Health Budget

Quality of Care
Ms Matsau addressed two issues of concern:
- Standardisation of services/equity
- Quality of care delivered

A tool has been developed to address the need for equity in the delivery of services, known as The Comprehensive Health Care Package. It is defined by a set of norms and standards for service delivery and has a defined package of services. The tool will ensure that health services rendered in one health care facility at one level is delivered in the same way at another facility regardless of geography, dominant patient group and so forth.

This tool allows managers to assess the quality of services. It will help the community to know what level of service to expect and demand. It helps managers of facilities plan and budget for services. It allows them to plan for staffing and for the utilisation and range of services that will be offered.

Three months ago the costing for the tool was finalised. It showed that the level at which services are currently being delivered is slightly lower that they could be for the amount of money being spent. In general, there will be a shortage of R3 billion if a public health care package is delivered according to defined norms and standards. Some facilities are offering these services, others are not.

The Department has just embarked on a program of quality improvement using as guiding documents the Constitution, White Papers and other informative documents. It is trying to expand and formulate programs to improve quality of care. There are already a number of initiatives/activities supporting this goal:
- The development of a policy on quality in health care. This policy will establish a framework in which services are delivered.
- Patients Rights Charter - launched at the end of last year. The focus is now on implementation and workshops are being held in the provinces.
- Complaints procedure-an attempt at formalising a system of complaints to bodies up to and including statutory bodies.
- Peer review System - the system will allow patients and clients recourse for complaints and allow them to get a good assessment of their case even from peers of the physician they are lodging the complaint against. The Department is trying to formulate a properly constituted body.
- Survey on the quality of care in public health care facilities. The survey, to determine the level of quality of care currently being delivered, has just been completed and the results are being studied. Preliminary findings show that quality has been neglected.
- National Hospital Competition. Although there is a strong move to have an accreditation system for hospitals, it will be much less threatening to have a competition as a form of evaluation and later implement the accreditation system.

Human Resource Development
Prof Gumbi submitted that there was an uneven distribution of health care professionals in the public health sector. In urban areas the ration of medical doctors to the population is 1:800 but in the rural provinces such as Eastern Cape, Northern Province and Kwazulu Natal it is 1:27000. The recommended WHO ration is 1:1000 population. The Department has developed a number of strategies to redress this imbalance, one being community service.

Since July 1998 community service has been instituted. While a total of 1159 doctors were allocated, only 1108 turned up. However, Prof Gumbi acknowledged that they had a constitutional right to elect to pursue other activities before completing their community service. Among those completing their community service, the gender and race ratios need closer attention.

The benefits of community service are that under-served areas are now staffed with medical doctors. There are now less sessional doctors used from the private sector. All of the above improves access to health care. It has reduced the need for recruitment of foreign doctors.

Currently only 10% of doctors work in the public sector and 11% of all pharmacists. In January 2001 community service for pharmacists will be implemented and by July 2000 for dentists.

Management of Hospitals
The focus of this chief directorate is to promote and facilitate decentralisation of management authority and responsibility with the aim of improving cost efficiency and the cost effectiveness of services. This would improve the quality of care. The following are the cluster of directorates and their budgets. They are all different but address complementary aspects of co-ordinating the revitalisation of hospital services in the country.

The Hospital Management directorate is concentrating on some of the following activities:

- Although decentralisation of hospital management is important for efficiency, capacity must be developed to bring about the change. The project receives funding from the EU and the World Bank to supplement our fiscus fund.

- Performance Management Agreements (PMAs) are a high priority for the directorate. The PMA contains a number of schedules including finance and revenue, Human Resource and Organisational Plan. A multi-departmental team has been set up to overcome the legal hurdles blocking the full implementation of PMAs.

- Cost centres have been set up at Groote Schuur Hospital and Wentworth. A hospital information system to support the cost centre initiatives has been in place since 1 April 2000.

- The capacity of managers is an important area to focus on, especially developing and supporting senior women managers.

- The quality and coverage of emergency medical services (EMS) needs to be improved. Norms and standards are being developed and appropriate regulations are being drafted.

- Disaster management; the main activity is the development of policy and guidelines for the spectrum of disaster management. The unit is heading the Department of Health task team co-ordinating health sector responses to the floods in Mpumalanga, Northern Province and Mozambique.

The Facilities Planning Directorate are mainly focussing on the Hospital Reconstruction and Rehabilitation programme (Hospital R&R). It is dealing with the inadequate maintenance of public hospitals over many years as well as restructuring the entire hospital sector.

The Health Technology Policy is a new directorate that is developing a policy framework and a whole range of specific policies related to the efficient and cost effective use of health technology.
The Radiation Control unit does work on the control and regulation of the medical and industrial applications of certain technologies.

