Provincial Budget Briefings: North West & Eastern Cape

Meeting report

HEALTH PORTFOLIO COMMITTEE
6 April 2001
PROVINCIAL HEALTH BUDGETS: NORTH WEST, EASTERN CAPE

Chairperson: Dr S Nkomo (ANC)

Documents handed out:
North West Province: Health Budget Review Part 1 and Part 2
Eastern Cape: Health Budget Review

SUMMARY
The Health Departments from North West Province and Eastern Cape presented. The Committee expressed dissatisfaction with the presentation made by the Eastern Cape as it focused on future projections and not on past performance as requested. The Eastern Cape will re-present after the parliamentary recess.

MINUTES
North West Province: Health Budget Review
The delegation from the Provincial Health Department in the North West Province was headed by Dr H Gosnell, Deputy Director General and accompanied by Mr P Netshipale, Acting Chief Director: Health Services, Mr C Vundule, Principal Specialist, and Ms T Chababa, Director: Finance.

Budget and Expenditure
Ms Chababa gave a report on the Department's budget for 2000/1 and the three ensuing years under the Medium Term Expenditure Framework (MTEF), which she read out to members followed by an explanation.

She said the previous year's total expenditure was R1.5 billion with a variance of R36 million. This year the Department is allocated R1.7 billion, next year R1.8 billion and the following year R1.9 billion.

The Department allocates its budget in the following programmes:
Provincial Head Office and Administration
District Health Services and Provincial Hospitals
Health Science
Health Care Support Services
Health Facilities and Maintenance, and
Improvement of the Conditions of Services

The proportion of the standardized items under total budget is as follows:
About 66% of the total budget went to personnel or R1.123 billion of the total R1.7 billion
Pharmaceuticals supplies was second
Professional services was third
Transport payments have been dropped due to the provincialisation of the emergency medical services.

She said medical grants are allocated for the following programmes:
Health Training - R26 million
Hospital Rehabilitation and Reconstruction (R&R) - R40 million from where they are experiencing delays from the Department of Public Works to their Department in the rehabilitation, renovation and building of clinics, health centres and hospitals in the province.
Nutrition programmes were on course
Redistribution was allocated R36 million
HIV/AIDS R2 million
Financial Management Improvement R2 million

Revenue
Ms Chababa said the Provincial Treasury has set a R15 million target for the Health Department to raise through patient fees and other revenues. In turn the Provincial Health Department has set a R12.5 million as target for District Hospitals to raise. Next year that target has been set at R13 million, and the following year at R14.5 million.

Variance in Expenditure
Ms Chababa said personal expenditure, which enjoys the lion's share in the Department's budget was R1.071 billion and out of that R1.063 billion has so far been spent creating a variance of R8 million which was committed.

On administration expenditure she mentioned two problems:
- There was a negative variance of R4 million caused by poor services offered by the Department of Public Works on Health Department's vehicle fleet.
- Telkom had issued long outstanding accounts dating back three financial years that the Department had to pay.

With pharmaceutical supplies, nutrition and equipment the variances were positive except when it comes to medical equipment. This was caused by Provincial Treasury delays with tender procedures for acquiring medical equipment.

Areas were Expenditure has Changed:
- Management of Emergency Services
- Decentralisation of School Feeding Programmes
- Outsourcing and Distribution of Pharmaceutical Services, and
- the Creation of Four New District Offices.

Dr Gosnell gave a report on the administration and management of medical services in the province. He said his Department was working at creating equity services in hospitals throughout the province.

He told the Committee that management services in hospitals have changed. Superintendents have been replaced by General Managers with positive effect. The Department has also signed performance management with hospitals, which compels them to offer better services.

The Department was in the process of strengthening financial, human resources and procurement functions in all the hospitals in the province. In line with that they are also decentralizing these functions down to the hospitals. The Department will no longer carry out these functions.

They are putting in place uniform fee schedules in all the hospitals in the province.

He reported that over the last five years bed occupancy has declined due to a shift by patients from hospitals to clinics. The average length of stay in hospitals was now 5.5 days.

He reported that 31% hospitals/clinics operated seven days and twenty-four hours a week while 59% had electricity, water, sanitation and telephones. The average population per clinic varied from 3,900 to 20,000 while the number of doctors per 100,000 population varied from 2 to 21.

