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HEALTH PORTFOLIO COMMITTEE
10 March 2000
MPUMALANGA, GAUTENG, NORTH WEST PROVINCE: HEALTH BUDGET, EXPENDITURE & PERFORMANCE TARGETS
Documents handed out:
North West Province Report
The presentations by the provinces were primarily a response to a questionnaire sent by the Portfolio Committee to each provincial department:
The emphasis in this financial year falls on the implementation of the district health care system which will proceed unhampered by the new municipal demarcations. Capital projects continue to be a priority with those hospitals needing renovation receiving priority. HIV/AIDS continues to be a dangerous epidemic and where there are budgetary shortfalls for programmes money could be diverted from other projects.
Specific policy areas receiving attention this year are HIV/AIDS, primary health care facilities, hospital services, and a tuberculosis programme. Human resource issues were on the table (restructuring, redeployment, management training), information systems and facilities for data collection, and women's health issues.
Personnel expenditure in the province is increasing. This results in pressure on other programmes especially on the HIV/AIDS programme. Although more counsellors are needed there is simply insufficient funds and the only alternative is to train existing staff to perform such a function.
Dr Goolam Kariem, head of the Mpumalanga Health Department, remarked that his province had the lowest per capita budgetary allocation in the country as well as the lowest per capita personnel. The total allocated budget was R 1.06 billion. The budget appeared to have increased by 9% but Dr Kariem suggested this figure is skewed and in fact there is only a 5% increase. The redistribution and provisional grant was not included in the figures.
· District health system
The Department seeks to improve secondary health care services to minimise referrals to Gauteng and thereby minimise the costs of remuneration to Gauteng. An integrated, comprehensive primary health care service needs to be established.
· Community service for dentists and pharmacists
Because Mpumalanga is a rural area it is difficult to attract professionals to work there. Through the implementation of community service for dentists (from June 2000) and pharmacists (from 2001) equality in the system will be improved.
· Health care facilities
The report provides a breakdown of the Department's capital projects; its upgrading plans and building of new facilities. The Department seeks to prioritise those hospitals which need to be renovated.
· Information systems
Nothing has yet been spent on information systems. They had been through a tendering process last year but the system which proved to be compatible with that of national government's was too expensive.
An HIV antenatal prevalence survey between 1990-1999 was done. The report showed a gradual increase from 1999 but a drastic increase in prevalence from 1993. Dr Kariem believes this is largely due to problems in collecting data, which was not done prior to 1993.
· Terminations of Pregnancy
There were 1600 terminations performed in the province in 1997,1998 and 1999. Although there are persons trained to undertake these routines, it was an aspect of health care services which needed improvement.
· Malaria in 1990-99
The province experienced a decline from 1996. Although the recent floods have caused the number of cases to drop an increase is expected with a drop in the water levels.
· Emergency medical services
New EMS vehicles were acquired on lease last year. The service is improving but the problem remains that too much overtime is being paid out. More staff needs to be appointed to the EMS service. Generally, 63.8% of the total budget is spent on personnel. There is need to reduce management costs and to downsize structures.
Dr Cwele (ANC) asked for clarity on the information systems on which the Department has spent nothing last year nor this coming year. Did the Department believe each province should have their own system and national government their own?
Dr Kariem was of the opinion that it is necessary for there to be a compatible system in place. The problem was that there might be financial exploitation of the Department when accepting tenders for the new system. He preferred that there be slow progress at no cost. Dr Kariem favours one national information system compatible with that of all nine provinces. The Department is now proceeding cautiously on this matter.
Dr Cwele (ANC) expressed concern that there were such a large number of maternal deaths in the province especially at a small hospital in Shongwe.
Dr Kariem said that these deaths were largely due to the fact that many patients had never been to an antenatal clinic before giving birth. In some cases there were pre or post-partum complications or complications during surgery under anaesthetic.
Dr Jassat (ANC) asked where the money for the HIV/AIDS projects was coming from.
Dr Kariem said that although the budget showed an increase it was insufficient overall to cope with increasing demands. The Department did however see a potential for saving and diverting funds. Wherever there was a potential for saving it had to be done.
