Health Budget: Northern Cape, Mpumalanga and Free State

HEALTH AD HOC COMMITTEE
14 June 2004
HEALTH BUDGET: MPUMALANGA, FREE STATE AND NORTHERN CAPE SUBMISSIONS

Chairperson: Mr J Nculu (ANC)

Relevant Documents
Mpumalanga Budget Hearing presentation Part1
Mpumalanga Budget Hearing presentation Part2
Mpumalanga Budget Hearing presentation Part3
Free State Health presentation
Northern Cape presentation
Free State Answers to Questions
Northern Cape Answers to Questions
Northern Cape Budget Submission

SUMMARY
The Health Departments of the Mpumalanga and Free State Province presented the Committee with their 2004/2005 budgets. The provinces made detailed presentations emphasising their key achievements, priorities and challenges. The Committee was especially interested to know the problems faced by the provinces in retaining rural staff. Committee Members asked searching questions about medical supplies, and service delivery. Both provinces expressed the need for more ambulance vehicles.

The Northern Cape Department of Health informed the Committee that its emphasis on accelerated service delivery is reflected in the improved access to health care service in all districts and the revitalisation of hospital services among other key priorities. The Committee welcomed the Department's commitment to excellent services especially in the Kimberley hospital, which is renowned for its outstanding service to the people of the province. The Committee however urged the Department to extend this level of excellent hospital service to other institutions in the province.

MINUTES
Mpumalanga Province submission
The delegation comprised of Mr S Lubisi (Mpumalanga MEC), Mr H Verachia (Deputy Director General), Mr R Mnisi (Chief Financial Office), Dr K Michael (Chief Director: Hospital Services), Ms G Mathebula (Chief Director: Primary Health Care), Ms R Manyamane (Director: Human Resources), Mr J Mlangeni (Deputy Director: Communication), Ms P Gwala (Deputy Director Finance: Strategic Planning), Ms P Rousseau (Deputy Director: Office of the Deputy Director General)

The MEC started the briefing with an overview of the key achievements and challenges of the province.

Mr Verachia led the Committee through the presentation document. The focus was on the key achievements and challenges against the National Department's ten-point plan. The Committee was given an outline of the province's mission and value statement, the key priorities for the next three years, and a brief description of the budgetary trends from 2000/01-2006/07.

Discussion
Mr I Cachalia (ANC) wanted to know which level 2 and 3 service specialities were catered for. He asked what tertiary services were available. He also wanted to know the component of human resources in health and allied professions, including any backlogs.

Dr Michaels responded that there was only one hospital that offered the prescribed package for level 2 services. Specialist services were offered at that hospital. These services included surgery, internal medicine, paediatrics and family medicine. There were also sessional specialists among the full time specialists that offered services such as ear, nose and throat. Dr Michaels said that there were two hospitals providing a small range of tertiary services. The province rendered six tertiary disciplines. For these tertiary services the province received the National Tertiary Services Grant.

Ms T Ngcobo (ANC) asked whether condom use education referred to the male or female condom. She asked if the female condom had been distributed at all. She also asked what the level of immunisation coverage was. She wanted to know whether the mobile services in the province were adequate. She also wanted to know if the province screened women for breast cancer. She asked what would happen to the savings in the budget. She also wanted to know how the empowered hospital boards were constituted.

Mr Verachia responded that the Department of Health in the 2003/04 financial years had encountered certain administrative problems that caused the savings. The lack of administrative capacity had been resolved by the appointment of ten directors and two chief directors. He stated that not much emphasis had been placed on the transitional arrangements. This was an area that required urgent attention. In the interim, staff was trained about the roles and functions of clinic and hospital boards.

Ms G Mathebula stated that both the male and female condom had been distributed around the province. In addition the province had maintained a 90% immunisation rate. Through the Management of Childhood Illnesses Programme emphasis was placed on the immunisation of children under the age of five. Breast cancer screening was provided for in the Mother-Child and Women's Health Programme.

The Chairperson commented that the National Department of Health had said that there had been a problem in the supply of the female condom. In the previous year only 194 000 had been distributed nationwide. The chairperson wanted clarity on the distribution of the female condom in the province if there had been a shortage nationwide.

Ms G Mathebula responded that the demand for the female condom was not high. Although there had been a shortage nationwide the province had a supply of the female condom.

