Provincial Budget Briefings: Northern Province, Western Cape & Free State, Mpumalanga

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Health

04 April 2001
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Meeting Summary

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Meeting report

HEALTH PORTFOLIO COMMITTEE
5 April 2001
PROVINCIAL BUDGET BRIEFINGS: NORTHERN PROVINCE, WESTERN CAPE & FREE STATE, MPUMALANGA

Chairperson
Dr S A Nkomo

Documents handed out
Western Cape Budget Review
Free State Slide Presentation
Free State Budget Review
Northern Province Budget Review
Mpumalanga Budget Review
[it will take some time to obtain this documentation]

SUMMARY
The Northern Province, Western Cape, Free State and Mpumalanga presented their Budget Review. [The Mpumalanga session will not be available until 20/04/01]

MINUTES
Northern Province Health Department
Mr Senti Thobejane tendered the budget estimates on behalf of the Northern Province Heath Department. Dr. Nelly Manzini and Mr.Nelson Tshikovhi from the department assisted him.

The Northern Province Health Department said that it had overspent last year's budgetary allocations by R63million. The Department noted further that the current financial year budgetary allocations had witnessed a slight increase in all programmes save for the specialised services, which had shown a slight decrease. The department had forecasted an increase of R190 million in the current financial year.

The department stated that it had experienced revenue under collection of 14.8 million in last financial year. The committee was critical of the department's disbursements of conditional grants to targeted projects. The department blamed the lapse of conditional grants on delayed disbursements of funds to the Provincial Treasury.

The Department gave a concise summary of this year's budget estimates. The Chair explained that due to time constraints, he would only take one round of questions. He advised members to confine their questions on areas of clarification only. The presentations, would be scrutinised and debated by committee members after the recess.

Discussion
Ms Malumise {ANC} asked why the current estimates for health care support were less yet the Department is said to have exceeded the allotted funds in the previous financial year. She wondered what miracle might have brought the figure down like that. M.Senti, in reply, explained that mechanisms have been put in place to improve revenue collection which would supplement budgetary allocations.

Ms Baloyi {ANC} inquired if pharmaceutical supplies were outsourced. She also noted that no provision had been made for integrated poverty alleviation programs. She wanted to know how the Department handled medical aid patients.

Mr Senti explained that Pharmaceutical procurement had been outsourced since 1998. He said that the department had experienced a drastic decline in the shrinkage and expiry of drugs which incidence he put at below 5%. He attributed this to improved service delivery and closer delivery monitoring. He added that the department had hired a security company to foresee risk management following which a number of the department officials had been arrested for intercepting and stealing drugs between the depots and the hospitals.

In her query, Ms Gxowa sought clarification on the issue of recruitment and retention of staff. She also inquired about the innovative ways the department had devised to increase revenue collection.

Mr. Senti informed the committee that the department had implemented a new mechanism with the utilisation of modern new technology. The system, he said ensured that patients on medical schemes were billed directly and instantaneously. He added that this system ameliorated the problem of delays in payment and the debilitating malaise of issuance of style cheques.

Mr. Senti pointed out that the upgrading of information technology had tremendously improved data collection for efficient revenue management. The department had entered an understanding with private practitioners to refer patients to public hospital which would expand the department's revenue base. With all these measures in place among others, Mr. Senti confidently forecast that the revenue estimates are likely to be surpassed.

On the question of recruitment and retention of staff, Mr. Senti informed the committee that the department was currently running a program of bursary allocations to medical students who contracted to work for the department after graduating.

The beneficiaries who opted to quit before the expiry of their contracted time were forced to repay the bursary funds in cash. He said this measure helped to discourage the exodus of medical personnel from the department. However, this was not totally foolproof as the department was involved in lawsuits of 80 bursary beneficiaries who left the department before the expiry of their contractual term. He observed that most of the province is rural hence largely unattractive working environment for these youthful doctors who prefer urban settings.

Dr. Mulewa wondered why funds for HIV Aids had not been spent. Mr. Senti explained that these funds were disbursed to the national treasury late. By the time the funds arrive, he lamented, there was already a deficit in the account for the project in question. Such funds were eaten up in the pre-existing deficit. Mr Senti, however, promised the committee that things are set to change in the current financial year. The department, he reiterated, would ensure that funds were expended only on projects for which they were allotted.

