Department Budget and Strategic Plan 2007/08 briefing

HEALTH PORTFOLIO COMMITTEE
27 March 2007
DEPARTMENT BUDGET AND STRATEGIC PLAN 2007/08 BRIEFING

Chairperson: Mr L V Ngculu (ANC)

Documents handed out:
Presentation on Strategic Plan & Budget 2007/08 to 2009/10
National Department of Health Budget 2004 to 2010
Strategic Plan 2007/08 – 2009/10 [available late at www.doh.gov.za]

Audio Recording of the Meeting

SUMMARY
The Department of Health briefed the Committee on the strategic plan for 2007/08 – 2009/10, and provided a progress report on the key challenges and priorities. The Ten Point Plan was detailed and specific achievements in respect of each of the programmes were given. These included the new legislation, service transformation plans, communication improvements, achievements of separate health programmes, nutritional support and review of the medicine pricing legislation. Health Service Delivery programmes were detailed and explained. On human resources the Department reported development of a skills plan and policy, regulations for community health workers and training of other workers. Challenges were listed as human resources challenges for development and implementation of policies, poor health infrastructure, disease and other socio-economic factors. The priorities were listed for the forthcoming year, but these could not be achieved without sufficient resources, and a more integrated approach which also tackled social problems. The Health budget had grown by 11.9% and new allocations were tabled for the rebuilding of the Department of Health Civitas building, allocations for Lovelife (including evaluation), hospital revitalization, HIV & Aids and for the National Tertiary Services Grant (NTSG). The Department felt it might be useful to present a composite budget that included both the national and the provincial tiers of government.

Members raised several questions on the hospital revitalisation programme, which did not appear to be working well, the amounts allocated for cessation of smoking programmes, the amounts allocated to the Maternal, Child and Women’s Health programme, the cost breakdowns, tuberculosis programmes, and the allocation for human resources. The integrated nutrition plan was questioned. Concern was expressed that the Department had not reported fully on the problems leading to the qualified audit reports for the last three years, the poor spending by provinces and the difficulties in monitoring. The Committee noted that the budget did not correlate with the Strategic Plans. Further questions were asked on training and remuneration of health professionals, including nurses, the disability strategy, the Komanani Communication Plan, treatment of TB patients, the meetings of the audit committee, the funding for assisting with the cholera epidemic, the budgets for HIV and Aids, Emergency Medical Services and NGO funding.

MINUTES
Strategic Plan Briefing by National Department of Health (DOH)
Dr Yogan Pillay, Chief Director: Strategic Planning, DOH, apologised for the absence of the Director-General, Mr Thami Mseleku. He reminded the Committee of the vision and mission of the Department of Health as outlined in the presentation.

Dr Pillay outlined the Department of Health’s Ten Point Plan, which included improving the governance and management of the National Health System, promotion of healthy lifestyles, improving hospital care, improving management of communicable diseases and various internal management issues.

With regard to the Administration Programme, Dr Pillay highlighted that five new pieces of legislation were processed, and all provinces, having produced Service Transformation Plans, (STPS) had strengthened the culture of planning. Historically, communication had been a challenge but had now been strengthened significantly amongst key stakeholders, as witnessed by the hosting of the National Health Consultative Forum (NHCF), the 18 imbizos that were held and the range of publications produced. Other achievements included key cabinet decisions regarding Social Health Insurance (SHI).

With respect to the Strategic Health Programmes, Dr Pillay briefed the Committee on the achievements of the Maternal, Child and Women’s Health sub-programme. The Integrated Management of Childhood Illness (IMCI) project was taken to 136 out of 284 local municipalities’ sub-districts, and 60% of health workers seeing children were trained in IMCI. 65% of those living with HIV and Aids and other debilitating conditions were provided with nutritional support, and 88% of facilities now offered Voluntary Counseling and Testing (VCT). The medicines pricing regulations were being reviewed. 24 000 applications for compensation from ex-miners were processed.

The Health Service Delivery Programme achievements were detailed. Primary Health Care (PHC) outlets were increasingly used by the public, and all nine provinces had delegated authority to hospital managers as requested in the 2006 State of the Nation address. New hospitals were accepted on to the revitalization programme, and the National Infection Control Policy was being implemented.

The Human Resources Management Programme of the DOH had developed a country human resources plan, adopted the Skills Development Policy, developed draft regulations for Community Health Workers (CHWS) and trained 11 958 health workers to implement the comprehensive plan for HIV & Aids.

