Western Cape Appropriation Bill: Vote 6: Health

Health (WCPP)

17 March 2021
Chairperson: Ms W Philander (DA)
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Meeting Summary

Video: Standing Committee on Health, 17 March 2021, 08:00

In a virtual meeting, the Western Cape Department of Health briefed the Standing Committee on Health on its Third Adjustment appropriation and 2021 Vote Six allocation.

The Department said there was an increase of 0.43% to the budget. The lion’s share went to the district health services, while a smaller amount has gone to the provincial hospitals services. A significant amount of the budget went to the compensation of employees, and another significant amount went to goods and services. The initial budget for the Brackengate Hospital of Hope needed to continue for the remainder of the financial year.

The idea behind the allocation is to fund Covid-19 activities related to staff and facilities. This includes personal protective equipment (PPE), and field hospitals. Allocated funds are earmarked for equitable share. The bulk of the budget would go to programmes two, four, and five. The total earmarked allocation amounts to R2.144 billion.

The Western Cape Health Department was funded with R832 million to continue its fight against the Covid-19 pandemic. It was also funded with R306 million to assist with implementation of the vaccine programme during 2021/22 financial year. The Department’s expenses for medical equipment and certain medical consumables are subject to changes in the rate of exchange. On average the South African Rand devalued by approximately 14 percent against some of the most prominent currencies in 2020. The population of the Western Cape is growing and the demand for services is growing by about two percent per annum.

The Department said the Covid-19 pandemic has had a profound impact on the demand for health care, and how the Department delivers health services. The Department needs to minimise the risk of virus transmission to protect both users of the service and its employees.

In the coming year, the Department is embarking on the largest vaccination programme in the history of the country, with 5.1 million people needing to be vaccinated in the Western Cape alone. The Province is also most likely to face a third and possible fourth wave of the pandemic. This, coupled with the existing quadruple burden of disease, is going to place significant strain on the health system in the coming year.

Members wanted to know if there is a timeline for the existence of the Brackengate and Sonstraal facilities; if it is properly equipped, considering the third surge is on its way; wanted to find out what other innovations the Department would introduce so as to avoid making its service inferior; asked if there were any interventions in place considering the decrease in conditional grants; wanted to find out what the risks are given there are no salary adjustments; asked if the Covid-19 allocation budget includes testing capacity; wanted to understand if the R1.1bn provided for infrastructure is in line with upgrading the capacity of clinics and day hospitals, especially in rural areas; wanted clarity on the decrease of allocation in the maintenance of HIV/Aids; asked if the home delivery of chronic medication is outsourced, and the details of the suppliers; and wanted to establish if the medical depot has enough capacity to administer the vaccine rollout, and why its budget has been decreased.

The Committee resolved the Department should send a report on infrastructure; and a report on the Mobile Medication Distribution Plan and Strategy, for the rollout in the Western Cape.

Meeting report

Briefing by the Western Cape Department of Health

Dr Keith Cloete, Head of Western Cape Department of Health (WCDH), told the Committee the third adjustment budget for 2021 is testimony to the unusual year the Department has been through. There has been extreme disruption while the Department had to deliver a service. The Department recorded a clean audit during the year. The finance unit had to keep afloat of what was to be spent during this time, and had to make adjustments to spend wisely during the pandemic.

Mr Simon Kaye, Chief Financial Officer (CFO); WCDH, reported there has been an increase of 0.43% to the budget. The lion’s share went to the district health services, while a smaller amount has gone to the provincial hospitals services. A significant amount of the budget went to compensation of employees, and another significant amount went to goods and services. The initial budget for the Brackengate Hospital of Hope needed to continue for the remainder of the financial year.

Money was allocated to fund Covid-19 activities which are related to staff and facilities, including personal protective equipment (PPE), and field hospitals. Allocated funds are earmarked for equitable share. The bulk of the budget would go to programmes two, four, and five. The total earmarked allocation is in the amount of R2.144 billion, and would be disbursed in the following manner:

  • Infrastructure (R1.1 billion)
  • Covid-19 response (R832 million)
  • Vaccination Programme (R150 million)
  • Home delivery of chronic medication (R33 million)
  • Staff Wellness (R5 million)

In fulfilling its constitutional mandate to progressively realise the right to health care, the Department is committed to ensuring the provincial health system delivers high quality care to all people of the Province.

