KwaZulu-Natal and Northern Cape Health Budgets: Province briefings

Meeting report

HEALTH PORTFOLIO COMMITTEE
6 April 2005
KWAZULU-NATAL AND NORTHERN CAPE HEALTH BUDGETS: PROVINCE BRIEFINGS

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
KwaZulu-Natal Department: PowerPoint presentation
Northern Cape Department: PowerPoint presentation

SUMMARY
The KwaZulu-Natal (KZN) Department presented its outlook for the current financial year, guiding principles, strategic focus, priorities and challenges. Although the budget for 2005/6 fell short of requirements by R1.82 billion, they were optimistic of improvements in service delivery. Of particular concern was the low cure rate for tuberculosis (TB) patients. The Department’s equitable share for 2005/6 was higher than the rate of inflation. The shortage of skills was not limiting at this stage.

Members commended the Department for a thorough presentation and asked for clarity on a number of issues including per capita expenditure, and the budget percentage dedicated to primary healthcare and HIV/AIDS care.

The Northern Cape Department presented its performance for 2004/5 and programmes for the current financial year. They were likely to complete their hospital rehabilitation projects on schedule, ahead of all the other provincial departments. They were also ‘leading’ in the vaccination campaigns against measles and malaria. Teenage pregnancy prevalence had declined. The province’s equitable share had grown by only 7%. They had struggled with deficits over many years.

Members asked the MEC asked for more clarity on strategies to reduce teenage pregnancies, and the situation with alcoholism among winefarm workers.

MINUTES
The Chairperson accepted the apology for the absence of the Member of Executive Council (MEC) for Health and Social Services in KwaZulu-Natal (KZN) due to a Council meeting. He also noted that they did not attend budget hearings the previous year either.

The KZN Department Head, Professor R Thompson, said they had not been able to attend because of ongoing strategic challenges. They would deliver their budget speech on 6 May. This had also not been presented to the Registrar General. Both the Provincial Portfolio Committee (PCC) and the Provincial Committee on Finance had considered and approved the budget in a pre-hearing. However it had not been presented to the provincial Legislature. It was necessary to arrange the hearings in a sequence for it to be approved by the Provincial Legislature before it was presented to the Portfolio Committee.

KwaZulu-Natal briefing
Mr R Thompson said the outlook for the current financial year was better than for the previous five years. Guiding principles for the strategic plan included poverty alleviation and improved service delivery. He called for a concerted approach among provincial departments for service delivery. The top priority was to halt the spread of HIV.

The budget of R10.37 billion for 2005/5 fell short of the R12.2 billion ideal funding requirements. However, the moderate increases in real terms would enable improvements in service delivery. Comprehensive management of HIV/AIDS and TB, and the skills shortages, continued to remain challenges. Its Emergency Medical Services (EMS) had improved over the last financial year but they needed 940 ambulances (according to the 1996 census). All EMS vehicles had tracking systems to prevent hijacking. R58 million of the budget had been allocated to clinics in the municipalities outside the metropolitan area. The only way to integrate primary healthcare services was to bring all clinics outside the metropole under the province’s authority. Central and tertiary health services had been added to.

The Department had completed restructuring the District Health System. The dispensing of antiretroviral therapy (ART) had commenced this year and was available at designated institutions. It would be available in all hospitals by the end of 2005/06. The cure rate for TB was unacceptably low at 35%, and they planned to increase this by a tenth percentile per annum. They had controlled malaria in the province, but the challenge was to still control it in Mozambique and Swaziland.

The shortage of staff and increaseds workload created quality of service below the envisaged standard. The revitalisation of facilities had been below expectations, due to problems with tenders and non-performance of the Public Works Department.

Mr H Conradie, Department Chief Financial Officer, added that staff numbers had remained the same but workloads and salaries had increased in all institutions in 2004/5. They expected a rollover of R13 million in the health professionals’ training component of the conditional grant, because of unfilled posts. They also expected a rollover from HIV/AIDS treatments. Current expenditure indicated the amount needed for revitalisation next year would be substantial.

The province’s equitable share (17.8%) was higher than the rate of inflation. Conditional grants had increased by 16%. There would thus be substantial increases in HIV/AIDS treatment, provincial infrastructure and hospital revitalisation grants, to improve service delivery. Their medical stores were upgrading stock for the next three years. They had received Global Fund monies of R86 million.

Discussion
Ms N Nkabinde (UDM) commended the Department for their thorough presentation. She wanted to know the per capita expenditure for 2005/6, and the number of patients on ART.

Ms P Tshwete (ANC) was aware that their mobile medical teams had had to fly dire medical emergencies to referral centres in Ubombo on the Lebombo Mountains. He asked if this was sustainable. Were there any collaborations with other departments to train rural people to assist in healthcare? How many children and adults were living in that area? Had there been a noticable spread of communicable diseases, such as measles?

Ms B Ngcobo (ANC) wanted clarity on how much had been allocated to primary healthcare. How much of it had been absorbed in cross-border cases? Which non-governmental organisations (NGOs) had been funded by the Department in 2004/5? Did these offer training to volunteers for home-based care (HBC) – what were the implications for the budget?