Dr Pillay stated that the Department faced challenges in terms of developing, implementing and monitoring policies, which included a lack of sufficient and skilled human resources for health (both at the clinical and management level), poor health infrastructure, the triple burden of disease (communicable, non-communicable, injuries and trauma), and other socio-economic factors such as poverty, unemployment, low levels of education and a poor transport infrastructure.

The key National Health Scheme (NHS) priorities for the forthcoming year were described. These included developing provincial service transformation plans, strengthening human resources as related to the national skills development strategy, improving the quality of health care, strengthening infrastructure and strengthening priority health programmes, which included the implementation of mass media campaigns to promote nutrition, to ensure that 60% of health districts had staff trained to implement the Reach Every District (RED) Strategy, to strive to a 5% reduction in smoking by adults and youth, and to support 85% of the institutions with maternity beds. Full details of each programme were tabled.

Mr Gerrit Muller, Chief Financial Officer, DOH, highlighted the fact that the Health budget grew by 11.9% over the period, and tabled the new allocations for 2007 with respect to the rebuilding of the Department of Health Civitas building, allocations for Lovelife (including evaluation), hospital revitalization, HIV & Aids and for the National Tertiary Services Grant (NTSG).

In conclusion, Dr Pillay made clear that the Department faced a range of challenges. Changes in the social contexts and adequate resources for the health system were vital to the successful implementation of the plans, and intersectoral collaboration across government and with key stakeholders as crucial. The Department would engage with National Treasury for further resources.

Discussion
Mr G Morgan (DA) mentioned that the Hospital Revitalisation programme formed a very important part of the budget, which was achieved through transfers to provinces. He questioned the status of transfers to provinces, since in the past there had been problems in provinces failing to submit plans. He enquired whether this had improved, and what the Department was doing in order to encourage further compliance. Mr Morgan further mentioned media reports that included comments from provincial officials from Northern Cape and KwaZulu Natal to the effect that hospital revitalisation programmes would not proceed due to funding cuts for the 2010 World Cup. He requested clarity.

Dr Pillay replied that much of the expenditure took place at the provincial level, and emphasised that the budget presented reflected the budget at the national level. Dr Pillay suggested that the Department should present a composite budget that included both the national and the provincial tiers of government, for the benefit of the Members.

Mr Muller added that there had been a significant improvement in reporting, and highlighted the fact that the Department had worked very hard to establish project management units. He confirmed that the Department was aware of the rumours suggesting that the construction of hospitals in some provinces had ceased owing to the 2010 World Cup, but this was not true. Delays in the construction of hospitals needed to be considered from the point of view of the construction industry and their ability to work. The construction of a hospital was an extremely technical matter. The building of the hospital in De Aar in the Northern Cape province was yet to start.

Mr Morgan mentioned that the Portfolio Committee had recently been working on the Tobacco Products Control Amendment Bill. He had been informed that the amount allocated for assisting people to cease smoking was only R400 000. He was concerned that this was a meagre sum. He asked the Department where programmes relating to smoking cessation were included and if the figures would be increased over the next financial year.

Dr Pillay replied that it was particularly difficult to separate the spending on any particular priority, largely due to the integrated fashion in which many units in the Department functioned, and cited the example of the comprehensive programme on HIV & Aids. The Human Resources Programme would also make a contribution to smoking cessation, which might not be reflected in the budget for health promotion. Dr Pillay emphasised that it would be most difficult to disentangle the budget as requested by Members. However, he did note that the smoking cessation programmes would be achieved through a collaborative effort between civil society, the private business sector and all three spheres of government, and acknowledged that it was not only the work of the National Department of Health that would contribute to the 5% reduction in smoking. The Department of Education also played a role and DOH worked closely with the Education Department’s unit. An implementation plan would be useful for the amended tobacco legislation.

Ms C Dudley (ACDP) noted that the Maternal, Child & Women's Health (MCWH) Programme did not seem to have a large enough increase, based on the extensive plans that the Department had produced.

Dr Pillay responded that many of the activities of the MCWH programme would take place at the provincial level. The role of the national department would be to provide support and training for the provinces.

Ms Dudley stated that 60% of approved facilities provided Choice on Termination of Pregnancy (CTOP). She asked where the cost breakdown could be found in the budget.

Dr Pillay said that he did not think it was possible to provide such a breakdown.

Mr Muller confirmed that CTOP and Tuberculosis (TB) programmes were built in together in the budget.

Ms Dudley stated that that TB was a great challenge in South Africa, and asked why the budget for TB Control & Management had risen by such a small margin.

