Department of Health Annual Performance Plan 2024/2025; Department of Health Budget Vote Report, with Minister and Deputy Minister

Meeting report

Opening Remarks By Minister and Deputy Minister
Minister of Health, Dr Aaron Motsoaledi, saluted new Committee Members and asked them to introduce themselves because because it was the first meeting of the Committee after the elections.

Deputy Minister of Health, Dr Joe Phaahla, saluted Members of the Committee and announced that Mr Sandile Buthelezi, Director-General (DG), National Department of Health (DoH), would deliver the presentation on the Department’s Annual Performance Plan (APP) 2024/25.

Department of Health Annual Performance Plan 2024/2025
Due to technical issues, Mr Buthelezi was unable to deliver the presentation. Ms Jeanette Hunter, Deputy Director-General (DDG): Primary Health Care and Hospital Management Systems, took over. She provided some context for the APP:

- Life Expectancy has improved since 2022, despite the reversal in gains made prior to COVID-19.
- The Central Chronic Medication Distribution Programme (CCMDD) which enabled collection of medicine parcels for stable patients at pick-up points of choice, had contributed positively to access to treatment and reducing congestion at health facilities.
- Pandemic Prevention, Preparedness and Response had been introduced as the 10th Pillar of the Presidential Health Compact.
- The burden of non-communicable diseases continued to increase largely due to the adoption of unhealthy lifestyles.
- The Department remained committed to continue its efforts to progressively reduce inequities in our health system through implementing the National Health Insurance (NHI).

She outlined the Department’s key focus areas for 2024/25:

- The National Strategic Plan for HIV, TB and STIs, launched in 2023, would drive key interventions towards achievement of the 95-95-95 targets.
- Non-Communicable Disease campaigns would drive awareness, prevention and early detection.
- Key interventions to aid improvement of quality of health care would be made.
- Maintenance and refurbishment of health infrastructure.
- Community engagements would be conducted to promote participation and aid responsiveness to health needs.
- Reduction in maternal and infant mortalities would be sustained.
- Critical functions for the implementation of the NHI would be capacitated.
- A hospital strategy to guide leadership, management and governance of hospitals would be developed.

She then discussed 2024/25 performance outputs for each of the Department’s six programmes:

- Administration
- National Health Insurance
- Communicable and Non-Communicable Diseases
- Primary Health Care
- Hospital Systems
- Health System Governance and Human Resources

(See slides 6-12 for further detail)

Mr Phaswa Mamogale, Chief Financial Officer (CFO), DoH, presented the 2024/25 budget. He summarised it according to departmental programme and economic classification and explained reasons for variances. He summarised the payment of conditional grants according to province.

See attached for full presentation

Discussion
Mr M Sibande (ANC, Mpumalanga) asked to what extent the national Department controlled the conditional grants transferred to the provinces. Secondly, he pointed out that the 2024/25 APP had been compiled before the announcement of the NHI Bill and asked if this would have any bearing on the allocation to the National Health Insurance Grant. He asked how the Department would commit itself to making workplaces conducive to health for the workers there, given that it had indicated that some workplaces were not. He asked whether the Department was equipped to achieve the goal of implementing the NHI. If it was committed to the NHI but there were no systems and plans of implementation, then there was a problem. He observed that there were a lot of unemployed young people with skills. Some of them were doing internships in the Department. He asked the Department for details on how many people it had absorbed into internship programmes, per province if possible.

Ms L Arries (EFF, North West) asked if the Department was only going to have two community engagements, because this seemed too few. She asked for clarity on the target of enrolling 3.3m HIV patients on Differentiated Model of Care, given that elsewhere the Department was talking about the 5.5m people who are already on anti-retroviral drugs (ARVs). She asked for clarity on the maintenance, repairs and refurbishment target of 400 public health facilities. Was it covered by the R1.3bn budget for building construction? She noted that R622m was budgeted for contractors and asked for details. She asked what programmes were in place for non-communicable diseases and stated that community outreach programs were lacking in educating the public about these diseases.

Ms T Breedt (FF+, Free State) said that the Auditor-General of South Africa (AGSA) had found that the annual reports of the Department were unreliable, and asked what had been done to improve the reliability of performance information, since the Department had deleted performance targets. She discussed the stability of leadership and the vacancy rate in senior management at the Department. She requested clarity on the NHI grant. She observed that there were a number of plans to improve primary healthcare facilities and hospitals, but wanted to know how the grant would be implemented. She noted that there had been a number of fires at hospitals, such as Charlotte Maxeke Hospital and the National Hospital in Bloemfontein and asked how those fires would impact the improvement of hospitals. Would the opportunity to upgrade these hospitals be taken? She asked how the Department's policies on mental health had changed to ensure that they did not have another tragedy like at Life Esidimeni. She asked what action had been taken by the Department after the Special Investigations Unit (SIU) report on COVID-19 procurement. She asked about the impact of the social media campaigns on the ground. She asked what the strategies to combat vaccine misinformation were and how the Department would ensure that people got vaccinated for the multitude of diseases that they had almost been able to eradicate. She asked how climate change had affected malaria and what was being done to address it. She discussed the digitisation of patient records and the implementation of electronic patient records. She inquired about the budget and timeframe for the digitisation of patient records, as previous digitisation efforts had been marred by issues and wasted resources.