Mr I Cachalia (ANC) wanted clarity on how the 2005/6 budgeted expenditure compared to the previous year? Wanted to know the percentage of the budget allocated to care of HIV/AIDS and whether expenditure for each programme had been disaggregated? Was there any additional funding for HIV/AIDS? How much funding had been transferred to NGOs? What were the criteria used for this, and the monitoring mechanisms?

Professor R Thompson said the number of patients on ART was not as important as the quality of treatment, how they identified patients, and what had been done to ensure access to hospitals in rural areas. The number of patients on treatment was between 12 000 and 15 000, and more than 35 000 on the programme in total. The number would increase significantly this year. The challenge was with physical facilities and human resources, but these were not limiting at this stage. There was no problem with availability and distribution of drugs, and laboratory services. When the programme was expanded, the numbers would drop. It was misleading to use a prevalence figure, such as 35.6% at maternal clinics in the province, to extrapolate for the country. The prevalence rate differed from area to area. One area in the province with lower prevalence at 19% was Church of Scotland.

The number of adults and children living in the Lebombo mountains would be provided to the Committee. Flying in emergency medical services was unsustainable, as it cost R62 000 for a round trip. Community healthworkers (CHW) were in the area. Training had been given to primary healthcare nurses and an AIDS team, which had a growing home-based care system. Funding was being sought to improve the roads in the area. There had also been a spread of measles.

Cross-border migration from the Eastern Cape (EC) had increased and they had had to transfer equitable share funds to some districts because per capita expenditure was not enough to cope with this cross-border flow. Where cases were referred, the Department asked for compensation. All cross-border patients had to be treated, even though it was a constraint on the budget.

The criteria for funding NGOs depended on their purpose. For instance, his Department had contracts with NGOs that trained, supervised and cared for community healthcare workers. They were in the process of absorbing NGO health workers as enrolled nurses in hospitals.

Much of the expenditure for HIV/AIDS was for treatment of recurrent diseases in hospitals. One of the top ten causes of death was HIV-related meningitis. He could not give a figure to the cost of managing HIV. He felt it was essential to integrate prevention of mother-to-child transmission (PMCT) and ART programmes into general healthcare because stand-alone clinics were not sustainable. Conditional grants for HIV/AIDS were supplemented by funds from its equitable share. Tertiary services were also getting additional funding from the equitable share.

Mr H Conradie said the HIV/AID budget included educational campaigns and ARV drug rollout, but did not include services rendered by hospitals. Part of the nutritional grant also went to treating HIV and TB cases. Community-based programmes were paid from the HIV/AIDS grant, which included a substantial amount of provincial funding.

Per capita expenditure could be manipulated in a number of ways and was not comparable to other provinces since it was dependent on population sizes. The per capita expenditure for 2004/5 was R927 and that for 2005/6 was R1 073. Funding for community healthcare workers was R8 million in 2004/5 and R10 million for 2005/6.

M Madumise (ANC) expressed concern about the ‘unfairness’ of the skills shortage allowance, and felt coverage had to be extended. Was the TB rate a result of the Direct Observation Treatment Strategy (DOTS) not functioning well?

Ms R Rabonowitz commended the Department on the layout of the budget. Since funds were allocated through the government, how had they seperated out what they had collected from the Global Fund and from central government? How much of it had gone to hospitals, traditional healers and other multiple groups?

The Chairperson asked for an indication of the cases of mulitdrug-resistant TB. He also said the skills shortage allowance was a policy matter that needed quantitative and qualitative changes. He mentioned a previous interaction with the national Department where it was noted that some clinics in the Eastern Cape, KwaZulu-Natal and Mpumalanga did not have access to basic amenities. He asked if those departments could give an indication of the situation in their provinces. Why had their laboratories not been integrated into the national system? Under-expenditure in hospital services was attributable to the relationship between the Departments of Health and the Public Works. The issue should be tabled for in-depth discussion.

Professor Thompson responded that the scarce skills remuneration had made a difference in retaining and attracting personnel. Nurses were earning more in terms of benefits. It was important to get Treasury to increase funding in order to extend its coverage. Rural allowance had been given to professional nurses but not enrolled nurses. Staff were moved from one hospital to another, and this had created vacancies. Scarce skills rural allowances were ‘working’, but not substantially. It was time to review remuneration of professional healthworkers.

Professor Thompson reported that all clinics in the province had water, but some did not get it from the municipality. The Department was purifying water and had provided water by carriers when waterholes were dry. All community health centres had flush toilets or KVIP latrines. Only two clinics did not have phones, but they used radiophones. The Global Fund monies had not been taken into government, and there had been no changes in allocation.

The cure rate for multidrug-resistant cases was 50%, and this was a universal problem. Multidrug-resistance was largely due to poor patient follow-up. They had underspent in only two programmes. All other monies had been spent and the Department was optimistic about optimal spending this year.

He continued that a decision had been taken at national level on how to incorporate their services into the national health system. He thought they ran an efficient and cost-effective service.