Dr Pillay agreed with Ms Dudley that there had been a recognition, at least since 2005, that there was a TB crisis. He referred to the increased burden of disease, the increased number of TB cases, the very slow process of increasing the cure rate, and the fact that it was high on the agenda, both at the political and at the technical level, of every meeting of the National Health Council. Dr Pillay mentioned that the Committee could play a significant role in assisting the social mobilisation of TB. The budget had increased significantly in four districts in particular, the Amatola district, the Nelson Mandela municipality, eThekwini municipality, and the City of Johannesburg, in line with the TB Control plan.

Mr Muller added that conditional grants for TB were a standard item on the agenda of the National Health Committee, which was made up of Heads of Department of all of the nine provinces and representatives of the National Department of Health, who meet on a regular basis.

Ms Dudley questioned why the allocation for human resources had decreased. She also expressed an opinion that more needed to be spent on the Integrated Nutrition Programme, given that nutrition was a very important factor in healthcare.

Mr Muller stated that in regard to human resources management, the allocation had increased quite dramatically in the 2006/2007, which was why there was a decrease in the forthcoming allocation, and then a gradual increase up to 2009/2010.

Dr Pillay responded that the Integrated Nutrition Plan was made up of a number of components, including food fortification, food supplementation, persons with debilitating illnesses, the integrated management of childhood illnesses, and the comprehensive nutrition plan. Hence it would be difficult to comment on the increases globally, but he assured the committee that it was a high priority.

Mr Muller reminded the Committee that INP had been moved to the Department of Education, and hence no longer featured as such on the budget of the National Department of Health.

The Chairperson mentioned that the Committee would need to revisit the question of the transfers to provinces, and the conditional grants. He was concerned that the DOH was reporting that all was well, and he was not sure that this was so. He made particular reference to the report by the Auditor General and the Division of Revenue Act (DORA) relating to the monitoring and expenditure of the department, the fact that monies were not being spent, and that the provinces were not accounting.

Mr A Madella (ANC) concurred and mentioned that the under spending and lack of delivery had formed the basis of the Auditor General’s qualified opinion of the Department of Health for three consecutive years. He questioned the CFO regarding what measures had been taken in this regard, as the situation could not continue.

Ms M Matsemela (ANC) agreed with the Chairperson and Mr Madella regarding the Auditor General’s report. She noted that the budget did not correlate with the main strategic points.

Dr Pillay confirmed that the 2005/06 audit report had been qualified in respect of conditional grants, and acknowledged that provincial grants were not monitored adequately. Referring to the CFO’s earlier comment, Dr Pillay reiterated that there has been an improvement with respect to reporting for the 06/07 year, yet acknowledged that it was not perfect. Dr Pillay reported to the Committee that the matter of transfers had constantly been on the agenda, with a number of provincial visits having been undertaken. He emphasised that this was the reason that the Director General was in Kwazulu Natal at the moment.

Mr Muller clarified that there was an improvement in the reporting, but agreed it was not yet perfect. He explained that the Division of Revenue Act determined how the funds must flow in terms of the schedule, but emphasised that there were no punitive measures in respect of failure to deal with the particular grants. In respect of the hospital revitalization and forensic pathology DOH had the facility to withhold transfers. The Division of Revenue Act also required that monthly reports be submitted to the national department. The due date for provinces was the 15^th of the month, and the due date for National departments was the 20^th of the month. Although the National Department of Health usually met the reporting deadline, the provinces often missed their deadline. Quarterly reports were usually late, but at least the national department was receiving them this year, as opposed to last year, due to the regular visits by Departmental staff to the provincial offices.

Professor Ronnie Green-Thompson, Special Advisor to the Minister of Health, mentioned that it was important to look at provincial budgets, and agreed with Dr Pillay that it would be helpful for the Portfolio Committee to aggregate the national and provincial budgets with regards to programmes.

Mr Muller said that the Hospital Management and Quality Improvement grant had been merged with the hospital revitalisation grant.

Mr Madella asked the Department to expand on the difficulties that they faced with the hospital revitalization programme.

Mr Madella referred to the President’s State of the Nation address, which detailed the expansion of training and numbers of nurses and, more importantly, gave the number of nursing colleges that would be opened. Mr Madella asked the department for a status report on nursing colleges, and asked how many had been opened to date.

Dr Pillay reported that an audit had been completed amongst nursing colleges, and mentioned that DOH had evaluated those colleges that had been closed, investigating also why they had been closed or rationalised, such as in the Western Cape. Dr Pillay mentioned that the Department would be able to provide the Committee with the report of the audit undertaken for nursing colleges.

Mr Madella finally questioned the department on the status of the disability strategy whose target date was December 2006.

Ms Matsemela referred to Hospital Management and Quality Improvement and asked why there was no allocation in the 2006/2007 year. She agreed with other members on the hospital revitalization programme, and mentioned that it was high time for conclusion on this matter.

