Eastern Cape, Free State and Northern Cape Budgets: briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
18 April 2000
BUDGET BRIEFINGS BY PROVINCIAL DELEGATIONS FROM THE EASTERN CAPE, THE FREE STATE AND THE NORTHERN CAPE

Documents handed out:
Free State Budget Presentation
Northern Cape Budget Presentation
Eastern Cape Budget Presentation
Report on the provincial health budget

SUMMARY
Three presentations were made on the state of healthcare and the breakdown of the respective budgets for each of the Departments of Health of the Eastern Cape, the Free State and the Northern Cape. The Eastern Cape had overspent on its budget by R571m and some concern was expressed over this by members of the committee. The Eastern Cape Health Department was experiencing managerial problems but a large number of projects had been completed and were underway. The Free State had remained within its budget but had not been able to undertake any significant capital projects.

The Northern Cape Province is working within the strategic framework of the Bill of Rights, the National Sectoral Strategic Framework and the White Paper on the Transformation of the Health Services. Their one-year plan is targeted at certain policy areas such as primary health care, trauma victims, HIV/AIDS and tuberculosis. The province has aligned their budget with policy. They face the challenge of having to be more output orientated and to develop a revenue retention policy which will ensure greater revenue creation.

MINUTES
Eastern Cape
Dr S Stamper, the Head of Department, said the department had been battling to reprioritise its programmes but had finalised the following priorities: As the first priority, was the District Health Service Programme, which was essentially the vehicle for public health service delivery. The second priority was the Specialised Hospitals Programme and the third priority, the Administration Programme.

Mr P Peppeta, the Director of Financial Management Services, said that they had produced documents showing the financial reports for the years from 1996/97 to 1999/00. He apologised for not having the 1995/96-year; it had already been archived. The province's budget was broken down into seven programmes. For the year just ended, their total allocation was R2.87bn and their projected total expenditure was R3.4bn. The expenditure was a projected figure because not all transactions for March had been concluded yet. The result was an overspending of R571m, but this was not cause for alarm. A large part (R420m) of the R571m was due to rank promotions and a further portion (R87m) was covered by a grant for the improvement of conditions of service of personnel, leaving a net overspending of just R64m.

With regard to revenue collection, the department had been set a target in 1995/96 of collecting R75m, which they believed at the time to be too high. A factor working against the collection of revenues was competition from the private sector. Their actual total revenue collection for that year was R39m. In 1996/97 it was R32m, in 1997/98 - R33m, in 1998/99 - R30m and for 1999/00 it was R29m. The total revenue figures included hospital fees as well as statutory fees, such as board and lodging in the department's institutions, and some incidental sales. From these total collections, all non-statutory funds went straight to the Paymaster-General's fund.

Mr Ngoma, acting director of personnel, said it was not fair to begin charging fees to rural people for hospital services. It was worth noting that tariffs had been rationalised and that these rationalised tariffs had been introduced for those that were able to pay. Ensuring overall revenue retention (i.e. that all funds collected in their institutions remain in those institutions) was an important issue they faced.

The targets for revenue collections had remained constant at R75m until 1999/00 when it was reduced to R52m, which however was still not reachable. For the coming year it had again been reduced, this time to R32m and this was a reachable target. If funds were collected over and above the target, it was hoped that would be to the benefit of the department and not count against them.

Dr Stamper addressed the overspending by the department, repeating that the very large overspend of R571m was due to the pressures of rank promotions. These pressures did impact negatively on the amounts available for service delivery. It was a great relief that extra funds had been made available for the entire province and, after all that had been taken into account, the overspend was just R64m. The department was aware that this was not a negligible figure.

The department needed proper managerial processes in order to ensure revenue collection did not perpetuate inequities and they eagerly awaited the implementation of proper procedures. Also hampering better revenue collections was a lack of adequate technology, specifically better computerised billing systems. The department was busy addressing this issue. The department was also trying to work out mechanisms for collecting revenues in conjunction with the private sector, to address such issues as patients hiding their medical aid membership to avoid payment. One last issue that the department was aware of, was the existence of extra capacity in hospitals in Port Elizabeth and East London, which they had to make better use of.

