WC Appropriation Bill: Health and Wellness

Meeting report

Minister’s Opening Remarks

The Western Cape Provincial Minister of Health, Dr Nomafrench Mbombo, informed the Committee that the Western Cape Department of Health and Wellness has brought forward the appropriation of its budget for the 2024/25 financial year. The tabled budget amount is R30.4 billion which is an increase of 2.21%.

Minister Mbombo expressed gratitude towards those in charge of budget allocation, acknowledging the country's challenges in balancing fiscal consolidation with economic growth. She noted that in the previous budget year, 2023/24, there was a reduction in the baseline, which has continued into the current period. While the budget for 2024/25 shows an increase, it is lower than the original amount due to adjustments made towards the end of the year.

The ongoing global crisis, particularly geopolitical conflicts like those in Ukraine and other regions, has significantly affected the prices of medicine and food. Despite this, a substantial portion of the budget is allocated to purchasing goods and services in the healthcare sector.

The Minister emphasised that, like last year, the current budget does not account for inflation. Therefore, when examining the budget, one should not focus solely on the currency aspect. Other factors, such as rising medical legal costs and dealing with blackouts that Health must manage without conditional grants or additional funding for load shedding mitigation, need to be considered.

While grateful for the budget, they emphasised the need to carefully allocate it. They urged members to recognise that their baseline has been affected by last year's budget cuts. Even though there appears to be an increase in the current year, it may not translate to a real increase when considering inflation and other factors.

Head of Department (HoD’s) Remarks
Dr Keith Cloete, Head of the Western Cape Department of Health (DOH), recalled presenting a budget Dr to the Standing Committee about a year ago, as the financial year approached, and it fell short by R1.5 billion due to the following factors:

1. Wage agreement that was not factored in the budget at all.
2. Reduction of conditional grants
3. The equitable share formula for health was adjusted in National Treasury, resulting in Provinces like Gauteng and Western Cape getting smaller proportions of the equitable share allocation compared to other provinces.

They returned to the Committee in November to table the adjustment estimate which was R780 million or conditions of employment which was 78% of the cost. In addition, it borrowed R100 million from the provincial treasury for service pressures. In total it got about R800 million against being short R1.5 billion. The overall picture for the last financial year was with a bit of saving to be R600 million short on what was spent resulting in having to work within the context of reducing baseline.

Referring to the current budget, the R30.489 billion represents a 2.5% increase on the adjusted budget and inflation is 5.3%. The budget represents a curtailing of activities to the tune of R807 million entering the financial year. The money requires the department to discontinue R807 million worth of activities funded in the financial year. This calls for the next financial year to look for activities to reduce. He indicated that two things have been done, the first being to maintain the money spent on staff by not reducing the staff members below what they currently have. To be able to keep the current staff members and pay them their salaries, they must take a 5.9% cut on goods and services to maintain the staffing numbers. This refrain will run through the whole budget. Implications would be that it cannot continue to do what it did if there is not enough money to maintain the services.

Service prioritisation needs to be done to identify what will be continued and discontinued in this financial year. This is being done responsibly by engaging all partners and walking a journey with everyone in terms of the implications of the budget as of 1 April.

He emphasised that the primary focus is responsible governance, given the multitude of challenges and crises facing the health system. Therefore, it is necessary to collaborate with other sectors to navigate these challenges.

This budget represents a reduction, despite a nominal increase of 2% or 3%. It necessitates the entire system to collaborate and deliver services to the best of its abilities within this shrinking financial envelope.

Discussion  
 
Mr C Fry (DA) welcomed the introductory remarks by the Minister and the HoD. He asked if staff costs would go ahead considering the public service wage increase because that would be the refrain from all departments, as it was a refrain of the Premier earlier that morning. He asked if that is the reason why it is not cutting staff and going to goods and services, slashing it by 5.9%.

Dr Cloete responded to Mr Fry, noting that between November, December, and January, they faced considerable financial pressure, with projected expenditures forcing them to reduce staff numbers to align with the budget. This substantially impacted their service delivery, affecting everything from primary care nursing to highly specialised services. The situation led to an open letter from academic heads at Groote Schuur and Tygerberg to the National Minister and the finance minister in the province, highlighting the necessity of curtailing services due to financial constraints. This backdrop was against the backdrop of the R600 million shortfall in the previous financial year.

He indicated that it has entered this financial year having had years and years of consolidating a bare minimum of staffing, it cannot go below that staffing as it will disrupt the services to the point that certain places risk collapsing. It is taking a system’s approach; the money is decreasing but cannot go below that at staffing. It is taking this on and is visiting almost the entire shortfall on goods and services which requires the Department to significantly reduce waste, costs and what they do to be able to meet the good and services challenge in place.

Ms R Windvogel (ANC) welcomed the input by the Minister and the HoD. She indicated that while they understand the fiscal consolidation environment as explained by the Minister and the HoD, there is above R800 million as per understanding from last year and an additional 2.2% in the present year. She was concerned that the Department could not be that short in budget, considering the increase was R1 billion. She asked to what extent did the vandalism of the taxi industry protest of last year influence the budget.

