National Health Budget: briefing

Meeting report

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

Documents handed out:
Health Budget
Cluster: Non Personal Health Services
Cluster: Financial Management
Cluster: Corporate Services and External Relations
Cluster: Maternal, Child and Women's Health
Directorate: HIV/AIDS and STDs
Pharmaceutical Services
TB Control Programme
Cluster: Health Information, Evaluation and Research
District Health System - Performance Framework (1999/2000)
Cluster: Facilities Planning and Hospital Services

SUMMARY
The following clusters made presentations:
Non-Personal Health Services, Financial Management, Mental Health and Substance Abuse, Maternal, Child and Women's Health and AIDS/HIV and STDs. After each presentation, questions were put forward by the committee members to the officials of the Department of Health and in these questions, a number of serious concerns were raised by the members.

MINUTES
The chairperson, Dr S Nkomo, opened the meeting reminding all the members that it is the role of parliament to provide oversight of the department. The department, he said, was taking parliament seriously, holding themselves accountable, and it was therefore the duty of every committee member to stay at the meeting for the whole day. He welcomed to the meeting, the Minister of Health, Ms M Tshabalala Msimang as well as Ms Jacobus, the chairperson of the Select Committee dealing with Health in the NCOP.

Mr Harm Pretorius, the acting Director General (DG) of the department of Health thanked the members of the committee for the opportunity to speak to them. He said that the department's position had strengthened ever since 1994 and that they are at the stage at the moment, "of really making things happen". The Directors General, he said, "can brag about what they've achieved." He introduced Mr G Sekobe, the cluster manager for Non-Personal Health Services.

Cluster: Non-Personal Health Services
Mr Sekobe gave a presentation to the committee (see document) wherein he said amongst other things, that his unit was within their budget for the previous year and "not expecting any problems" with the budget for the coming year. He outlined some of the areas that his unit was concentrating on, including the Medical Bureau for Occupational Diseases and the National Centre for Occupational Health. Members of the committee put questions to Mr Sekobe.

Dr B Mbulawa (ANC) asked for greater details on the transformation of the Environmental Health department, and in particular the Port Elizabeth Technikon where environmental health was taught. Mr Sekobe replied that a consultation forum had been held in Mafikeng where it was agreed that the way national environmental health was being provided at the moment was not in line with the department's policy and as a result, the laws governing this would be reviewed. There would also be a re-curriculation and standardisation of institutions providing courses in this field. This would be done by August.

Ms S Baloyi (ANC) asked why there were fewer benefit medical examinations than expected. Had miners from outside South Africa been considered for these and what was the general strategy in this regard? She also asked why the disposal of effluent in Gauteng had not been properly managed and what was being done about this problem?

Mr Sekobe replied that the issue of health examinations for miners from outside South Africa, particularly Botswana, would be addressed in consultation with other Southern African Development Community (SADC) countries, at the next SADC conference. The strategy guiding benefit medical examinations, had been transformed and these are now taking place at centres around South Africa, not just in Johannesburg. More general practitioners (GPs) had been brought in to assist with this programme but the department did not receive the flood of applications for such examinations which they had expected.

With regard to the disposal of waste on mines, this was partly the responsibility of the Department of Mineral and Energy Affairs. A 1996 Act had transferred responsibility and his department therefore had very little authority in this area, however he reassured the committee that things were being done to address this issue.

A committee member asked about the regulation of cosmetics, remarking that there were some hair products on the market which "smelled like brake fluid."

Mr Sekobe said that generally mainstream salons were using products that were safe, however some informal salons were using unsafe products. Efforts would have to be made to assess the chemicals used in these products.

Ms F Marshoff (ANC) asked about the implementation of the department's policies in mine hospitals. She remarked that the skills levy, which was due to be implemented, had not been budgeted for by management of certain mines and that they were also not complying with the Medical Schemes Act. The private sector was "running amok", she said.

Mr Sekobe replied that his department had no direct control over mine hospitals. They were managed under the Mines Health and Safety Act and its implementation was the responsibility of the Department of Mineral and Energy Affairs.

The chairperson remarked that it was the responsibility of the Department of Health to ensure norms of health and safety were being adhered to, even though other departments also have responsibility in some areas. He stated that this would need to be revisited. "We do not want a number of separate health departments in one country." He indicated that he did not expect a response to this statement there and then. He asked Mr Sekobe to say a few words about the AIDS problem.

Mr Sekobe said that condom usage in particular had been promoted together with the general HIV/AIDS message. His directorate was working together with Dr Msimang and the AIDS directorate and generally, they were concentrating on communication strategies.