Dr. Rabinowitz {IFP} asked about the sharp increase in drug utilisation. Mr Senti attributed this to the increase in the number of medical personnel who made prescriptions to patients. He stated that the ratio of senior to junior doctors was still unsatisfactory. He noted that most of the community doctors were junior who used up a lot of drugs on experimenting whereas senior doctors would have given a straight prescription. This too, he explained, contributed to the increase in drug utilisation.

Mr. Baloi inquired on how cross border administration was being handled, Mr. Senti told the committee that officials from Gauteng, Mpumalanga and Northen Province are set to meet and discuss how referral issues could be co-ordinated to avoid duplication of functions. He said, further, that these meetings would incorporate provincial health authorities and local councillors.

Mr. Senti said that the department was handicapped by under-funding. The province was only second to Mpumalanga in terms of the least budget provision. Mr. Senti, however, said that the department was determined to clear all deficits so as to commence the financial year with a clean bill of health.

The Chair stated that due to time constraints the group from Mpumalanga would now proceed with presentations.

Western Cape Health Budget
Dr Lawrence highlighted aspects of the report emphasising particular figure tables contained in the document.

Discussing Table 1, Budget Trends (p 5), Dr Lawrence emphasized the 4.2% budget dip for the period 2001/2002. Dr Lawrence felt that there was reason for concern as a dip such as this would mean that there would have to be a reduction in staff and services. As the budget increases, as it is forecast in the period 2003/04, the staff would then have to be reemployed.

Dr Lawrence proceeded to speak about Programme's 1 through 6 (pp 13-18). In Programme 5 he pointed out that four nursing colleges had now been amalgamated into one, and had been a traumatic period due to labour relations. There are now additional funds for nursing training. Programme 6 mentions the reduction of backlogs and waiting times for orthotic and prosthetic devices. Dr Lawrence pointed out that these backlogs seriously affect the quality of life for the patient, and it was therefore important for backlogs to be reduced.

Dr Lawrence felt that it was important to evaluate what the department is doing in terms of meeting its objectives. Page 29 shows a summary of the evaluation of objectives. Dr Lawrence mentioned that community service had been implemented for dentists and had already commenced and that a further community service for pharmacists was in the process of implementation. The department had found that having pharmacists complete community service was particularly valuable, as there was a noticeable reduction in pharmacy queues. He felt that this community service would make an important contribution to health services.

The Emergency Medical and Rescue Service table (pg 35) explains what upgrading is taking place in the emergency services. Dr Lawrence added that besides the 20 new ambulances purchased, the department also aimed to raise the number of personnel manning the ambulances to at least two, as this would enable the service further.

The table showing the trends in planning and evaluation of regional hospitals (pg 3) explains the business plans for revenue generation at regional hospitals, including G F Jooste, Mowbray and Karl Bremner. For example, it is planned to allocate 77 private beds to Karl Bremner in order to raise revenue for the upgrading of this hospital.

The Department has four psychiatric hospitals. At the Lentegeur hospital it is planned to launch a new unit for youth. Valkenberg Hospital is to receive R8 million raised from a combination of the provincial health budget, Friends of Valkenberg and NGOs. Also, a new substance abuse programme is due to be launched at De Novo centre.

Much new equipment has been purchased for academic hospitals (pg 33) in the last financial year. R2 million has been put towards the treatment of cataracts to address the backlog of cases.

The evaluation of 2000/1 and planning for 2001/2 for nursing colleges is explained in the report (pg 34). Dr Lawrence expressed concern that the intake for nurses was less than the department had hoped for.

The report shows that funding for the treatment of HIV has doubled (pg 41) and Dr Lawrence stated that it is planned to double the funding again in 2003.

