Department of Health 2020/21 Annual Performance Plan: with Deputy Minister

NCOP Health and Social Services

16 March 2021
Chairperson: Ms M Gillion (ANC; Western Cape)
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Meeting Summary

Annual Reports 2019/20

The Deputy Minister of Health gave context for the 2021/22 Annual Performance Plan highlighting that they were coming from the hardest year ever not only as a department but South Africa as a whole. Irrespective, things would get much better with the rollout of the Covid-19 vaccine.

The Department outlined the health sector's priorities in its Annual Performance Plan (APP). The Director General told the Committee to ignore the APP target of 16.6 million people vaccinated in 2021/22. The Department wanted to ensure that 40 million people were vaccinated - thus reaching herd immunity - before April 2022. They would send an amendment page to replace that target.

Members asked if Department of Health was going to reach their target for vaccinations, the timelines for the different phases and the end date for 67% vaccinated; if the Department was prepared for a potential Covid-19 third wave as the country approached winter; how the registration process would work for the Phase 2 vaccination of high-risk persons in congregate settings, persons over 60-years and persons over 18-years with co-morbidities. They also asked about the health programmes that had been neglected through the lockdowns such as oncology, HIV, TB and the HPV campaign in schools.

Meeting report

In a virtual meeting, the Chairperson welcomed the Deputy Minister and noted this was the Committee's first meeting of 2021. Apologies from the Minister were received. The Deputy Minister and the Director General had another meeting at 11 am and would therefore be excused then.

Health Department Director General, Dr Sandile Buthelezi, said the Deputy Minister was expected to give remarks and the Parliamentary Liaison Officer would continue to try to reach him. The Minister of Health had requested the Deputy Minister stand in. The Minister was deeply involved in the preparations for the 'planting' of King Zwelithini in KZN. He had been involved since His Majesty was admitted to hospital where he eventually died.

The Director General requested that they proceed to the presentation of the Annual Performance Plan submitted to Parliament. The Deputy Director General in the Department responsible for Planning, Monitoring and Evaluation would lead the presentation.

Department of Health (DoH) 2021/22 Annual Performance Plan
Dr Gail Andrews, Deputy Director General: Planning, Monitoring and Evaluation as well as Chief Operating Officer, introduced the Health Sector priorities and how they had been derived. She covered the strategic plan and the Annual Performance Plan. Department of Health Chief Financial Officer, Mr Ian van der Merwe provided the financial information in the Annual Performance Plan.

Deputy Minister of Health, Joe Phaala, logged into the meeting and gave his sincere apologies for not being able to make remarks at the start as he had load-shedding. The Minister was unable to attend because he was attending to matters in KZN. The Annual Performance Plan was being presented against the backdrop of a very difficult year. The 5 March had marked the anniversary of the first Covid-19 case in South Africa which indeed had defined the year 2020. This had happened just a couple of weeks before the start of the 2020/21 financial year. The past year one could describe as the most challenging in the history of South Africa. In 2020/21, two waves of Covid-19 had placed huge demands on the health system and especially on health care workers. Certainly, many of the health care workers paid the ultimate price with their own lives in saving the lives of many South Africans.

It was a year were most people in South Africa came face to face with the loss of a loved one and tragically in some cases, it was several family members. It was a very difficult time in that many people lost their jobs and their families struggled a lot. This had an impact on resources as is evident in the 2021/22 Annual Performance Plan. This was a very important backdrop because resources declined during that period. During the various phases of lockdown, there was a reduction in the utilisation of health services which had an impact on the 2020/21 Performance Plan. A comparison between 2019 and 2020 showed that utilisation of routine health services had declined in hospitals and clinics including chronic follow-up. DoH would therefore look at the five year strategic plan and see if there was a need for adjustments. These adjustments would only be made based on full information. However, the pandemic revealed resilience in health services which was a very positive note as it was able to absorb most of the shocks resulting from Covid-19.

