Department of Health 2020/21 Annual Report; with Minister and Deputy Minister

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Health

19 November 2021
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary

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Annual Reports 2020/21

The Department of Health (DoH) briefed the Committee on its Annual Report for the 2020/21 financial year.

After the onset of COVID-19 in South Africa, various programmes were affected by disruptions and many of the resources were diverted to fighting the pandemic. By September, the number of infections and lockdown levels had both reduced. South Africa soon faced a second wave of infections, which was even more vicious than the first. The two waves of the pandemic in 2020/21 financial year pushed the DoH back with the number of programmes implemented.

In spite of the difficulties COVID-19 presented, the DoH was able to recover some ground regarding the disruption of normal services. This included child immunisation, non-communicable disease treatment, and elective surgery in many health facilities.The pandemic created setbacks, such as only half of the targets aimed to be achieved, were reached.  The DoH spent 99.1% of the R58 billion budget allocated. In January, following the Second Adjustment Budget, National Treasury said DoH would receive an additional R102 billion for COVID, which was subsequently spent out of budget. The Budget of the National Health sector over the next Medium Term Expenditure Framework (MTEF) for the next three years was cut by R76 billion.

For the past ten years, the National Department of Health obtained and sustained unqualified audit opinions. However, the Department showed significant improvement in 2020/21 audits.

Members raised questions on matters including nurse training and retention rates in the provinces; speculation of a fourth wave despite low infection rates; the need for booster doses for the elderly and at risk people; vaccination of children aged 12 – 18 years with informed consent; and expenses incurred during legal costs.

In other matters, the Committee Members wanted to discuss the National Health Act (NHA) public hearings timeline, and discussed it at the end of the briefing, in a closed meeting.

Meeting report

Committee matters
Regarding the public hearings, Ms E Wilson (DA) said the DA would not accept being asked to finalise the matter in a rush. Members are overwhelmed with work after the election period and would not be doing a service to the public hearings by not giving it the deserved attention. She suggested the Committee reconvene a week before Parliament re-opens to deal with the matter.

Mr P Van Staden (FF+) said it is a very complicated piece of legislation which cannot be rushed through, as this could hamper the democratic process. Mr Van Staden asked to reconvene two weeks before the opening of Parliament or a week into the new year.

The Chairperson said the matter should rather be discussed at the end of the meeting.

Ms A Gela (ANC) said it would be an injustice to South Africans to delay the public hearing process. The process was already delayed because of the elections and cannot be further postponed.

The Chairperson allowed further comment on the matter but said it should be discussed at length after receiving the briefing from the Minister and the Department of Health.

Dr S Thembekwayo (EFF) said the matters should be discussed in a closed meeting.

Ms M Sukers (ACDP) reserved comment for the closed meeting.

Department of Health 2020/21 Annual Report
Minister’s Overview

Dr Joe Phaahla, Minister of Health, said the Annual Report for the 2020/21 financial year is premised on the National Development Plan (NDP) 2030, the Medium Term Strategic Framework (MTSF) 2019-2024, and guided by resolutions from the World Health Organisation (WHO). The MTSF aims to improve the life expectancy of South Africans to an average of just under 67 years, with the belief it will improve to 70 years by 2030, through the NDP.

The MTSF also aims to achieve universal health coverage for all South Africans progressively, to ensure South Africans are protected from catastrophic financial impact when seeking healthcare through the implementation of the National Health Insurance (NHI).

The DoH is guided by decisions of the Presidential Health Summit of 2018. The Minister said the DoH is embarking on an integrated national health system which responds to priority challenges. This includes the cultural burden of communicable and non-communicable diseases, improvement of maternal and child health, and alleviating the burden of accidents and violence.

When reporting on the financial year in context of the MTSF, the Minister noted some achievements and challenges which related to the COVID-19 pandemic. He noted there has been continuous improvement in life expectancy and reduction of various mortality trends, which was attributed to improvements in maternal and child health. This resulted in a reduction of child and infant mortality rates.

In the process of expanding various services, including human immunodeficiency virus (HIV) and tubercolosis (TB) rollout of antiretroviral treatments, the DoH continues to prepare for the implementation of NHI.

While waiting for approval of the Bill, Parliament must prepare the groundwork to ensure the infrastructure and various implementation plans are ready, pending approval of the Bill. The ongoing work towards the improvement of health is hindered by the COVID-19 pandemic, which was declared a public health emergency of international concern by the WHO before the beginning the 2020/21 financial year.

After the onset of COVID-19 in South Africa various programmes were affected by disruptions, and many of the resources were diverted to fighting the pandemic. By September, the number of infections and lockdown levels both reduced. South Africa faced a second wave soon after however, which was even more vicious. The two waves of the pandemic in 2020/21 financial year pushed the DoH back with its number of programmes.

