National Health Budget: briefing

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Health

07 March 2000
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Meeting Summary

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Meeting report

HEALTH PORTFOLIO COMMITTEE
8 March 2000
DEPARTMENT OF HEALTH: BUDGET BRIEFING

Documents handed out
Pharmaceutical Services briefing
National Health Information Systems briefing
Presentation by the Kwazulu-Natal Department of Health delegation
Presentation by the Northern Province Department of Health delegation

SUMMARY
The Minister of Health addressed the committee, saying among other things, that she wanted a good relationship between the department and the committee. The National Department completed its presentations on its various directorates started the previous day. These being the Pharmaceutical Services and National Health Information Systems clusters.

The Northern Province and Kwazulu-Natal Health Departments gave presentations to the committee. The Northern Province Health Department claimed the achievement of significant improvements in both quality of health services and the access to health care. The Kwazulu-Natal Health Department had been hampered in their efforts by the very high prevalence of AIDS in the province, estimated at approximately 40%.

MINUTES
The chairperson indicated that the scheduled presentations of the provincial departments of health would be delayed until the National Department's unfinished presentations of the previous day were completed. The chairperson introduced the Minister of Health, Ms M Tshabalala Msimang, who made the following remarks to the committee:

She gave her apologies for being absent for part of the previous day's meeting, indicating that she had to be at a meeting with other SADC Health Ministers, to address the post-flood disaster situation in Mozambique. She said that concerns had been expressed about the quality of some of the presentations of the previous day. She had noted these concerns and she thanked the committee for holding her department to a high standard. She said that important health issues, must be addressed uniformly across all the provinces, however she reminded the committee that her powers to effect this were limited under the Constitution and that the basic implementation of policies, was in the hands of the provinces.

She also remarked that she had been to some hospitals which were in a very sorry state, however she said that other hospitals had used the conditional grant funds which the government had allocated for the purposes of reconstruction, in very creative ways. She cited two examples of this, Witbank and Kimberley Hospitals. She said that she had taken note of the concerns expressed the previous day about the state of some hospitals and that she would be conveying these concerns to the relevant provincial government heads of health. She also said that if any MPs had suggestions as to how the rate of rehabilitation and reconstruction of hospitals could be increased, they should please let her know. She concluded that the last thing she wanted to see, was a rift between her department and the committee for any reason. If some of the presentations from the previous day were not up to scratch, she would definitely address that.

The chairperson thanked the minister, reiterating that the committee must use their oversight role directly, to visit hospitals and to raise the relevant concerns here. He indicated that any questions for the minister would have to be answered by other members of the department.

Cluster: Pharmaceutical Services
Dr Sekufa gave a presentation on his cluster (see Appendix 1), indicating some key points within the presentation. He said that his department had to manage the drug supply management process, better. He also said that they had to check that they were buying drugs wisely as a state.

Miss Pateni, from this directorate, stated that the Essential Drugs List (EDL) which had been completed in December 1998, still had to be made available to all facilities, both private and public. For the EDL to work, they would have to ensure rational drug use and in order to achieve this some prescribing habits among doctors would have to be changed. Dr Sekufa added that drug registration would have to be facilitated and co-ordinated with other SADC countries.

Discussion
Dr S Gous (NNP) asked what was the amount of lost drugs for 1999, either as a Rand value, or in terms of a percentage? Was it as high as 50%? He believed there was the need for an effective drug quota for provinces, to ensure that they were paying for drugs.

Dr Sekufa said that he did not unfortunately, have a figure to report for drug losses, but that it was somewhere in the region of 20 - 30% which amounted to many millions of Rands. He said that appointing good people in management roles would reduce this figure and therefore cost less in total than what is currently being lost. He said that there would be a firm study in 2000, which would ascertain accurate figures of what was being lost.

Dr R Rabinowitz (IFP) noted that there were three provinces, which had delivery of drugs under private management. Was there a difference in the rate of theft in these provinces? Since drugs were mostly stolen in small clinics, was there any way to address this, and had bar coding been implemented? She also asked what was the state of legislation on alternate medicines?

Dr Sekufa replied that there would be a firm study in 2000, which would ascertain accurate figures of what was being lost. The outsourcing of distribution in these provinces was not working well and that in rural areas for example, private companies were facing the same difficulties that the government was facing such as poor roads. The key question that needed to be answered in this regard was whether or not the depots were well managed?

A member asked about the substantial backlog of drugs and how this was being addressed?

The backlog was being reduced and there was ongoing reporting of its status. He expected that it would be completely eliminated by the middle of the year.

Ms S Baloyi (ANC) asked for clarification of the drug purchase and supply process and who monitors what goes on in the depots? She also asked about the department's role with respect to genetically modified (GM) foods and in respect of dietary studies, were black cultural traditions being taken into account?