Dr Cloete reiterated that when the Department allocates funds for activities, it must consider various factors such as the actual activities, the number of staff ("warm bodies"), and the annual inflation rate for staff employment, which stands at 5%. Without this 5% increase, they would have to reduce the number of staff members. Despite a nominal budget increase of 2.2%, the real challenge lies in the fact that inflation is above 5%, a conservative estimate given that the Department imports equipment from overseas, which can see price hikes of up to 9% in some cases. The crux of the issue is that the budget effectively decreases unless there are inflation-related increases. Therefore, with the allocated funds, they must manage unforeseen expenses such as increased spending on fuel for generators, repairs, preparations for disruptions like taxi strikes preventing staff from getting to work, and unexpected events like floods in the Overberg, which require immediate action and spending adjustments.

He explained to the Committee that despite the 2.2% increase, the Department is facing a shortfall of R800 million in the current financial year. Additionally, there are anticipated expenses that it cannot currently predict, which means it might need to allocate funds for unforeseen circumstances and expenses it is not currently accounting for.

Mr Fry indicated that the Minister and the HoD both referred to the challenges of the shortfall in the budget; he was concerned that without the shortfall, would it still render the service to the people? What innovative ideas, programmes, and projects the Department launched this year to overcome these challenges?

Dr Cloete responded to Mr Fry, stating that what the Department is implying is despite all of this, it continues to see babies at health facilities, continue to do immunisations, continue to see people in emergency centres and people that need operations, and ambulances are still operating. The issue is these cannot be at the same level as they were before. If one needs care, they will get care in the system, but the system must give it. The saddest thing is that the poor people in need of the service feel the discomfort as they are disadvantaged. In rectifying these issues, the Department started delivering medication, and going to the community to assist instead of people going to the hospitals; this was a lesson learnt during Covid.

Minister Mbombo referred to the figures from the 2023/24 main appropriation, which initially stood at R28.8 billion. After adjustments, it was revised to R29 billion. When comparing this to the current R30.4 billion, one must consider that an appropriation was done during the year, leading to the adjusted appropriation. Part of this adjustment was for additional funds for the wage bill, covering 78% of staff members. However, compared to the R30 billion, it still falls short of the baseline due to the drop in equitability. Adding the difference of 2.2% does not fully account for increased prices, inflation, and the growing population. This indicates an increasing need for resources, including more HR staff, to accommodate the rising number of patients requiring attention.

The Chairperson mentioned the vote at the Premier's office and highlighted the ongoing interdepartmental dispute, noting that mediation is scheduled for next Wednesday. He inquired whether a successful mediation would result in the return of the portion of money that is still short. He also asked to what extent this return of funds would assist in providing expanded services.

Dr Cloete responded to the Chairperson by reflecting on the lessons learned during the Covid-19 pandemic. The Department learned to adapt its services, expanding and contracting based on available resources. They emphasised that their response is aligned with the nature of the budget, which is currently contracting. Dr Cloete mentioned that when there is an opportunity to expand, it will do so responsibly, particularly focusing on primary healthcare, where access is challenging for the most vulnerable. Regarding the inter-governmental dispute, he noted that it is unlikely to result in additional resources for the department, but it is a necessary process. He highlighted one of the department's strengths as being able to responsibly expand or contract as needed. As an example, he mentioned returning unused funds to Treasury to avoid irresponsible spending.

Minister Mbombo emphasised that the Department has taken a holistic approach to examining the healthcare system within the broader ecosystem it operates in. They recognise that some issues can be addressed effectively through prevention and promotion initiatives within the social development or job sectors. If research indicates a compelling need, funds may be redirected accordingly, all in the pursuit of ensuring public health. Minister Mbombo emphasised the Department's commitment to equitable budgeting, as resources are allocated where the need is greatest.

In response to the Chairperson's question, Minister Mbombo provided an example concerning the Road Accident Fund, emphasising that they expect the corresponding payment when services are rendered. Regarding the intergovernmental disputes, she reiterated that if the R1 billion could be returned, they would certainly like a portion of it unless it could be more effectively utilised elsewhere.

She mentioned that given the circumstances, there are elements of unfairness, suggesting that other sectors should also contribute funds to health, as the Department also provides support to other sectors in need. Minister Mbombo appealed to these sectors for assistance and collaboration.

Ms N Bakubaku-Vos (ANC) referred to page 226 and enquired, given the realisation, why the department opposed the National Health Insurance (NHI) as it is one of the best mechanisms to address health inequalities and universal health coverage. On page 228, what are the key decisions taken on this engagement? Are any projects likely to be phased out and if so, which ones? What facilities are likely to be affected? On page 232, table 7.1, what will the increase allocation cover and where are the shortfalls?