Ms Marshoff (ANC) asked to what extent the Department plans a medium term framework without taking the conditional grant into account. For instance can provinces work on buildings without using the provisional grant for building rehabilitation?
Dr Kariem said that if the provisional grant was not used the province would not have the ability to maintain and renovate.
Dr Rabinowitz (IFP) asked why there had been underspending of the AIDS budget. Was it because of a lack of communication between provincial and national?
Dr Kariem said he could not comment on this. He did however emphasise that there needed to be accountability at local levels. If there was a partnership with local government, expenditure might improve.
Dr Rabinowitz asked Dr Kariem to speak about the procurement process in the province. She emphasised the need for there to be a single batch control method to track supplies.
Dr Kariem assured the Committee that there was no delay or problem in procuring medicines or equipment. However, the management of medicines was a problem. In the financial period 2000/2001 the Department was hoping to decentralise the management of medicines to hospitals. He said that although he knew that R22 per capita was spent on drugs last year it was difficult to quantify losses resulting from theft.
Dr Cwele (ANC) asked whether primary health care institutions would still be managed after restructuring had taken place.
Dr Kariem explained that in terms of the new municipal demarcations, the districts are larger. Local authorities have in effect become sub-districts. There was therefore only a change in terminology, the policy remains the same. Both the primary health care system and the district health system would provide primary health care service. He said that at all district meetings, local government is present. This partnership is crucial. He made it clear that the Demarcation Board Report would not impact on the implementation of the District Health System.
Dr Nkomo (ANC) asked for comment on the fact that Western Cape salaries have been negotiated to ensure parity between personnel in local and provincial spheres.
Dr Kariem said that by and large the gap was minimal in Mpumalanga, especially for nurses. A gap continued to exist in respect of medical officers.
Ms Marshoff (ANC) said that where money was transferred between local and provincial government there were some disparities. For instance medical aid or tax may appear as a deduction on a paysheet but never be paid over to the medical aid or Receiver of Revenue. In some instances the Receiver has obtained a garnishee order to ensure they received money owing to them.
Mr Mabope of the National Department chose to respond to Ms Marshoff's concerns. He said that deductions were not an overall problem. It was rather the case that individual incidents needed to be investigated. While provinces give local governments subsidies for service delivery, transfers are not strictly dictated therefore there is little control over how money is used.
Dr Rabinowitz (IFP) asked whether any attempt was being made to keep nurses from leaving the province and the country.
Dr Kariem said their reasons for leaving were multi-factoral. In the main the benefits overseas are tempting besides which they had a right to earn a good salary. It was therefore not necessarily the case that it was due to local problems. He added that there was also a distinct lack of patriotism: are we sufficiently committed to the State?
Dr Rabinowitz (IFP) said that staff morale was low. How was accountability to be ensured? What role could performance contracts and the Charter play?
Ms Matsau (MEC for Health) said that the Charter had been launched in November 1999. A meeting was later held and a strategy drawn up. This strategy was to be adopted by the PHRC next week. Through surveys done it seemed that there was large-scale awareness of the Charter. Dr Wilson (from the Department) added that a number of performance agreements had been signed between the hospital and the province. The performance agreements concerned issues of quality, for instance waiting times at casualty. The difficulty they faced with these performance agreements was that the hospital was the same legal entity as the province was and the contract was therefore not binding. This legal problem was being resolved.
Dr Rabinowitz asked why a health ombudsman was not appointed or some similar programme implemented.
Dr Wilson said that two provinces were looking at the concept of a mental health ombudsman. He said that the performance agreement set out what provinces are required to do, therefore the legal problem had to be resolved first. He said that although they were not legally binding, they did seem to have had an impact in certain hospitals already.
Dr Nkomo (ANC) asked to what extent people get initiated into the culture of research.
Ms Matsau said that government now has a representative sitting on the Medical Research Council which approves research topics. She spoke in favour of using students as much as possible to do research.
Dr Rabinowitz (IFP) referred to research into malaria. Would research into traditional plants remedies have any impact on our intellectual property laws?
Ms Matsau explained that there was a new Bill which would adequately cover the intellectual property issues. She said that before the Bill was in place however, other avenues of protection would have to be sought.