Ms N Chirwa-Mpungose (EFF, Gauteng) said she assumed that the Department’s social media strategy was being implemented by an outsourced company and asked what company it was. If the Department had a plan to build internal capacity to carry out such functions, it was short-sighted to constantly outsource them. The Department must start acknowledging the dangers of outsourcing healthcare services, especially following the judgment in the Life Esidimeni inquest. Building state capacity was pivotal to building a sustainable healthcare system, ensuring that the public sector was catered for and that government was able to carry out its own duties. She stated that the Department kept reducing its own targets without explanation. For example, in 2023/24, the Department did 399 social media health promotion messages, but the target for 2024/2025 was just 200. What was the reasoning behind reductions in and the removal of targets? She asked whether the community outreach programme target of 14m patients included tracing lost patients, an important target dropped in 2024/25. Removing the indicator affected other programs such as the HIV programme and non-governmental organisation (NGO) interventions. This was a crucial measure, particularly in relation to mental health issues. She asked for more information on planned constructions and revitalisation of facilities, including whether the targets included projects started in 2023/24. She asked if the Department had managed to lower medico-legal claims, particularly concerning obstetric violence, where the number of claims was the highest, and what its intervention plan was. She discussed cases where a mother gave birth and the child was injured but the injury was not immediately visible. How did the Department ensure that mothers were covered in such cases? She emphasised the effectiveness of community healthcare workers for in-house visits and tracing lost patients and questioned the current six-month or three-month contracts for those workers. Was there a plan to absorb them into the system permanently?

Ms N Du Plessis (DA, Gauteng) said that, as always, it was heartening to hear the Department’s plans, but she remained concerned about implementation. She asked why income and expense reports were not available for most provinces. These would improve the Committee’s oversight capability. She emphasised the need for the national Department to support the provinces to obtain clean audits. There needed to be monitoring and evaluation of how funds were spent to ensure accountability. She discussed issues at provincial clinics, where requested upgrades had not been implemented for almost 20 years. She asked the Department to address medico-legal issues. She said that external lawyers often squashed relevant claims. She emphasised the importance of patient dignity and ensuring South Africans felt heard. She asked for information about progress made in multiple drug-resistant tuberculosis (MDR-TB) treatment. She said that the Department was not adequately addressing neuro-divergence, anxiety, and depressive disorders, drawing attention to the fact that the country’s suicide rate was in the top ten globally. Mental health issues need to be addressed within healthcare systems but also through mental health education and household visits. She also highlighted the crisis in emergency medical services (EMS) in South Africa, with patients waiting for hours and patients dying while waiting for ambulances. She asked that the people responsible for handling large budgets for electronic medical records (EMR) be held accountable for not implementing them. She suggested decentralising infrastructure development to address small issues and lower costs, and gave Thelle Mogoerane Regional Hospital in Vosloorus as an example of officials being held accountable. She mentioned the need to ensure that child feeding schemes got value for money and that anyone responsible for wasteful expenditure was held accountable. She stressed the importance of supporting nurses, not only financially but also mentally and educationally. For example, there was a lack of understanding about triage in emergency. An increasing number of nurses were leaving public healthcare for private healthcare, even for lower salaries, finding the system easier to work in. She also mentioned the potential for increasing Public-Private Partnerships (PPPs) to ensure the private sector supports the healthcare system in South Africa.

Ms J Adriaanse (DA, North West) stressed the importance of EMRs, as paper records could get lost and were not readily available. She mentioned that the South African National Health Laboratory Services (NHLS) had been hacked in June, causing the public healthcare system to be paralysed. She emphasised the need to secure and protect information, the need for systematic staff training in clinics, and basic care to capture medical records. She also raised concerns about the compensation of employees, particularly doctors and interns, who were often required to work double shifts in hospitals.

Responses
Mr Mamogale explained that the decrease in compensation of employees (COE) was only for the national Department, and that the R56bn conditional grant to provinces was included in the total COE budget of R259bn. The national Department had managers who monitored these grants. They were also monitored through the CFO’s forum, and the DG approved business plans and annual procurement plans for each grant, including expenditure and compliance reports. The R455m NHI grant to provinces included healthcare professional contracting and mental health programmes in provinces.

