeting on 26 November on how the Department proposed to address the matter once and for all. This was an issue that was really taken seriously by the Department because it understood the importance of community healthcare workers in the public health sector in general.

The issue on interns had been covered. The letter of allocation was released on 16 November. After it was discussed with the provinces, the Department had to present this to the Technical National Health Council.

There was a composite report on the effect of COVID-19 on TB, HIV and immunisation services. The report could be made available, because it was work that the Department had done which included the development of catch-up plans as a Department, working with partners such as the South African National AIDS Council, to assess how it could catch-up on those services that were affected mainly because of the lockdown, but also because of resources. The testing platform for COVID-19 was the same as that used for TB. This report would show that the Department was able to pick up with many of its services, including immunisation after the lockdown. The main issues were the shifting of resources, and that people were afraid to visit facilities because of the lockdown and the high risk of infection.  

Regarding a reduction of vacancy rates, in line with the NHI Bill and aligning the Department’s structure to this, the organisational structure of the NDOH had to be revised. This structure was now with the Department of Public Service and Administration (DPSA), and had been signed off by the DM and the Minister. The Department would be prioritising these positions. A challenge was that the budget cuts were getting worse. With the midterm budget policy statement (BPS), the Department had lost close to R700 million. It had been informed that there would be cuts in the medium term expenditure framework (MTEF), and most of these cuts affected the compensation of employees. The Department would reassess what was critical in filling these vacancies.

Chairperson Gillion proposed that the Committee receive responses to its questions in writing by Friday at 12 pm if responses were not addressed by 13h00 today.

The DG agreed to this proposal.

Dr Andrews responded to Ms Gwarube’s question on information systems and the 45 million patients in the patient registry. The Health Patient Registration System (HPRS) that was created by the Department used the unique patient identifier, which was the South African ID or passport. The HPRS had created this patient registry, which was referred to as the Master Patient Index for the country. More than 50 million people had been registered on this HPR system. It would go beyond being a registry of patients. Some data was imported, because it was easier than registering patients in each facility. The achievement of registering 50 million people to date was quite a big achievement. In addition to the HPRS, there was also a digital health strategy that aimed to establish an electronic health record. The electronic health record would have to be established from an integrated information architecture for interoperability, which was not something that could be achieved overnight.

The Department had been working towards multiple achievements on various aspects of this strategy over the past few years. This architecture for interoperability and the electronic health record would ensure safe sharing of patient health information across health systems and services. She commented that the Department may not move to a complete paperless system in her lifetime, but that this was the trajectory the Department was on. COVID-19 had showed the Department’s capability to create interoperability among various systems linking lab data with patient level data, and even linking provider registry data with lab data. This was the reason that one of the Members had been able to indicate that the COVID-19 infection rates amongst healthcare workers were amongst the top five in the world. A key component that the Department had achieved was the review of the 2014 Health Normative Standards Framework for interoperability. The Department had completed this review and it was awaiting final approval from the NHC next year. This would go a long way in ensuring that existing systems could be interoperable and ensure a steady move towards an electronic health record.

In response to Dr Dyantyi’s concern about the AG’s comment on the reliability of the Department’s data, Dr Andrews responded that the Department had a structured way that it managed health information. In every health service area, whether maternal health or child health, data elements were collected by a set of registers which had standard definitions in the national indicator data. Unfortunately, this was a paper register, but this information was transcribed daily into the Department’s electronic systems, where these existed, in real time or through offline systems. This data, which had been captured by data capturers at facility level, was then validated on a monthly basis. The facility manager would sign off after the data was validated or verified. It moved from the facility to the district, where the district manager must ensure that the data was verified and sign it off to go to the province. At the provincial level, there was an aggregation of district level data from various districts, and the data undergoes validation. The Head of Department (HoD) would sign it off only once it had been validated, which was then pushed through the national system. This was the data that the Department used for reporting.

She said that for the first time in the 2019/20 year, the AG had wanted the Department to introduce a process of reconciliations at the provincial level before it did the audit. When it selected its samples and the indicators that it would audit, provinces had to reconcile the data. The Department had developed a tool called Rapid Internal Performance Data Audit (RIPDA) that enabled the districts to conduct internal assessments across all their facilities in every quarter, to capture the results where there were discrepancies, and to implement improvement measures for the data capturing at facility level. Dr Andrews said that the data was never 100% perfect, and that this was always disputed with the AG. It worked in an accounting system way, where it could work with accurate figures. In a real-life context, such as a health facility, the data would always have a margin of error, and it would never be 100% accurate, but it should be reliable and accurate within certain margins. She added that the Department had had ongoing discussions and managed to educate the AG on how its systems worked and how they should be interpreted. The Department had trained provinces to use the RIPDA to ensure the minimisation of errors. The data capturers were also faced with personal issues that could affect their work.

The DM asked Dr Andrews to wrap up her response in the interest of time.  

Dr Andrews noted this comment, and said the point was to explain that “there would always be a margin of error with data capturing because human beings would always err because to err was human.”

The DM asked Mr Ramphelane Morewane, Chief Director National Department of Health, to briefly respond to the question on the Ideal Clinic and the report on the Office of Health Standards Compliance (OHSC), and the relationship between them.

