Department of Health Annual Report 2005/06

HEALTH PORTFOLIO COMMITTEE
29 May 2007
DEPARTMENT OF HEALTH ANNUAL REPORT 2005/06

Acting Chairperson: Ms M Madumise (ANC)

Documents handed out:
National Department of Health’s Annual Report 2005/06 presentation
Department of Health Annual Report 2005/06 (available later at www.doh.gov.za)

SUMMARY
The Department of Health presented their Annual report for 2005/06.  Improvement of Health Administration, Strategic Health Programmes, Health Service Delivery and Human Resources were discussed.  The audit outcomes and current adjustments were mentioned, as well as the strengthening of the systems that were already in place. The challenges included those associated with poverty, unemployment, low education levels, poor transport infrastructure and social cohesion. Other challenges arose through the triple burden of disease (communicable, non-communicable and trauma). lack of sufficient & skilled human resources for health at both clinical and management levels, the poor health infrastructure and community mobilization and patient adherence issues.

A report was given on the budget and financial performance. It was noted that there had been both over and under spending but that overall across all programmes there was a small under spend of 1,03%. There had been a qualified Audit Report, resulting from the fact that business plans had not been approved and there was therefore a discrepancy between the plans and the amounts requested from the Division of Revenue Act, as well as late and non-submission of monthly and quarterly financial reports. Matters of emphasis related to the functioning of the Audit Committee,the failure to attend to the Environmental Management Act report and the lack of full functioning of the Supply Chain Management Unit. All of these issues were being addressed. The key  priorities for the Department were to develop provincial service transformation plans, to strengthen human resources, to improve quality of care, to strengthen infrastructure and to strengthen priority health programmes.

The discussion by Members centred on the Health Professionals and their education as well as the lack of skilled professionals in the current health system.  This also included nurses training and working conditions.  The XDR TB and treatment of TB was discussed and the treatment plans that were in place to increase the cure rate of TB in SA.

The Human Resource issue was to be discussed in a more detailed meeting between the committee and the NDOH focusing only on that issue.

MINUTES
National Department of Health briefing
Dr Yogan Pillay (Cluster Manager Strategic Planning, NDOH) introduced the members of his team and proceeded to outline the presentation.  This would cover the Legislative Mandates, the key priorities of the National Health System for 2004-2009, a summary of the key achievements and challenges per budget programme (comparing the progress between 2004/05 and 2005/06), as well as the budget and expenditure report.  The key priorities as were reflected in the NDOH strategic plans for 2006/07-2008/09 and 2007/08-2009/10.

He reminded the committee of the vision and mission of the NDOH.  The legislative mandates were covered and a few were highlighted from the 2005/06 Annual Report.  The budget programme structure was discussed with regard to the current four programmes including Administration, Strategic Health Programmes, Health Service Delivery and Human Resources.  It was noted that the Budget Programme Structure had changed between 2004/05 and 2005/06 with programmes such as Districts and Development moving from Programme 2 to Programme 3.

The key priorities in the National Heath Plan for 2004-2009 were mentioned.  This included the improvement of the governance and management of the National Health Strategy; the promotion of healthy lifestyles; contributing toward human dignity by improving the quality of care; improving the management of communicable and non-communicable diseases; the strengthening of the Primary Heath Care (PHC), Emergency Medical Services (EMS) and hospital service delivery systems; strengthening support services; human resource planning, management and development; planning, budgeting and monitoring and evaluation; preparation and implementation of legislation and the strengthening of international relations.

Under Programme 1:Administration, comparison was made between 2004/05 and 2005/6 with regard to all the programmes undertaken. In administration five bills were processed during 2005/6 and the National Consultative Health Forum (NCHF) was hosted in May, there were eight ministerial Izimbizo’s held and a range of publications produced. 