Prof Nicholas Crisp, DDG: NHI, DoH, discussed the implementation of the NHI Act and the timing of budget approval and preparations for this year. He said the NHI was not yet implemented, and the budget cycle was just beginning. The NHI Fund would be run by a Schedule 3a entity, which would need to be established in the coming three years. The capacity to run the entire NHI was not yet established. He expected significant changes in management during this term, with the largest part of the NHI budget focusing on infrastructure, in particular, improving public sector clinics and health centres to meet the standards for accreditation. The digital system would allow patients to move between providers, GPs, public sector clinics, and hospitals, and their records would be accessible for future practitioners. He said that the Department's anti-corruption forum, which included both public and private sector players, had reported numerous activities which were now ready for prosecution. The national Department and provinces were working to monitor medico-legal cases and address issues related to patients not receiving awarded money. He acknowledged that there was a lot of corruption by legal professionals relating to patient claims. A comprehensive report on the problem had been delivered to the anti-corruption forum. The SIU was proceeding with investigations into COVID-19 procurement corruption and some cases were ready for prosecution. He explained that the CCMDD had started as a small project using donor funding but had grown into a large programme, with staff paid by donors. This made the program vulnerable and raised concerns about the lack of authority to create full-time posts to manage it. He hoped that more permanent posts could be created in the coming year. He discussed the progress of the EMR project. Phase one, the minimum viable product, was currently in field testing, focusing on HIV and TB records. The project was expected to be implemented more widely by November this year. He highlighted the need for training personnel to access the new system. He acknowledged the recent hacking incidents in the NHLS, highlighting the importance of regular penetration testing. The budget for the project was divided among provinces and the national Department, with some funding coming from regularly allocated budgets or conditional grants.

Mr Ramphelane Morewane, DDG: HIV, AIDS, TB and Maternal and Child Health, DoH, explained that the 3.3m patients who would transition to decentralised models of care referred to patients who would receive three months worth of medication at one time. Modules had been developed to train clinicians in maternal, child, and neonatal spaces. All clinicians, even from the private sector, were free to join. The first cohort was mainly from the public sector, and the Health Professionals Council of South Africa (HPCSA) had approved guidelines for maternal, child, and neonatal care. Additionally, new vaccines have been introduced to protect children from vaccine-preventable diseases. He discussed the public's access to information about MDR-TB through advocacy, civil society engagement, and communication. He highlighted the National Strategic Plan for HIV, AIDS, STI, and TB, which included specific reference to TB. The TB Recovery Plan, endorsed by the HPCSA, was a key tool for public awareness and engagement. The APP included the MDR-TB response to ensure it did not fall by the wayside. The targets for MDR-TB were being met.

Ms Hunter explained that in having only two community outreach programmes, the Department was guided by a framework from the Department of Planning, Monitoring, and Evaluation (APP). The programmes aimed to balance strategic and operational issues, with the former being a new intervention that was removed from the APP once it became operational. The Minister and Deputy Minister led the two community outreach programmes. Other outreach programmes included the expanded screening programme, which involved visiting districts with community health workers, examining the work of traditional health practitioners in health education, and making referrals to clinics. This link was crucial for early identification and implementation of remedies for environmental health problems. Clinic open days were held where the Minister interacted with community service representatives at well-performing or poorly-performing clinics. The Department reviewed licensing regulations for institutions and set up a multidisciplinary task team to develop new guidelines for residential and day-care facilities for people with mental and intellectual disabilities. These guidelines had been approved by the HPCSA in April, and would be used for regular inspections. Climate change increased malaria incidence in the country. Sensitivity tests were conducted to ensure the chemicals used for spraying were effective, as spraying areas where disease vectors breed was the most effective way of combating malaria. In Kwazulu-Natal, the spraying of mosquito repellents had shown great success, and the Department moved from seasonal spraying to year-round spraying. The business case for formal employment of community health workers was being updated with 2023/24 figures to determine the appropriate Treasury request. However, absorption was not being discussed, and individuals must be formally employed using public service prescripts. The National Bargaining Council was engaging organised labour but short-term contracts for community health workers were no longer available. However, the stipend for community health workers had been significantly improved, and contracts lasted for at least a year. Further extending the contract period was also being discussed. Community health workers without matric were concerned about their future employment as the current policy required them to have passed matric. The policy would be phased in to ensure the continued support of experienced workers. When it came to mental health, neuro-divergence was addressed this issue by the Department of Education through school psychology services and teacher training, while community health workers played a crucial role in addressing lower levels of anxiety, which were often caused by social conditions. They were trained to recognise symptoms and refer individuals to social workers for help. A special grant was used to train primary healthcare professionals to better handle mental health and identify symptoms early.