There was also excellent social mobilisation displayed during the course of Covid-19. Many people came from civil society, government and business to work together. Globally, many have come to appreciate the threat posed by pandemics. Many countries have accepted the fact that investment in health was indeed an investment in the economy as stated by a World Bank report in 1993 on investing in health. Many partners came together and were able to deliver interventions that improved the ability to respond rapidly. The calibre of talents in the country, especially scientists, came on board and showed what the country was able to do. Scientists were recognised throughout the world. It was within that context that the 2021/22 Annual Performance Plan (APP) and Budget is being presented. The hope is that the vaccination programme in the new financial year will make this year a better one and the setbacks will lessen.

Dr Buthelezi spoke about the vaccination targets. This had been a moving area because they had been working very hard to pull together the targets and to get the vaccines in time. He requested the Committee to retract the targets in the APP because they wanted to vaccinate as many people in 2021/22 as possible which was about 40 million. The targets put forward had been those suggested as they had worked earlier on the APP. The targets were moving because it was work that was ongoing every week and every day. Those targets would be amended to 40 million people by the end of the financial year.

The Chairperson expressed her appreciation to the Deputy Minister and Director General for their hard work as a department — the Deputy Minister was to convey the message to the Minister. Even though it had been a very difficult year, whenever they required assistance in the different provinces, the Ministry and team were excellent in their response.

The Chairperson appreciated the presentation. She asked about the output of 100 health promotion messages through social media under the Administration programme. Why was that in Programme 1 and not Programme 3 which dealt with Non-Communicable Diseases. How DoH was addressing the Auditor General’s audit findings in 2020 on Programmes 2, 5 and 6. She asked why the number of targets had been reduced compared to the previous year APP. For instance, 400 public health facilities were to be maintained / refurbished while in the previous APP, the target was 450 public health facilities.

Ms N Ndongeni (ANC; Eastern Cape) asked how would the decline in the Primary Health Care programme affect service delivery? How would District Health Services be affected by the reduction in the budget? She asked if DoH could provide a detailed report on the state of disaster on medical services. How was the progress on the eight mega infrastructure projects, including the Limpopo Academy hospital, going to be affected by the Covid-19 pandemic? How much money was dedicated to maintenance of infrastructure and equipment? Could DoH provide a detailed report on the sub-programme Hospital System and how the money allocated was used?

Ms S Luthuli (EFF, KZN) asked how many HIV performance indicators there were and how they reflected allocations for tracing HIV clients that had been lost during the pandemic. What was the reason for the significant reduction in the Child, Youth and School Health programme budget? What were the implications of the reduced funding for the human papillomavirus (HPV) vaccination programme? How had Covid-19 affected the HIV programme and what had the done to address this? What measures were in place for DoH to obtain a clean audit?

Ms A Maleka (ANC, Mpumalanga) asked what DoH had learned from the Covid-19 pandemic and how these lessons would be incorporated into the running of DoH and the design of the NHI. How had Covid-19 impacted the NHI programme? Were there any design changes? She asked about the process for medical aid beneficiaries being registered on Health Patient Registration System (HPRS) and the spending on the NHI grant.

Ms D Christians (DA, Northern Cape) noted that the aim was to vaccinate initially 16.6 million people and then eventually 67% of South Africans to obtain herd immunity. So far, a 150 000 vaccinations had been rolled out. She asked if DoH thought the target of 16.6 million people could be reached. This was of particular concern as the winter months were approaching and there was talk of a third wave. When would the target of 16.6 million people be reached? If there were a third wave, was there a plan in place for provinces to deal with that third wave? She was particularly concerned about the baseline reductions for infrastructure.