Mr Ngoma continued, addressing the issue of human resources. He indicated they had an overall human resources plan and there were efforts underway to improve their human resources management. The department was currently operating with a limited team but efforts were afoot to fill those critical posts that were vacant. They also had a training report for the previous year, which indicated the efforts that had taken place in order to build capacity with respect to operational management. The overall list of what training had taken place was long indeed. The department had experienced some difficulties at the top management level, as they should have three deputy directors and currently only had one. They had advertised the two posts and were busy filling them. One of their main conclusions in how to improve their overall levels of service, was the necessity of stabilising their leadership.

Ms J Matebese, the Acting District Health Services Manager, said the District Health Service (DHS) was the vehicle for primary health services and in order to contribute effectively to communities, this had to be seen as the department's main priority. 21 Districts had been developed but, unfortunately the department had been unable to fill the management posts for all these districts. This was currently being sorted out. The district demarcation process was currently underway and this would result in the realignment of districts in line with other departments' (such as Education) district demarcations.

The devolution of health services was currently underway and the metro areas were being used as the pilots for this plan. It was decided that if they could not deliver services under this model it would be extremely difficult for the District Health Services to deliver where the metro areas had failed. The department was currently busy with the redistribution of the use of assets to where it was most needed and they had established a committee, the Eastern Cape District Health Systems Task Team, to do this.

In terms of areas of health care, the department had established their specific priorities as follows: (1) HIV/AIDS, including other sexually transmitted diseases (STD's), (2) Tuberculosis (TB) and (3) Mother and child healthcare. The department wanted to increase its efforts in a number of areas including health education, home-based care and others.

In addressing AIDS care, the department had set itself the target of 80% of all nurses trained in the syndromic care of AIDS. Thus far they had achieved 70%. They had completed an integrated plan for addressing AIDS in conjunction with the Departments of Education and Welfare and this would ensure the necessary political commitment at the top leve,l all the way down to the local government level. Under this plan, each department would have to allocate funds from its own budget towards addressing AIDS.

Plans for the distribution of condoms were well underway, with a great number of condoms having already been distributed. Requirements for trade unions to develop their own plans to target AIDS had also been put in place. The province currently had six hospices in operation and seven centres for home-based care. New models of home-based care were being developed and these would run as pilots during the current year in one of the rural districts. Two resources for AIDS training (one in Umtata and one in Mount Ayliff) had been established. Young people were being trained in condom use negotiation and awareness was being promoted through radio station programmes, NGO's and community centres organisations. The department had also chosen as representatives, two HIV positive people, in order to put a human face on AIDS.

Hospitals had been tasked with the implementation of the patients rights charter. Also, the department had put together the primary healthcare package, which commissioned the provision of primary healthcare in all areas. An increased level of 24-hour cover had also been put forward as a requirement and, in this respect, the number of centres offering 24-hour care had been increased. The provision of primary healthcare had been looked at, at all levels but had not been successfully implemented in all areas due to the lack of roads, amongst other things.

With respect to TB, the figures for those suffering from the disease were rising. In 1996, it was 25000 and in 1999, it was 39000. One reason for this was the improved notification process and another reason was the relation of the disease to AIDS. The department had to achieve certain goals in their smear conversion rate as well as in their cure rate. Significant increases in the cure rate had already been achieved with 1998 showing a 45% cure rate and 1999, a 78% cure rate.

With respect to the department's third area of priority, the goal was to improve the quality of care in women and children's health. A number of facilities had been selected as suitable centres where terminations of pregnancy (TOP's) would be carried out. The number of such facilities had increased from 1997 to the present year with one or two additional facilities being made available each year. The previous year's statistics on TOP's were the following: 1054 had been carried out on women under the age of eighteen years while 8305 had been carried out on women over the age of eighteen. 6725 had been carried out on foetuses below the age of twelve weeks while 2634 had been carried out on foetuses above that age.