Dr Cloete responded to Ms Bakubaku-Vos's question on page 226, explaining that the department submitted specific responses to the NHI Act through the Western Cape government cabinet. These responses were related to the powers and functions of provinces compared to the national department. The NHI Bill involves certain powers being shifted from the provinces to the national level. Dr Cloete expressed the belief that the Department has a well-functioning provincial healthcare system that integrates all components of the healthcare system. He emphasised the desire to retain these powers, as the provincial healthcare system must remain intact to effectively provide universal healthcare coverage. The Bill raises concerns about centralising certain hospitals like Groote Schuur and Tygerberg, potentially disconnecting them from the Western Cape system to directly report to the National department.

There is a possibility that if the Bill is fully implemented with all its stipulations, Groote Schuur and Tygerberg hospitals could be completely detached from the provincial department and report directly to authorities in Pretoria. Dr Cloete clarified that the concerns and specific comments regarding the Act pertain to certain stipulations and matters outlined within it.

Universal health coverage forms the foundation of the entire healthcare system. In the province the Department in the province wholeheartedly supports universal health coverage. They are collaborating with their national colleagues, having registered the matter and are fully cognizant of the position.

On page 228, specifically in the second-to-last paragraph, Dr Cloete responded to Ms Bakubaku-Vos regarding a strategic budget engagement held on 31 August. He explained that managers across the entire department faced an in-year challenge of being R1.5 billion short. Although some adjustments were made, this shortfall is likely to persist into the following years. During this discussion, two important principles were adopted. The first is the necessity of prioritisation, which must be done in a consultative manner following an ethical framework for decision-making when resources are limited. This framework is based on international best practices, emphasising transparency, involvement of stakeholders, and thorough consultation. The second principle agreed upon in that workshop was the importance of working collaboratively with other sectors. This framework signifies their commitment to open and collaborative relationships with other sectors and stakeholders, all in the best interest of the people they serve.

Another point that emerged from the workshop was the identification of small, immediate, quick wins where inefficiencies could be addressed. This allowed for prudent decisions regarding financial use. A variety of strategies stemmed from the reprioritisation workshop.

On page 232, Dr Cloete elaborated on the budget for the year, explaining that the equitable share has increased by 7.2% and the conditional grants by 5.7%. These numbers may appear as substantial increases but do not match the adjusted estimate. The actual increases are less than what inflation would allow for. They fall short of the amount needed for the Department to sustain its services, necessitating a need for reprioritisation.

Minister Mbombo referred to page 232, providing an example of the equitable share for 2022/23. Initially, it was about R20.6 billion, and by the end of that year, it had been revised upwards to R21 billion. Similarly, for 2023/24, the equitable share started at around R20 billion and was adjusted to R21 billion. When considering these figures, one should not compare the starting R20 billion to the closing amounts in 2022 and 2023, but rather observe the revisions. This same pattern applies to the conditional grants, which began at 7.4% for 2023/24 and then adjusted to 7.1% in the main appropriation, and eventually dropped. Minister Mbombo explained that while the 7.4% may appear to be a 5.7% increase for this year, historical comparisons show no real increase.

Ms Windvogel raised a question regarding page 227, particularly the reduction of staff numbers in the department's budget over the 2024 Medium Term Expenditure Framework (MTEF) period, from R34.629b in the 24th and 25th book years to R33.389b in the 26th and 27th book years. She inquired whether this reduction in staff complement was a result of the MDP process and asked for the reasons behind it. Ms Windvogel also questioned the impact of cutting staff while service pressures are increasing in health facilities and requested mitigation measures in place. Additionally, she asked for a breakdown of the numbers in terms of occupations affected, specifically inquiring about the number of posts for doctors and nurses to be cut over the stated period. She highlighted the department's long-standing complaint about insufficient budget from National and expressed concern that this could serve as an easy excuse for the department or government to hide its shortcomings. Ms Windvogel noted that despite services being contracted, the department still finds funds for new programmes like the violence prevention unit, seeking an explanation on where this budget is sourced from given the reduction in staff numbers over the MTEF period.

Dr Cloete responded to Ms Windvogel's question on the first paragraph of page 227, explaining that the management alignment and efficiency alignment project focused on reviewing all managerial posts within the department, from the HoD to all administrative positions. They underwent a process of realigning these establishments, ensuring there was no growth in administrative posts. As of 1 April, 2024, there will be adjustments to the technical reporting lines of these posts to ensure they are in the right places. Dr Cloete emphasised that there was no expansion of managerial structures; instead, they were consolidated to enable the department to prioritise staffing at service-rendering institutions.

On page 263, Dr Cloete mentioned that public service appointees not covered by the Occupational Specific Dispensation (OSD) decreased from 11 325 to 11 212, resulting in a corresponding drop of 121 posts. Public service appointees yet to be covered by the OSD remained at 42, and the number of professional nurses decreased from 13 353 to 13 219. He explained that between October, November, and December, the Department adjusted its post establishment and what it could afford during those three months.