Mr H Conradie reiterated that the Global Fund monies were not indicated in the budget. They were part of agreements to record such expenses in a separate account, and had been asked to audit.

Northern Cape briefing
Th MEC for Heath and Social Services in Northern Cape (NC), Ms Shiwe Selao, reported on her appointment ten days previously. She said this large province was sparsely populated and thus had unique challenges.

The Head of Department, Mr D Madjo, reported that they had struggled to work within the 2004/5 budget as there had been deficits for many years. This had resulted in their inability to budget for pharmaceuticals and the number of people using facilities. R42 million would be rolled over from their Mental Health Facility project. They had been successful in hospital revitalisation and were at the ‘top of the list’ for completing their projects. They had overspent in administration by R4.9 million, and in health support services by R53 million. Increased expenditure in administration was as a result of rural allowances. They had generated revenue of R25 million.

Priority areas for 2005/6 were primary healthcare clinics and emergency medical services. Their equitable share (7%) had grown far less than the conditional grant (42%). This did not even cover medical services, but only salaries. Personnel expenditure had decreased from 60% in 2004/5 to 58% in 2005/6, because of challenges in recruiting staff in critical areas.

They had ensured stability in the prevalence of HIV between 2001-2003. ART rollout had started on 26July 2003 with five treatment sites. The hospital revitalisation programme had gained momentum. Colesberg and Calvinia hospitals had been upgraded and services were comparable to those in private hospitals.

Discussion
The Chairperson commented that the hospital revitalisation problems between the Departments of Health and Works had caused underspending. A more comprehensive discussion was required.

Mr I Cachalia said mental healthcare needed a more comprehensive approach. He asked if they had adequate staff to provide treatment, and more about the anticipated rollover. What was the per capita expenditure for 2005/6 and how did this compare to 2004/5? Was there any expected rollover of the conditional grant monies?

Ms P Tshwete noted the decline in teenage pregnancies, and the number of terminations of pregnancy. Other provinces had high and increasing prevalences, so what had been their strategies?

Mr D Madjo replied that there was a shortage of staff in mental health facilities. They did provide occupational therapy services. However, they had only two psychologists, two social workers and one psychiatrist. They were now recruiting staff for their new mental health facility, and had employed some student on bursaries. Currently a number of patients were being referred to the Free State and Gauteng because of personnel shortages.

The decline in the numbers of teenage pregnancies was due to different strategies, especially strong youth and adolescent programmes. They had four Youth Centres where they distributed contraceptives, and had organised workshops on the use of condoms, and counselling on sexual and reproductive health problems.

The Chairperson noted that the ‘bulwark’ of their budget was the conditional grant and asked if they expected a rollover?

Mr D Madjo responded that R17 million from hospital revitalisation would be rolled over. All other grants had been spent and the province had overspent on HIV/AIDS. Hospital and infrastructure development were capital projects of municipalities. Funds would not be transferred to municipalities that had not adhered to Service Level Agreements. Some services could be transferred to district municipalities.

Ms B Ngcobo wanted to know how much of the budget had been allocated to the delivery of comprehensive primary health care. What percentage had been transferred to NGOs and for what purposes? What was the impact of cross-border healthcare on the budget? What was their response time to emergencies?

Ms R Mashigo wanted clarity on the prevalence of Foetal Alcohol Syndrome, and what vaccination campaigns had proven successful.

Ms S Selao added that HIV/AIDS prevalence had stabilised among the 15-20-year age group.

Mr D Madjo responded that they provided cross-border healthcare for some districts in North West province, and for some small farms in the Free State. There were negotiations ongoing to charge for tertiary services. Cross-border healthcare to North West patients had cost R20 million. NGO funding amounted to R10.5 million. Per capita expenditure for 2004/5 had been R990 and was predicted to be R1 144 for 2005/6. Comprehensive primary healthcare should cost R187 million, which represented 19.96% of the total budget. The standard time for emergency treatment was 20 minutes, but did not include transfers from very distant areas.

Fetal Alcohol Syndrome was prevalent in Upington because of the wine farms, and this caused growth retardation and other defects in children. The Foundation for Alcohol Research continued to seek ways to address this problem. There were NGOs that educated women and mothers on alcohol abuse and reproductive health in selected clinics. The province was ‘leading’ in the vaccinations of children under five against measles and polio, at 90% coverage.

Ms M Madumise asked if the Direct Observation Treatment System (DOTS) for TB was working in the province, especially on wine farms.

Mr D Madjo confirmed that it was working. They had had discussions with other associations around DOTS, and as a result raised awareness.

The Chairperson said perhaps there was the need to follow up on the briefing by the wine industry two years ago about workers’ abuse of alcohol. He asked if the Department was experiencing any problems with the Cuban doctors.

Mr D Madjo reported that the problem was that some Cuban doctors wanted to remain in the country after their contracts had expired, and that the Department had taken a stand not to extend their contracts.

The Chairperson commended the Department for an extensive presentation. Their issues and problems were not peculiar to that province.

The meeting was adjourned.