He said the prevalence of HIV/AIDS in the province was 18.1% in 1997, 21.3% in 1998, 23.1% in 1999 and 22.9% in 2000. However, he said sexually transmitted diseases have dropped from 14-17% in 1997/8 down to 3.6% in 2000.

The main challenge for emergency medical services is equity and they are working towards ensuring that there is even distribution of emergency medical services across the province especially in rural areas.

He said the average number of vehicles per district vary from 18.2 per 100,000 down to 0.1 per 100,000 in some districts.

About 87% children were fully immunized last year and over the same period there were no polio cases reported. The infant mortality rate has declined from 52 per 1,000 in the first quarter of last year to 42 per 1000 in the third quarter of last year.

However the number of maternity deaths in the province shot up. In 1999 it was 54 per 1000 but last year it went up to 84 per 1,000. The cause of this rise is attributed to improved reporting or to the number of AIDS related cases which had still to be confirmed.

Dr Gosnell was pleased with the curbing of measles in the province with zero reported cases last year.

Discussion
Ms M Njobe (ANC) asked whether the Department of Public Works and the local government authorities were aware of the frustrations they were causing the Department as the result of their non-performance. She also observed that there were big variances on TB, home base care and HIV/AIDS and queried the meaning of this. Lastly, she wanted to know about the youth's response to condom distribution.

Dr Gosnell conceded they experienced problems with the Department of Public Woks and local authorities which have been discussed in many forums. Recommendations have been made to transfer the budget and for the Department to have greater influence. Now they are in the process of establishing service agreements to ensure proper performance.

Dr Gosnell also conceded that there was a vast variation on TB, home base care and HIV/AIDS. On TB he said the variance was caused by the degree to which the presence of management teams was felt. Where they were felt, there was dramatic improvement, and visa versa.

The same can be said of home base care. Improvements in home base care and HIV/AIDS was due to the presence of NGOs. Where there were none, problems were experienced and the Department was attending to both issues.

He said the distribution of condoms among the youth was going well and this could be due to awareness amongst them.

Ms N Gxowa (ANC) wanted to know why the post of the Financial Director has not been filled when there are so many qualified unemployed graduates with B.Coms.

Dr Gosnell responded that they advertised the post and conducted interviews but have not yet found the right person for that position since it requires a highly qualified person.

Ms M Malumise (ANC) asked what happens in areas where there are no doctors and patients need to see a doctor. She also asked about the use of female condoms.

Dr Gosnell said that where there were no doctors, clinics referred patients to hospitals. The Department prefers doctors to visit such clinics once a week. They are working hard to make that happen.

He said female condoms have been piloted. There seems to be a demand from women for this. If women prefer to use male condoms then that is fine. However they have budgeted to make the female condoms available.

Ms F Marshoff (ANC) complained that the presentation mentioned mental health only in passing. She also wondered why the distribution of condoms was inadequate in areas with a high incidence of HIV/AIDS such as Klerksdorp. She doubted that the principles of Batho Pele were being implemented when there was a high incidence of patients being turned away without referrals. She suggested that outsourcing might reduce the high incidence of hijacking and theft of pharmaceutical medicines. Lastly, she asked if the reduction of patients in hospitals was due to the imposition of fees.

Dr Gosnell responded as follows:
- He conceded that mental health services are under prioritised and that one of their problems was the shortage of skilled people. They have only one full time psychiatrist in the whole province.
- The Klerksdorp area has the biggest regional hospital complex with tertiary and secondary services. This means that there is less money available for primary health care. There is a high incidence of HIV/AIDS as this is a mining area with a large migrant population. These two factors usually go together.
- They have not experienced incidents of patients being turned away in their province.
- Pharmaceutical outsourcing has reduced hijacking and theft. They have put in place a system of monitoring progress.
- Hospital fees is one factor in reducing the numbers of patients. The hospital fees do have an impact. Someone who is seriously in need will not be refused treatment especially if the person comes to the hospital through a clinic. Where a patient owes them money and it is not recoverable then they write the amount off.

Dr S Cwele (ANC) asked why was Telkom not paid and observed that the Department was always blaming others for their shortcomings, for example, the Department of Public Works and wondered whether they were obliged to use them. He also wanted to know how centres function without water, electricity, sanitation and telephones.

Dr Gosnell said Telkom was not paid because in many instances they were simply not sending bills or reminders. They must improve their billing system in terms of the public sector. They had been sending one account for all the departments in Mafikeng and had not been billing hospitals properly, which compelled the Department to talk to them and sort out the mess.