The DoH initiated its first rollout of the COVID-19 vaccination. On 1 February the Department acquired the first consignment of 1 million doses of the Oxford, AstraZeneca vaccine, expecting a further 500,000. AstraZeneca was ineffective, therefore half a million doses of the Johnson and Johnson vaccine was used to vaccinate healthcare workers.

The Minister said, in spite of the difficulties COVID-19 presented, the DoH was able to recover some ground regarding the disruption of normal services. This included child immunisation, non-communicable disease treatment, and elective surgery in many health facilities.

2020/21 Annual Report
Performance Information
Dr Nicholas Crisp, Acting Director-General, DoH, said the disruptions in 2020/21 did not deter the Department from working towards the NDP 2030.

Programme One
Dr Crisp said the Annual Performance Plan (APP) had to be redone with certain indicators removed in each of the six programmes. In Programme one, the Equitable Share Formula Review was revised accordingly. The DoH received an unqualified audit report for 2019/20.

Dr Crisp said plans for development of medico-legal cases within the legal framework were finalised to the extent of a coherent sector-wide approach to the medical legal claims system. The case management system which falls under the Quality Improvement Programme was implemented in three provinces.

Outstanding challenges in Programme One included reviewing Conditional Grants, and continuing to roll out the Case Management System to all provinces.

Programme One faced a big re-organisation of institutional responses to the COVID-19 pandemic. During the financial year the DoH paid for a social media campaign and provided legal contributions to National Joint Operational and Intelligence Structure (NATJOINS) to look into the evidence for lockdowns.

Programme Two
The DoH formed a comprehensive response to the Committee and the National Council of Provinces (NCOP), though the Bill is still incomplete. The publication of the National Accreditation Framework for Public Health Care (PHC) facilities and general practitioners was delayed because of disruptions during the year. The Service Benefit Framework is not finalised. The Terms of Reference for the Technical Working Group on the Service Benefit Framework is finalised.

The Health Patient Registration System (HPRS) exceeded the target of 46 million people, by registering 49 million people on the system. Dr Crisp said just under 4000 facilities installed HPRS. The Master Health Facility list was started, but suffered delays because of COVID-19.

The Health Facilities Reporting Stock visibility exceeded targets in most instances, excluding hospitals. This was accelerated because of the need to monitor the vaccine, and critical stock items distributed.

The Central Chronic Medicines Dispensing and Distribution (CCMDD) changed to enable more patients to collect medicines from the system, exceeding projected targets.

The DoH aims to complete the public hearing processes for the NHI going forward.
During COVID-19, the DoH did not receive any new budget allocations for planned activities. Much of the NHI budget was moved into getting personal protective equipment (PPE’s) in facilities and ensuring the efficiency of digital systems and medicine distribution.

Programme Three
The DoH targeted a monitoring and reporting system for neonates and children under five years old, which was not achieved because of a shifting emphasis to COVID-19 patients. Dr Crisp said the systems to enable this were sustained.

Quality and Safety of Care issues were worked on, yet targets were not reached. A Mass Drug Administration (MDA) programme for schistosomiases was also not possible during this time. The DoH said the target was almost met for establishing PHC facilities in youth zones. Health messaging and promoting exceeded the target greatly due to diverting outreach methods to the digital space.
On improvements, Dr Crisp said the DoH has to put in a lot of work to reach the targets of the MDA programme. COVID is a communicable disease, and this meant engagements with the National Institute of Communicable Diseases regarding strengthening reporting capabilities, strengthening the Daily Hospital Surveillance (DATCOV) system, and institutionalising data management systems have all been accelerated. Other activities have been hindered from progressing but improvement is expected this financial year.

Programme Four
Realigning the Budget caused revision of APP targets for the primary healthcare environment. Many did not see progress. Activities which did not see growth included aims to get community healthcare workers to do tracing, which later turned into a COVID-19 Tracing Unit.

Quality and Safety Care Improvement saw drastic underperformance in PHC facilities, hospitals, and clinics. The policy on traditional medicines was not finalised because of the Traditional Practitioners Council not being established at the time.
Port Health Services exceeded the target, as more activities were concentrated in the port health space. Community participation to ensure health system responsiveness met the targets for developing training material for public hospital boards, and piloting guidelines for monitoring effectiveness of clinic committees.

On community participation, Community Outreach programmes and Client Tracing exceeded targets, while the target of recruiting additional Community Healthcare Workers (CHW) and Outreach Team Leaders did not see growth.

On improvement strategies, Dr Crisp said the National Quality Improvement Plan (NQIP) is a focus for this financial year, and is in the process of implementation.

The DoH said port health safety and screening travellers is an ongoing issue. There has been a re-organisation of focus to ensure adequate space and facilities available for providing COVID-19 services.