Cervical cancer was the most common form of cancer in women and pap smears were the most effective means of screening for this. It had been established that the screening interval should be set at three screenings every ten years. With respect to breast cancer, instruction had been given to women on how to recognise the early signs of breast cancer themselves. Some of the most common problems affecting this overall area of healthcare were that the facilities were often far from the communities concerned and that there was often inadequate equipment at the facilities. In this regard it was worth noting though, that since 1994, approximately 122 clinics had been built and 14 community health centres had been completed or were close to being completed.

Mr Ngoma addressed the capital works programme, indicating that there were eight projects for new facilities underway, with one having already been completed. Also, there were six upgrade projects underway, with two having been completed. The one major project that they had underway, was the Nelson Mandela Academic Hospital in Umtata. Water sanitation projects were under construction in rural areas and much had been accomplished in the nine projects in building up doctor's accommodation. The security at most hospitals had been significantly upgraded and for those facilities in rural areas, almost all had been electrified.

Dr Stamper continued by saying that with regard to foreign doctors in the Eastern Cape, they were all employed on a standard contract, most being from Cuba but a few were from the European Union. Some foreign doctors had been providing a heroic service in some of the poorest rural areas. Were it not for these foreign doctors, there would be no hospital services at all in some areas. These doctors had been crying out for improvements in their conditions of service and this issue was being addressed. Additionally, part of the allocation for clinics was going towards an incentive package for foreign doctors and nurses.

With respect to their drug policy, the Eastern Cape followed the national government's lead from where most drug policies were driven. The essential drug list programme had been successfully implemented although there was still a serious problem of drug availability in some rural areas. The problem was a management one at the depot level and the distribution level. It had been decided that this entire package was to be outsourced though and this was being looked at. On the whole, some improvements had been made but at some points, there was still much to do.

Discussion
Ms M Njobe (ANC) asked a number of questions as follows:
With regard to the R571m over-expenditure, was it envisaged that at some point in the foreseeable future, the department would be able to spend within its budget, noting that the previous MEC had complained that they had been under-budgeted?
With regard to the collection of revenue, some hospitals had not collected any revenue at all and the total amount collected was as low as half of the target set out. In this regard, were there any programmes whereby customers could be educated in the payment for health services?
With regard to HIV/AIDS, there were women trying to form NGO's to address AIDS issues but who had no clear direction. What could the committee do to assist such groups and to assist the department's own efforts on this?
Ms Njobe also expressed concern that the delegation had told the committee nothing of the status of community service and that with respect to drug redistribution, it seemed that nothing much had been done to address these issues.

Mr Peppeta replied that they were currently operating only within the grace of the treasury, as their over-expenditure was 2.7% whereas the maximum allowed was just 2%. It had to be noted that service delivery would be significantly affected though, if less was spent than what they were currently spending. Hospitals such as Bedford Hospital, which showed no revenue collection at all, were specialised hospitals such as those that supplied artificial limbs or mental hospitals. The department was hoping to raise the awareness of paying for services amongst people, but patients were requesting better service, such as improved and separate hospital wards.

Ms Matebese said that with regard to NGO's, their department would be in a better position to assist the NGO's since they now had a budget of R33m just to assist with AIDS programmes through a number of co-ordinators. The politicians could help by publicly addressing the AIDS issue whenever they went into communities.

Dr Stamper said that there was excessive wastage in the province, including in some cases, ghost personnel. The department would turn around its hospitals though and make savings. As a means of improving revenue collections it would also start charging other departments such as the Justice and Correctional Services Departments, for the use of healthcare services.

Mr M Mpehle (ANC) asked the following questions:
How long would it still take for proper managerial processes to be implemented?
With respect to AIDS, particularly in the rural areas very little seemed to be done in improving people's consciousness on AIDS. What could the committee do to help this process?
Was AIDS counselling being given and, if so, what were the reactions to it?
Noting that illegal abortions had been ended by the availability of legal TOP's, what impact was this having?
What was being done to address the problem of tax rationalisation and what could the committee do to help in this regard?
Noting that the metro area covered Port Elizabeth specifically, what was being done for the areas just outside Port Elizabeth?

Mr Peppeta said that with respect to the rationalisation of tax, an agreement was reached nationally in 1995/96 on tax rationalisation and as a result funds of R77m had been distributed. Those funds had all been paid back.