Across the country hospitals were in a dire state and were dilapidated. Infrastructure was a real challenge and with the baseline reductions, what did DoH foresee about fixing the infrastructure problems. What were the implications for so many baseline reductions? Would there be retrenchments? Would posts be frozen? Would there be a backlog in the appointment of nurses and doctors as well as other staff? Can the Committee have an indication for the coming years of the impact? Another concern was were the provinces capacitated to deal with the additional funding for Communicable Diseases allocated to them? The Communicable Diseases subprogramme increased by R4 billion. Two provinces had a plan to roll out that programme but it was tied to the reduction of the Child, Youth and School Health Programme budget which had been reduced to R154.2 million.

There were concerns in 2020 about the reduction of the HPV vaccine programme within schools. However, there had been reports in the Northern Cape that some learners had received the first HPV vaccine but had then missed the second dose. Would the children receive the correct dosage? How would HIV and TB programme be impacted with the huge reduction in the school health programme? How would the school health programme be ramped up? In oncology, there was a huge concern about the backlogs in operations and treatments and the plans of provinces to catch up. There had been media reports about backlogs in the forensic chemistry labs and the impact on court cases. How would those be dealt with urgently?

The Deputy Minister responded to the questions on vaccines. The Director-General had noted that DoH would submit an amendment to the page on the vaccination programme in the APP because it stated 16.6 million. The target was to reach herd immunity by going up to 40 million in 2021/22 financial year, not in 2022/2023 as indicated. The expectation was that there was going to be a lot done before the end of March 2022, especially in the second quarter going forward. The procurement plans had already been signed although it was anticipated that problems would arise.

Ms Aneliswa Cele Acting DDG: Primary Health Care and Hospital, responded to the question on the decline in PHC services and how it affected services. DoH was already faced with allocation challenges as they were responding to the pandemic. Certain posts had to have contracts renewed but given the reduced allocation, they had not done so. They were trying to negotiate with National Treasury to see how they could be assisted when it came to PHC because the reduction would have a direct effect on service delivery. As a Department, they were closely monitoring the situation and were trying their level best to put a business case to Treasury because that would compromise service delivery.

Mr van der Merwe, CFO, spoke about infrastructure and equipment, he pointed out that the total reduction on the Infrastructure grant was R227 million of which R107 million was for the normal programmes. The reduction on equipment was R180 million and that was the one that would mostly affect the mega infrastructure projects especially the allocation to the Academic Hospital. They were working with the provinces in mitigating that and looking at funding arrangements and how they could assist with that. He would have to check the grant expenditure and update the Committee after the meeting. However, by the end of Quarter 3 in December 2020, they were sitting at 71.1% of expenditure but that excluded claims received for oncology from the provinces. They could foresee that the grant would be spent close to 100% by the end of the financial year.

DoH had come close to getting a clean audit every financial year. Its biggest issue was the changes to financials mainly due to technical opinions received from the Auditor General in the handling of infrastructure expenditure. They had significantly dealt with that in the past three previous financial years and they believed DoH had a system in place that would help mitigate that position. This was not to say that they were guaranteed a clean audit, because they were dealing with several audits simultaneously and that would put some pressure on their capacity.

On the baseline reductions to the infrastructure budget, the contractual agreements DoH had on the maintenance programme in provinces would continue. They could not postpone those contractual agreements since they had been signed. Stopping those would mean spending more on penalties. For programmes that had not started or those that were still at the conception stage or pre-tender stage, they would have to be put on hold until budget certainty was restored. That could not be prevented.

Health Department Technical Adviser, Dr Aquina Thulare, replied about what was learned from the Covid-19 pandemic for the NHI. One of the goals of the NHI was to move towards universal health coverage and it was premised on some principles of resilience, sustainability and equity. They learned that the system had demonstrated resilience and this had shown they were able to deal with health shocks that the health system was facing due to the pandemic. On equity, they looked at social determinants of health and how those had an impact on how people accessed health care services. Community engagement on health emergencies was important and community participation was mobilised around the response to Covid-19. DoH looked at ensuring that they invested in health to reduce fragmentation. It was important to have a unified health system if they were to respond effectively to situations such as Covid-19.