This includes preventative, promotional, curative, rehabilitative, and palliative care services, which are provided across 591 service points which consist of 467 primary health care service points, 53 hospitals, and 49 Emergency Medical Services (EMS) stations. There are 33 district, five regional, two central, one tertiary and 12 specialised hospitals. The Department also provides EMS from 49 EMS stations, and has 16 forensic pathology facilities.

The budget was divided between the programmes and facilities using the following principles and assumptions:

  • no provision for salary adjustments was made, except for pay progression (0.4 percent), housing allowance (4.2 percent), and medical aid (6.2 percent).
  • inflation of 3.3 per cent was provided for on most non-clinical goods and services, while inflation of 5.3 percent was provided for on clinical goods and services.
  • no allowance was made for new facilities, increased services, or increased patient numbers, other than the expansion of capacity of the Observatory Forensic Services Facility.
  • inflation of 3.3 percent was provided on finance leases. A fixed budget in respect of machinery and equipment was allocated to specific facilities/entities

National Treasury reduced the National Tertiary Services Grant by R154 million from the 2020/21 main appropriation, and the Human Resources and Training Grant by R85 million, from the 2021/21 main appropriation. This is going to have a significant impact on service delivery of health institutions dependent on these grants. Due to the uncertainty the Covid19 pandemic created around revenue generation and its collection, the own revenue allocation has also been reduced for 2021/22.

The Western Cape Health Department has been funded R832 million for its continued fight against the pandemic, as well as R306 million to assist with implementation of the vaccine programme during 2021/22 financial year. The Department’s expenses for medical equipment and certain medical consumables are subject to changes in the rate of exchange. On average the South African Rand devalued by approximately 14 per cent against some of the most prominent currencies in 2020. The population of the Western Cape is growing, and the demand for services is growing by about two percent per annum.

The Covid19 pandemic has had a profound impact on the demand for health care and how health services are delivered. The Department must minimise the risk of virus transmission to protect both users of the service and its employees. In the coming year, the Department would be embarking on the largest vaccination programme in the history of the country, with 5.1 million people needing to be vaccinated in the Western Cape alone. The Province is also most likely to face a third and possible fourth wave of the pandemic, and this coupled with the existing quadruple burden of disease is going to place significant strain on the health system in the coming year.

(For full presentation, see attached document)

Discussion

Mr R Mackenzie (DA) wanted to know if there is a timeline for the existence of the Brackengate and Sonstraal facilities, and if these are properly equipped, seeing the third surge is on its way.

Mr Kaye said the two facilities have been funded for another year. The Province has signed a lease agreement with Brackengate for the current financial year. There is also a fairly substantial investment from a provincial perspective when looking at the third and fourth wave, including the vaccination process.

Western Cape Provincial Minister of Health, Dr Nomafrench Mbombo, made it clear the Western Cape Department of Health has appropriated a budget amounting to R27.391 billion for the 2021/22 financial period. For the first time there has been a decrease in the budget since she took over as the Minister six years ago. The major blow is in the conditional grants. It decreased significantly, but the Provincial Treasury has come to the rescue. The Budget is coming at a time where the Department had challenges regarding many pre-covid diseases. The situation gets worse when you add a layer of Covid onto diseases which have not taken a back seat. Trauma and domestic violence decreased during lockdown, but since the Province opened up, trauma and domestic violence increased again. The roll-out of vaccination is very low at the moment. The uncertainty regarding the third wave and when to get vaccines has had a negative impact on non-Covid activities such as tuberculosis (TB), HIV, and so forth. The major challenge is on healthcare workers.

In the next Medium Term Expenditure Framework (MTEF), the budget is going to decrease further because the country is facing so many socio-economic challenges. There is no provision for building new clinics, and such. The Department has been trying to be innovative by escalating the delivery of chronic medication which has to go out to people, and has escalated services related to mental health.

Dr Cloete said Covid-19 has reset the world and health care system everywhere. Many people have been affected by Covid. In the Western Cape 11 500 people lost their lives due to Covid. The Department and society have grieved collectively. Covid-19 has taught us many things about ourselves. Putting up a hospital of Hope at Cape Town International Convention Centre (CTICC) and Mitchell’s Plain is testimony to what can be achieved with the system, how to work together, and value relations with people outside the Department.