The other questions were not answered.

Another member asked what was the impact of the lack of availability of drugs on people living with chronic diseases? This question did not appear to be addressed by any members of the delegation.

A different member asked a number of questions as follows:
He noted that it had been said that the increase in the levels of TB was partly due to its relation to AIDS. Was this not in fact because it was not being treated?
When would the necessary drugs be available to people in the rural areas?
When would the problem of poor roads no longer be used as an excuse for the provision of proper care for people in rural areas?
Noting that certain centres had been designated as TOP centres, what was being done about those centres that were not operational and where were people in those areas supposed to go?

Mr Ngoma said that in the management of TB, one had to go beyond a purely clinical approach because people often failed to take the medication. In such cases community assistance was needed. One problem that this raised though, was that wherever members of the community were asked to serve as monitors, they later demanded payment.

Ms Matebese said that they had to ensure centres were able to perform TOP's safely and efficiently, before they could be declared available to perform them. As far as the lack of roads was concerned, inter-sectoral co-operation was essential in order to address this. Different departments had to work together as a team. One area, Lusikisiki, was already benefiting in this respect. In general, a number of different teams were assisting the department in the improvement of quality of care in hospitals.

Ms S Mnumzana (ANC) asked, noting that they had a shortage of personnel, what the department was doing to ensure that it was not affected by volunteer severance packages? This question was not answered by any of the delegates.

Ms F Marshoff asked the following questions:
Were the District Health Service areas in line with the new municipal demarcations?
If healthcare was being handed over to local authorities, did they have the necessary capacity and would the budgets be transferred too?
How does the Eastern Cape compare in terms of the reporting of AIDS, with national averages?
Was the department within budget in the provision of care for AIDS sufferers?
Where in the budget were the conditional grants reflected?

Ms Matebese replied that the 21 districts were not in line with the new districts outlined in the demarcation process. She said that they might not also have the necessary capacity but the capacity would have to be transferred from the provincial to the local levels. She also said that the Eastern Cape had the third highest rate of HIV infections. Mr Peppeta said that some of the conditional grant allocations were add-ons and some were included within the budget.

Another member noted that there seemed to be an alarmingly high number of unwanted pregnancies. Were there any programmes to address this and who paid for TOP services? These questions were not answered.

Dr S Cwele (ANC) asked whether there were any bursaries being provided by the department in order to address their personnel shortages and if so, how many and how much had been budgeted for them? With respect to TB, had the DOTS system been implemented? The questions on bursaries were not answered but Ms Matebese said that the DOTS system was being implemented.

Another member asked if there were any programmes for senior citizens in place? This question was not answered.

The Chairperson said the committee needed a further explanation of the amount allocated for rank promotions. He noted also, that there had been a problem in some cases, such as with Gauteng, where there had been overspending in order to secure greater allocations from the treasury. Was it not the case that this was happening with the rank promotions allocation? Finally, were there any instances of buildings that could be used for healthcare facilities, standing vacant? The chairperson's questions were not answered.

Ms M Njobe (ANC) asked whether the department had any programmes to change the mindset in healthcare providers on how they cared for patients? How was the current drugs distribution programme going to improve on the previous programme? Finally, noting that there had been complaints from Kwazulu Natal border areas, that Eastern Cape people had been using Kwazulu Natal facilities, how was this going to be addressed?

Mr Ngoma said that it was true that there was some cross-border resource utilisation although it had to be noted in this regard that inequalities existed in the north-eastern areas of the Eastern Cape. Creative ways of dealing with this problem were needed and even the help of the committee could be useful in this regard. It should be noted that a cross-border forum did exist though.

Also, Rietvlei Hospital had been upgraded and was as a result, one of the best hospitals in the area but the backlogs were nevertheless still enormous, severely affecting this issue.

With respect to establishing a work ethos, there were programmes in place to conscientise workers in respect of the patient's rights charter and care in general.

The Chairperson indicated that the unanswered questions as well as any additional questions would have to be put to the delegation in writing or addressed to them at the lunch break. He then adjourned the meeting for lunch.