In respect of strengthening health sector planning Annual Performance Plans for 2006/07 and Annual Reports for 2005/06 were reviewed, eight of the nine Provinces produced Service Transformation Plans for 2007/08, District Health Planning (DHP) guidelines were published and used by 53 Districts to develop District Plans for 2006/07 and the quality of most District Health Plans needed further strengthening.

In the Strategic Health Programmes the Integrated Strategy for Child Health (ISCH) guidelines were integrated from the World Health Organisation (WHO) into the Integrated Management of Childhood Illnesses (IMCI), which was expanded into 136 of 284 local municipalities.  There had been a  decrease in the percentage of Health workers providing services to children, and trained in IMCI, from 64% to 60% as there was a high demand and staff in hospitals had also been rotated.  The National Immunisation coverage had increased to 82% and the district-by-district coverage of immunization had improved.

72% of districts provided Phase 1 of school Health Services and 60% of approved facilities provide Choice on Termination of Pregnancy (CTOP) services.  There was an increase in condom distribution and an increase in Voluntary Counseling and Testing (VCT) at facilities, as well as Prevention of Mother to Child Transmission (PMTCT) services.  The expansion of the comprehensive treatment (CCMT) plan meant that 65% of people living with HIV&AIDS, TB and other conditions were provided with nutritional support.

There was a drive to strengthen TB control with the Directly Observed Treatment System (DOTS) however defaulting patients did not aid in the continuing effective treatment of the illness.  There was ongoing collaboration with NGO’s in curbing HIV & AIDS and International Health relations had been expanded.

Accessing of safe and affordable medicines included 70% of Pharmacy licenses issued against applications, and dispensing fees were published but were under challenge, and the medicine pricing regulations were reviewed.  Malaria control had also been strengthened in the three provinces most affected, namely; KwaZulu-Natal, Limpopo and Mpumalanga. 

In Programme 3:Health Service Delivery, there had been an increase in utilisation of Primary Health Care (PHC) services. There was expansion in the Hospital Revitalisation Programme (HRP) and the delegation of authority was given to hospital CEO’s. There were additional Telemedicine sites established in the Eastern Cape and Mpumalanga, the transfer of Forensic Labs and Mortuaries to the Department of Health was completed, the expansion of the cataract surgery project was continuing and the report for UNGASS (United Nations General Assembly Special Session) was completed.

Under Programme 4:Human Resources Management, more health workers were trained in the implementation of the Comprehensive plan for HIV &AIDS Care, Treatment and Management (CCMT).  The draft regulations for Community Health Workers, as well as a policy framework for CHW were developed.

Dr Pillay noted that several challenges remained. These were largely attributed to poverty, unemployment, low education levels, poor transport infrastructure and social cohesion. Other challenges arose through the triple burden of disease (communicable, non-communicable and trauma). lack of sufficient & skilled human resources for health at both clinical and management levels, the poor health infrastructure and community mobilization and patient adherence issues

Mr Gerrit Muller, CFO: DOH, stated that there had been small under spend in the DOH in the Administrative sector.  He pointed out the under spending of R4 million in Maternal, child and women’s health was due to the vacancies of posts for Pediatricians. The under spend in Programme 3 was due to the fact that the orders were received late.  The International Health Liaison was dollar based and the World Health Organisation gave a discount to members therefore there was an under spend in this area as well.  There was a saving from the previous year of R2 million from the Global Fund and Lifeline and this would cancel out the R6 million overspend on the non-communicable diseases.  Therefore there was a break-even point reached.  When measured across all the programmes the NDOH had under spent by 1,03%. 

Mr Muller noted that the NDOH was given a qualified audit report. This was done prior to the approval of Business Plans, and because of the difference between the total amounts of Business Plans and Division of Revenue Act (DORA) applications, as well as the late and non-submission of monthly and quarterly financial reports the qualification had been noted. In addition, the quarterly visits to the provinces had not always been conducted and the appointment of monitoring staff had happened late in the year.