There are various task teams in the Directorate working on cost centres, organisational development, district hospitals and Public Private Partnerships.

HIV/AIDS
Dr Simelela outlined the strategic goals of the Department of Health's HIV/AIDS programme:

Broad Strategic Goals
- To work towards a reduction in the number of new HIV infections.
- To work towards a reduction in the impact of the HIV epidemic on individuals and communities.

Priorities
There are four main priority areas: treatment/care/support, the protection of human rights and monitoring/research/evaluation.

Specific Objectives
There are units within the HIV/AIDS Directorate to support the above goals. Their specific objectives and strategies are as follows:
- Providing counselling, care and support.
- Providing interdepartmental support.
- Providing support to non-governmental organisations and their other partnerships.
- Creating awareness of HIV/AIDS and sexually transmitted diseases (STD's). - Educating people on HIV and TB and on barrier methods.
- Building youth awareness and skills.

Counselling
The priority is to increase access to medical and non-medical voluntary testing clinics (VTCs). There was a need to establish counsellor mentorship programmes. Criteria have been established for lay counsellors. These lay counsellors will have mentors and will focus on counselling for children -addressing their psychological needs. An integrated team is going around to inform provinces and assist them in setting up task teams.

Care and Support
The Department is still busy finalising models. Impact study tenders were awarded last year to examine whether a hospice type facility or a community model is suitable. Provinces have selected the model most suitable to them. A rollout plan for home-based care is being put into action.
Guidelines on the treatment of opportunistic diseases and infections have been developed. These also cover paediatric and palliative care.

The Department is looking at creative ways of involving people in the Directorate's work. For instance, five sufferers have been employed in different government departments to create awareness and drive the response to the campaign. A new appointee has just taken up a post to work with business to initiate projects.

Interdepartmental support
There is a need to develop HIV plans and programmes in all national departments in order for government to plan for short and long-term recruitment, benefit plans and so forth. There is a strong interdepartmental committee currently conducting HIV impact assessments.

NGO support
The Department funds 10 national and 200 provincial NGOs. There is a strong need to build the management capacity of funded NGOs. There is also a need to build provincial capacity to fund and monitor provincial NGOs. NGOs should be encouraged to twin with other civil society groups to build capacity.

Partnerships
The trade unions are proving to be strong partners. They have become involved within their own communities in the fight against disease. Business is a strong partner and they largely fund their own initiatives and projects. The Department is making use of traditional healers - there are two in the directorate. This is an attempt at building rapport, assisting the healers and using them as a resource for the Department.

From the civil/military alliance someone has been seconded into the Directorate as a liaison. Lastly, there is a small unit working with the Law Commission providing technical assistance on necessary law reform.

HIV Public Awareness
Billboards are being used to create awareness. The focus is dealing with the language challenge and communication with the handicapped and other target groups. Disclosure and acceptance in the community is a challenge.

This year there must be at least two health care providers in a facility who know the protocol. There is also a move to examining activity in the private sector. For instance, in respect of STDs the infected male partner usually seeks treatment in the private sector and generally private physicians do not adhere to the protocol. These physicians need to be trained. The directorate is also working with miners and sex workers. Interventions in case of TB need to be strengthened and AIDS counsellors must be equipped to counsel TB sufferers. Especially amongst dual AIDS/TB sufferers there was a need to alleviate poverty and educate people on nutrition.

Research
The Directorate was collaborating with the Medical Research Council on vaccine research. Research was also being done on the prevention of mother-child infection. There are pilot projects underway. Other areas of research are on STDs and HIV / STD transmission after sexual assaults on women.

Youth Programmes
A number of youth programmes have already implemented sustainable HIV/AIDS programmes.

Life Skills Programme
R75 million has been allocated to this programme. There is meant to be an integrated life skills programme in primary and secondary schools. As part of the programme the training of teachers as lay counsellors would be piloted. Peer education would also be implemented which would allow capacity building amongst the youth themselves.

Mother and Child Health
Dr Mhlanga outlined some of the initiatives of his unit:
- National Programme of Action for Children
- Integrated Management of childhood illnesses; concentrating on nutrition to immunisation to promote the health and development of children
- Human genetics and genetic services
- Chronic diseases in women and children

Reproductive health initiatives are becoming essential due to the high levels of maternal deaths. There is a distinct lack of skills and infrastructure to deal with birthing complications. HIV has also had an impact; it is the second most common recurring factor in deaths. The Termination of Pregnancy service needs to be improved in rural areas particularly. Midwives need to be trained and registered. Dr Mhlanga emphasised that male involvement in the choice of contraception is crucial.