Dr A Luthuli (ANC) wanted to know why the province was under spending. She asked if there were any hospital boards at the moment. In addition she asked what the rural staffing position was. She wanted to know in particular the problems associated with rural staffing. She also waned to know the effectiveness of the tele-medicine programme in helping community health workers.

Mr Verachia responded that rural staffing was a serious challenge. This problem was compounded by the incorrect designation of rural areas as urban. This meant that rural areas that were meant to get the Rural and Scarce Skills Allowance did not get that allowance. Re-designation of the areas was necessary. The province had managed to recruit 1006 people. He stated that a head hunting exercise had been embarked on. The province was in close link with the Medical Research Council. The province intended to strengthen tele-medicine because of it was effective in bringing health care to people in the rural wereas.

Mr Y Wang (ID) said that one of the key priorities for the next three years was the health information system but this system did not appear to be budgeted for. He asked if the system was related to the national system discussed by the National Department.

Dr K Michaels responded that the health information system had two sources of funding which were not reflected in the budget. These were the Italian Corporation and the Management and Quality Improvement Grant

Ms P Tshwete (ANC) wanted to know what incentives there were for home based volunteers, health care workers and lay councillors.

Mr Verachia responded the 680 home care based volunteers were given R500 per volunteer. From the 1^st of April this amount had been increased to R1000 per community health worker. There were no specific incentives. He said that the needs of this category of personnel needed to be addressed.

Mr S Nxumalo (ANC) wanted to know if the province had received any donor funding. If so, how much and how had it been spent.

Mr Verachia responded that the province had received no donor funding for the year 2003/04

Ms R Mashigo (ANC) commented that 90% of the rural population was dependent on public health services. She wanted clarity on the outreach programme. She suggested that mobile clinics could be the solution. She also wanted to know how the emergency services were coordinated and by whom.

Dr K Michaels responded that the emergency services were coordinated from the provincial office. This was done mainly through three control centres in each of the districts. Most of the ambulance stations were based in the actual hospitals. The local hospital management worked closely with the ambulance stations. There was a need to increase the number of vehicles and personnel to ensure that the rural wereas were serviced. He said that the response times were 50% of what they should be.

Ms G Mathebula said that each of the three districts have two or more district hospitals. The district hospitals were referral hospitals for the 24-hour service clinic. The district hospitals have a number of satellite clinics, which were eight-hour clinics that referred matters to the community health centre or directly to the district hospital. The mobile clinics visited those areas where there were no health services. This referral network served rural wereas. Tele-medicine was taken to the most rural areas where the referral network would not have benefited the rural communities. Telemedicine was particularly effective in diagnosing patients where there were few senior doctors to do so.

Dr A Luthuli (ANC) asked how the rural doctors in the rural areas were supported. She wanted to know the movement of senior doctors from provincial to district hospitals and clinics. She commented that doctors in rural areas needed to be given support to prevent them becoming demoralised. She wanted to know the effectiveness of drug supplies to rural areas.

Mr Verachia responded that drug supply was a cause of concern because of the vast size of the province. The turn around times for drug supplies to rural areas was quite narrow. Staffing was a challenge. The province competed with the other provinces to attract professional staff. The province needed to come up with a strategy to attract staff. He also stated that Shongwe Hospital now had 25 doctors from the nine it previously had.

Ms M Manana (ANC) asked whether the province had budgeted for all types of persons that fall under the home care based volunteer category. She also wanted to know if the province was using DDT for malaria prevention
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Mr Verachia responded that the home care based volunteers category had been included in the budget for the financial year. These people had to undergo a 59-day training programme. They also had to sign contracts.

Ms G Mathebula stated that the province used DDT for malaria prevention.

Mr S Njikelana (ANC) asked what impact the appointment of Chief Executive Officers (CEO) had. He also wanted clarity on labour relations. He asked what the level of utilisation of the patient hotline was.

Mr Verachia responded that labour relations were an issue. The province intended to strengthen the labour relations unit and ensure that labour concerns were tackled. Rehabilitation services were an area that required attention. The patient hotline was launched at the end of March 2004. The province had not yet had the opportunity to assess patterns of use over a longer period.

Dr K Michaels said that the CEOs improved the reporting structures and coordination of hospitals. The desired impact of the CEOs had not been felt because CEOs had not been issued with delegations. This situation was been rectified. The province together with National Department had drawn up job descriptions and delegations for the CEOs.

The Chairperson wanted clarity on the drug supply situation that existed before. He also wanted clarity on the number of sites.