Dr Cloete mentioned that the department is entering the financial year with 34 629 staff members, and this number will remain stable; their intention is not to decrease staff by the next year. They are committed to maintaining and potentially growing this number. Dr Cloete clarified that the figures presented are not the actual numbers but rather a technical exercise to balance the books. The department has diligently worked on an approved post list that aligns with the resources they have available.

Dr Cloete emphasised that the department does not compromise on staffing and services to fund other initiatives. Regarding the Violence Prevention Unit, he clarified that it is a specific entity mentioned in the Premier's State of the Province address. The additional resources for this unit are sourced from the provincial fiscus and added to the health department; they were not taken from the health department's budget. This funding is part of a safety plan, and additional money was brought in, augmenting the funds the department already spends on these services.

Minister Mbombo emphasised that when they make budget cuts, they must balance it carefully to ensure they have enough staff and resources for medicine. The Public Finance Management Act (PFMA) does not permit the appointment of staff when there is a shortage of staff and funds. When appointing new staff, they consider the entire package, not just the salary, as it is crucial for effective service delivery. Minister Mbombo reiterated that there are no health services without adequate staff and resource allocation.

The Chairperson posed questions based on page 242, specifically under the heading "Expenditure Trends Analysis" in the third paragraph, sub-paragraph 2.6. He requested the Department to elaborate on how those funds will be utilised. Additionally, on page 243, concerning the priority allocation for the Violence Prevention Unit increase, he asked the department to provide more details on how it will be involved in violence prevention initiatives.

Dr Cloete responded regarding the HIV allocation, stating that it is part of the national conditional grant allocation within the system. He provided context by mentioning the Provincial Council of AIDS and TB's adoption of an enhanced localised trigger response for HIV and TB, which is now incorporated into the new five-year national strategic plan. Dr Moodley's unit focuses on the 95-95-95 principle, which aims to detect 95% of people who are HIV positive, test them to know their status, and pinpoint areas at the clinic and suburb level where testing figures are below expectations. This allows for targeted interventions to increase testing in specific areas. The second "95" presents challenges, where individuals who are HIV positive know their status, remain in care, and continue taking their medication as prescribed. The department is aware of neighbourhoods and areas where there is a significant drop in people remaining in care. The final "95" refers to individuals remaining in care whose viral load is suppressed, indicating that they take medications effectively. Dr Cloete mentioned that the department is performing well in this aspect.

Regarding tuberculosis (TB), the primary challenge lies in achieving the first 95, which involves the need to test more people. Although these issues are not confined to the same areas, the department intends to allocate additional funds towards TB testing. When these two aspects are combined, the increase in funds partly goes towards this initiative. However, the budget books do not explicitly show the relationship with external funders because the budget is appropriated. The department has partnerships with government-to-government programmes such as USAID, additional funding from USAID through PEPFAR, a relationship with the Gates Foundation that provides funding, and an agreement with the Global Fund. Therefore, when reporting, they aim to include these additional resources for accountability purposes.

He also mentioned that the violence prevention referred to by the Chairperson is very specific in that the money was made available from the provincial fiscus unit. This is specifically to set up violence prevention units. The unit has been established in the department, and a director and three deputy directors work with the central unit. This unit has two arms; the first arm is to coordinate, convene, and help bring together an area-based response.

To prioritise areas where there are the biggest crime numbers in the province, the department’s job is to bring people together and make sure the numbers for violence and crime are big and use Dr Moodley’s data-based approach of recording the people coming into emergency centres breaking it down to women and young people. The department’s job is to bring people together from all sectors and prioritise work in three areas and these are Hanover Park, Delft and the Swartland outside the Metro as the first step. They convene but do not do the intervention. They use the data so that they convene to ensure people do things better.

18 areas have been identified for violence prevention initiatives, with 13 in the metropolitan area and five in rural regions such as the Swartland, Mossel Bay, and Beaufort West. Dr Cloete emphasised that violence prevention ultimately links back to issues of inequality and poverty, where individuals do not have equal opportunities. The department's role is primarily one of stewardship and convening, bringing together various stakeholders. As a health sector, they stand to benefit greatly if fewer people require emergency services, call for ambulances, or are victims of violent incidents.

Minister Mbombo highlighted the 18 areas identified by Dr Cloete, specifically mentioning seven areas in Kleinfontein and Mitchells Plain, including Gugulethu, Mitchells Plain, Nyanga, Philippi, Hanover Park, and Philippi Samora Machel. In the Northern Tygerberg area, there are Bishop Lavis and Kraaifontein, while in Khayelitsha Eastern, there are Harare, Mfuleni, and other non-metro areas. Out of these 18 areas, 12 coordinators are from the Health Department. The Violence Prevention Unit has already been launched, with successful outcomes in Delft. Minister Mbombo pointed out that evidence indicates high levels of interpersonal violence, with many cases initially reported to hospitals before reaching police stations. Despite ongoing complaints about budget shortages and a perceived lack of visible progress, the Violence Prevention Unit is a significant part of the Health Department's work. Minister Mbombo emphasised that health financing is integral to strengthening the entire ecosystem of the health system.