Another member asked about medical waste disposal and how long it would take for proposals regarding this to be put into effect. In one area, she said, people are living in the immediate vicinity of a hospital waste dump and despite efforts to stop the hospital dumping there, nothing was being done. She also asked in which three provinces the pilot programme on HIV/AIDS, would be run. Another member also asked about health and safety in regard to industries other than mines and another, about the department's policy on car rentals.

In response, Dr Sekobe indicated that the three provinces, in which the pilot programme on HIV/AIDS would be run, are the Eastern Cape, Kwazulu-Natal and Northwest. The chairperson said that due to time constraints, the unanswered questions would have to be addressed later. He excused the minister from the meeting for a while and introduced Mr Muller from the department's directorate of Finance

Cluster: Financial Management
In Mr G Muller's presentation (see document), he indicated that approximately R50bn was being spent annually across South Africa's entire health sector. He said that the national department's budget for the year was R6.3bn. There were unspent funds from last year, he said, but these were due to conditional grants and were mostly intended for capital expenditures. He answered questions from the committee members.

Ms F Marshoff (ANC) enquired as to the reason for the saving in Programme One. She asked what support was being given to the provinces in respect of the cost centres which were being introduced and also in this regard, whether or not a survey with the Department of Finance had been done. She also asked what reporting mechanisms were in place for the HIV conditional grant.

Mr Muller said that a new deputy DG was to be appointed and this unfilled post would account for much of the savings. The cost centres, he said, were being driven within the hospitals themselves. The department, through national programmes, was also getting a better handle on the funds being spent on health and the monitoring of conditional grants had to be done through programmes within each province.

Dr S Gous (NNP) asked about the growth of the budget of 6-7%, which was in line with inflation. Shouldn't we be publishing a separate health inflation rate, he asked? The perception is that such a rate would be higher than overall inflation. Is this correct? He also asked where in the budget, the minister's costs are budgeted for?

Mr Muller responded that inflation in the cost of health was higher than the overall rate of inflation, primarily due to the devaluing of the Rand against other currencies. The department was looking at what they could do about this. The minister's costs (including advisors) fell under Programme One he said, and these amounted to R1.4m last year.

Another query was raised about the budget amount for HIV/AIDS quoted in Programme One. What exactly does this represent?

Mr Muller pointed to the figure of R51m which represented the department's overall AIDS/HIV programme.

Another member asked if there was any unauthorised expenditure in the department. Mr Muller replied that there was not, although with 1200 staff, one could never be sure. The department's controls were good with a committee meeting twice a week to screen all major expenditure.

Dr R Rabinowitz (IFP) asked Mr Muller to point out in his presentation, the headings under which each programme falls. Further was there any plan to compile a national database of health records of the public and whether there were any partnership initiatives with international bodies with respect to AIDS/HIV?" She pointed to the budget item 'Stores and livestock' and asked "Are chickens kept in the hospitals?"

Mr Muller responded that he was not aware of a database being put together at the moment and that there was good co-ordination in the AIDS/HIV programme. He said that with the advent of the Public Finance Management Act (PFMA), the item, 'Stores and livestock' would be changed to 'Inventory'.

A member asked what was the impact of all the car rentals being done through one company.

Mr Muller replied that previously most transport for the department came from the government garage. In line with the Department of Transport's plan, they had now signed a six-year contract with Imperial Car Hire. There were initially some problems with this system, but it was subsequently working well.

There was a query on the increase of the figure for hospital rehabilitation from R200m to R400m. What had made the expenditure rise so fast and where does this figure come from?

Mr Muller replied that approximately R9bn was needed to bring all hospitals up to speed. The provinces submitted plans which were discussed at a national level, and then funds were allocated.

The chairperson indicated that the presentation by the AIDS Directorate would have to wait till after the minister returned, therefore the next presentation would be that on mental health and substance abuse. Ms S Kalyan (DP) then questioned when the minister would in fact return. There was a further interchange between the chairperson and Ms Kalyan about the change in the schedule of the meeting before it was decided that the presentation on AIDS/HIV would indeed take place later. The chairperson then welcomed Prof. Friedman to give his presentation on mental health and substance abuse.

Cluster: Mental Health and Substance Abuse
Prof. Friedman made his presentation (see document), indicating that much had been achieved in the previous year, including good progress on reviewing the Mental Health Act and a number of policy documents in Parliament, and strategies for primary and secondary mental health care being developed. He invited questions from the committee members.

Ms F Marshoff (ANC) asked whether it was a bill or a white paper on mental health and how soon would it be brought before parliament? She also asked how far were the surveys that were being conducted?

Prof. Friedman replied that at this stage there was a draft Bill on mental health care, but it was still out for public comment. The surveys that were being conducted, were initially only done in mortuaries, on causes of death, but that they were now being expanded in conjunction with a United States institute.