The other lesson learned was how services had been integrated. During the response to Covid-19, in the first wave, the public sector was able to refer some of its patients to the private sector. In the second wave, it was vice versa. The lesson learned from this was that to be able to respond to such health shocks, integration would be imperative. There was collaboration between the National Health Laboratory Service (NHLS) in the public sector and the private sector laboratories. When there was insufficient capacity in the public sector in the NHLS they were able to use private sector capacity to conduct tests and vice versa. Infrastructure collaboration and upgrades had taken place in the response to Covid-19.

DoH was able to provide more hospital beds either through field hospitals that were not permanent or increased hospital beds. They were able to acquire additional equipment improving hospital infrastructure such as our ventilators. There was improved oxygen reticulation in hospitals, even in district hospitals, as part of preparation for the future NHI dispensation. They standardised treatment guidelines and protocols between the private and the public sector so there was some form of uniformity. Deployment of human resources to areas of greatest need was looked into to service patients. Human resources were moved from one district to another as the need. DoH was able to work on policies that ease the burden of admissions into hospitals such as that related to alcohol. Some work on digitisation was conducted using the electronic health care record. The electronic vaccination data system formed the basis on which health registration was based. Going forward this would be done for other programmes for NHI. The procurement of vaccines through putting resources together to purchase vaccines for both the public and private sectors was in line with NHI goals. The goal was to ensure they coordinate procurement. Purchasing power economies of scale were used to ensure that they achieve equity goals to ensure that everyone was able to access based on their needs. Collaboration between the private and public sector was established in the distribution and administration of the vaccines as a key NHI goal.

The last lesson was the strengthening of primary health care approach principles knowing that the primary health care approach was the heartbeat of NHI. The DoH primary platform was used for some of the interventions, for example, using general practitioners to form the platform that they were going to use in future for vaccinations. They promoted key messages on wellness, healthy living as part of health promotion and disease prevention especially with the use of a non-pharmaceutical intervention. This was part of primary health care interventions. The strategy of community mobilisation was used to reduce the rate of transmission. It included a popular rise in the use of masks through community mobilisation to prevent the transmission of the infection. This had multi-sectoral participation including the involvement of unions and civil society in the attempt to control the epidemic. On the health patient registration platforms for medical schemes beneficiaries, DoH was working with the Council for Medical Schemes which was the regulator for medical schemes and they are consolidating the data so that it can be transported through the HPRS. There were a few problems around the Copyright Act where the schemes were reluctant to provide information. DoH was however working together with the CMS and their legal team so that they clarify the issues so schemes can provide the information required in the HPRS.

Dr Andrews replied that there had been an ongoing problem of case backlogs in the forensic chemistry labs. Needless to say that reducing these backlogs was not made easy by the Covid-19 pandemic because they had to stick to the stipulations of not overcrowding the labs and had to ensure they rotate staff. This in turn had a ripple effect which internally led to more backlogs. The labs were however doing their best to deal with it by having people work overtime. They were hoping that the backlogs could be reduced over time.

Mr Popo Maja, DoH Head of Communication, replied that the reason they were trying to integrate communication into the stream of corporate communication was that they wanted to move away from a situation where the programmes communicate their activities. They were trying to bring all activities under one roof so that they could communicate in an integrated manner. Part of the reason DoH wanted to amplify communication about non-communicable diseases (NCDs) was that many people had complained that the focus was more on HIV and other communicable diseases while neglecting communication on non-communicable diseases. DoH ensure that they communicated effectively on NCDs as they were becoming one of the major pandemics in the world. They intended to do this by the use of social media and community media to broadcast messages targeted at preventing NCDs such as hypertension, sugar diabetes and all other such preventable diseases. Most of these NCDs were quite preventable so they wanted to work with programmes to position and frame messages in such a way that the larger population was able to interact with those messages. The use of social media was becoming very big plus it was immediate and interactive. DoH was able to interact with large numbers of people on the management and prevention of NCDs.