Discussion
Ms Baloi (ANC) raised the following issues:
- Regarding the personnel budget, how would the department manage the expansion at present on personnel spending.
- The department was focusing more on the treatment of AIDS and less on prevention. How is the department financing its AZT programme, is this programme funded from a separate budget or is it included in the overall health budget?
- Where was the budget allocation for pharmaceuticals within the report?
- Does the Mother to Child programme used Nevirapine or AZT in its treatment?
- What was being fed to the infants in the infant feeding programme?
- She questioned the close link that the report drew between AIDS and Tuberculosis as the Western Cape has always had high TB rates. Is the department able to manage these high rates? She noted that the highest TB rates are within the rural areas of the Western Cape. Why were the other areas lower? Did they feel that they were controlling it in some areas but in other areas failing to manage the problem? And if so, could they explain why this would be?

Ms Marshoff (ANC) asked the following questions:
- How would the department manage and monitor its home based care programme.
- Although the department had explained how it would manage the infectious rate of TB, had it thought about the high level of alcoholism in the Western Cape, and did the department have a programme to deal with this particular problem?
- Is there a by-law or ordinance against the national Tobacco Legislation that allows the province to "go on your own"?
- Was the budget for the infant formula feeding scheme supplemented from the funds for the school feeding programme?
- What protocols (AZT or Neveripine) did the department use for the Mother to Child programme. As Neveripine has not yet been registered, what are the ethics of using this drug, if indeed the department is doing so if it is unregistered? How is the programme monitored and evaluated?
- She welcomed the fact that funds had been raised to improve Valkenberg hospital.

Ms S Mnumzana (ANC) asked how the outreach of programmes worked in the context of informal settlements. How are the lives of people in such settlements improved by the outreach programmes and what efforts is the department making to reach these communities? She asked the department to explain the administrative fees mentioned in the report relating to the treatment of AIDS. According to the Pharmaceutical Manufacturers Association all administrative fees and charges must be 'unpacked'.

Dr Mbulawa (ANC) commented that it is a pity that the Western Cape Health Department has shifted from a social to an economic focus. She believes that the informal settlement and rural areas will suffer because of this shift in focus. She asked about the following:
- The costing of the protocols used in the treatment of AIDS and HIV.
- Had the drug Nevirapine had been used, and if it has been used, had anyone sued the department for treatment with the drug Nevirapine. She also asked if there had been any exhaustion of health staff, as an increase of drugs meant a burden on the staff.
- How was the department addressing equity in the recruitment of student nurses. She expressed concern that raising hospital fees to generate funds would put blacks and coloureds at a disadvantage. Has the Western Cape established, or is it contemplating establishing, gateway clinics such as the KwaZulu Natal Department of Health had established?

Dr Rabinowitz (IFP) raised the issue of the number of people taking voluntary packages, which the report states is more than 9000. She asked if this was due to national or provincial legislation. And if the department wished to contract more health personnel, would it take direction from national or provincial legislation? Are people who have taken a voluntary severance package able to be re-employed by the department? Is there any way of holding people financially accountable?

How is the department monitoring the public private partnership between Groote Schuur Hospital and Rhone Klinikum (pg 33) so that it can be evaluated? Is there a model of the partnership that can be made available to other provincial health departments?

Dr Rabinowitz (IFP) asked how the department is testing for AIDS. Is AIDS testing free in the Western Cape? If the department had the opportunity would it take advantage of the offer of a million free AIDS test? And if the department had the opportunity to test many people, would this knowledge help the department?

Dr Lawrence's response on behalf of the department:
He pointed out that the provincial government of the Western Cape had made the decision to shift from social to economic focus, and not the provincial Department of Health.

The only tool that the department had at its disposal to comply with the budget was to offer severance packages. In 2001 the department employed 24 000 personnel, in 1996 the department employed 32 000 personnel. The personnel budget determines whether we can employ new staff. The department is not allowed to have a budget deficit, so they are forced to employ new staff or services to the department. There is no longer a moratorium on employment.

On HIV/AIDS treatment, the Mother to Child programme is a Western Cape initiative. There is the extra problem of TB that compromises individual treatment. They deal with issues surrounding HIV/AIDS, such as handing out condoms, running information programmes at school, so they feel that their focus is preventative, rather than treatment only. They have 139 mobile clinics for the rural areas. They therefore do not believe that they focus on treatment rather than prevention.