The Chairperson, referring to Dr Cloete's mention of external funding, particularly from the Global TB Fund, recalled attending the African TB caucus in Nairobi last year, where they discussed contributions to South Africa. He has been attempting to ascertain how this funding reaches South Africa. The Chairperson inquired whether it comes through the treasury or directly to the Department, and how the funding is distributed.

Dr Cloete responded to the Chairperson and mentioned that in 2003, the Department was a primary recipient of the Global Fund, so they used the ART programme in the province catapulted with the Global Funding. In those times, the money came through Provincial Treasury, and they created programme 2.10 and that was what was reported to members that were around during the time.

The current arrangement involves the funds passing through the National Department and not being integrated into the voted funds' financial structure. Instead, it is held in a separate account designated for donor funding. The Department itself is not a direct recipient; rather, the money flows through the National Department, with certain NGOs also receiving a portion of these funds. Dr Cloete mentioned a recent meeting with the Global Fund, noting that the official end of the current Global Fund grant for South Africa is on 31 March 2025. However, there is a new Global Fund grant for the next five years, starting 1 April 2025. He added that there was an agreement that any unspent funds between now and the end of March will be accessible to the Western Cape.

Ms A Bans (ANC) posed a question regarding page 285, focusing on the new infrastructure table 8.3. She observed that the Klipfontein Regional Hospital's building and completion date has been extended to 2035 and requested clarification on the reasons for this delay. In the same table, she noted the department's annual report mentioning 26 facilities in poor condition. She inquired whether the allocation was sufficient to address the state of these infrastructure issues in hospitals. Additionally, she asked how many of these facilities are categorised as C1 and C2 conditions and whether they are included in the budget.

Dr Cloete responded to Ms Bans about the delay of Klipfontein, the consulting fees, and the timeframe for completion. He said the Department is currently working closely with its colleagues in infrastructure delivery also in the City of Cape Town. The idea is to speed up the delivery for Klipfontein. He also asked Dr Angeletti d Toit to give a clear understanding of the delivery.

On the second question, Dr Laura Angeletti Du Toit, Chief Director: Infrastructure and Technical Management, Western Cape Department of Health, was also asked to respond. Dr Cloete mentioned that the current allocation is not sufficient, but they have a prioritisation process in place. Their goal is to work towards achieving a basic standard across all facilities to reach C3 and C4 classifications.

Dr Angeletti Du Toit provided an update on Klipfontein Hospital, stating that they are currently working on the composite design report, which is expected to be completed by October 2024. Following this, they will need approval from the National Department of Health through a process called peer review before proceeding to stage three, which involves a more detailed design. This project is significant as it involves the construction of a 600-bed hospital, requiring adequate time for design and construction processes. The timeline provided by the implementing department in the infrastructure sector considers the necessary time for all processes to be completed and approved. The hospital will be constructed in phases, with the first phase accommodating approximately 400 beds and the remaining beds in phase two.

Regarding the categorisation of maintenance and facility condition assessment, Dr Angeletti Du Toit explained that this classification is based on assessments conducted every five years in collaboration with custodians. Facilities categorised as C1 are considered for replacement because they are non-functional. Fortunately, despite the limited maintenance budget in the province, they strategise and prioritise maintenance, resulting in facilities being in reasonable condition. On the other hand, C3, C4, and C5 classifications refer to brand-new facilities. Dr Angeletti Du Toit highlighted the current infrastructure backlog, including maintenance and capital replacement, which amounts to billions of rands. Unfortunately, they receive only R1 billion per year, which is insufficient to address this backlog.

Minister Mbombo responded regarding the Klipfontein Regional Hospital, mentioning that funds for such projects come from National Treasury. Despite the delays, she acknowledged that this is a significant project that will have a substantial impact not only on the hospital itself but also on the surrounding infrastructure, including roads, bridges, and schools in that area.

Ms Windvogel raised a question regarding the Department's ability to provide proper meals to patients, referencing a Facebook post suggesting a lack of budget for this purpose. She expressed agreement with the Head of Department that improving living conditions can help prevent violence. Ms Windvogel inquired whether these issues, including the treatment of patients and the need for collaboration with other sectors, are discussed in Cabinet meetings with the Minister and colleagues from Social Development and other sectors. She also expressed concern about the attitude of staff at Swellendam, emphasising the importance of treating patients with respect.

Dr Cloete concurred with Ms Windvogel regarding the situation in Swellendam and the concerns about staff attitudes. He explained that during the meeting in August, it was highlighted that staff members can feel hopeless when institutions are consistently underfunded. In November, December, and January, the decision to halt the filling of posts was particularly difficult for staff members. Dr Cloete emphasised that staff members experience moral distress because they desire to help others but lack the necessary resources to do so.