He said that they were obliged to use Public Works. They have tried to look for a preferred provider but have not yet been able to achieve that.

Dr Gosnell said when they say rural clinics have no electricity, water, sanitation and telephone they do not mean that these clinics have none of these resources. There may be a clinic with a refrigerator that is operated by gas. Likewise with water, there may be a borehole with a tank and that tank may be full of water but "it is not an adequate water service". He however reiterated and acknowledged that several clinics do not have adequate provision for such services.

The Chairperson asked if there was a structured way of monitoring care by hospitals.
The Doctor replied that there is. Hospitals do a patient survey for example. This conscientises the hospital so that they are aware of what patients think of the care that they receive. They also have a ''clinical inspection committee''. Complaints of poor treatment get referred to this committee. The committee has the power to take disciplinary action. They also apply the Batho Pele principles. They try to institutionalise protocols and try to monitor them.

Other comments by Dr Gosnell:
- AIDS treatment is a concern. They try to ensure that patients are not discharged too early before the treatment is complete.
- Outsourcing is not a national policy. In their province outsourcing takes place in respect of catering and the pharmaceuticals. Their experience with outsourcing has been a positive one. It has resulted in an improvement of services.
- Communication between communities and departments depends on the government structures. They have quarterly reviews.
- They check to see that ghostworkers have been eradicated. Treasury also checks on these things.
- Doctors in rural areas: the problem is that medical students do not come back to work for the public service. They have sent students to Cuba so that they can have doctors who will end up working in the public service. They also have various training programs.

A final question was asked as to what happens to managers if they are not performing up to standard. The response was that they are trying to implement proper performance monitoring and reviews. There is a process where on a monthly basis they meet with staff and they show them what their peers in neighbouring areas are doing. This acts as a form of peer pressure.

Eastern Cape
Dr T Mjekevu (Acting Head of the EC Department of Health) made the presentation. Mr Peppetta (Director of Finances) was also present.

Summary of presentation
The current position is that they have R3.8 billion in the budget for this financial year. This budget serves 6.3 million people.

The challenges which they face include:
- Performance management system must be implemented
- They must look at how the conditional grants are managed
- There is a lack of management skills within the Department
- There is also a focus on hospital management

The main strategic areas include:
- Focus on hospital transformation
- Deal with district development for the next three years
- Infrastructure development is a key priority area

Budget:
Some examples of conditional grants are the HIV/AIDS provincial grant of R33 million and the Redistributory grant of R49 million.
There are also some earmarked funds. These have been set aside out of the equitable share to deal with focus areas. For example R12 million is to go to a clinics upgrading program and R5 million is to go to overhauling drugs management.

Budget and Operational Plans for 2001/02
Dr T Mjekevu highlighted their key performance areas. Within the administration sector the plans they must develop and implement include:
- An employment equity plan to reflect representivity.
- A Workplace Skills Development Plan. The budget for this is R450 000
- A Service Delivery Improvement Plan

Within the District Health System they:
- have put aside R 16.5 million to establish 24 Health District
- there is also a budget to establish and implement a Health Promotion Program. The budget for this is R1 million.
- there is a budget of R38 million for implementing an HIV/AIDS program. R12 million rand of this is to be spent in other departments but the Health Department will co-ordinate these programs.

Dr T Mjekevu proceeded to discuss the document by noting the programme on provincial services but the Chairperson interrupted him to indicate his dissatisfaction with the presentation.
Chairperson Nkomo said that the information they were giving the committee were projections into the future. It does not deal with what is happening now. The committee members agreed and noted that this was not the first time that the Committee was unhappy with a presentation made by the Eastern Cape Provincial Department.

Dr Chetty (from the National Department) commented that it might be partly the fault of the National Department. She said that when they faxed the format that the presentations should take to the provinces the EC did not receive the last page of the fax. This is why their presentation is not on what the Committee wants to be briefed about.

The committee agreed that they would meet with the EC again after the recess period. They pointed out that they would like to interact with the EC on the same level that they interacted with the other provinces. The Chairperson added that the EC must not take the comments as ''personal criticism''.

Dr Chetty concluded by saying that the committee has an important oversight role. The input received from the members has been useful. The presentations showed that there have been improvements in a number of areas but a lot more must be done. They must continue to improve in the areas where there have been successes, they must not become complacent.

The meeting was adjourned.