Ms Matsemela asked whether the avian flu mentioned in a Department of Health report last year had been budgeted for. She further asked whether drought relief had been budgeted for.

Ms Matsemela expressed her frustration regarding the lack of knowledge of the status of the government-led communication campaign funded and driven by the Department of Health. She was amazed that LoveLife received extensive funding but that there was no allocation for other communication projects, such as the Komanani Communication Plan, that she believed had better achievements.

Mr Muller responded that the Komanani communication plan tender had lapsed, and that it had been re-advertised, and was being reviewed for adjudication.

Ms M Tlake (ANC) agreed with Ms Dudley that there were serious concerns on human resources, and highlighted that in order to have improved quality of healthcare and proceed with the hospital revitalization programme, sufficient human resources were required. She asked how the Department was planning to meet those needs, and noted that the “brain drain” of healthcare workers was a problem. She asked where the allocation for nursing colleges was located in the budget. She expressed concern with the meagre allocation of the Health Professions and Training conditional grant, and did not believe that such a human resource challenge could be managed with the available sum of money.

Dr Pillay acknowledged that human resources were indeed a problem, and mentioned that the human resources plan and the draft nursing strategy were both matters of urgency and detailed how the nursing profession could be upgraded. He further reported that the Department intended to give quite significant salary increases to nurses, which was not included in the budget, in an attempt to address the nursing shortage in the country. The salary increases were currently the subject of bargaining council negotiations.

Mr Muller clarified, with respect to the Health Professions Training and Development grant, that R1.5 billion was allocated, not to pay for training, but for remunerating a facility (including professors and lecturers) that involved in the training of students.

Prof Green-Thompson further emphasised that human resources was most definitely a challenge, and mentioned that the Department of Health had already made the point that the allocation had already increased substantially in previous years.

Ms Madumise pointed out that poverty was one of the challenges of the department. She was concerned that there were TB patients “on the street” who could not be accommodated due to a lack of capacity in hospitals.

Dr Pillay mentioned that the poverty challenge was being addressed through the Department’s involvement as a member of the Social Cluster and the framework for poverty alleviation, which was led by the Presidency. He said that not all patients who had TB needed to be hospitalised, and that most patients could be successfully treated in their homes or communities. Only chronic TB patients, or those who had developed drug resistant TB would need hospitalisation. Dr Pillay also mentioned that Extensively Drug Resistant (XDR) TB patients had specific accommodation requirements in hospitals, hence there had been a waiting list in some instances, such as in Kwazulu Natal.

Mr Morgan mentioned that it was important for Committee to understand how the Department spent its money. He asked whether the Department had met the requirements for the minimum number of meetings of the audit committee in terms of section 77 of the Public Finance Management Act (PFMA), given that this was not achieved for the 2005/06 previous financial year. He also questioned what percentage of calls was handled on the fraud hotline.

Mr Muller reported that a new audit committee had been appointed, who had already met twice this year, already meeting the minimum number of times required for a year. He said that the Department of Public Service and Administration (DPSA) now had centralised the fraud helpline, so that DOH no longer handled the hotline directly, but received complaints via the DPSA. .

Ms Matsemela asked about the cholera epidemic in Kwazulu Natal, and whether it was catered for under the Provincial Equitable Share.

Dr Pillay replied that the cholera epidemic was previously dealt with as a specific emergency. Since the key factors to the control of cholera were water and sanitation, DOH was now working very closely with the Department of Water Affairs & Forestry. Mr Muller mentioned that in 2002/2003 control of this epidemic was funded from the national contingency fund.

Ms Matsemela asked why the comprehensive plan on HIV/Aids appeared twice in the budget.

Mr Muller responded that it was stated in two separate statements, as one was the budget for the HIV/Aids Cluster within the department, where the monitoring of grants took place, and the other related to transfer payments to the provinces.

Ms R Mashigo (ANC) requested enlightenment regarding Emergency Medical Services (EMS), which had not been mentioned, but which was a crucial factor in Primary Health Care (PHC).

Dr Pillay mentioned that the Department had a national planning framework for EMS, and provinces had increased the number of personnel and ambulances. Ambulance and patient transport had been separated. The Red Cross had been used in many hospitals for air ambulance services, where very specialised personnel would go to outlying areas, and this had been very successful.

Ms Mashigo requested a provincial and national breakdown of NGO funding.

Dr Pillay confirmed that NGOs were being funded by both the national department and the provincial departments, and mentioned again that it would be useful for the Department to brief the Committee on the distribution of budgets.

The meeting was adjourned.