Dr Cloete elaborated that all institutions have funds allocated for salaries, payment to service providers, and provisions such as food. While these funds might not be abundant, they are sufficient. He noted that the challenge arises when staff members experience moral distress, leading to a scarcity mindset where they struggle to see positivity. Dr Cloete expressed empathy for this situation and emphasised the need to shift from a scarcity mindset to an abundance mindset. Dr Cloete mentioned that the Minister has been consistent in lifting the living conditions of people.

Minister Mbombo highlighted that many health issues stem from socio-ecopolitical factors, and despite the health sector's efforts to address these issues, they are not adequately funded. She emphasised that high-demand areas are often in impoverished communities, where health services can be provided but are not the main issue. At the government and cabinet levels, they implement Community Oriented Primary Care (COPC), which involves faith-based organisations and NGOs in small clinics to address population health. Additionally, the department collaborates closely with private hospitals and does not work in isolation. Minister Mbombo emphasised that the health system encompasses socio-ecopolitical factors, recognising that public health is inherently political.

Ms Bakubaku-Vos asked a question on page 243, table 9.2, regarding the budget cuts for the three sub-programmes and sub-programmes on 4.2 on page 249. She asked what the reasons are for the cuts and what the impact on service delivery is. In respect of mental health illness that leads to increased service pressures, how is the budget responding and which facilities will benefit?

Dr Cloete responded to Ms Bakubaku-Vos regarding the three programs: community health clinics, nutrition, and district hospitals. He mentioned that there has been no change or growth in numbers: 684 for nutrition, a small number, and 249 for TB hospitals, which is now 237. Similarly, there has been no movement in the numbers for general regional hospitals. The impact of this is that the allocated budget must now be divided between staff and goods and services, resulting in minimal movement in the amounts due to the budget situation. Dr Cloete explained that there is essentially a holding pattern, as it is a pooled resource. However, there has been an increase in community health clinics due to the Department taking over responsibilities from the City of Cape Town.

Dr Cloete noted that there has been an increase in mental health cases, and efforts have been made with partners to enhance capacity for stabilisation. The primary challenge faced by the health department regarding mental health is the tendency to medicalise it. He emphasised the need to shift this mindset, explaining that feeling unwell does not necessarily warrant admission to a psychiatric facility. Dr Cloete highlighted the significant challenge in reframing how mental health is approached and understood.

Minister Mbombo responded on the issue of mental health and stated that APU’s will be completed soon in Khayelitsha, and many are mentioned on page 259. In terms of health care in mental health, there are now specialists in outreaches everywhere. The adolescents end up being mixed with adults and children and some psychiatrists specialise with the adolescents’ doing outreaches. The additional money put was to address these issues and geriatric mental health especially among women which was ignored. Mental wellbeing should not be pathologised as, at times, it is the matters of the mind and not the matters of the brain. She also mentioned that in primary health care, advanced mental health nurses come once a week or a month to visit. Not looking for the patients discharged but to have a conversation.

Ms Windvogel followed up on the APU, acknowledging its potential impact but highlighting that they are not sufficient on their own. She inquired about the number of step-down facilities that will be constructed within the budget.

Dr Cloete clarified that the APU serves to alleviate acute pressure on district hospitals, providing immediate relief and allowing for patients to be moved to different spaces within the system. Regarding step-down facilities, the department had moved away from this concept during Covid and has been using transitional care instead. Transitional care involves transitioning patients from acute hospitals to community settings. Dr Kariem and his team are exploring the expansion of transitional care facilities, considering whether they should be separate from mental health facilities or integrated into the same location.

Mr Fry raised a question regarding the increase in budgets for psychiatric and rehabilitation hospitals by R19 million and R36 million respectively. He asked for clarification on how these additional funds will be utilised. Referring to Table 9.4.1 on page 249 which shows a decrease of 2.8% in goods and services, and another decrease of 9.43% on page 251, he shared his recent experience at Groote Schuur hospital, where he observed poor conditions in the bathrooms. Mr Fry inquired about measures to assist in improving these conditions and how awareness can be raised for people to take ownership of Groote Schuur and Tygerberg hospitals to prevent such experiences in the future.

Dr Cloete responded to Mr Fry and stated that the increase is about transitional care and bringing additional capacity to the system online. He asked Dr Kariem to elaborate. The increase in psychiatric hospitals only refers to four specific institutions. They were given additional resources. On the issue of Groote Schuur, he stated that when facilities are provided for public consumption, it is sad because they get vandalised. It is about making a call to the public that uses these facilities to appreciate it as a common good. It is important to consult with community leaders and the facility board to address the issue.

Dr Saadiq Kariem, COO, Western Cape Department of Health, responding to Mr Fry, mentioned that they had released a policy on transitional care allowing them the funding for a multidisciplinary approach which is being pushed hard. This is built on transitional care provided by the NPOs as part of community-based services. It is a whole policy the department has embarked on and it is excited about the additional funding.