The core of these patients are in the Mother to Child programme, in an effort to prevent the children contracting the virus. This needs a whole programme, including counselling, feeding, support for the mother, support for the child, support for what happens after the treatment, once the mother passes.

In the Mother to Child programme, there are two research sites per province (18 sites throughout the country). There are two sites in the Western Cape including Khayalitsha. The research sites were already using the drug Nevirapine, so they decided not to change this. When they rolled to the next site in Gugulethu they decided to stay with Nevirapine. The mother has to take the tablet until she goes into labour.

There was some confusion about the registration of this drug, but the staff had been trained to use Nevirapine. They went ahead with the programme with the understanding that the Medicines Control Council (MCC) had approved the drug. They were recently confronted with a letter from the MCC asking why the drug was being used. Western Cape had understood that the drug had been approved for the Mother to Child programme, though not for general use. They then decided to use the drug 'off-label', to legitimize its use. They have replied to the MCC informing them that they had understood that the drug was registered for use in the Mother to Child programme, but that they wish to comply with their ruling. They await the final outcome of the discussions on Nevirapine.

They are unaware of comments in the media and other portfolio meetings on this issue. There will be no more rolling out of the programme until this matter is solved. The existing programmes will continue to use Nevirapine until they hear otherwise. They will not use generic drugs unless approved of first by the National Government. They have learnt a great deal about counselling around this programme, and will share this knowledge with other provinces.

Ms Dr Mbulawa (ANC) interjected to ask what provincial health departments had visited their Mother to Child programme and also if the patients in the programmes are aware that the drug they are taking is off-label.

A colleague of Dr Lawrence replied that the Health Departments of Mnupumalanga, Northern Cape, Northern Province and the Orange Free State have visited the programmes in the Western Cape to gain knowledge. Other provinces had expressed an interest and were ready to visit, but national government had halted visits due to the controversy surrounding the use of the drug Nevirapine. Dr Lawrence explained that the patients in the programmes were very good at asking questions, so the status of the drug had indeed been explained to them.

Dr Lawrence explained that AIDS testing and counseling is still one on one. There was a lot one could achieve in group counselling but the pre-test and post test counseling is one on one.

Dr Lawrence replied to Dr Rabinowitz that the Western Cape has not been offered the one million free test kits, and if they did they would consider using them, but it was a question of sustainability.

Dr Rabinowitz (IFP) asked what the cheapest test was, but Dr Lawrence replied that they did not have that information at hand and would get back to Dr Rabinowitz (IFP).

Dr Cwele (ANC) commented on the issue of R6.1 million spent on the Mother to Child targets. He asked if it was in line with the budget as this was almost a quarter of the health budget.

Dr Lawrence replied that unfortunately the honorable member had not been present when he had explained why counselling had to be part of the budget. The R6.1 million is not for Nevirapine alone, but incorporates home based care, education and condoms.

Dr Cwele (ANC) again asked if this figure is not proportionately high?

Dr Lawrence replied that treatment forms only part of this figure. The department has to deal with the budget at hand. What the department has asked for in terms of funds they have not received. That amount of money is needed for the Mother to Child programme to work.

Chairperson Nkomo said that he wanted to follow up some of the main points. What the committee would like to know is, do people know what they are going to get (in terms of drugs)? People had said that they did not know what they were getting. These people are not highly literate but because of illness they were highly aware of the issues surrounding their treatment. Does the programme take into account the new national protocol that some people are guinea pigs? Here in Cape Town a translation programme was closed down, there was a big language problem. So saying that someone was told, does not mean that they have actually heard.

Dr Lawrence replied that the Western Cape is part of ongoing discussions, to be informed and to be informing. In any kind of research, or any modality to patient, questions will always arise. Patients' complaints are always taken seriously. If the 18 sites were to be opened tomorrow (countrywide) the same questions and complaints would be heard. They have assisted in the dissemination of information around the protocol to other provinces.

Dr Lawrence suggested at this point that the discussion should now move onto TB. He then introduced Dr Aiden Keyes, who would explain these issues.

Dr Keyes explained that TB damaged the immune system. Developing a DOT strategy also leads to an increase in the incidence of TB due to better knowledge of the illness. There is no doubt that HIV is feeding into TB cases. 40% of TB cases are HIV positive. The national average is also 40%.