Mr Morewane said that the relationship between the Ideal Clinic and the OHSC was that one was an internal mechanism and the OHSC was external. The Department had realigned the measurement tools so that the discrepancies on measuring areas did not continue. From this financial year, the Department had realigned this, and the OHSC had accepted its measuring tool as the baseline status determination assessment.

Mr Van der Merwe responded to the AG’s “sweeping comment” that there had been no regard for financial statement compliance with legislation, and said he would have contested this statement if he had been at the meeting. In the current financial year, the Department had dealt with more than 250 requests for information from the AG, and with an excess of communications of 50, and not one was outstanding. The Department had to assess the basis of these sweeping comments. It had complied to every emergency procurement process by the National Treasury. It had reported to the AG and to the National Treasury on each and every deviation. On the issue of the under-spending of R422 million, this was a reduction of R1 million from the previous year, but the Committee had to note that many of the budget allocations were earmarked.

The DM interrupted Mr Van der Merwe to correct him on the figure that he had stated.

Mr Van der Merwe thanked the DM and said that the underspending of R422 million was a reduction from R1 billion in the previous financial year. Many of these were earmarked funds that were appropriated, which meant that as soon as they were used for anything else than what they had been appropriated for, the Department risked further irregular expenditure because of non-compliance to the law.  

On the under-spending in Programme 3 and 4, the COVID-19 preparations had begun in February, way before the emergency was declared. He explained that by this time, the Department had been forced to move budgets into the programmes of communicable and non-communicable diseases. The reason for this was because the system did not allow it to commit funds when there were no budgets against these funds. The Department had done this so that it could put out orders and commitments against these budgets.

He agreed that it was necessary to contain and reduce the irregular expenditure, and that there was a need for consequence management. The Department was also in a position where it had to take the brunt of the irregular expenditure when the agents that it implemented transgressed. In this year in particular, with the Development Bank of South Africa and some of the Coega colleagues, there were supply matters raised by the auditors of those entities, and by default these irregular expenditures came on to the Department’s books. To deal with irregular expenditure on the irregular framework, a proper determination was required on the reasons for this expenditure and the actions that had to be taken in line with the framework.

Mr Van der Merwe said that it was not necessarily true that the Department did not know the position of conditional grants at the provinces. It could only look at the audited numbers when they were audited. In the report, the Department had indicated the conditional grants per province, and the expenditure. It was untrue that the Department was unaware of this expenditure. He noted that if the report was too busy, his contribution to make it simpler to understand was to take the Committee through each conditional grant by province, with the recommended access that the Department had determined.

Mr Van der Merwe said that it was impossible for himself and the NDoH to be responsible for the audit outcome on the reports of the provincial Departments of Health. The provincial Departments had their own HoDs, CFOs and supply-chain and financial managers. The Department had intervened and assisted provinces, but it could not check everything that was in these reports. Certain matters could be targeted, such as Mpumalanga, which had issued contingent liabilities. The Department had assisted it with this, and it had been solved, and Mpumalanga was unqualified for this financial year for the first time in 10 or 12 years, and this was the same with Limpopo. Some provinces did regress, such as the Free State and Eastern Cape, but they had to put in efforts in place to sustain their own audit outcomes. He commented that this was one APP target that the Committee must reassess -- that it should not be part of the NDoH’s APP, but rather part of the operational reports.  

The AG’s report had stated that the irregular expenditure must be assessed properly to understand how to address it going forward. On the budget cuts, the DG and DM had touched on this. The Department had lost funding of R3.5 billion on only the NDoH over the MTEF period, and it had gone backwards on the compensation ceilings that the Treasury had put down. It was now at the numbers it was at in the 2014/15 financial year. This meant that there had to be enormous right sizing and a review of the total compensation envelope, and the capacity available within the Department. The budget cuts were a reality for the foreseeable future, and were reflected in the current projections by Treasury of 6%, 9% and 12% over the MTEF.

As part of the Department’s intervention with Treasury, it had put out an accruals plan, but unfortunately the budget cuts were definitely going to impact on this plan and the ability of provinces to deal with accruals. On performance against budget, the budget of the NDoH was largely not discretionary. The fiscal space within its budget to achieve all the performance targets was being reduced every year. This was an important point that the Committee should consider.

The Department initially had to reduce the budgets on mental health programmes because the uptake on this matter was extremely slow. The Department was now faced with provinces that regularly claimed on these grants, and this was the reason for the expenditure of 99 percent of the budget on this.

On the unqualified status of the Department’s performance indicators, there were two programmes that had unqualified performance, and one was qualified. This was an improvement on the last financial year. The Department had a longstanding record of unqualified reports for nine years. The matter that the AG had addressed was a material adjustment to the management fees on work in progress. The challenge was that in the previous financial year, the Department had had to adjust to include it, and this year it had to adjust to exclude it. It was important to assess this on a technical level, and to find ways with the AG and Treasury on ways to address this. In the current situation, the Department had to comply with the view of the AG, and it did not have enough time to explore the technicalities. If the status quo had been maintained from the previous year, then this would not have been a material adjustment in the current financial year.

Mr van Der Merwe concluded and handed over to the DM.   

The DM thanked the Members and concluded the presentation responses.

Chairperson Gillion thanked all the Members and the Department for its interaction. She wished the Minister and the DM well in the enormous task the Department was currently facing. She assured the DM that he could always rely on the Members of these Committees for any assistance.   

The meeting was adjourned.