The Chairperson asked a question on programme eight, Health Facilities Management. The additional infrastructure projects can be found on pages 259 and 260, and a breakdown of the plant infrastructure spending can be found on pages 110 and 239 of the Annual Performance Plan (APP) and pages 285 and 297 of the votes. He had visited three facilities in George where National promised action but up to date, there is a container and a shade put up, a year later. He asked the Minister if she could respond to what was happening.

Dr Cloete responded to the Chairperson's question, highlighting a challenge with infrastructure funding. He mentioned that resources for infrastructure come from programme eight and other sources, not directly from their vote but from the National department. This raises questions about responsibility for delivery, as the money is not within their voted funds but with the National department. Dr Angeletti-Du Toit was asked to provide details on the implementation process for the ARV extensions funded under the national grant, which further complicates project management and oversight due to the involvement of multiple parties.

Dr Angeletti Du Toit explained that the project under the in-kind grant managed by the National Department of Health allocated funds and selected projects and provinces. The Garden Route project was chosen as the provincial nucleus for the NHI a few years ago, and that is where they started with the in-kind grant project. There is a three-part agreement involving National Health, the Department of Infrastructure, and the health department in managing the project. However, the health department has minimal influence on the deliverables. In this specific project, the service provider, Independent Development Trust (IDT), was appointed by the National department but failed to perform and was subsequently removed. As a result, the project came to a halt. Despite their efforts, they were unable to get the attention of the National Health to resolve the issue. Given that the budget and implementation come from the National health, they are limited in what they can do.

Dr Cloete further elaborated on Dr Angeletti Du Toit’s response, mentioning that during the National Health Council technical committee meetings, reports from other provinces indicated similar experiences. This suggests that the challenges faced in project implementation are not unique to the Western Cape.

Minister Mbombo also provided background information on these projects, stating that they were initiated in 2012 as part of the NHI phase one pilot across all districts. The pilot was in Eden in the Western Cape, now known as the Garden Route. Some of these projects have recently been completed. The Chief Director at the National level responsible for infrastructure made promises and revised the budget during the last update.

Interaction with the public
Ms T Hendricks inquired about services for children within vote six and questioned why the term "child" was only mentioned ten times, excluding references to the Red Cross Children’s Hospital.

Ms C Nomdo highlighted the goal of teaching children to hold government accountable by making budgets child-centred and child-friendly, thereby advancing children’s rights. She mentioned that the Department of Health has agreed to support the children in their child budget analysis campaign, where they will track the allocation of funds for children’s health services within communities, starting at the end of the month.

Ms P Lekker (ANC) raised a question regarding the transition of health facilities from the city to the province. She sought clarification on the adequacy of consultations with communities and stakeholders, expressing concerns she had heard from people. She inquired about the possibility of revising such a process based on varying conditions in different areas.

The Minister addressed Ms Lekker's question by explaining that nine facilities were inherited from the City of Cape Town, and nothing has changed in that regard. The tenth facility, the new City clinic, has had more packages added to its services. She clarified that Hanover Park has never been part of the transition, and Hanover Park Community Health Centre (CHC) is not being closed.

Regarding Ms Hendricks' inquiry, Minister Mbombo emphasised that the approach encompasses the entire ecosystem. While they may not directly address children in certain instances, such as tackling teenage pregnancies through family planning for young adults, it is part of ensuring a brighter future for newborns in their first 1000 days. Providing optimal antenatal care not only benefits the mother but also the unborn child. Immunisations for children under five years old are another aspect of the department directly addressing children's health. After completing immunisations, children are mostly outside the health system unless they fall ill. Community and school health programs also play a role in providing primary healthcare for children.

Dr Cloete addressed Ms Lekker's concerns about the transition of facilities, clarifying that the Hanover Park CHC building is not directly related to the City of Cape Town transfer. The transition of nine facilities from the City of Cape Town to the province was seamless, with the same packages of services being offered, but now under provincial authority. There has been movement of staff since the transition, as they now operate within the provincial system.

Regarding Fisantekraal, it represents an expansion of services as the building, completed by the City of Cape Town, now offers more services than before under provincial management. The two outstanding facilities in Atlantis are in the process of being transferred from the city to the province, following requests from the community. The consultation process for these transitions involves three steps: rigorous consultation with community structures, discussions with organised labour within the City of Cape Town, and consultations between the provincial department and the City of Cape Town to ensure alignment.

In Hanover Park, a future site has been identified for a new building, which has already been purchased and consultations have taken place. The new facility's operational model is under consideration, with discussions about whether it will operate on a 24-hour or 12-hour basis due to the violence in the area. The facility's memorandum of understanding (MOU) indicates that it will serve a wider area beyond just the residents of Hanover Park.

Responding to Ms Hendricks' question about child-centred services, Dr Cloete explained that the entire healthcare system is oriented towards meeting the needs of children and their families. While the budget book contains terms related to 8 programmes, each of these contributes to the wellbeing of children and families. However, there is no specific "child budget" as children's services are integrated into the overall system. Dr Cloete acknowledged the importance of child advocates visiting clinics and places that serve children but clarified that there isn't a dedicated line item specifically for children in the budget.