Free State
Prof. K Househam of the Free State Department of Health gave a presentation to the committee. Addressing human resources (HR) cost reduction measures, he said that the department had developed a HR plan to bring down personnel costs from its highest level of 72% of the budget. Also, it was significant to note that the Free State was the only province to have an eighth programme in addition to the usual seven. This programme was one for supernumerary staff.

Other cost reduction measures had also been implemented by the department, including the implementation of cost centres and the reduction in the usage of blood and blood products. The Essential Drugs List had not yet been implemented in the Free State.

A number of financial management issues were on the department's agenda and the department had a Financial Control Committee (FCC) which met on a quarterly basis. There were also institutional FCC's in some institutions. Within these institutions there were R1000 committees which approved all expenditures for amounts from R1000 to R9999 before the expenses actually took place, and at the head office, a R10000 committee which similarly approved all expenses of R10000 or more. To address losses the department had reformed budgeting training and had increased the amount of basic budget training dispensed. Over 300 managers had been retrained with this basic budget training.

The challenges that faced the department were the following:
The effective maintenance of financial control measures
The monitoring of weekly cash flows
The implementation of the Public Finance Management Act (PFMA)
The reduction of personnel expenditures to 65% of the total budget
The improvement of financial control measures
The maximising of revenue collection.

The department was currently within their budget and had even under-spent by approximately R10m, but it was hoping to rollover these funds for equipment purchases. The lessons the department had learnt was that they should use all the available skills, monitor cash flows as closely as possible, control expenditure before it occurred and, most importantly, ensure ownership of the budget at all levels.

The most important individual programmes in the budget and their most important features were the following:
- Programme One covered a new Directorate of Financial Management, with a new director due to start on the 1^st of May.
- Programme Two covered local government payments.
- Programme Three was for regional and specialised hospitals, and mainly for essential equipment in these hospitals. A moratorium had been placed on new equipment purchases, which had addressed the problem of over-spending but in turn had resulted in obsolescence of equipment in some cases. To address this the department was hoping to achieve a controlled rollover of funds, which would be used for equipment expenditures.
- Programme Four included conditional grants.

It was worth noting that due to a very tight provincial budget, there had been almost no new capital expenditure at all. An exception was three clinics, which were funded by the Irish Government. With regard to revenue generation, the department had an outdated debit system, which was hampering progress. They had applied to the treasury for funds to purchase a new system. Flexibility was important in increasing revenue generation and the department also found the medium term expenditure framework (MTEF) to be a useful process.

With regards to HIV/AIDS, Prof. Househam claimed that the Free State had the third highest rate of prevalence of HIV infections. He acknowledged that the Eastern Cape had also claimed to have the third highest prevalence of AIDS, but the Free State believed that it was the third highest. An interdepartmental committee on AIDS had assisted in mobilising large portions of the community to assist with addressing AIDS issues. It was important to note in this regard, that this committee had secured specific pledges for contributions from the community with measurable and reachable goals. Seventeen NGO's had been funded in the AIDS programmes the department looked after. The budget for AIDS had not been significantly increased in the last three years, which was cause for some concern. The budget for AIDS projects was R3.3m. The department was looking into the establishment of an AIDS fund similar to the one, which had been set up in Gauteng. With regard to discrimination against AIDS patients, the department did not have a specific programme to address this although it did have one, which addressed discrimination in general in the workplace.

With respect to the implementation of the District Health System, the key points that were being looked at were the following: Ensuring effective governance structures, ensuring the implementation and adherence to the Patients Rights Charter and the implementation of the Primary Healthcare Package.

The department was looking at the overall equitable distribution of healthcare resources. There was currently an inequitable distribution particularly in the goldfields region because of the families of the gold miners in that region. The province only had one central hospital and this was probably the most effective level-three hospital in the country. The department had effective relations with the Northern Cape because of the necessity for them to refer patients to this hospital from time to time. It was noted that revenue generation should be incentivised. Hospital fees were currently revised on an annual basis. Some of the realignment measures that were being considered, included public-private partnerships.