Programme Five
On Hospital Systems, there was a particular focus on infrastructure which enabled the targets to be met or exceeded. There was a massive refurbishment of oxygen supplies, Intensive Care Unit (ICU) and ventilation devices in all hospitals for COVID responsiveness. COVID-19 responses dominated as budgets were spent on ensuring laboratories were satisfactory. This had a knock-on effect on ICU’s, general wards, and all facilities.

Quarantine and isolation units were a major challenge for the DoH in 2020/21, which forced DoH to acquire additional bed capacities from other facilities.

Programme Six
On government resources, many targets were removed because of the shifting budget. Targets related to ensuring HRPS was working effectively, and tracking COVID-19 infections, were exceeded in the last financial year. The National Health Research priorities were identified and the targets for the year were met.

On improvements, Dr Crisp said DoH must engage with the Nursing Council to fast-track the provincial nursing colleges accreditation on various programmes. The Department continues to aim to fast-track Health Patient Registration inactivity and the interface with laboratory systems. It also aims to finalise the publication of the Interoperability Norms and Standards for Digital Health, during the first quarter of 2021/22.

Programme Six focused on recruiting doctors and nurses on short notice to get larger numbers of staff available to assist in hospitals and community outreach programmes. The Department worked closely with South African Health Products Regulatory Authority (SAHPRA) to expedite research approval and to introduce therapeutics, diagnostics, and vaccines.

Only half of the targets aimed to be achieved, were reached. While many of the targets achieved were outside the Annual Performance Plan because of COVID-19 in the beginning of the financial year.

Financial management
Mr Hadley Nevhutalu, Acting Chief Financial Officer (CFO), DoH said the past financial year was of particular difficulty to the bookkeepers and financial managers because of three adjustment budgets. This included a Special Adjustment Budget in June, Normal Adjustment Budget in October 2020, and a Second Adjustment Budget in January 2021.

The DoH spent 99.1% of the R58 billion budget it was allocated. In January, following the Second Adjustment Budget, the National Treasury said DoH would receive an additional R102 billion for COVID. However, this money was not appropriated through the parliamentary processes. The money had to be spent without it being approved. The DoH spent R612 million, which increased the expenditure to R58 billion.

Most programmes were plagued with under-spending. Programme One spent 83% due to being unable to pay officials increases over the past two years, which was dealt with this year. In September 2020 the DoH fell into a dispute over the building it was renting. The dispute was over rental fees. The DoH took residence in other government buildings, resulting in poor co-ordination and invoices being sent out late.

Programme Two spent 85% of the budget. This was due to COVID-19 protocols and system issues experienced at the end of the financial year. Many transactions were processed, though only appeared in the new financial year.

Programme Three saw marginal under-spending. This was due to numerous projects being cancelled to accommodate the reprioritisation towards COVID funds.

Programme Four had over-spending by 13.7% due to overtime payments made to the port of entry staff who had to work abnormal hours to accommodate the needs at the time.

Programme Five had marginal under-spending due to low spending on goods and services.

Programme Six saw over-spending by 0.2% of the budget due to a system issue which produced a double payment to KwaZulu-Natal amounting to R30 million. Though the money was repaid, it was done in May 2021 and consequently could not be written off from the previous financial year.

Expenditure Classification
On the Adjustment Budget, regarding economic classification, Mr Nevhutalu said of the R612 million, R462 million was spent on the procurement of vaccines, and R150 million was transferred to the Medical Research Council.

Compensation of employees saw under-spending by R1 million due vacant posts which were unfilled, and the increases which did not happen over the two years.

Goods and services expenditure only saw 80.2% of the budget spent due to non-payment of rental for the DoH building, and slow implementation of projects due to lockdown. The same reasons affected the capital expenditure, of which only 95.1% of the budget was spent.

Sector Conditional Grants
Regarding conditional grants, 100% of the Direct Grants Budget was transferred to the provinces to render services. Provinces used 97.4% of its budgets, which is marginal under-spending compared to the previous year. The biggest contributor to provincial spending was the Health Facility Revitalisation Grant which provinces spent 91% of the Grant Budget.

Provincial budgets saw a decrease in expenditure by 1.5% in 2020/21. This applied to the Free State, Gauteng, Limpopo, KwaZulu-Natal, Northern Cape, and North West, which all under-spent the allocations of provincial budgets.

National Health Insurance
All provinces spent within the budgets allocated, except for Gauteng, Free State, and KwaZulu-Natal. These provinces under-spent due to an inability to attract general practitioners and the effect of COVID-19, as some doctors withdrew from practices. No rollovers were requested, as funds were not committed by the provinces.

COVID-19 Component
The Total Adjusted Budget amounted to R3.4 billion after receiving further funding in June 2020. All provinces spent allocated budgets, excluding Eastern Cape, Limpopo, and Mpumalanga. There were delays with delivering PPE and equipment, which caused under-spending in these provinces.
KwaZulu-Natal experienced over-spending of the budget b 14.1% due to voted funds expenditure, processed against the grant.