Dr Keyes explained why rates varied by area. The mobility of people in search of work leads to a concentration of susceptible people. The lowest incidence of TB is in the metropole region, as there is affluence in the city.

There are mobile clinics in rural areas that operate on a monthly cycle. These clinics are picking up on the rate of TB infected patients, and will go back to the area to continue treatment of the cases before the next monthly round is due.

They have trained 100 people for this work and are embarking on a programme to train trainers for farms. They are at the beginning this project only. Western Cape also has a massive fishing industry. They treat the sailors on the boats before they go out to sea, sometimes up to 6 weeks, the captain is then responsible for handing out their medicine while out at sea. They hope to extend this programme so that they can evaluate the treatment of the sailors.

In terms of the mobility of the population, if the patient notifies the sister at the clinic he or she can be given a supply for the holiday period, for however long they will be away. The patient can also go to any other clinic in other provinces and if they produce their green card, the clinic is legally bound to provide treatment.

Mrs Marshoff (ANC) pointed out that in the Western Cape the rural areas are not that rural, so why are there pockets of areas that there are no existing statistics. She also asked how could the department assist in the informal areas in hygiene.

Dr Lawrence replied that his department does not have a say in where sewerage pipes are laid in informal settlements but they can possibly influence some of the decisions. He also explained that the department could give a further breakdown of statistics.

Chairperson Nkomo asked what the department's position was on spending on secondary treatments for AIDS patients. He pointed out that the committee had not heard about the sustainability of the department's programmes. People start to treat AIDS, then stop treating TB in a patient. Western Cape is supposed to be one of the richest provinces, why is there still a high incidence of TB. There seems to be no introspection by the department, why is this?

A committee meber asked how the TB rate affects the AIDS rate. He said that he expected if the TB rate is high, then the AIDS rate should also be high, but this was not the case.

Dr Cwele (ANC) pointed out that many questions had been left unanswered by the debate, and would it be possible to receive a written reply.

Chairperson Nkomo asked if the Western Cape Department of Health see themselves as part of South Africa?

Dr Mbulawa (ANC) said that Dr Lawrence has been saying that his department has been informing the national body, then what is their reaction to what is said in these meetings (with the national body)?

The Chairperson drew this hearing to a close, as they had run over time, and thanked the Western Cape Department of Health.

Dr Lawrence thanked the committee on behalf of the Western Cape, part of South Africa.

Chairperson Nkomo pointed out that there was very little time left. He invited the Free State to present their budget the following day, but the department declined. The Chairman then asked if the department would present very quickly, so that there would be time for questions afterwards.

Free State Health Budget
Dr Victor Litlhakanyane presented the Free State budget report, accompanied by Ms Elize Malan, Director of Finance. He noted that he had only recently been appointed as head of the department, as from April 1 2001, although he had been with the department since 1994.

Dr Litlhakanyane talked through the report, using slides to highlight the main points. He pointed out that the department had overspent its budget in 1997/98 and in 1998/99 and because of this strict controls had been put in place. The strictness of these controls resulted in an underspending in the financial years 1999/2000 and 2000/2001.

Another main pointed highlighted by Dr Litlhakanyane was that his department believed that the statistics for AIDS infections in their region had stabilized. The Free State used to have the second highest provincial rate for AIDS infections, they had now dropped to fourth place nationally.

Discussion
Ms Baloi raised the following issues:
- She was concerned about the pharmaceuticals, as she could not see this figure included in the budget. She asked if all the primary health care services were covered in the report. It was good that the department was concentrating on training people from the Free State for health personnel, as it showed that they were using their own resources, but does this mean that there is a shortfall in personnel?
- Why there had been overspending previously by the department?
- The community care programme that the department is bringing in is very important, but it does not always warrant a fully equipped ambulance.
- She expressed surprise at the statement that the AIDS statistics are leveling off because of the mining operations in the province. Mining attracts prostitution, and thus the spread of AIDS. Do the TB rates of infection in the province mean that the DOTS programme is failing?