Dr Sekufa said that depots and the monitoring thereof were managed at a provincial level. He added that there was one head of pharmaceutical services for each province and that his directorate communicated with each provincial head. The provinces were the ones who specified what quantities of drugs were needed and the State Tender Board managed the tenders for these drugs at a national level. The provinces bought the drugs from the companies who had won the tenders and the drugs were delivered to the provincial depots which in turn sold them to the hospitals. Monitoring of this process was a provincial function and it was at all levels of this process that the system breaks down. Qualified professional people were needed in these monitoring roles but that the provinces said they could not afford to appoint such people. The first step in addressing this problem was the conducting of a study in 2000 which would ascertain accurate figures of what was being lost.

Another member of Dr Sekufa's team said that the Department of Agriculture managed the issue of GM foods. She said that with respect to dietary studies, many had already been done and their findings were being incorporated into the department's policies and, yes, black communities and their traditions were given critical importance in this regard.

A question was raised about what was being done to monitor the quality of foods that were being imported into South Africa? Concern was expressed that poor quality food, such as mutton, was being imported and dumped into rural areas where people bought it because it was cheap. Further, what was the department's concerning the street foods project?

The response was that the Departments of Health and Agriculture worked together and their veterinary surgeons to apply quality control to imported meat. A new member of staff with a Masters degree had just been appointed to look after the street foods project and that the department's efforts on this, would be combined with that of the World Health Organisation. People on the ground would also definitely be consulted.

Ms F Marshoff (ANC) asked whether the department was upgrading their computer systems so that the computers would be linked to one another?

In response, it was acknowledged that this was an important point and an essential one in order to monitor the theft of medicines. They were not currently linked but this issue was being investigated.

Ms S Nqodi (ANC) asked how far the Eastern Cape was towards privatising the distribution of medicines from depots to institutions, and whether or not such was a national strategy?

In response, the answer to an earlier question was referred to and it was indicated that such privatisation was not currently a national strategy. The key issue that needed to be looked at is the effectiveness of the management of the process, regardless of whether it is handled by the private or public sectors.

Another member asked whether there were standardised protocols in place that clinics could use in prescribing drugs?

The answer was that there was not yet a formula for primary health care and that the development of flowcharts to diagnose ailments, for example, had not yet been fully implemented. It was a very involved process.

Another member asked how drugs that were used in mobile clinics, were monitored?

A member of Dr Sekufa's team answered that the issue of drug management, and specifically management of the cold-chain in mobile clinics, was currently being looked at.

A final question was whether the national department had control over the distribution of drugs to clinics and what was being done to assist the Eastern Cape with its drug shortages? She also asked what legislation on cosmetics, was being planned? These questions would be answered later, it was indicated.

Directorate: National Health Information Systems
Dr Matsau gave a presentation on National Health Information Systems (see Appendix 2) wherein she indicated a number of important points. It was the department's goal to develop a smart card nationally that each patient could carry, which would contain his or her medical history. This system was currently being developed and was the reason why Health Information Systems consumed such a large portion of the department's budget. She said that her directorate was ensuring that research was being co-ordinated nationally and that the issue of ethics in health research was being addressed. The department had launched a patient's rights charter and adherence to this was being implemented. Also, the development of a primary health care norms and standards package, which had taken four years, had just been completed. It was currently being costed. A secondary health care norms and standards package would be completed by September.

The chairperson indicated that there was not sufficient time for questions to be addressed to Dr Matsau as the presentations by some of the provincial delegations had to be completed before lunchtime as one of these delegations had a plane to catch.


Northern Province Presentation
The Northern Province Department of Health delegation consisted of Mr Thobejane, Dr Buthelezi, Mr Chikane and Miss Mazibuko. Their MEC for Health, Mr Moloto, gave his apologies for his absence, which was due to his having to attend to the disaster situation in his province caused by the recent floods.

In his presentation (see Appendix 3), Mr Thobejane said that his department had changed significantly in terms of its key personnel. The previous five years had been spent primarily on trying to establish facilities and now his department was in a position to focus more on quality and service. He said the department had re-evaluated its priorities, making sure they were in line with national priorities and standards. He said that the 115 facilities in the province had been increased to 175 and that the number of doctors had increased and as a result, the doctor to patient ratio had improved. He also said that they were continuing with the hospital reconstruction and rehabilitation programme.

The Financial Director from the department briefed the committee on the province's health budget, which totalled R2.368bn. He said among other things that one of the province's biggest challenges as a lower income, and predominantly rural province, was to recruit more professional staff. In this regard, he said, they were pursuing a bursary programme as well as other initiatives. He said too, that the budget could expect savings from a number of its programmes for the coming year.