See presentation for amounts relating to indirect grants.

Audit Outcomes 2020/21
The budget of the National Health Sector over the next MTEF for the next three years has been cut by R76 billion. The budget for Direct Grants has been reduced by R11.6 billion for the next three years. The Department has already engaged with National Treasury concerning the effects on service delivery which these cuts may have.

Indirect grants were estimated to reduce by R668 million over the next three years, which will also have an impact on service delivery.

The DoH received an unqualified audit opinion in 2020/21 and aims to receive a clean audit in the next financial year. When looking at audit outcomes per province, it was noted Gauteng, Western Cape, North West, and the Northern Cape all received unqualified audit outcomes. Limpopo saw a qualified audit outcome, which was in dispute with the Auditor General, concerning assets in 2020/21.

Discussion
The Chairperson said the health of the nation is its wealth. Investment into the health system of a country improves the health outcomes and saves the lives of the sickly. This was affirmed by the president in the State of the Nation Address (SONA) when health was recognised as a fundamental condition for growth and development, which South Africa continues to struggle with under the quadruple burden of disease.

Ms H Ismail (DA) said a mental health patient in Durban died after eating food which was a week old. The DoH did not conduct any hospital assessments on food and services due to travel restrictions. She asked what plans have been made to compensate for lost time, and if the DoH could not use officials in the provinces, considering the issues of travelling.
On compliance and monitoring, she asked about how the Department foresees the quality of compliance under the proposed NHI with the current issues the Department is facing in this regard.

Ms Ismail asked how many nurses from nursing colleges are absorbed into the Department, and what the current nurse vacancy rate is.
She asked what the reason was behind there being no money spent on screening capacity.

She said she received many enquiries on booster shots for people over fifty. She asked when this process would start or if DoH were still in a trial phase.
On ideal clinics, she asked which areas and provinces the clinics which did not qualify, were predominantly located in.

Ms Ismail asked what the Department’s total expense were for legal costs and corruption in disciplinary processes.

Mr M Sokatsha (ANC) asked about provincial under-spending on conditional grants, asking what the amount of under-spending was in each respective province.

He said provinces are training nurses and Cuban doctors using its own budget. There is no retention strategy available, while the vacancy rates are high in certain provinces and nurses are sent to other provinces to work. He asked what the reason might be for this problem.

Ms Wilson said there was unauthorised expenditure of R49 million according to the Financial and Fiscal Commission (FFC), R30 million of which was given to KwaZulu-Natal before being recovered. She asked what happened to the remaining R19 million and what the unauthorised expenditure was for.

She said there were no investigations by the DoH in Supply Chain Management (SCM), which has resulted in poor consequence management. She said the matter must be addressed quickly to avoid it continuing, while ordinary citizens lose out on the benefits of this money.

Ms N Chirwa (EFF) asked what the Department’s position was on the discontinuation of the low-cost benefit option. She said this option is primarily used by the working classes, who do not have the money and time to seek out alternative options, such as government clinics. She said the Council for Medical Schemes (CMS) has done this in preparation for the NHI, which will not be implemented in 2026. She said it is unfair to impact one of the poorest cohorts with this burden.

The DoH has been regressing yearly, while telling the Committee there has been improvements. She said there has to be greater accountability for the effects of this. She asked what the consequence management of the team is for the Minister and DoH, for failing to bring South Africans sustainable and capacitated healthcare.

Ms Chirwa was removed from the virtual briefing by the Chairperson because of inappropriate language used in the meeting,

Ms Sukers noticed a worrying trend in the organisational capacity and ability to provide leadership on the high priorities set out by government. The Department states its role as providing leadership and enhanced governance in the health sector, yet it is beset with issues severely affecting its credibility. This points to organisational inefficiency and a culture of impunity within the DoH, which allows mismanagement and corruption.

Ms Sukers said, as people dealing with those experiencing crises on the ground, it has created an emotional overload from the Department’s failures. She asked what plans are being put in place to affect organisational redesign and change in the Department. She said the credibility of the DoH is a major concern which must be addressed in communications to the nation and the Committee.
These organisational issues affect operational issues. The DoH must present on how it is dealing with the evident problems within the Department, to then progress to dealing with high priority concerns.

On procurement and strategic sourcing, she asked why government experiences difficulties in demonstrating discipline, to ensure taxpayers money are being utilised in a principled and cost effective manner. She asked what the DoH planned to do to provide capacity from a strategic sourcing level.

Ms Sukers said, concerning vaccine rollouts, processes have been compromised due to lack of research, lack of communication, and the like. She asked what research has been done to determine and track South Africa’s intention to be vaccinated; how many people intend to be vaccinated; and what research has been done to determine the causes of vaccine hesitancy.