In addition to the qualifications there had been matters of emphasis. These related to the fact that the audit committee had not been functional; the internal audit was not effective, the National Environmental Management Act report had not been done and the Supply Chain Management Unit was not fully operational. All of these issues were being addressed. The key  priorities for the Department were to develop provincial service transformation plans, to strengthen human resources, to improve quality of care, to strengthen infrastructure and to strengthen priority health programmes.

Discussion
Mr G Morgan (DA) thanked the DOH for their report and commented that the previous Auditor General’s report raised specific issues. He queried why the report was qualified.  With regard to the delegation of CEO’s to hospitals, he questioned the level of delegation and the variances between the provinces, as well as the implementation of this in the hospitals.  He asked as to why the district level plans were so varied in quality.  He also asked as to why there was a change in vacancy rate in the hospitals and if NDOH was downgrading or changing posts.

Mr B Mashile (ANC) queried if NDOH were aware of the impact of under spending on service delivery and if there was an improvement in the accountability of the managers and in the monitoring of service.

Mr A Madella (ANC) asked why there was a breakdown of the sub-districts and why not all of the sub-districts had not been reached in the immunization process.  He queried as to why the bargaining council employee relations were not being considered, as this would benefit the health workers.  He queried the general vacancy rate of 30% and noted that it would have a great impact on Public Health Service delivery.

Mr Muller referred to the questions on the audit and stated that the payments had been paid prior to the business plans been submitted, that the quarterly reports were not fully under control and the monitoring staff had been appointed late in the year.  The bargaining council was paid by Human Resources and the current vacancy rate was previously the same or worse.

Dr Pillay drew a parallel between the vacancy rates and the under spending and pointed out that those positions that were unfilled were for technical specialists who would earn less in the DOH than in private practice and that pharmacists were also affected in this way.  In the clinical services it was difficult to acquire certain professionals. Some of the work was outsourced to other academic institutions and specialists outside the DOH.

In relation to the perceptions of managers and their role in running the hospitals. Dr Pillay emphasised that they were essentially CEOs, but their skills and training varied widely.  This included their skill to do the allocations of budget and decide what budget was needed in the particular hospitals.  This also had implications for service delivery.  The managers did not know of or could not properly exercise their authority to handle and order according to the needs of the hospital and the budgets allocated. However, he noted that there There was a management grant available to improve the hospitals and 50% of the staff had been enrolled in formal courses.

Dr Pillay said that the National Health Council definitions of level of care had changed and had come into effect in February 2007.  At regional and tertiary levels there was not only one level of care and the level of service also differed as to the needs of the population that it served.  The specifics of the Health Promotion were not understood and the Health plans submitted from the regions varied in their degree of competency.

in regard to vacancies, he noted that there was currently an ongoing exercise of “right sizing” of the staff as to the needs of the population and levels of service required. 

Mr Muller added to the issue of the vacancy rate, commenting that this also depended on the services that were offered by the hospitals.  He said that there were only two hospitals that offered tertiary care.

Mr Muller said that with regard to the governance, an audit committee had now been appointed and with regard to the internal auditing this was now done by an internal audit team and co-outsourced as well.

Dr Pillay noted that the data for the quarterly reports had come in late and the quality of the data received was not always of a high standard.

Ms N Mathibela (ANC) enquired as to why the funding of NGO’s had been reduced from 74 to 70.  She  enquired why the quarterly reports were not also given to the committee, and why more money was issued to the DORA projects

Mr Mashile enquired as to the cataract aftercare and the training of the health professionals with the budget that is available.  He enquired as to the interventions done with the CEO’s of the hospitals and what was done in coaching them on their responsibilities and on service delivery.  With regard to the district plans he enquired how those plans were put into action.

The Chairperson enquired as to why the NGOs had not complied with the audited financial statements.

Mr Muller replied that the NGOs applied to National government to be funded and that the provinces reviewed this and also gave allocations, so that the NGOs were not funded twice in government.