Dr Ngijima, Superindentent of the Gauteng Health Department, outlined the challenges facing his province this financial year:
The prevalence of AIDS was a major concern, especially the impact it would have on the number of beds required and the patient care required. The current strain of influenza also promises to be problematic this year.
Staff morale is very low due to restructuring. There were high levels of absenteeism and generally productivity was very low. Dr Ngijima said that staff notch payments would be accommodated this year. However the Department was also seeing the need to improve financial and management systems to resolve the lack of management skills amongst staff.
· Financial control
The Department was facing budgetary constraints this year. This was resulting in loss of nurses and making expansion at district level very difficult. Personnel costs were increasing. Dr Ngijima said that the budgetary allocations left little room for the development of the primary health care system and other programmes envisaged by his Department. Financial management was to be a key focus in 2000/2001.
· Women's health issues
In providing safe and accessible facilities for women consideration had to be given to the need for safe motherhood, prevention of unwanted pregnancies and the reduction of violence against women. The bulk of pregnancy terminations take place in Gauteng but there is still resistance by staff.
Dr Rabinowitz (IFP) asked whether the private/public partnership was still limited and whether there would be authority at district level for a hospital to, for instance, contract the services of a private laundry company.
Dr Ngijima said that in respect of laundry outsourcing in particular it was important to look at how efficient the hospital laundry service was. Hospitals did have the capacity to perform this function but it would have to be assessed if a private company would not be more efficient?
Dr Cwele (ANC) asked how many beds were needed in the province.
Dr Ngijima said that there was a need for equity in the province. In other words certain norms and standards had to be applied; the number of beds needed in Gauteng had to be compared to the numbers in other provinces. These norms and standards were developed having regard to medium term finance. If the interim grant did not decrease, the Department would be closer to performing all their functions.
In respect of termination of pregnancies (TOPs) Dr Cwele (ANC) asked whether patients were referred elsewhere or merely turned away by resistant staff members. He asked whether the legislation had any flaws.
Dr Ngijima said that he could not give specific figures of the amounts of TOPs in the province - Gauteng also accepted a number of referrals from other provinces. He said that there was a weakness in the services offered to women. For instance, counselling is required for TOP candidates. The Department was doing all it could to encourage staff to offer all the facilities available to women.
Dr Jassat (ANC) pointed out that last year three or four cardiologists resigned from their posts and were subsequently refused sessions at the same hospital. He also asked whether patients should bring their own sheets when being admitted.
Dr Ngijima said that the doctors in question resigned after limited private practice was stopped last year. Those doctors would not necessarily have been given preference when sessions were offered. In response to the second question he said that patients in Gauteng were not encouraged to bring their own towels and sheets. However, it had been recommended that laundry facilities be separated from the main hospital building. A feasibility study recommended that this be done as soon as possible for the sake of cost efficiency.
Dr Cwele (ANC) asked how population growth in the province was being challenged and what percentage of the population were illegal aliens.
Dr Ngijima said that they were finding more people coming into Gauteng from other provinces rather than illegal aliens.
Dr Cwele followed up on his question and commented that there were large numbers of foreign doctors in the province. Did Gauteng have a problem filling posts?
Dr Ngijima acknowledged that there were many foreign doctors in the province both in the specialities and in general practice. These doctors continue to seek registration each year. The Department is hoping to encourage and recruit South African doctors from the community.
Ms Marshoff (ANC) commented that the development of mental health care facilities did not seem to be a priority for the Department. Would it be implemented in the primary health care package?
Dr Ngijima said that health care remains a priority. All measures referred to in his presentation referred to psychiatric hospitals as well.
Ms Marshoff (ANC) asked whether the new municipal demarcation would be a further constraint on district health care.
Dr Ngijima said that demarcation was not an immediate problem for resources at district level. They now had a much more manageable relationship with local government. However, the budget was restraining the Department in the area of pharmaceuticals.
Dr Cwele (ANC) asked Dr Ngijima what the incidence of HIV/AIDS was in the province. He also asked if there were any trials in the province. Lastly he asked whether tuberculosis was on the increase.