Dr Buthelezi spoke to the committee outlining some of the department's recent achievements. He said that they currently had 25 full time and 63 part time specialists working for them, and that the redistributive grant they had received, had enabled them to pay for the extra part time specialists. He said also, that they had recently erected a trauma centre and a training centre using the health-training grant and would soon be building a new facility in Pietersburg. They had also managed to decrease the number of referrals to Garankuwa Hospital by 20%. Community service doctors, numbering 545 in total had also contributed greatly in the province to, among other things, the training of nurses. He also said that a recent study had shown that 95% of all essential medicines are available in the province and he concluded by saying that both the quality of health services and the access to health care had improved within the province.

Miss Mazibuko said a few words about the transformation process underway in the hospitals and health centres in the province. She said that the number of regions making up the province had been changed to six. She also said that two hospitals, Duiwelskloof and Phalaborwa, had been transformed into health centres and that the department was working well with local government structures in order to realign health service areas within the province.

Discussion
Ms F Marshoff (ANC) asked why there had been a decrease in the district services budget and also asked the delegation to explain the issue of attaining equity in the provision of primary healthcare.

Another member asked what percentage of the province's total budget, the health budget constituted and what was the current doctor to patient ratio within the province? He also asked why the department was not purchasing new vehicles, in light of the current flood disaster situation?

A query was raised as to what was the reason for the decrease in the prevalence of AIDS as noted on p. 8 of the department's report? How did they ascertain this, and what were local attitudes towards AIDS?

Concern was expressed about the savings recorded in each and every programme, noting that this had happened in their province, which was the second poorest in the country and at a time of budgetary constraints. What was happening with this money?

A request was made for the exact figures on how many hospitals had been upgraded, and how far the province was in the provision of home-based care?

Ms S Baloyi (ANC) asked how the department had achieved 95% availability of essential drugs and how they had achieved such a good response rate to their AIDS programme, asking exactly what programmes they were employing?

Ms F Marshoff (ANC) asked why staff costs were coming from conditional grants and when would these costs come out of the department's own budget? She also asked to what extent conditional grants had been used for the reconstruction and rehabilitation of facilities?

The chairperson commended the delegation on the fact that they had been able to supply useful statistics to the committee. He said that because of the time constraints, they would have to provide answers to the questions later in writing. [Ed note, once these answers are supplied they will be inserted here]

Kwazulu-Natal Presentation
The chairperson indicated that the Kwazulu-Natal provincial Health Department's budget had not yet been put before the Kwazulu-Natal legislature and as a result, was not to be reported on.

The superintendent general for health, Prof R Green-Thompson, gave his presentation to the committee, remarking that there had been a 1.3% increase in the province's health budget for 2000/2001 to a total of R5.5bn. He also indicated that the projected overspending of the department, would be R269m and the one main reason for the increase in expenditure was AIDS and associated illnesses. He said that the exact prevalence of AIDS was not known but that amongst antenatal patients it was 32% and across all wards, it was between 30% and 40%. Of those tested in mortuaries, 50% were HIV positive, he said, meaning that the prevalence of AIDS in the province might well be 40% in total. Effectively 40% of all funds were spent on HIV positive patients. He said that it was more costly to treat HIV positive people than those who did not carry the infection.

Prof. Green-Thompson said that there had been an increase in the rate of attendance at antenatal clinics and that 90% of pregnant women in the province were now receiving antenatal care. He also said that more patients were being received at clinics and community health centres thereby increasing the provinces total patient base. Unfortunately as a result of this, he added, referrals to hospitals were increasing putting the hospitals under greater pressure. More also had to be done, he said, in order to improve revenue collection but as far as working with local government structures was concerned, they were currently doing very well.

Discussion
A committee member asked Prof. Green-Thompson if the department was looking at reducing the total number of beds in hospitals in line with national objectives? Prof. Green-Thompson replied that in some cases, they had been able to reduce the number of beds in hospitals but in other cases, not. Overall, the number of beds had not decreased significantly, however the department was defining levels of care in line with national objectives.

Ms F Marshoff (ANC) asked how promotions within the department would affect their overall budget? The reply to this was that promotions were an ongoing process and as such, there would not be any once-off effect.

The department was asked what if they were unable to repay private companies under the PFI plan? Prof. Green-Thompson replied that his department was working closely with the province's Finance Department and that they would not make the mistake of not being able to repay private companies.

Another member expressed concerned about the King Edward VIII Hospital, noting that R15m had been earmarked for development of this hospital. Was this money still to be spent on the hospital, she asked? Prof. Green-Thompson replied that this was a multi-year budget which would account for those funds. A report had in fact shown that it would be cheaper to build a completely new hospital, which was what would be done, than to try to fix King Edward VIII, which was, "being eaten up by white ants."

Ms F Marshoff (ANC) asked whether the budget allocation of R20m for AIDS was sufficient, to which Prof. Green-Thompson replied that the figure of R20m was for prevention programmes only.

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