Mr Verachia responded that the province identified 12 sites for accreditation. Of the 12 sites six were accredited in February 2004. Of these six sites Shongwe and Witbank were ready. The four remaining sites would be ready by the end of July. The existing pharmaceutical depots had inadequate structures. There was a need to construct a depot that was centrally situated

Ms T Ngcobo (ANC) asked what impact the supply of services to person from Mozambique and Swaziland had on the budget.

Dr K Michaels responded that the impact of the foreigners on the budget was unclear. The collaborations with Maputo province may be able to clarify these figures.

Ms G Mathebula stated that free health services to the disabled had been launched. Disabled persons that passed the means test qualified for free health services.

Free State submission
The delegation from the Free State province comprised of Mr S Belot (Health MEC) and the Head of Department Dr V Litihakenyan

The Head of Department led the Committee through he presentation. He touched upon the vision and mission statement; corporate goals; the strategic plan; achievements on strategic objectives; the 2004/2005 budget; and the challenges and priorities for 2004/2005.

Discussion
Dr A Luthuli (ANC) asked what the demographics of the province were. She wanted to know whether the province had any difficulty retaining staff and how this was dealt with. In addition she wanted to know the monitoring and financial incentives for staff.

The MEC responded that geographically the province had 80 towns. The achievements of the Health Department have reached 74 out of the 80 towns. Some of the towns were densely populated while some were sparsely populated.

Dr V Litihakenyan said that it was difficult to set up a 24-hour service in the sparsely populated areas. In the rural areas health professionals receive additional financial incentives. He said that mobile services helped reduce turn around times from 4 weeks to 2 weeks. The province had mobile dental services. The staff for these mobile services worked under difficult conditions and must be retained. There were further none financial incentives that were provide to retain such staff.

Mr I Cachalia (ANC) asked if there were proper patient records and filing systems at all the clinics. He asked if there were any proper stock control sheets. He asked if there was an adequate and regular supply of medicines. He wanted to know if there were sufficient ambulance support services to secondary and tertiary levels. He wanted clarity on the treatment of tuberculosis (TB). In addition he wanted to know if the decrease in the grant for health professional training impacted negatively.

Dr V Litihakenyan responded that a manual system was used to maintain patient records. The province had piloted a patient carrying card system. The stocks were always above 80%. He said that there was an advanced electronic stock control system that automatically made orders for stock as soon as they reached a certain level. Order deliveries were made weekly. This enabled small orders to be made. The emergency services fleet was uninsured. The vehicles have to be replaced when damaged. The province has 120 vehicles but to operate efficiently it needed 120 vehicles.

Ms T Ngcobo (ANC) wanted to know why the province gave bursaries to matriculants. She wanted to know if persons in the Department did not need those bursaries. She wanted to know the progress that had been made with the anti-retroviral (ARV) rollout. She also wanted to for how long the primary health clinics would be open.

Mr Belot responded that there were five districts in the Free State. In each of these districts there were ARV sites. The provinces' approach to the rollout was a phased in approach. This approach assisted the province to learn from its experiences from the first phase-in.

Dr V Litihakenyan said that bursaries were not only for matriculants. There was a skills development levy that trained nurses. Base level staff such as cleaners and gardeners had also benefited from the bursaries. The province had 24, 12 and eight-hour clinics. The introduction of the flexi-hours system meant that staff was available at all hours.

Mr S Njikelana (ANC) wanted to know if the department had any other international partners besides the World Health Organisation (WHO). He asked what health services the province was marketing. He asked how the salary parity programme has been handled and how it has functioned.

Dr V Litihakenyan responded that the province collaborated with Lesotho, Angola and Brazil. A delegation had recently gone to Brazil to share resources on tackling the AIDS endemic. He said marketing was necessary because people do not understand how the health system works. This would promote self-reliance and inform the community about health issues and the services provided. The salary parity programme created stability. It also helped retains staff in small towns.

The Chairperson commented that the presentation was commendable. He said that it was only deficient in one respect. It failed to adequately give the Committee an understanding of the strategic objectives in line with the National Departments ten-point plan.

Northern Cape Department of Health submission
Mr Deon Madyo - the Head of Department informed the Committee that his Department is committed to achieving its vision through a decentralised, accountable, accessible and constantly improving health care system within available resources. The Department's caring, multi-skilled, effective personnel would use evidence-based informative health care and maturing partnerships for the benefit of its clients and patients. He noted that over the planning cycle, 2004 to 2007, the emphasis on accelerated service delivery was reflected in the improved access to health care services in all districts. The Department would ensure the implementation of service packages in all districts and decrease the morbidity and mortality rates through integrated strategic interventions. The Department exceeded its budget by R72, 977 million representing 9.6% on the final allocation of R759, 647 million.