Dr Ngijima said he had no figures with him but in the adult medical wards especially there were a large number of AIDS-related diseases. In terms of the budget the Department was allocating resources away from other functions to fund the envisaged HIV/AIDS programmes. They also get resources from national government. In response to the second question, he said that trials on AZT were being undertaken at the Helen Joseph, Johannesburg, Chris Hani Baragwanath and a number of other hospitals.
NORTH WEST PROVINCE
Dr Gosnell went through the slide presentation before taking questions from members of the Committee.
Dr Rabinowitz (IFP) asked where the budget would come from to increase the number of AIDS counsellors.
Dr Gosnell said that there was no budget for this and they could not afford to employ additional staff. They were looking at ways of making use of the existing staff force, through retraining programmes.
Dr Rabinowitz was concerned whether the AIDS counselling consisted or group pre-test counselling. Dr Gosnell said that in spite of the fact that counselling incurred significant costs there was no group counselling. Instead they were training staff to cope with a larger workload.
Dr Rabinowitz (IFP) asked whether the procurement policy was too complicated and whether it was leading to problems.
Dr Gosnell said that the procurement policy was only a problem when it caused delays. The Department was trying to streamline it with the tender board procedures.
Ms Marshoff (ANC) commented on Schweizer-Reinicke and Taung, two districts where there are serious problems in the health infrastructure.
Dr Gosnell said that in Taung especially they were making big strides in the TB programme. Although they were a little behind in Schweizer-Reinicke in the sense that there was always a severe shortage of personnel, he did not feel that the situation in these two towns was as bad as Ms Marshoff implied.
Ms Marshoff (ANC) also asked on what the conditional grants are spent.
Dr Gosnell did not expand on this but said that the grants went to particular facilities.
Ms Marshoff (ANC) asked Dr Gosnell to clarify the causes of maternal deaths. She also asked what the difference was between unreported and unknown causes of death.
Dr Gosnell said that a large percentage of maternal deaths were due to HIV/AIDS. Another cause was post-birth infections. In this regard they needed to find ways to reduce such infections. Unknown causes meant that after the investigation the cause of death remained unknown and unreported meant that the cause of death was unknown because no investigation had taken place yet.
Ms Marshoff (ANC) said that in certain wards prisoners were being held without security or a police guard. Nurses felt threatened by the ability of prisoners to roam freely around the hospitals. She asked who was in charge of these prisoners.
Dr Gosnell agreed that these prisoners posed a problem. He also acknowledged that staff morale was very low. The matter of prisoners had to be looked at. In respect of the staff problems he said that currently there were approximately 800 persons additional to the establishment. They would be encouraging these persons to move voluntarily to where they could be accommodated. Existing staff could also be trained to take on new functions.
The National Department sums up
Mr Pretorius outlined a long-term plan for the Department. He said that their operational plan was being formulated into performance agreements which would regulate staff performance. The Department has a 5-year HIV plan. An AIDS council has already been formed and they had the cooperation of the President. The formation of a provincial AIDS council was important as the battle against the epidemic must take place at a local level.
Regarding occupational diseases the Department would be trying to rationalise the compensation system and the multiplicity of occupational services. The Department faced the challenge of dissolving the tension between the victims and those in the community exploiting the system.
Mr Pretorius said that Medicines and Related Substances Control Amendment Act (Act 90 of 1997) was a policy Act which could not be implemented. If it was implemented in a modified form it would help the Department deal with the Medicines Control Council.
Mr Pretorius touched on community service. He said it had got off to a bad start but it was up and running now. Soon dentists would also be required to perform community service.
In conclusion Mr Pretorius looked at the financial situation. The amount in the budget was R26.2 billion. The amount to be spent was R25.3 billion, up by 1%. No deductions could be made yet because the Northern Cape, Eastern Cape and the Free State's figures were still excluded. Mr Pretorius said it was unclear what has happened to conditional grants and capital expenditure.
In general he said that the money granted was less than inflation. With increasing demands on services and personnel expenditure and increasing violence the money for improving systems was less. Therefore they needed to work smarter. Quality control was important and they could not afford the inappropriate spending of resources. Better management was crucial to financial control.
The meeting was concluded.
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