On vaccination without parental consent, Ms Sukers said Dr Crisp went onto national television and said children from 12 years old and above can be vaccinated. Informed consent is a foundational ethical concept in healthcare, and children do not have the capacity to give this. She said this is evidence of a corrupt system and it is wrong to vilify families for being against this.

She asked how many children have been vaccinated with and without parental consent and if written formal legal opinions were given from the DoH’s legal department before making the statements made on child vaccinations. She asked if Dr Crisp obtained legal opinions from an independent senior counsel before making these statements, and if he did not, she asked why not. She said if he did, she would like the opinions forwarded to the Committee. 

Ms Sukers asked how many schools would be used as COVID-19 vaccination sites and if the DoH is planning a mass vaccination campaign of learners in conjunction with the Department of Basic Education (DBE). She asked how much money is being allocated to these planned programmes.
She noted the aim of the DoH is to improve community engagement and to re-orientate systems towards primary healthcare, through community-based healthcare programmes to promote health. She asked how the Department plans to do this and if it is willing to provision state healthcare services in the community, subject to the control of the community.

Dr Thembekwayo read Ms Chirwa’s questions, and asked about certain surgical mesh which patients received, that was corruptible. She asked what the reasons were for this; called for an internal investigation on the general mesh complication crisis; asked how many people received this information; how many instances similar to this there are in the country currently; and asked what the way forward would be for the victims. She said the DoH should consistently report back to the Committee on this request.

On discontinuation of vaginal mesh, Ms Chirwa asked how the Department plans to conduct investigations into the outcries of the survivors who are organising as mesh awareness activists in the country. She asked what the role of the South African Health Products Regulatory Authority (SAHPRA) is in this, noting it previously misled Parliament on its awareness of the matter.
Concerning Forced Sterilisation Commission deviations and exceptions, Ms Chirwa asked how the Department planned to resolve the crisis of failing to comply with this legislation.

Dr Thembekwayo said the Auditor-General (AG) reported financial statements of the DoH were submitted for auditing, but were not prepared in accordance with the financial reporting framework and were not supported accordingly. She asked why this happened and how the DoH plans to remedy it.
Some people working in the Department with private or business interests in contracts awarded by the Department failed to disclose such interests. A disciplinary process took place for some of the officials involved. She asked who the remaining officials were outside of the officials mentioned; when these officials would be identified; and when the disciplinary hearing would take place for these individuals.

Regarding Programme Six, Dr Thembekwayo referred to the AG being unable to report on the reliability of the achievement of 76 primary healthcare (PHC) facilities. She asked how the Department planned to ensure these facilities are reported on with reliable information. She asked for the latest developments on the North-West Provincial Department of Health; asked what the health promotion intervention in the Department being implemented is, with regard to antenatal care; and asked what the state of Emergency Medical Services (EMS) is in the country.

Dr Thembekwayo noticed during the election period there were very few reports of COVID-19. After the election, numbers grew and reports of a fourth wave stirred. She asked who was controlling these narratives and if it was business for companies who benefited financially from these reports of COVID-19 waves.

Mr Van Staden said in the previous report under Programme Five, approximately R85 million was wrongly paid over to provincial departments by the DoH.
 
He asked if the transaction was reversed. He said there were reports in the media of the DoH and governments selling the COVID-19 vaccines to private companies. He asked if these reports were true, and if so, he asked if private companies are now allowed to procure vaccines independent from the DoH.

He said on the latest COVID-19 statistics, the numbers are relatively low. He asked when the fourth wave can be expected, because according to the number reported lately, a fourth wave does not seem likely.

The Chairperson congratulated the Minister on an unqualified audit opinion, though he noted the AG found continuous material misstatements in the financial statements of the DoH. He asked what the plans are for the DoH to provide feedback on any action plans; if there are action plans in existence; and what progress there was to address the poor audit outcomes occurring on a quarterly basis.
The Chairperson asked what will be done by the DoH to prevent irregular expenditure in the future, and what the plan is to help provincial departments to address increasing levels of irregular expenditure.

Regarding the accruals of the Department, he asked how DoH plans to deal with accruals, including on a provincial level.

Minister’s Response
On booster vaccine doses, the Minister said the only booster offering is in relation to the Sisonke Two study undertaken by the Medical Research Council (MRC), using the Johnson and Johnson vaccine. This is because at the current stage, there is no recommendation from the WHO and internal regulators. The vaccines were approved for a particular application and usage. The DoH has only approved additional doses in specific cases of immunodeficiency conditions, including radiotherapy, renal dialysis, and auto-immune treatment upon doctor’s recommendations.

The MRC and SAHPRA approved an additional study which will entail a booster dose for healthcare workers who were the first ones to receive the vaccination through the Phase One Sisonke trials. This will enable the Department to receive further information. Booster doses must be approved through the relevant assessments and regulations. There is currently insufficient information through authorised bodies to look into offering booster doses to the general public.