Covid is not finished. The third and fourth wave is coming. The Department needs to vaccinate 30 000 people in the Province every day. Vaccination needs to be escalated. Non-Covid care in diseases such as TB, HIV, and mental care had to be deferred, but these came back escalated. The Department needs to redesign what it does and how to engage with its stakeholders so there can be mitigation. The Budget is calling on everyone to be resilient and work together.

Mr Mackenzie wanted to find out if the communication strategy of the Department includes issuing masks and sanitisers to churches, seeing the Easter weekend is coming.

Minister Mbombo said Covid would remain with the Province until 70% of the population is vaccinated. Healthcare workers are being vaccinated. Most people are still at high risk of being infected. So, it is still important to wear masks, keep the social distance, sanitise, and avoid big gatherings. The message has not changed. Those who are able to donate masks are encouraged to do so, to old-age homes and those people who are vulnerable. The Department cannot buy masks for everyone because it has to reprioritise its budget and buy medication. The Minister urged the public to continue to help and protect the vulnerable.

Mr Cloete said the campaign is being launched currently. Messages hitting the media are going to be heard or seen soon, and the Minister would be engaging religious leaders in the province.

Ms L Botha (DA) wanted to find out what other innovations the Department would introduce, so as to avoid making its service inferior.

Mr Kaye said the Department has got to be innovative to be able to continue to render the service it is required to, within the shrinking fiscus. The Department has time to transform the service and to deliver the service at the same time. The Department would continue to invest in district health services. Even though there is a decrease of expenditure in health science and training, the lion’s share of the budget would continue to go to goods and services, and compensation of employees.

Ms R Windvogel (ANC) asked if there were any interventions in place, seeing there is a decrease in conditional grants.

Mr Kaye said the Department has not yet finished the current year. It is still spending against the conditional grants. The Department would respond to the question when it has to account for the 2021/22 budget for conditional grant allocation. The Department has got to provide services to 75% of the population, which amounts to seven million people. It is the Department’s constitutional mandate to realise the right to health and to ensure it delivers the right service to the Province.

Ms Windvogel asked for clarity on the Covid-19 allocation of R832 million; she wanted to know if the Province has enough PPE; asked for a detailed update on the procurement process, Broad Based Black Economic Empowerment (BBBEE); and details of the team working on the vaccine procurement. She wanted to understand why there is no allowance for new facilities or rebuilding the Jooste Hospital, seeing there is growth in the population.

Minister Mbombo said at this stage there is no confirmation of approval of any vaccine, except Johnson & Johnson. Once a vaccine is approved, the Department would be able to procure it. The Province is putting things in place, so it is able to procure when the time is right. The procurement of the vaccine is the responsibility of the Department, taking into account the new variants which might come into play. The processes of procurement are in place, and the procurement team is the same. The allocated R832 million was for the overall Covid-19 response. It is a whole package, taking into consideration the third wave. The Department might not be able to pursue new facilities, but those planned, would continue to be completed. The Budget for infrastructure has been itemised. In this MTEF, the health sector budget is decreasing, and with decreasing budgets the Department has to stop dreaming big.

Mr Kaye said the Department has been given R100 million for population growth and innovation. Over the MTEF, the Fund would be for chronic medication and distribution. It is cheaper to take medication to the person rather than for the person to come to the facility and wait to be served. Those are the kinds of innovations which need to happen. The future of health service is around the use of technology. This is where investments are happening. The R832 million would cover testing and surveillance, PPE, sustaining hospital platform, Brackengate hospital, Sonstraal hospital, and the rest would be allocated across the platforms for staff retention and additions.

Ms N Bakubaku-Vos (ANC) wanted to find out what the risks are, as there are no salary adjustments. She asked if the Covid-19 allocation budget includes the testing capacity.

Minister Mbombo said testing is the competence of the national Health Department. Testing is about resources and scientific evidence. When the infection rate is high, one has to reprioritise resources, taking into account high risk people, instead of testing people who want to know their status yet are not showing any signs of Covid-19. Unions have been negotiating with the national government on wage increases. The Finance Minister said the country was not in a position to afford automatic increases. Money had to be ringfenced. What happens at national level has an impact on the provinces.

Dr Cloete said there would be no increases for salaries. This is indicated in the Department’s budget. If it must be implemented, the matter would have to be discussed with national Treasury. The Department would continue to engage with organised labour. On Covid testing, he said the pandemic has waves. When it peaks, the Department must decide how to use its limited capacity. It depends on the level of the peak. Young and old are now free to get tested because the peak is low.