Mr Madyo reported that in terms of the Public Finance Management Act, savings on items such as capital, transfer payments and other earmarked funds must be surrendered to the National Treasury at the end of the financial year. He said that the Department surrendered an amount of R68, 622 million based on the provisions of the Act and this increased the unauthorised expenditure to R141, 599 million. He explained that included in the amount of R72, 977 million was a suspense account that amounted to R24, 486 million that were cleared in the 2003/04 financial year. Furthermore the increase in specialist services offered in the Department has an adverse impact on the budget because of the waste of running the services. He added that although the rand has strengthened against major currencies as of March, food, fuel and pharmaceutical prices also increased. He said that the equitable share allocation to the Department of Health increased by 7.6% to R623, 792 million for the 2004/05 financial year. This allocation is augmented by an additional amount of R190, 565 million representing National Conditional Grants. An amount of R22, 407 million representing the Primary School Nutrition Programme within the Integrated Nutrition Programme conditional grant was transferred to the Department of Education as they are the implementing department from the current financial year.

Discussion
Ms Thwete (ANC) wanted to know the criteria used for the treatment given to disabled people in the province. She referred to the five nurses that are undergoing training in primary health care and wondered whether these were for the entire province given the small number involved.

Mr Madyo said that there was no criteria in offering treatment to people with disability. The only qualification is that they have been certified as disabled. This information was supplied by the Department of Social Development. It has been ascertained that 4.8% of the population are people with disabilities. He clarified that the Department has five community nurses in service and that was where it has embarked on an ambitious programme to train a total of 300 community-based nurses this financial year.

Dr Cachalia (ANC) said that mental health patients require a psychiatrist and an occupational therapist. He wanted to know whether the Department has all these specialists. He asked the Department to comment on the provision of mobile clinics in the province. He noted that Hepatitis B was a very serious condition and asked whether the Department has an adequate drug control system in this regard.

Mr Madyo said the Department has one psychiatrist and were in the process of recruiting a second one. The Department has an occupational therapist in every district hospital. The psychiatrist is based at the Kimberly Hospital and therefore the Department relies on an outreach programme to take this service to people in other parts of the province. He confirmed that the Department had mobile clinics but that it has tried to reduce the number due to the dehumanising manner in which treatment is conducted in these facilities. The facilities lack privacy and adequate infrastructure for patient management. The Department is instead concentrating on building visiting zones. The difficulty here is in the farming communities where farm owners are not receptive of these developments on their property. The Department has resorted to the use of container clinics on some farms to make it easy to move them should the property owner eject the service provider. He noted that the cost is the major driver of drug management. The Department has put in place an electronic system to monitor drug movement and levels within the departmental drugs stores. This system gives early warning when drugs are about to run out. It also reads in monthly arrears. It is important to determine at what point to maintain minimum stock, he said.

Ms Ngcobo (ANC) wanted to know how far the Department has gone in the roll-out of the anti-retroviral programme. She noted that incidents of violence against children and women are prevalent in the province and asked the Department to explain how it dealt with this. She also noted that the Department has only one crew member for its Emergency Services and wanted to know how it copes with this deficiency.

Mr Madyo informed the Committee that the Department has not commenced the roll-out of the anti-retroviral programme but that it is working in partnership with the national office with a view to determine the best way forward. The Department would depend on the support of the national office. It is a risky affair since the possibility of running out of drugs was real and frightening. It would be better not to start than start and run out of drugs. The drug companies have on their part admitted that they do not have adequate supply in store. The Department is currently collecting data on the incidence of violence against women and children. It is also running a parallel programme with the Department of Social Development on the very same matter. The Department occasionally sends a psychologist to schools to assess the potential for such incidents. He admitted that the Department has been at times forced to make do with one EMS vehicle due to a chronic shortage of this facility. He however, assured the Committee that the Department is planning to secure 200 EMS vehicles this financial year. The Department is also negotiating with the SA Air Force to collaborate in the provision of emergency services.

Dr Cachalia wanted to know whether the Department separates acute from chronic medication to avoid a fatal mix-up.

Mr Madyo said that the Department has a record of the number of chronic patients and that the problem lies with the lack of adequate supply of the necessary medication.