On training nurses and retention rates, the Minister said this happens on a need and availability basis. The decline in budget rates impacted the provinces, which will not be rectified until revenue stabilises. The compensation of employees takes a large portion of the budget which impacts other areas such as equipment maintenance, purchasing consumables, and upgrading facilities.

Regarding investigations, the Minister said there are fairly robust checks and balances to mitigate this, including internal auditing and audits conducted by the AG. Due to the COVID-19 vaccine rollout, the DoH is audited almost on a weekly basis. Deeper investigations are conducted when the Department is alerted to a matter.

Concerning low-cost benefit systems, the Council for Medical Schemes (CMS) is mandated to protect consumers in relation to health insurance products. Products are continuously approved, and operations of schemes are looked into to ensure it is in the interest of consumers. The Minister said administration costs will be covered by members contributions. This results in very limited coverage on goods and services for consumers. He used the example of consumers being allowed three visits to the general practitioner (GP) per year. Costs are predominantly siphoned into administration rather than consumer benefits.

Addressing Ms Chirwa’s claims of corruption, the Minister said her claims were unfounded. He said months ago a research company looked into the confidence of the public in various public services. The research indicated health performed well in comparison to many other public services.
He did not dispute the pressures health professionals and the Department face, though he said the Department managed to maintain the confidence of the general public.

On organisational design of the DoH, the Minister agreed that this sector could be improved. This could be done by relooking its structure, with the help of the Department of Public Service and Administration (DPSA). He acknowledged credibility gaps in the public a few months ago. The DoH planned to communicate truthfully with the public when targets are not able to be actualised.

Regarding vaccine acceptance, the DoH conducted research into this and confirmed the vaccine saves lives. The Minister acknowledged the rollout and acceptance rates have decreased over time, though he assured the Committee the Department is doing all it can.

On vaccinating children, the DoH followed the Children’s Act, concerning medical care. It refers to medical treatment which children 12 and older are deemed to be cognitive enough of, to make decisions about. The Department encouraged this to be done with the support of parents and guardians.

The Minister assured the Committee it will receive a report on disciplinary action for officials once investigations are concluded.

Concerning private sales of vaccines, the Minister said the DoH does avail vaccines to private companies to vaccinate people covered by medical schemes. People not covered by medical schemes may get vaccinated, and are reimbursed by the Department for service and medical product costs. Government has never banned the sale of vaccines to private institutions, though the government and vaccine providers preferred the process to be done through government. This made it redundant for private companies to source vaccines when it could be done in conjunction with the government.

On the fourth wave, the Department said while infection rates are currently low, from experience a resurgence is seen to be a cyclical event driven by variants and movement of people. The Minister said this has been foreshadowed in Europe, which is currently in its fourth wave and in lockdown. He said talks of a fourth wave are more protective than based on speculation, as increased safety measures will take place.

Deputy Minister’s Response
The Deputy Minister, Dr Sibongiseni Dhlomo said on the matter of the surgical mesh, he was in discussions with Ms Chirwa on the matter, looking into the case of a particular patient. He detailed events of the patient being admitted to hospital and offering support to the patient for any further assistance required. Upon offering arrangements to receive medical assistance from the head of the Gynaecology and Obstetrics Department at a KwaZulu-Natal hospital, the patient declined the offer. Later, the patient changed her mind and was seen to by the head of the Department. The patient was assisted, and referred to another hospital where the patient was being seen to. The Deputy Minister said he was giving particular attention to this matter raised by Ms Chirwa.

On children getting vaccinated, the Deputy Minister agreed with the Minister about the Department being governed by legislation on the matter, mainly the Children’s Act. He said many households in South Africa are child-led and it is in these instances where children may exert bodily autonomy when deciding to get the vaccine or not.

Department’s Response
Dr Crisp acknowledged the difficulties experienced by the Department over the years. He said the Department currently relocated into new premises, though there are still issues surrounding the finalisation of the move.

On vacancy rates, Dr Crisp said there are many vacancies within the staff complement, some of which was prior to COVID-19. Every senior post has delegated a person to be the acting stand-in with the authority required to perform in those roles. The vacant roles were prioritised, advertised, and three of the chief director positions have been filled with appointments. The deputy director general positions were advertised, though sufficient applicants were not identified. Head hunting processes are in action, as prescribed by public service regulations.

Dr Crisp said the organogram will change going forward, as the administrative support required to build capabilities for the NHI were not filled yet. This will be done through a goods and services supply system as there was insufficient funding in the budget to create new posts. From the other directorates re-organisation is necessary because of compliance with the DPSA, and a functional shift in programmes. Many functions are being consolidated and harmonising with other programmes. Certain vacant posts will be abolished to create other posts. After this there must be an organisational restructure in the Department in the upcoming year.

The DoH meets with provincial administrations regularly, through the National Health Council Technical Committee (NHCTC). There are regular meetings scheduled four times a year, as well as special meetings planned because of COVID-19, in conjunction with the provinces.