Most issues concerning drug policies were only relevant at a national level, since drug policy was driven from the national level. The department did have a problem with the distribution of drugs and they were working to rapidly address this problem. There was one particular problem in the eastern Free State, which they were aware of and were dealing with. The community service programme in the province was very successful with 26 of the community service doctors in rural areas electing to remain in the areas they were in. The department was moving towards an integrated nutrition programme. R21m was earmarked for primary school nutrition and the rest to the integrated nutrition programme.

With respect to TOP's, it was not possible to give the exact costs of performing TOP procedures as it was an integrated cost. From 1993 to 1996, the department had performed approximately 50-90 TOP's per year and this figure had risen sharply since then up to last year when 4168 TOP's were performed in the province. This was not a popular procedure amongst staff, and was even quite disturbing for those who had to perform it. It was also unpopular in the communities.

Discussion
Dr R Rabinowitz (IFP) asked whether the department had tried to obtain the cheapest possible AIDS tests and were AIDS tests going to be made routine? Also, what was the Provincial AIDS Council responsible for and where there were privately funded initiatives, did this mean privately managed too, in those cases?

Prof. Househam replied that they did not have routine testing for AIDS but they did have counselling. There was however, usually no reason for staff or even in many cases, patients, to disclose their HIV status. A decision on routine testing was a policy issue and therefore needed to be made at a higher level. It would be welcomed though, among some groups of staff, such as surgeons, who faced high risks of HIV infection.

The Provincial AIDS Council was due to replace the interdepartmental forum and would take over its functions. The entire process of public-private partnerships was due to be outsourced and it would therefore be privately managed.

Dr S Cwele (ANC) asked why there was such a large component of doctors from SADC countries; was it due to an intergovernmental initiative? He also expressed concern that the attitudes shown by staff towards performing TOP's seemed reminiscent of Apartheid attitudes where black people were refused treatment in some cases. The TOP centres were, after all, providing a healthcare service and should not be affected by religious views.

Prof. Househam said that the Free State had not had any new foreign doctors since 1996 and so those they had were inherited from previous years. There were two exceptions to this, which were two new doctors in academic posts.

Resistance to performing TOP's was not a racial issue and in fact there was a cross-cultural alliance against TOP's. The entire issue was fading away as a problem anyway, though.

Ms F Marshoff (ANC) expressed concern over the large proportion of funds that had gone specifically on administration in the Elizabeth Ross Hospital. She then asked the following additional questions:
How effective was the DOTS strategy in the Free State?
How successful were public-private partnerships in the province?
What initiatives were there with mining hospitals and had the department made any specific approaches to mining hospitals seeking partnerships?
What percentage of funds went on personnel at the Universitas Hospital?

Prof. Househam replied that Pelanomi Hospital was not funded by conditional grants but that the funds came from other sources such as the Public Works Department. There was a great need for funding at this hospital. The expenses at the Elizabeth Ross hospital had been addressed and this hospital was currently on phase three of a seven-phase reconstruction and rehabilitation project.

As far as the DOTS programme was concerned, TB needed the complete availability of the required drugs, for its effective treatment. Related to this issue, was the current shortage of pharmacists that the province was experiencing. If there were more community service pharmacists, this issue would be adequately addressed. The department had engaged the mine hospitals over public-private partnerships but in most cases, had been disappointed by their responses. Consultants at the Universitas Hospital were being funded from academic funds.

Ms M Njobe (ANC) asked a number of questions as follows:
What were the proportions spent on personnel in previous years, such as in 1994/95?
Noting that the Eastern Cape delegation had said that trying to reduce expenses negatively affected service delivery, what was the Free State's experience in this?
Why did the department not have a revenue retention programme?
What were the issues and problems most commonly raised by community service doctors?
What was being done with regard to promoting gender issues in the department?

Prof. Househam said that they were currently spending 66.5% of their budget on personnel costs, with 65% being their overall target. This was down from a previous high point of 72%. Related to these figures though, were those of the average cost per head which had gone up tremendously in the last few years (from approximately R47000 to R61000 in just a few years). The department had not granted volunteer severance packages to any managers, except for those cases where posts had been abolished.