Dr R Rabinowitz (IFP) asked whether the national Drug Master Plan included alcohol? Did not the community services role of the Health Department represent an overlap with that of the Department of Welfare? Were the mental problems of young people being addressed? Was this area receiving the necessary funds?

Prof. Friedman said that warning labels for alcohol products were being considered, but that this would fall under next year's plans. His department was working to check that there were no overlaps with other departments. Their budget had doubled from R2.5m to R5m, but this was still a small amount, he said.

Dr E Jassat (ANC) asked whether the tot system on farms was being addressed as well as the problem of rural bottle stores selling illegal substances? He also asked whether the department was failing its obligations in respect of granting liquor licences when some outlets were quite filthy?

Prof. Friedman said that he was aware that use of the "dop" system was still going on in some areas, even though it was not legal and this was being addressed. The Department of Trade and Industry (DTI) was responsible for granting liquor licences but where health issues were overlooked, there would definitely be consultation with them.

Dr B Mbulawa (ANC) asked whether implementation of the Liquor Act was being monitored, noting that in some places, there were shebeens right next door to schools? Also, were the needs of patients being cared for in the community, in respect of crime, being looked after?

Prof. Friedman said the issue of shebeens being right next door to schools would be addressed in conjunction with DTI and as for patients in the care of the community, yes, their needs were being looked after.

Another member asked whether the de-institutionalising of patients in mental hospitals was being done in conjunction with the Department of Welfare?

Prof Friedman indicated that the rehabilitation of patients was being handled with the Education and Welfare departments and in fact, more of these people could be in the community.

Ms S Kalyan (DP) asked whether the counselling training of nurses was being taken care of, to which it was not apparent that Prof. Friedman provided an answer.

Another member asked whether after-care services were being provided for de-institutionalised mental health patients?

Prof. Friedman replied that de-institutionalised people were not just being discharged into the community. The department was trying to spend the same amount of money on the care of each patient both before and after being discharged from a mental health care facility into the community, although in practice this was not easy. NGOs could help in this regard and funds were being spent on, for instance, day-care facilities as well as on assisting the families of de-institutionalised people.

Dr R Rabinowitz (IFP) asked whether additional taxes on alcohol were being considered but Prof. Friedman did not address this question.

Another member asked whether the implementation of mental health was being done at a national or a provincial level to which Prof. Friedman replied that policies were determined at a national level, but the implementation thereof was done at a provincial level.

A question was raised about who was responsible for hospitals and was the recommended closure of Mzimkulu Hospital still on the cards in the light of public opposition to its closure? Further, was there any interaction between the Departments of Health and Education, with respect to teaching people with learning disabilities?

Prof. Friedman said that the general issue of hospitals would have to be looked at on a national level and that important issues in this regard would be addressed. Dr Stamper, he said, would answer the question on the Mzimkulu Hospital, because it is a provincial issue. If this hospital were to be closed down, he said, that would be a problem. The rehabilitation of young people, he said, as indicated earlier, was being handled in conjunction with the Education and Welfare departments and more of these people could be in the community.

Another member asked, with the chairperson restating the question, about provincial inequalities in mental hospitals. Frustration was expressed about these continuing inequalities, and were standards not being put in place?

The implementation of norms and standards across all the provinces had to be looked at on a national level, Prof. Friedman said. This issue would definitely be addressed

Another member asked how the Groothoek hospital was serving the province and what was the current state of this hospital? She also asked what was the state of traditional healers in respect of mental health care?

Prof. Friedman replied that some wards at Groothoek had already been closed, but the relevant provincial representative should rather address the issue. With respect to traditional healers in mental health care, he said that on the whole, they had an important role to play, but in some cases their role was a limited one.

Cluster: Maternal, Child and Women's Health
The chairperson introduced Dr Mahlanga, the Chief Director of the Maternal, Child and Women's Health cluster. Dr Mahlanga gave a presentation (see document) of the budget for this cluster. She indicated that of the various areas of concentration within her cluster, overall the bias was on women's health issues. However she also indicated that South Africa had ratified the UN Convention on the Rights of the Child and was in fact, co-chairing that initiative. This issue was traditionally seen as falling under the Welfare Department but it should be seen more as a crosscutting issue, definitely also involving the Department of Health. She indicated that South Africa's immunisation programme was now covering approximately 60% of all children, which represented a big achievement. Youth and adolescent health issues were very important.

The maternal mortality rate had been decreased but more work was needed in order to address the issues surrounding this. The goal was to reduce the rate to below 100 in 100 000 whereas it was currently estimated at 150 in 100 000. Another goal of the department was to improve access to termination of pregnancy (TOP) services. This was being done through the training of more midwives. Unsafe TOPs caused 50% of all cases of maternal mortality. One other "gold medal" aimed for by the department, she said, was to be polio free by the end of the year.