Dr Anban Pillay, DoH Deputy Director General: Health Regulation and Compliance, replied to the questions on Covid-19. It was important to emphasise about the 150 000 vaccinations given to date that the pace of vaccinations at this stage was dictated by the requirements for the Johnson & Johnson Phase 3b clinical study. This meant that they could not have sites all over the country as they normally would in a mass rollout. This was the way the study was designed and so the pace was much slower than when they had a mass rollout. There would be a maximum of 500 000 doses of the vaccines coming from Johnson & Johnson as part of the study. However, they were anticipating that by the end of March 2021 they would receive delivery of the Pfizer vaccine. That vaccine would not be subject to the study conditions and it would be rolled out at a much faster pace. The Johnson & Johnson doses came through as part of the commercial procurement which would have probably been in April. In May they would be provided with significantly higher volumes and they would not be restricted. Therefore using 150 000 as an indicator of pace was an inaccurate indicator of pace simply because that clinical study would end shortly.

Thereafter they would go back to the usual way of rolling out vaccines where they would have sites across the public system, the private sector, pharmacies, GPs as well as mass vaccinations. This could only be done that as soon as the huge volumes of doses were received. On the question of the third wave, he assured members they were certainly planning for a potential third wave and knowing that during the Easter period it was a potential risk as well as moving into the colder months people tend to stay indoors more. In the previous week, they had a workshop with provincial colleagues to get them ready for a potential third wave. This was to make sure that all the potential systems were in place for that. They hope that a third wave would not happen but they needed to prepare for that in terms of various equipment, staffing, supplies, etc. All these were discussed and coordinated so that they could respond to the third wave. The third wave would only arise if people decided that they were not going to continue to adhere to the restrictions such as wearing masks, social distancing as well as sanitisation. The likelihood of a third wave would be reduced quite significantly if everyone was encouraged to follow the measures.

Dr Makaniya replied that the second dose of the HPV vaccine was not given to Northern Cape. The HPV vaccine was part of the overall programmes affected by the lockdown restrictions. These services, were disrupted in 2020 with the pandemic and subsequent school closure. The school health nurses had to be repurposed so they could assist in the screening and management of Covid 19 cases. School Health services were providing the HPV vaccine and it has restarted this year and routine school health services were going to resume. There was no dedicated health budget so the impact of budget cuts would only be seen in overall service once they resume. The campaign restarted in 2021 as an integral part of the catch-up plans. The biggest risk with budget cuts was that provinces would struggle to buy the necessary HPV vaccines. This was already the case in some of the provinces. DoH was however in the process of implementing catch-up plans as soon as the stock became available in the provinces that were able to provide the vaccination.

On HIV and other priority programmes, the impact of Covid-19 had been quite measurable and through their M&E mechanism, they noted a disruption in all three levels from prevention to initiation of treatment and retention of client service. This was the case across the HIV programme, TB Programme and, Maternal and Child Health services.

Based on these, they were able to develop the catch-up plans that prioritised the programmes that had been affected. The focus of the priority interventions was to accelerate case findings, particularly those that were lost during the peak of lockdown and movement restrictions. If they can do that they would then look into accelerating and maintaining all clients back to treatment through several interventions and optimising community-based outlets for medication particularly to ensure that patients were moved from mainstream health facilities to differentiated modes of care through the Central Chronic Medication Dispensing and Distribution (CCMDD) programme. In the APP they were sitting at about 2 million people that were able to continue with their treatment through the CCMDD. The new target of 4 million was cutting across all priority programmes particularly to ensure that clients were retained. Other measures of bringing back lost clients during the service disruption was the Cheka Impilo campaign driven by SANAC which would be the driving organisation in the implementation of some of the priority programmes, particularly HIV and TB. There was a big campaign targeting and tracing all clients that have missed their appointments so that they could be brought back to care. This was linked to the integrated district-based model where community health workers were playing a critical role in an integrated way to ensure there was continuity of service delivery by integrating all preventive programmes in the context of Covid 19 including tracing and checking of patients that have been lost.