The Department is working with Welfare and Justice to combat violence against women.

The directorate has set certain targets: the elimination of polio, eradication of measles, changing from percutaneous to intradermal BCG. They face certain training challenges; in the areas of immunisation, termination of pregnancies, maternal health and deaths and human genetics.

Pharmaceutical Services
The main focuses of the National Drug Policy (NDP) are economic, health and social objectives.

Each component of the drug supply chain-selection, procurement, distribution and rational use must be in place in order for the chain to work and resources must be carefully monitored. There is a real need to make equitable health care available in all facilities.

Ms Peteni acknowledged that drug use is a difficult area to monitor. The standard is 'rational use'. The role of the national office is to co-ordinate these activities. They must make use of the media to inform the public and prescribers.

In the area of human resources, the turnover of pharmacists is very high due to lack of motivation, poor remuneration and staff being overworked. The Department is looking to implement community service for pharmacists by January 2001.

In the area of financial resources Ms Peteni pointed out that the provinces with the largest budget do not always use funds efficiently and effectively. Capacity building is necessary. There is poor or non-payment of supplier accounts and this is not necessarily due to lack of funds but to lack of capacity and co-ordination. Shrinkage due to poor stock control and poor estimates has a negative effect on finances. There is a need to implement budget training so that staff can manage the budget more efficiently.

In the area of drug procurement Mr van Den Berg pointed out that SA pays more for drugs due to the effects of the closed market caused by apartheid and sanctions. The feasibility of bulk purchasing is being looked at. There are currently negotiations with suppliers to lower the prices of malarial and TB drugs. In some cases tendering functions are being duplicated because of the national department and provincial department submitting the same tenders at times.

Regarding the distribution of drugs, government manages five warehouses and four have been contracted out. Uniform data is required for more effective stock control.

Mr van den Berg concluded that the priorities in the area of pharmaceutical services are to implement community service, to standardise information services, to implement a cost-effective procurement process and a communication strategy.

Discussion
Mr Mkhaliphi (ANC, Mpumalanga) asked Dr Pretorious why there was a zero capital budget for 1998/99 if there was a backlog of facilities? Dr Pretorious said Mr Mkhaliphi was probably referring to the budget for the national department, which does not show the allocations to provinces even though there was a lot spent on capital equipment.

Mr Mkhaliphi asked what the nature of the legal problem is in respect of performance agreements? Dr Sibeko explained that you cannot have a legal contract between the same entities and the province and the hospital are the same entities.

Mr Mkhaliphi asked the Department to clarify the duplication of tendering functions referred to in the last presentation. Mr van Den Berg said that provincial treasuries are involved in the tendering procedures as well and a lack of capacity in the provincial treasury was delaying the process. He advised delegates to take the issue back to the provinces and correct it.

Mr Mkhaliphi asked whether there is currently an oversupply of pharmacists in the country? Why was community service for pharmacists being implemented? Could their salary scale not be raised?

Ms Peteni said a proposal was put before the central bargaining chamber to raise their salary scale but it was rejected and referred to the health and welfare bargaining chambers. Structural career paths for pharmacists should also be considered. Prof Gumbi added that the human resources team is also looking at the health professions broadly. The Code of Remuneration requires that all posts be graded. It is a process responsive to needs because the number of posts available in the province depends on the number of posts the province has funds for. The current ratio for pharmacists was 1:25000 population and while this is an acceptable ratio only 10% work in the public sector which is why community service is being implemented. Within the national planning for resources, education and training needs to be reorganised.

Ms Jacobus (ANC,Gauteng) asked whether there are only three hospitals been restructured in terms of the Hospital R&R? Dr Sibeko said that the R&R project is designed for all the hospitals in SA. An audit has already been done to show the cost of such rehabilitation.

The Department of Health will answer the following questions in writing:
Ms Jacobus's (ANC, Gauteng) questions:
Have there been any increases or decreases in the budget and in which areas?
When will the six initiatives in the area of quality care be implemented?
In the area of human resources have the budgetary allocations been adjusted to meet the costs of deployment of doctors from other provinces?
What impact has the HIV/AIDS virus had on the health budget, where particularly in the area of human resources nurses and doctors may also be suffering from HIV?
How does the budget support the objectives outlined by Dr Simelela?

Dr Nel (NNP, Free State) question:
The HIV/AIDS consulting process had fallen through in five provinces, which provinces were these?

Mr Mkhaliphi (ANC, Mpumalanga) questions:
What remedies are there for the poor quality of health care services?
What remedies are in place for complainants since it is inevitable that staff will cover up for each other when a complaint is lodged against a colleague?