With regards to revenue retention, the department did not see any of the money that was collected; it all went straight to the Paymaster-General's coffers. The issues that faced community service doctors, was commonly the lack of equipment as backup and the problems adapting to a rural lifestyle for those who were from cities.

Ms S Mnumzana (ANC) asked, if Universitas Hospital was a level three hospital, how other hospitals such as Pelanomi were classified? Did this budget go through NGO's for the areas where they were involved? Lastly, were there currently more assistant nurses than trained nurses at Pelanomi Hospital and was this being used as a means to reduce its budget?

Prof. Househam replied that hospitals were classified as service level one, two or three hospitals, Universitas being a level three hospital (a specialist hospital) and Pelanomi, a level two hospital (a regional hospital). Level one centres were community health centres and clinics. It was increasingly necessary to look at the use of professional nurses and also to see staff establishments cut to functional levels.

Northern Cape
Dr Peters, MEC: Health in the Northern Cape, was accompanied by Dr Hendrickse, Dr Maphungu and Dr Akhawaray.

The One Year Plan and its priority areas
Primary health care services would target certain critical problems such as maternal deaths and the care of trauma victims, especially rape victims. In this regard the interrelationship between the Department of Health and programmes in other Departments, supportive structures and programmes between various external agencies was important.

HIV/AIDS: The main objective is to strengthen integration between the HIV and TB programmes, with personnel working closely together. The Province is seeking to strengthen the working relationship between provincial and district levels. The Province's policy is aimed at moving towards home based care for infected persons, in cooperation with the Hospice. It is important that testing is voluntary and furthermore that counseling facilities are set up at the test centres. An inter-departmental Committee on AIDS has been established to involve government departments in HIV/AIDS mobilisation. The Provincial cabinet have been very supportive and funded the AIDS summit as well as the World AIDS Day campaign.

TB: Dr Maphungu stated that tuberculosis was a high priority disease in Southern Africa and a common cause of death in AIDS sufferers. With the introduction of air medical services, treatment can be given immediately. With the use of sputum based testing and bacteriology the province was hoping to reduce false reporting. The Provincial Department was funding 50% of SANTA's budget; this enables SANTA to train volunteers and community leaders and facilitate the community process in addressing the epidemic.
A demonstration and training programme has been established around Upington, an ISDS initiative assisted by SANTA. This programme needs to be extended to the Kalahari area. Gordonia Hospital in Upington and West End Hospital in Kimberley are designated test hospitals with specialised management teams and programmes.

A demonstration and training programme has been established around Upington, an ISDS initiative assisted by SANTA. This programme needs to be extended to the Kalahari area. Gordonia Hospital in Upington and West End Hospital in Kimberley are designated test hospitals with specialised management teams and programmes.

District management structure: the province has embarked on a process for achieving equity in the allocation of primary health care services. Fifty nine percent (59%) of the budget is allocated to districts. The use of national norms and standards for the implementation of primary health care services will ensure equity. The province was seeking to address their relationship with local government structures. There were many small villages in the Northern Cape and people generally worked closer together. Local government representatives sit on all health structures.

Since 1997 no new clinics have been built. Dr Maphungu said his Department was expecting the demarcation of municipalities to impact on service delivery modes and the flow of patients.

Drugs: in respect of drug procurement every facility has EDL (Essential Drug List) accredited medication. Facilities are compliant and pharmacists have been trained on EDL.

Hospital services: there are no central hospitals in the Northern Cape except in Kimberley. They are hoping to get a grant to upgrade it very soon.

Reproductive health issues: About 446 terminations of pregnancy were done up to July 1999. Dr Maphungu acknowledged that the Northern Cape was a very conservative province and workshops had to be held to educate people on the issues.

Serious problems in the province
The effect of AIDS on the capacity of facilities is a problem. Fifty percent of patients in Kimberley are AIDS-related. The home-based care unit is working to provide counselling and to reduce the stay in hospital for those not in the acute stage.

Presently 59% of the budget is spent on district health services but they have to grapple with low morale among staff which affects service delivery.

Financial Report / the Budget
Dr Akhawaray explained that the province has had to align the budget with policy. There was a move from urban to rural district health care.