The DoH M&E system informed them based on the monitoring of the HIV 90-90-90 Treatment Cascade, that in the overall performance in the previous financial year, there had been a glaring gap in that youth were missing at each level of intervention from prevention to initiation of treatment to loss of follow-up. Therefore they were looking at mechanisms and platforms where youth, both men and women, can be reached using a common social platform. The focus was to ensure they recovered those that had been lost completely. The performance of the HIV Treatment Cascade in the APP, given resource constraints, was to reprioritise but ensure they were using the systems in place. Service delivery models were in place to ensure that programmes were integrated at a local level so that all the systems that work across programmes were used to manage the various problems at a facility level.

Follow-up questions
Ms N Ndongeni (ANC) asked if National Cancer Registry was functioning and to provide details if there were challenges. She asked how had its mental health policy changed since the Esidimeni tragedy. DoH should provide a report on the implementation of the National Mental Health Policy Framework and Strategic Plan 2013-2020. Would they present the new policy to replace the outgoing one? What initiatives had DoH implemented in the fight against TB? How was DoH addressing TB drug resistance? How was DoH mitigating the impact of Covid 19 on TB services including testing, contact tracing and treatment?

Ms Christians asked if DoH was only going to get two vaccines – Johnson & Johnson and Pfizer. Are there any other vaccines on the horizon that South Africa would obtain? She asked if the timelines had been drafted already and did they have an end date envisioned for the 67% to be vaccinated?

The Chairperson asked if DoH had plans ready and had cooperation from all provincial departments of health for the 50 million vaccines that would be rolled out in the country.

Dr Pillay replied that currently they had entered into procurement agreements for the two vaccines: Johnson & Johnson and Pfizer. At this stage, those would be the vaccines rolling out unless procurement was extended to other vaccines. On the timelines, they would be finishing vaccinations for health care workers probably by mid-April to late April at the latest. They would complete the Johnson & Johnson vaccines allocated through the clinical study. The balance of the health care workers would be vaccinated with the Pfizer vaccine which they anticipated coming through at the end of March with around 600 000 doses. Further doses of the Pfizer vaccine would become available in April. They would be expecting that the Johnson & Johnson vaccine would be available in Phase 2. They would then start the Phase 2 rollout which would largely target the risk-prone populations such as the elderly, those with co-morbidity, those in congregate settings such as care homes, hostels, prisons, as well as workers working in high-risk areas. Phase 2 rollout would start in early May and continue until completion of that population group. They would then proceed to Phase 3 which would be for lower-risk adults. They could not vaccinate children because there was no data on whether the vaccine would be effective in children. They would therefore only vaccinate everybody over the age of 18. In terms of plans, the provinces had already prepared plans to roll out the AstraZeneca two-dose vaccine. These plans would need to be amended given that the J&J vaccine and Pfizer vaccine are a single dose vaccine.

There would be some challenges in that the one vaccine would be a two-dose vaccine while the other would be a single dose vaccine. The Pfizer vaccine would need to be stored at -70C. Those complexities would pose some challenges to provinces but NDoH would work very closely with their provincial colleagues trying to get them ready and support them in any way in the rollout of these vaccines. The private sector was working very closely with them through the National Vaccine Coordinating Committee (NVCC) which the Director General chaired. It had representation from the private sector, National Departments and all the provincial departments. They would plan the rollout strategy in that meeting and how to address the challenges. At this stage, they were getting confirmation from all provincial colleagues but they did not anticipate problems. However if they arise, they would take quick steps to address them.