Mr M Xego (EFF) wanted to understand if the R1.1 billion provided for infrastructure is in line with upgrading the capacity of clinics and day hospitals, especially in rural areas. He also wanted clarity on the decrease of allocation in the maintenance of HIV/Aids.

Minister Mbombo said the HIV Grant comes from the national Department. It also caters for TB, Human Papillomavirus (HPV), Covid-19, and mental health. It’s a whole package.

Dr Cloete said money has been budgeted for Sonstral and Belhar/Tygerberg. These institutions would be upgraded during the year, including other facilities in both urban and rural areas.

Mr Mackenzie wanted to know what the impact would be and risks involved, seeing there has been a decrease in health training and development.

Dr Cloete said the money has been allocated to warm bodies like registrars and specialists, and the matter would be discussed with the national Department and Treasury. No specialists and registrars have been taken out of training. The Department has compensated for the decrease by providing additional resources to prevent it from losing specialists in training, or any staff member.

Mr Kaye said the Western Cape is providing training for much more than just the province. The Western Cape is the national centre of training and this is why it is funded, because conditional grants are a national mandate for the benefit of the country as a whole. This is why the Provincial Department was planning to have a direct conversation with the national Director-General regarding the impact this would have on the country’s inability to train. A separate component, being statutory posts, is also included. These are medical interns. There has been significant pressure which came into the whole country because of the returning Cuban students. The Province has not been able to absorb additional students because of the funding envelope it has. Its main goal is to ensure it matches the number of people it is training with the amount of money it is ultimately getting.

The Chairperson wanted to know what role the Department is playing in procurement, seeing it has procured additional vacancies amounting to R75 million.

Mr Kaye said the calculated R75 million is for equitable share vaccine. The Department is unable to get into any agreement for procurement without a budget. The budget has been provided, should an opportunity arise, for the supplier to deal with the national government. This money is also for funding the compensation element. The Department has already trained 2000 vaccinators, and will train more. Money will be allocated to administrator per vaccinator, to make the system efficient.

Ms A Bans (ANC) asked if the home delivery of chronic medication is outsourced, and asked for the details of the suppliers.

Dr Cloete said the programme has been run as an external resource. It was funded externally. The Department is providing internal funding to it, to institutionalise the system. There are three to four options of what the Department would do.

Mr Mackenzie wanted to find out about the communication strategy which would be used to inform people about the service delivery of chronic medication.

Mr Kaye said the delivery of chronic medication would go out to tender. It did not cost the fiscus any money. It has been done in the metro area. A team based in rural areas is interested in being involved. The Department is going to map out its involvement. From there, the communication strategy would state how the service would be delivered.

Dr Cloete said the delivery of chronic medication is an innovation which has been implemented throughout the Province. It delivered 1.3 million parcels to people’s homes by means of an external donation in the metro. The external donation is going to come to an end, and this new money is about to enter the tendering process. Specifications would be spelt out to cover both urban and rural areas, and it will also show how this would be supervised by the Department. There is a distinction between what the Department wants to put out on tender, how the service provider is going to service the Department, and how the Department is going to monitor quality service. The Department is busy starting the process. For instance, in rural areas such as Hessequa, the pharmacy packs its own medicine parcels, and the GG registered cars deliver the parcels to people’s homes. The people there did not wait for the programme to come from the province or metro. These practices are already happening, and the Department is speaking about money for the external tender, and will award it accordingly.

Mr Mackenzie appreciated what people in small towns are doing. He hoped the Department would make use of smaller service providers operating in these communities for such innovations.

Ms Windvogel said Jooste Hospital has been in the planning for years. The government is speaking about taking service to the people, yet people continue to travel long distances to get the service. She asked for clarity on this matter and asked about the concept of ‘danger pay’.

Dr Cloete said the Klipfontein Regional Hospital is about to be rebuilt. The Department is at a stage where plans are being put together to start the rebuilding process. Though this has taken time, money has been put into ‘Planning’, to accelerate the delivery of the infrastructure for the Klipfontein Regional Hospital. He said ‘danger-pay’ is a national chamber determined condition. The Province does not have the powers to separately negotiate ‘danger-pay’ for people outside a national chamber negotiated process. When the Province says there is no money made available for salary increases, it is on the basis there would be no salary increases. When the Province says there is no money made available for ‘danger pay’, it is on the basis it has not been signed off in national chamber process. If there is a salary increase or ‘danger-pay’, it has to be nationally negotiated. The national Treasury must make provision for it. The current Budget does not make provision for salary increases and ‘danger-pay.’