Dr Crisp acknowledged there are numerous staff members on suspension because of digital bias. The investigation was concluded based on the initial documentation as well as other information the body gathered. The charges were formulated and presented to the suspended officials. The date has been set for disciplinary processes, based on the charges made. The process for the Director-General is managed by an external governmental body. The DoH followed due process, which accounts for the long time elapsed on the matters.

On low-cost benefit options, Dr Crisp agreed with the Minister regarding many products and packages within this price range which do not offer actual benefits to the consumers. In the next parliamentary session, further details will be provided on the topic.

Regarding vaccine rollouts, Dr Crisp said science and availability is constantly changing. The DoH conducts ample research on the matter, as well as conducting its own research. He said anyone interested in research must go to the departmental website or the South African Corona website to find the reports given to advisories and the Minister, which informs the DoH’s decisions.

The DoH has sufficient research on how the public reacts to the vaccine, providing constant information. He said the Department receives very mixed feedback due to the diverse cultures of South Africa. This information can be read on the Department’s website.

Dr Crisp said children are governed by the Children’s Act. The Department has made decisions in accordance with the medical provisions in this Act. The preferred way is for children to consult families on the vaccine, though in instances where children do not have this support, children may opt to get it without parental guidance. The Department received a legal opinion on the matter which will be shared with the Committee.

Healthcare workers are aware children and adults must provide informed consent to receive the vaccine. He said 328 000 adolescents between the ages 12 – 18 received the first dose of the Pfizer vaccine.

The DoH said it does not attempt to forecast the fourth wave, but rather does scenario planning. The team responsible considers if society should continue to use the non-pharmaceutical intervention; if so, if society has a measure of protection against spreading the virus; if society has immunity within communities; and also looks at monitoring the variants globally.

Dr Crisp said the DoH is not concerned about any new variants at the moment. If the Delta variant remains dominant the country is better equipped to deal with this on account of the long exposure since the third wave. The DoH is watching Europe and Gauteng very closely to determine patterns with the COVID-19 mutation and spread, as a precursor for the fourth wave.

Ms Valerie Rennie, Head: Corporate Services, DoH said on acquiring legal services, the senior counsels are appointed by the State Attorney’s office. Currently, the DoH does not have the cost as it is usually acquired after the services have been rendered. Under normal circumstances, government officials are used for disciplinary processes. These officials lodge claims for the cases the officials are dealing with on the DoH’s behalf.

Ms Rennie said there was only one instance of having to procure services, which was the investigation on the digital bias. Approximately R497 000 was spent on this.

Mr Ramphelane Morewane, Chief Director: District Health Services, DoH said concerning food safety in hospitals, it is very unfortunate the patient passed away in hospital after consuming old food.

Mr Morewane said the Department works with the Office of Health Standard Compliance (OHSC), as well as internal measures in the ideal hospital framework processes to ensure food safety in hospitals.

The process is augmented with a Nutrition Service Level Assessment tool to assess 98 health facilities which are providing food for inpatients as representative of food safety in hospitals, as it makes up 35% of the total healthcare facilities. The DoH plans to visit all hospitals over the next two to three years from the present day.

Mr Morewane said clinics failing to maintain ideal clinic status were predominantly in the Eastern Cape. This is not surprising as the province has the highest number of clinics. He also attributed this to the rural nature of the province. Shortly after Eastern Cape came Limpopo, Mpumalanga, and the Northern Cape. The ideal clinic tools are aligned with the OHSC to do the baseline assessment, afterwards only external assessments are necessary.

Dr Maggie Ravhengani, Director: Human Resources for Health (HRH), DoH, said the process regarding nursing retention rates entails posts being advertised, though only the best candidates are selected for retention.

There are 39 650 nursing assistant posts, out of which 35 946 are filled with vacant posts, amounting to 3704. Staff nurses amounted to 36 961, out of which 31 766 were filled and vacant posts amounted to 5195. Registered nurses amounted to 73 509 posts, out of which 64 016 posts were filled with 9493 vacant posts. Managers amounted to 21 694 posts, out of which 17 723 with 3971 vacant posts. The total vacant posts accumulated to 22 363.

Mr Nevhutalu said the audit was a difficult process for him as he was appointed at the tail-end of the financial year. On material misstatements, he said two days before receiving the final audit outcomes there were four material misstatements resulting in a qualified report. The issues related to Immovable Tangible Assets, which was later resolved. Other issues related to payables, receivables, and the Cuban programme.

To mitigate the Cuban programme issue, Mr Nevhutalu brought the financial management team to the Chief Financial Officer (CFO) office, where each province was visited to assess each of the students for auditing, which gets signed off by the CFO office by 17 December. There will be a follow-up assessment towards the end of the financial year.