Over 92% of the budget is allocated to service delivery. The unit cost of delivery is affected by many factors: medical inflation, the age of the population, new diseases such as AIDS and TB.

Personnel issues include the R17 million cost of implementing the Basic Conditions of Employment Act from June 2000. The Skills Development Programme needs to be funded. Back payments for District Surgeon Services need to be made.

The HIV/ AIDS and the high incidence of trauma impacts on hospital infrastructure. The Province is faced with 12 to 13 000 visits per year due to cross boundary flows. Dr Akhawaray felt the province should be compensated for this and they should be funded on a per capita basis.

Consideration has to be given about upgrading mortuary services and equipment which province was taking over.

Expenditure in 96/97 expenditure had grown by 20% and in 97/98 by 14%. Dr Akharwaray attributed this growth to the fact that nurses had been upgraded to professional nurses due to restructuring of services. In 1999/2000 services had been provincialised from local authorities in the restructuring process -therefore there was not a phenomenal growth. The baseline increased by R337 million, the current baseline is higher than expenditure. With an allocation of R418 million there appeared to be an increase of 13% but if you eliminated the conditional grant the increase is actually 12%. Dr Akhawaray pointed out that certain funds, a total of R19 million, were ring-fenced for particular purposes.

Revenue generation: R6.5 billion is currently generated. A new information system is being installed which will improve revenue collection services. They hope to introduce a revenue retention service soon. There has been a drop in private patients using public hospitals. Dr Akhawaray said that if revenue increased it usually impacted on services and vice versa. The conditional grants are as follows: training and research R23.480m, redistribution R16.458m, HR&R R7m, INP Project R10.096m.

Dr Akhawaray concluded by stressing that the Provincial Department had to strive to be output orientated. Secondly, there was a need to revise the baseline from within the province and nationally. Growth is needed and in this regard revenue retention policies was being discussed with the Department of Finance.

Discussion
Dr Cwele (ANC) asked whether there was any progress in the demarcation and restructuring of districts processes? Could functions at provincial level be devolved to district level? Dr Peters, MEC, said that municipalities were mostly bankrupt and appealing to provinces to take over certain functions so as not to compromise on health care. Certain functions would be devolved to provinces depending on the specific municipality and their ability to provide that service.

Regarding HIV/AIDS, what initiatives are being taken to promote adolescent health? Dr Peters said there were two youth centres in Upington, run from a clinic. The Youth Commission was part of this programme. The reason why it was not reflected in the budget was because it was run by the Planned Parenthood Association and funded by a trust. Dr Maphungu added that there was a youth feature in the Maternal Child and Adolescent Health Programme. The Department of Education has a budget for a life skills programme. The two departments were going to work together on an AIDS programme.

Ms Marshoff (ANC) noted that SANTA plays a big role in efforts to control TB. To what extent did the Department have oversight over the organisation and how did SANTA account for their spending? Dr Maphungu said in the first three years they had funded SANTA with R 700 000 but on a business plan basis. The Department plans with SANTA as to how the money will be spent.

Ms Marshoff was of the opinion that if patients identified certain hospitals with HIV and TB they would stop coming and possibly default on their treatment. How was this being handled? Dr Maphungu acknowledged that this was a danger but these hospitals had been around for so long it seemed unlikely.

Ms Njobe (ANC) asked whether the AIDS projects were not effective, seeing as the budget had dropped. Dr Maphungu said that, in respect of funding for HIV projects, it was for the amount of R75 million of which R500 000 was allocated to the mentorship programme in 1998. However, because the communities in the Northern Cape were small there was always a fear of the stigma attached to AIDS and it was therefore difficult to establish a mentorship programme.

Ms Njobe noted that the budgetary allocation to nursing colleges had been reduced - did this mean there was sufficient trained personnel? Dr Peters said that because of the reductions in the budget it was decided to reduce the intake of nurses. Although provinces needed professional nurses there was a lack of resources. A number of trained personnel resigned because of the remoteness of certain areas. People preferred to work in Kimberley, Upington or De Aar. The Department was trying to make community service compulsory for two years, using the quota system. They were also trying to recruit nurses through agencies, employing them for contract periods.

The meeting was concluded.