Dr Cwele (ANC) said that he was concerned with the underexpenditure by the province, which he believes was quite huge for such a poor province. Was it a problem of planning or other delays. He asked Dr Litlhakanyane to expand on the conditional grants in the report.

Dr Mbulawa (ANC) pointed out that there were no statistics for the termination of pregnancies, and she enquired what the budget is for TOP.

Ms Marshoff (ANC) asked if the department was closing down SANTA, and if so, why?

Ms Njobe (ANC) raised the following issues:
- In 2000/2001 the department collected quite a large fund, but that fund seems to be going down in subsequent years. Why are the projections of revenue lower?
- At what level does the department believe that the AIDS figures are stabilizing. The incidence of AIDS seems higher than some of the poorer provinces, so she does not understand this figure.
- The adult education and training programmest looked very ambitious to her. Was it possible to train all health personnel through bursaries within the year?

Dr Litlhakanyane replied that the mining sector is in fact reducing, and has a much different profile from 20 years ago. In terms of the stabilizing of the AIDS rate, there are many different factors in play, and that the stabilization could be due to measures that the department has been taking, but it could also be other factors. The department has been focusing on high areas of transmission, like the mines. All he can say is that the department is confident that something positive is happening, but they are unsure of what exactly.

Dr Litlhakanyane admitted that there had been problems in the supply of medication, and that the department only received approximately 70% of medication needed.

In the area of the training of health personnel, the department believes in training its own nurses. The department trains its own people, for example they had taken on cleaners who showed an aptitude for nursing to be trained. 30 students are currently enrolled on a bridging course and it is hoped that they will continue in their education towards a nursing diploma. The department loses its nurses to better paying provinces, not overseas. There is indeed a shortage of staff, but the department is now better than before in terms of staffing. 60% of the budget had been set aside for personnel. R4.5 million has been spent on basic equipment, such as stethoscopes.

Dr Litlhakanyane explained that the previous overexpenditure had been on stock and personnel, and that very tight measures had been instituted to control this overspending. In hindsight, however, the department believed that it had now been too tight in its control, nothing could be bought or no one could be appointed during this time. Personnel could not even move a car without official permission from a committee. The department is now softening its stance on this issue. They had learnt much from other provinces on how to manage the budget more efficiently, notably the Western Cape Department of Health, and he is very grateful for this help. He believed that this interchange is important because it saves on consultant fees. The committee applauded this statement. Dr Litlhakanyane added that he knew it was not good to under spend.

Dr Cwele (ANC) asked how the underspending had come about.

Dr Litlhakanyane explained that there had been a moratorium on the buying of new equipment and that the policy of the finance committee had been to focus on health care. Because of this focus on healthcare the department was able to move more funds.

In terms of the termination of pregnancies, the department had begun with a different approach to this issue than other provinces. They had begun small and increased their services incrementally each year.

In answer to the question on conditional grants, there was additional funding available for hospices. The department already owns a home for children with AIDS. Services to cope with children orphaned by AIDS are ready to receive these children.

Dr Litlhakanyane said that the budget should be seen as a multiyear plan, and therefore each year should not be seen in isolation.

Dr Litlhakanyane pointed out that there were many people in the Free State who were on some sort of ABET course. The province is thus bringing many people to the level of matric, and hopefully many will be able to enter the student nursing programme.

Ms Mnumzana (ANC) asked how absenteeism is controlled in the health services.

Dr Litlhakanyane stated that his department was focused on capacity building for its personnel. Many of its staff is sent on courses. If a student receives a bursary to train for four years, then the student has to work for the department for at least four years. If the student fails then they have to repay the department.

His department is very tight on discipline and that each hospital looks after its own disciplinary matters. Only very serious cases are brought to his office, such as fraud and abuse of patients. All hospitals provide his office with absenteeism figures, and staff members are asked to explain if they have too many days absent. He has in the past phoned people personally to ask why they are not at work that day. If they cannot explain satisfactorily the status of their day off is changed from sick leave to holiday leave. The committee applauded this statement.

Chairperson Nkomo drew the hearing to a close due to the lack of time. He noted that there was many questions unanswered and asked that these be answered in writing by the first week of May. Chairperson Nkomo thanked the Free State Department of Health.


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