Regarding unauthorised expenditure, the system issued a double payment of conditional grants. The Office is currently busy with the half yearly review of conditional grants to all the provinces, and there was overpayment of employees in port health, though this did not result in an overall over-expenditure in the Compensation of Employees Sector.

The over-payment in Programme Six was refunded by the KwaZulu-Natal province, though not in time to reflect on the 2020/21 financial statement. He said National Treasury was assisting with the correction of this issue.

Regarding accruals, he said this amounted to over R15 billion as a result of medical legal claims. He attributed this to there not being a budget provincially for medical claims. The DoH requested all provinces to come up with cost containment measures. He encouraged provincial departments to make use of treasuries to acquire additional funding where possible.

On procurement and SCM, he said there is no dedicated unit to deal with contract management, however this was corrected in the new organogram structure.

On under-spending on conditional grants in the provinces, he said provinces were allocated R52.6 billion where only R51 billion was spent. The provinces may request a rollover of the under-spent money if able to substantiate where the money will be spent, but this excludes grants paying for the compensation of employees.

On health promotion, Mr Morewane identified a number of services impacted by COVID-19. The Continuity of Essential Services programme receives updates from a health information system. Numbers were affected, but this did not impact the overall service delivery.

On the Cuban programme, Dr Crisp said over the past four years the absorption in the Eastern Cape has been 247, in the Free-State, 176, in Gauteng, 401, in KwaZulu-Natal, 663, in Limpopo, 313, in Mpumalanga, 175, in Northern Cape, 358, and in the North West, 105. The total amounted to 3434 during this period.

On Emergency Medical Services, Dr Crisp noted many challenges. In rural areas there are many problems where the government does not have sufficient ambulance coverage because of poor road infrastructure, and cannot afford to maintain ambulances. He said he would provide a more detailed report to the Committee at a later date.

Further discussion
Mr Van Staden said his question referred to the Fourth Quarterly report. Under Programme Six, R21.3 billion was spent out of an available budget of R21.2 billion, with an over-spending of R54.4 million. This was attributed to the transfer of subsidies. An amount of R85.5 million was erroneously spent on the Health Facility Revitalisation Grant. Provinces were asked to repay the excess money. He asked if the money was repaid to the DoH.

Ms Sukers thanked the DoH for answering the essence of her questions concerning the competency of children to receive the vaccine without parental guidance. She asked if the Department was planning a mass COVID-19 vaccination campaign of learners, in conjunction with the DBE; and asked how much money will be allocated to these programmes, if planned. The issue of informed consent regarding child vaccinations should be further looked into in the public hearing processes.

Mr Siwela said the country has an unemployment rate of 44%, while the Department has 22 000 unfilled posts. He asked what the reason could be for that and asked if the DoH has the intention of filling the available posts.

Ms Ismail asked what the total costs for legal fees and disciplinary proceedings were in 2020/21. She asked for this to be provided in a breakdown per province.

The Chairperson referred to food safety, and said there have been other instances, such as Koo cans being recalled and three children passing away from ingesting noodles. He asked if the Department has a role to play regarding this, and what it plans to do to bring awareness to food safety.

The Minister said there are divisions dedicated to Environmental Food Safety, and Quality Control in various aspects of food safety.

Regarding mass vaccination at schools, the Minister said there are no plans to conduct a programme of the sort. He said vaccinations of 12 – 17 year olds will be done in normal vaccination and mobile sites as a single dose vaccine, unless otherwise requested by the DBE.

The Minister agreed the DoH prefers parents to bring children to vaccination sites, though in certain circumscribed circumstances children will be permitted to receive the vaccine with informed consent.

On vacancies he said overall provinces and health facilities plan to fill vacancies, but are challenged with being able to compensate employees, along with providing all other aspects of comprehensive medical services. The posts are approved but lack funding.

Mr Nevhutalu said, on the R85.5 million owed, the entire amount was refunded to the DoH by the Western Cape and KwaZulu-Natal proportionally.

On food safety, Mr Morewane acknowledged many problems with food control within and outside the Department. The Environmental Services team has been hard at work since the publication of the noodle fatalities. The team found it has been fairly inconclusive regarding linking the food to the passing away of the children. Statements will be reserved for when more conclusive findings are known.

The Department is hard at work in providing methods of food control. This includes teams on Food Control, and Nutrition and Environmental Health working closely together to ensure instances of fatality does not re-occur. He said it is most likely the problems lie with informal traders who are subject to the local laws and authority, meaning the DoH has no direct control over this.
The Minister said a written report will be issued to the Committee regarding the total legal costs of the DoH.

The Chairperson mentioned the presentation dealing with ex-mineworkers, which will be coming up before the Committee, and hoped for support from the Department on the matter.

Dr Thembekwayo said the NHI public hearing discussions should take place in a closed meeting.

The Chairperson agreed and all external parties were removed from the virtual briefing.

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