The Chairperson thanked Dr Mahlanga and indicated that due to time constraints, it would not be possible for her to answer the committee's questions. Instead, he said, they would move straight on to Dr Similela's presentation on AIDS/HIV and STDs.

Directorate: AIDS/HIV and STDs
Dr Similela gave her presentation on AIDS/HIV and Sexually Transmitted Diseases (see document) wherein she indicated, amongst other things, that with respect to AIDS, the department had two goals. The first, was the prevention of AIDS and the second, the mitigation of the effects of infection. Members asked Dr Similela a number of questions.

Dr E Jassat (ANC) asked whether STDs were being handled as effectively in the private sector as in the public sector? He also asked whether or not there had been any success in reducing the AIDS rate, and if not, why not? Dr Similela replied that protocols were being put in place for private GPs and as far as the prevalence of the disease was concerned, it was not going down. All efforts were long term in nature so results could not be expected before three to four years.

Dr R Rabinowitz (IFP) congratulated Dr Similela on the amount of work being done by the directorate. She asked the following questions:
 Are there any incentives for openness in those who are HIV positive?
 What is the cheapest AIDS test currently available, how much does it cost and has the department investigated saliva testing?
 Is there a big enough sample base of willing people in order to test for AIDS infections?
 How is the denial factor being addressed?
 Who is paying for the role of the provinces in addressing the AIDS problem?
 With regards to NGOs requiring a business plan before being given funds, is this not "putting the cart before the horse?"

Dr Similela said that they were driving a massive campaign on openness and disclosure, which should see results in approximately one year's time. The cheapest AIDS test, she said, costs R10 and saliva tests were not reliable according to the United States Centre for Disease Control (CDC). They were therefore using a test, which required a spot of blood from the finger, and the department had in fact received one million free test kits. Those most at risk she said, were in fact literate people who did not believe they were at risk. High-risk people such as commercial sex workers were listening to the department's message. She also said that if NGOs did not provide reports it would be difficult to know how much money they were spending although the department would not be totally inflexible where there was a lack of business plans, especially with regards to community-based organisations.

Ms F Marshoff (ANC) repeated Dr Rabinowitz's congratulations to the directorate, and asked the following questions:
 What is the total amount of money being spent on AIDS?
 Are officials in the department not setting up their own NGOs for profit making reasons and if they are, how can this practice be avoided?
 How can HIV infections among health workers be prevented?
 Was there accreditation of material used for AIDS education?
She also expressed concern that AIDS counselling services were not always effective and said they should be uniform.

Dr Similela replied that there was a problem with the fraudulent use of funds among NGOs which was being addressed and as far as training counsellors was concerned, the department had a minimum standard for lay-counsellors, and she would see to greater implementation of this standard. An audit of the material used for training counsellors had been done and this material was being reviewed. She noted that it was up to the provinces to address disparities and to each bring themselves up to standard.

Dr B Mbulawa (ANC) commented that training for AIDS counsellors was available but that it was expensive. Where would the money come from for this training? Also was TB being addressed sufficiently? With regard to AIDS counselling, was any support being given to churches for playing this role? They are one of the most important groups in the process.

Dr Similela replied that one of her colleagues would address the issue of TB and that as far as churches were concerned, they would be used where they had strengths in the community, for example, in giving support to those who were infected. The use of home-based care would be emphasised, through NGOs. The department wanted to avoid getting into arguments with churches about the use of condoms, she added.

Another member expressed concern that some of the funds being given to NGOs wasn't getting through to the people for whom it was intended, and he asked whether these NGOs were still receiving funding, when they were clearly inadequate?

Dr Similela said that in some cases it was difficult to ascertain exactly what NGOs were spending funds on.

Another member also expressed appreciation for the amount of work being done by the directorate and reiterated Dr Mbulawa's comments about the importance of the role of churches. He also asked what was being done in respect of vaccine research, and indeed how close are we to a cure? Dr Similela did not seem to provide an answer to this question.

A member asked how South Africa's efforts in combating AIDS compared to other African countries and Dr Rabinowitz asked specifically about the Ugandan experience with Neviropene? Was South Africa examining the possible use of this drug?

Dr Similela replied that South Africa's experience could not be compared to that of Uganda's. In Uganda the rate of infection was very far advanced and massive behavioural changes had occurred as a result. In South Africa, the same behavioural changes could not be expected. With regards to Neviropene, there was only now an application for the registration of that drug and she noted that some concerns had been expressed about the problem of resistance to the drug being built up. South Africa was getting together with other African countries to discuss the AIDS problem, Dr Similela added.