Ms Tshwete wanted to know why the Department trains only five nurses when it in fact is experiencing a chronic shortage of these personnel.

Mr Madyo reiterated that the Department is currently training 300 professional nurses as a response to the shortage. The Department is also in the process of training nurses for community service.

Dr Luthuli (ANC) was happy to note that the HIV/ADS prevalence in the province had shown a decline. She asked the Department to comment further on how age groups are affected in this development. She acknowledged the fact that the Department, like other provinces, was under serious financial strain. She wanted to know what response the province gets from the national department whenever it presents these concerns. She said that it is possible to address the issue of equity in a five-year plan if concerted efforts were made in this regard. She registered her displeasure at the fact that ten years into democracy the poor were still marginalised.

Mr Madyo said that the prevalence level was highest in the 19-25 ages. This category had not recorded significant decline compared to the 25 and above age groups. The Department has a two-pronged approach to the question of budget allocations. In the first instance the Department has tried to improve its efficiency and increased levels of accountability. It has developed a core competency approach to ensure continued fiscal discipline. The second approach is the external one. In this case, the Department tries to advance its concerns in the budget councils. The Northern Cape was a particularly unique province with unique challenges that call for an innovative approach to resolve the challenges associated with ravages of poverty.

Mr Njikelana (ANC) said he did not see the Department's legislative reform to guide its competencies. He wanted to know how the Department proposes to translate Kimberley's success to the outlying district hospitals. He wanted to know what the Department is doing to address the incessant problem of lack of delivery in hospital boards. He also asked the Department to comment on its governance structures.

Mr Madyo said that the Department has clearly demonstrated its legislative programme in the budget presentation. He referred the Member to the relevant material. He reported that an institutional task team has been established to address the whole question of hospital boards. He admitted that there was a dire need to change the way the boards were managed. He said that the Northern Cape Department of Health was the leanest and smallest department. It has only four directors to run its expansive programmes. The Department is continuously improving its governance style to ensure effective service delivery. The Department has appointed new management for district hospitals which would be directly under the Kimberley Hospital. The success of this hospital was evidenced by the fact that other provinces such as the Limpopo Province, the North-West Province and the Eastern Cape have sent their managers for training.

Ms Manana (ANC) applauded the Department for establishing a team to train professional nurses. This fact she said would greatly assist in capping the exodus of nurses from the province. She wanted to know what happens to the auxiliary nurses who would like to progress too.

Mr Madyo agreed that auxiliary nurses require training. He said the Department has taken a decision to train them. This level of upgrade has tremendously changed their motivation levels.

Ms Nxumalo noted that nurse educators have a basic degree and wondered whether this is the requirement for the entire province.

Mr Madyo pointed out that the Department is dealing with the current number of educators first. Staff from the hospital come in to complement their work. He admitted that it was necessary to increase the number of nursing educators.

Dr Luthuli observed that the Department's HIV/AIDS prevalence scenario was different from other provinces. The decline in prevalence in other provinces was noted in the 19-25 year groups. She wanted to know whether the Department hosts NGOs like Love-life who have successfully helped to take the message of safe sex to other provinces.

Mr Madyo confirmed that the Department has a Love-life centre at Kuruman and Upington Youth Centre. Kimberley too has such a centre.

The Chair said that it is a national norm that the HIV/Aids prevalence rate in the 19-25 age groups had shown a decline. It is a matter that would need more statistical information to understand.

Ms Ngcobo wanted to know how the Department deals with the incidence of high-level pregnancy termination in the province.

Mr Madyo reported that the incidence of illegal abortions has been dropping drastically. A few instances still happen. The Department has rolled-out massive educational programmes with an express message for abstention, condom use or sticking to one partner. Every district centre has a termination of pregnancy facility. The message would reach more of the people as the number of nurses increased.

Ms Mashigo (ANC) wanted to know how the Department deals with the question of cross-border health provision in view of the fact that its budgetary allocation was far lower than that of the North-West Province.

Mr Madyo said that there was no parity of patient load between his province and that of the North-West. Most people on the border find it easier and convenient to seek health services from the Northern Cape side. This being a unitary state one cannot turn such patients away. The Department is currently negotiating with its North-West counterparts to seek the best way forward.

The Chair said that community health care was the main concern of the Committee. Various agencies would make submissions before the Committee. The Committee would be in a position to understand some of the challenges they encounter in this regard.

The meeting was adjourned.