Ms Cele replied about the question on oncology and the cancer registry. They had serious challenges with oncology however as a Department they were constantly in engagement with the Oncology Advisory Committee to the Minister. They were working closely. The Advisory Committee was monitoring the ground in terms of DoH services. DoH was managing the oncology backlogs through the use of NHI Grant and they had made up the backlog through the engagement of private oncology services and doctors. DoH was able make service level agreements with them and they would assist DoH in managing all the backlogs. The Gauteng Department of Health had been facing serious challenges – even in terms of reporting. An Oncology Head of Department had now been appointed. The hope was that there would be drastic improvement in the management of oncology in the Gauteng province. However it was worth indicating that they were still working very closely with the Minister’s Advisory Committee. This Committee was their eyes and ears in monitoring the situation and they gave DoH data including where the challenges are. They were able to pick these up and alert DoH. This was to ensure DoH did not compromise service delivery. The Committee had raised the point that DoH could not have other sectors suffer when it shifted its concentration onto Covid-19.

Dr Andrews added that the Cancer Registry was functional and people were reporting into the system, it was only that there were often challenges.

Dr Makaniya, National Department of Health, replied about the development TB management catch-up plan to address continuity of services that had been lost in the context of the impact of Covid-19. They had prioritised targeted screening particularly for men between the ages of 15 and 24...(lost connection)…to strengthen the contribution of the intervention that was done at the district level by civil society organisations and these activities have a stipend allocation. (lost connection) …There were targeted case findings in high TB communities using test xrays and symptom screening, triaging people eligible for testing using genespec and targeted universal testing irrespective of symptoms of high-risk groups, particularly people living with HIV. During household contacts done by community health workers, people that had been lost to treatment were identified and linked back to care.

DoH was linking all TB and HIV patients to the Khet'Impilo initiative. It used promotional messages through the mHealth app which provided an effective digital risk assessment and mapping tool allowing for TB early detection, mapping and management. They had integrated TB and Covid 19 at screening level and testing in the public and private sector, including workplaces. They were piloting private general practitioners in their role of engagement in assisting in TB case finding with specific regard to treatment efforts around the piloting of digital health solutions. The attempt was to accelerate linkages to treatment and treatment adherence. DoH adopted the Covid-19 digital health solution to include TB and the major key elements in promoting treatment in differentiated models of dispensing medication using community-based facilities. The last component in the TB programme was the overall health system and strengthening where they were enhancing monitoring and evaluation using an integrated TB real time surveillance system. They conducted geospatial modeling to be able to identify transmission hotspots and pilot social and behavioral change communication strategies to deal with stigma mitigation and piloting the provision of incentives to the service provider at the facility level. They were there to respond to the overall TB.

Multidrug-resistance (MDR) TB was managed by decentralised treatment at the community level and there had been an introduction of newer and shorter treatment regimens which excluded injections. There had been strengthening of surveillance to identify risk at an early age and deal with it. They provided psychosocial support which included grants earmarked for qualifying patients infected with MDR TB. They had strengthened lab testing for second-line treatment to identify pre-XDR and extensively drug resistant (XDR) TB early so that they could be treated appropriately. This resulted in increased treatment success for XDR from 15% to 60%. Deaths were still high despite these interventions.

Dr Andrews answered on the mental health question that in the APP there were several new indicators on mental health. The APP had targets for improving the quality and safety of care specifically for patients with mental illness. One of the indicators was the number of medical officers and professional nurses trained to improve their skills in the clinical management of mental disorders so DoH is not over-reliant on psychiatric hospitals. These doctors and nurses would work in facilities or units that had been accredited to conduct 72 hour assessments in addition to the psychiatric unit attached to general hospitals. It is largely through skills development and training of nurses and doctors. Dr Makaniya was doing work through the nursing programme to ensure that they could train more nurses in the specialist psychiatric nursing course who could then register as specialist psychiatric nurses. In rural areas this would provide care with the rotating psychiatrist who would come very occasionally. She was not up-to-date on whether they had a new strategy for mental health but DoH would send a brief progress report.

The Chairperson if Dr Pillay could outline the Phase 2 registration process and how it would be handled, especially for people in rural areas.

As Dr Pillay's network connection was lost, the Chairperson asked that DoH later update the Committee on the Phase 2 registration process. 

The meeting was adjourned.

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