Ms Bans wanted to establish if the medical depot has enough capacity to administer the vaccine rollout, and why its budget has been decreased.

Mr Kaye said the Department has moved non-pharmaceuticals like PPEs out of the pharmaceutical depot to the warehouse, which is under the control of supply chain.

Dr Cloete said the depot has sufficient capacity for vaccines. Every year child and flu vaccinations are given. The Cape Medical Depot (CMD) has the capacity to store and distribute vaccines. Where the complication comes in, is if the vaccine has different cold storage requirements. The CMD has negotiated with Stellenbosch University, which has storage facilities which can store vaccines at minus 70 degrees. That storage facility is in place. The process of relocating the CMD would be sped up during the year and there would be exact timeframes for this.

Ms Windvogel wanted to establish if the Department has enough capacity to render forensic pathology services.

Dr Cloete said the forensic pathology capacity has been under strain over the last few years. The pressure has been felt significantly in both Metro East and West. Metro West has the Salt River mortuary, while Metro East has the Tygerberg mortuary. In both instances, the Department is bringing capacity relief. Progress in the Salt River mortuary entails the establishment of the forensic pathology facility. The building is nearing completion. In Tygerberg there are smaller projects to increase capacity to store bodies, and manage the pressures at the Tygerberg institute.

Ms Bans wanted to know the total cost of the eight projects to be constructed in the hand-over stage.

Dr Laura Angeletti Du Toit; Chief Director: Infrastructure and Technical Management, Western Cape Department of Health said it was unfair for her to give full costs on such short notice. The forensic pathology projects are going to be finished towards the end of April 2021. The pathology centre in Victoria Hospital was very busy during the second wave. Some projects in Tygerberg would be completed at the end of March 2021. Details of separate costing would be forwarded to the Committee in a different memo.

Ms Kievet, a member of the public, wanted to find out if the Staff Wellness Programme was in a tender process, or focusing on frontline staff only. It has been discovered, those affected by Covid were not really looked after.

Dr Cloete told the Committee the Wellness Programme is aimed at all the staff components, including the support staff in the facilities. It is a metropolitan contract concluded by the Department of the Premier as a transversal contract for all the Western Cape government departments. The Health Department is the biggest user of this contract. R5 million has been allocated to this, including healing and grieving for all staff members. This Programme is being taken seriously and the Department works closely with organised labour on it.

Mr Kaye said the Department intentionally looked at the culture of the organisation where it creates spaces, and where it can connect with each other beyond the formal spaces. There were lots of daily hurdles and the Department focused on giving people the space to focus on humanity. This is part of the wellness journey which goes beyond the frontline, and it extends to families too. The key focus is on staff safety. The Department has done this in partnership with organised labour, where it invested a lot in relational power.

Minister Mbombo made it clear in her closing remarks, this year is one of the years where the public purse is shrinking, but one thing is guaranteed, and this is quality service. The health system has systems it needs to strengthen to deliver the services. First, leadership and governance have been provided. It is a team which has been exposed to lots of challenges. It is resilient. It brings matters of the heart to the workplace because the budget is about people.

Secondly, human resources underwent many challenges. Families of staff were affected by the pandemic. Human resources officials were stigmatised.

Thirdly, the information system has been strengthened. It has won awards against the private sector. It has mastered the dashboard.

Fourthly, the finance department received a clean audit, even for Covid related procurement matters.

Fifth, the Department has a plan to support and supplement the national plan, regarding the availability of medicine. This is another system to deliver the system package which needs to be delivered. Because of Covid, the Department had to reprioritise the budget, while making sure it attends to non-Covid cases as well.

Lastly, people come first in the Western Cape. The voice of the patient still matters. The Province prioritises people, but Covid has made it difficult to engage all stakeholders. The Budget is about people, and the Department has never taken a break because its concern is the people. It had to show the way and lead.

Committee Resolutions

The Committee resolved the Department should send a report on infrastructure; and a report on the Mobile Medication Distribution Plan and Strategy, for the rollout in the Western Cape.

Draft Committee Report on Budget Vote 6

The Chairperson took the Members through the document, page by page.

The report was adopted.

The ANC and EFF did not support the vote.

The meeting was adjourned 

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