Minister Mbombo emphasised that in the current context, a child is not just a child in isolation but must be seen within the entire ecosystem and environment.

In response to Ms Lekker's follow-up question about timelines for the Hanover Park facility, Minister Mbombo referred to the infrastructure phases outlined at the back of the budget. She clarified that there is no plan to close the clinic, but the discussion is focused on its location. While important, it is not urgent and might take around four to five years to finalise.

Dr Cloete addressed Ms Lekker's inquiry about the Hanover Park facility's progress. He explained that the consultation process led by the ward councillor resulted in the Deputy Mayor putting the process on hold due to disagreement over the location. As a result, the project is currently stalled until the issues are resolved. He also mentioned that the facility serves not only Hanover Park residents but a broader community.

Ms L Lake (sp) raised concerns from the child health community regarding austerity cuts and their impact on children's health services. She referenced organisations such as the Child Health Priorities Association and the South African Pediatrics Association, noting that the Constitution sets a high standard for children's healthcare. Section 28 of the Constitution outlines children's rights to basic health care services without qualification based on available resources, suggesting that child health services should be prioritised.

Ms Lake also expressed worries about declining immunisation coverage for children under one, especially in metropolitan areas where coverage is at 65-70%, below the national target of 85.5% needed for herd immunity. This led to a measles outbreak in 2023. She asked about concrete plans to strengthen child health services given the importance of immunisation as a primary indicator of children's access to care, particularly in the context of rising malnutrition and food poverty.

Further, Ms Lake highlighted the increasing demand for inpatient psychiatric care, including for adolescents, as indicated on pages 224 and 227 of the budget votes. Post-COVID, there has been an escalation in adolescent suicides, showing an increased need for mental health services. She inquired about the allocation of the R5 million for psychiatric and mental health services and how much is earmarked for child and adolescent mental health care. Additionally, she asked about measures to protect earlier commitments to strengthening child and adolescent mental health services, especially addressing the shortage of specialists capable of providing specialised care and building capacity across the system.

In response to Ms Lake's concerns, Minister Mbombo highlighted the role of the City Clinic in attending to child health, noting that the city runs most clinics in the Metro. She acknowledged challenges with immunisation due to anti-vax sentiments and mentioned that school health services and wellness buses are assisting in reaching children who may not be immunised. The department is aware of the shortcomings in immunisation in the city, as it falls under the City of Cape Town's jurisdiction.

Minister Mbombo recalled the allocation of R30 million for the mental health of adolescents and older persons, mentioning the appointment of child and adolescent psychiatrists to address these needs. Regarding the specific budget allocation, the department will provide a response, highlighting the challenge of separating budgets for children as it should be viewed within the broader ecosystem of healthcare. She also emphasised that there have been no budget cuts for immunisation, and efforts have been made to address the impact of anti-vax sentiments during the COVID-19 pandemic.

Dr Cloete addressed Ms Lake's concerns about mental health services, mentioning the investment made to strengthen child and adolescent mental health services. Professor Rene Nassen has been working with the department, to enhance the capacity of primary care providers to identify challenges to adolescent wellbeing. Professor Nassen, a child and adolescent psychiatrist, is at the forefront of this initiative. The focus for adolescents, as advised by the evidence advisory committee, is on teaching problem-solving skills and emotional regulation.

Dr Cloete responded regarding immunisation coverage, highlighting pages 46, 47, and 48 of the APP for detailed explanations. He noted the differences between urban and rural districts, particularly the ongoing first dose measles campaign, which showed a recovery in low immunisation coverage. He shared Ms Lake's concerns, emphasising that child health services are not neglected, and everyone is taking the issue seriously despite challenges stemming from the COVID-19 pandemic.

Regarding community governance structures, Dr Cloete referred to the breakdown in Hanover Park due to the absence of a clinic committee. He pointed to the governance structures within the department, stressing the importance of public engagement and community involvement. The stakeholder engagement strategy aims for collaborative governance, based on trust, honesty, co-creation, and fairness.

Regarding community-based services and the Community MCI, Dr Cloete emphasised the need to be intentional about services that reach children and their families. The Community MCI workers interact with social determinants of health, and support systems are crucial for their effectiveness. There's a conversation on whether the Community MCI is the right approach within the COPC framework.

Regarding incomplete buildings by contractors, Dr Cloete mentioned severe penalties for defaults under the department's oversight. The challenge arises when contractors default under someone else's jurisdiction, making it difficult for the department to influence.

The Chairperson added to the discussion on nutrition, mentioning Mohammed Adulas (sp) in Beaufort West, who has a plan for soup kitchens. He urged the department to collaborate with Adulas to implement his plan to address food insecurity.

Minister Mbombo and the HoD expressed their gratitude to the Committee and the public for their engagement and for holding the health department accountable.

The meeting was then adjourned.