Mr Mamogale said that since January 2024, 6588 interns, community service medical officers, and grade one, two, and three medical officers had been appointed. He thanked the Deputy Minister for obtaining an additional R3.7bn from Treasury to make these appointments possible. He said the Department knew the names of facilities that would receive maintenance or revitalisation and could be made available. Some were multi-year projects, however. He acknowledged that the reliance of provinces on the infrastructure departments frequently caused frustration. For example, in Gauteng, then-Premier David Makhura had had to intervene to transfer responsibility for repairing Charlotte Maxeke Hospital after a fire from the Department of Infrastructure Development to the Department of Health. Provinces were working on this issue. Recent fires in Gauteng had raised concerns about occupational health and safety, and two parallel investigations were underway. Health officials were working with the police to investigate the incidents. All facilities were certified fire-compliant by municipalities. The absence of EMS in some areas was another concern. The HPCSA was auditing provinces for compliance with regulations related to EMS standards and was working on an electronic system to centralise EMS across the country. National Treasury had approved two PPPs, and the team was working with the Department of Public Service and Administration (DPSA) to assist with others.

Closing remarks by the Deputy Minister
Dr Phaahla highlighted the importance of human resources for health in the success of the public health system. He highlighted the need for comprehensive, multidisciplinary teams, including doctors, nurses, pharmacists, physiotherapists, and dentists. Government worked with provinces to support professions requiring internships or community service, and put pressure on Treasury to assist it. Government has implemented conditional grants on human resources, which have stabilised the area over the last three to five years. However, there were still inefficiencies, such as rural allowances and overtime allowances, which were not aligned with staff interests. DPSA had been asked to address these issues, particularly in the area of remunerative work outside public service (RWOPS). The goal was to ensure that people were paid full salaries but spent time caring for patients.

Closing remarks by the Minister
Minister Motsoaledi explained that Cuba’s NHI model was based on primary health care rather than curative care. Cuba’s NHI provided free healthcare to all people at all times. There was no private health sector at all. It had led to eliminating many diseases, which was why medical students who trained in Cuba were required to complete their final year in South Africa. He also discussed the Life Esidimeni tragedy and said that the National Health Act should be re-amended to prevent a similar event in the future. He pointed out that the tragedy had only been possible because of amendments to the Act made in 2002, before which time it had required the signature of the President to move mentally ill patients. The 2002 amendments had devolved that power to MECs. The Department intended to reverse this amendment, but had been advised to wait until consequential amendments to nine acts that the NHI Act would necessitate had been passed. He said the Department was waiting for the President's assent to an Act on vaccination. He emphasised the importance of vaccination and the negative impact of anti-vaccination campaigners during COVID-19. Vaccination was responsible for the near-eradication of diseases like polio, tetanus and diphtheria. He said household spraying was the main weapon against malaria, and pesticides were also helpful in areas with stagnant water. He said outsourcing hospital food preparation had been ineffective, as service providers were incentivised to provide cheap, low-quality food. It was preferable to insource this kind of service by training workers to prepare food. This has been shown to be cheaper and more effective in Limpopo. Security was another area that should be insourced. He said that medico-legal fraud and criminality by lawyers was widespread. The issue of assisting birth injuries was also a concern. Many people did not receive compensation due to the current litigation model, which was based on the American system, which had been criticised by the former DG of the World Health Organization criticised the American model because it led to most money ending up with the lawyers who fought the cases on both sides. In this connection, he was very happy with the conduct of Enterprise Foods following the listeria outbreak in 2017. The Department was looking at a no-fault claim model, where a tribunal consisting of retired judges, retired professors of medicine, senior advocates, and social workers assessed the damage caused to a patient in the hospital. This method has been found to be more effective than a lengthy litigation process.

He acknowledged that the NHLS had been the victim of a cyber-attack. Attacks happened all over the world, even in sophisticated countries in Europe. However, the attack did not bring the work of the NHLS to a standstill. It was still possible to send blood specimens for analysis. It had just affected the automated result report system. The Centre for Scientific and Industrial Research (CSIR) was working with private specialists to resolve the problem and build firewalls to protect the system in the future.

Closing remarks
The Chairperson asked Members to send any further questions to the Department through the Secretary of the Committee. She thanked the Minister, Deputy Minister and the Department for their engagement.

The Committee adopted the budget vote of the Department. See report here https://pmg.org.za/tabled-committee-report/5887/

The Committee adopted its programme for July and August 2024.

The Chairperson thanked everyone for their contributions and the meeting was adjourned.