In the previous financial year there was a support programme to assist in the DORA applications and this meant that they needed Management and Auditing as line items.  Two business plans were not submitted.

He noted, in response to a previous questions, that condoms were manufactured in South Africa by at least one firm, but that the raw material is imported.

Mr Muller noted that the Health Professionals' training grant would remunerate the province for the training given to the students in the medical field.  This development grant would be allocated according the skills needed in that province.

Dr Pillay explained that the UK Development Agencies assisted in funding; however there was a need to make this sustainable.  The National Health Council did take monitoring land grants very seriously.  He stated that the Health system had been significantly under funded for the requirements it needed to meet.

With regard to the Cataract surgery he noted that professional and specialised staff were needed and follow-up appointments to check the eye had to be arranged.

The need for on site training with regard to TB was apparent and those skills needed to be efficient as well as effective.

The districts needed assistance in planning and implementation of their plans, as well as technical support, and the aid from the USA assisted in this.

Mr Madella enquired as to why the care rate of TB patients was not higher as opposed to the higher rate of defaulting patients.  He also enquired as to whether the newly qualified graduates were welcomed into the DOH.

Mr Mashile enquired as to the interventions taken for under performing CEO’s of hospitals and the dispensing fee for those areas that only had one chemist where medicines could be collected. .
Ms M Manana (ANC) stated that the provinces needed to be held accountable for the way they spent their budget.  The new definitions also needed to be made available to the Members.  She also enquired as to why there were now more training colleges for nurses even when there was a shortage of nurses in the country.

The Chairperson enquired as to why the Directly Observed Treatment System went wrong.

Dr Pillay replied that the National Health Council and the National Department had an advisory role to make sure that all norms and standards were followed.

The Hospital Improvement Plans were developed by the hospitals with the support of the Province and National oversight.  The National Committee would meet four times a year.  Plans for strengthening and monitoring of hospitals and pharmacies would continue and a report by the National Health Council would be given.

With regard to power failures and other problems in hospitals an early warning system or indicator needed to be given so that problems like power failures could be dealt with as quickly as possible.

The Department of Public Service and Administration guidelines needed to be revised.

The TB cure rate was lower as the patients would not return for their final smear or would not complete the whole cycle of treatment.  The patient needed to be free of TB for two months to be able to be declared “cured”..  Three different measures needed to be taken and employees were being trained for capturing TB data and following up on those that had not finished their treatment.

Health professionals trained were not in one specific field and there were about 1200 graduates every year.

The nursing colleges were available to accommodate the students and the colleges in each province were either amalgamated, new campuses built or closed down according to the need of the province.

The new Definitions of Health Service Providers would be made available to the Committee.

With regard to the dispensing fees, Dr Pillay suggested that the consumers needed to compare prices to get the best value.

Ms F Batyi (ID) commented that as the dispensing fee was so expensive in some cases the patients would use each other’s medication, especially if they did not have a medical aid.  She commented that in Beaufort West there was only one hospital and the doctors were not on duty during the weekends.  She asked how this was going to be dealt with.

Mr Morgan enquired as to the current status of internships for doctors and the current details for community service for nurses.

Mr Madella enquired as to why those suffering from the Extremely Drug Resistant (XDR) TB were being turned away from hospitals.  The output by doctors for the needs in the hospitals did not meet the health systems requirements.

Ms M Tlake (ANC) stated her concern of the brain drain from SA of qualified health professionals while new nursing colleges were also being opened and she suggested a more integrated approach in education in this regard.  The nurses that received degrees were at a lower risk than those that chose to study in nursing college.  She queried the disparity between the salaries of those nurses, who did the same work but did not receive the same remuneration.

Dr Pillay replied that the dispensing fee was based on a court ruling for a minimum fee to be charged to clients for medication.

There was a drive to encourage private sector doctors to support the rural clinics and communities, as well as the country-to-country doctors support programme.

With regard to Human Resources there would be a special session with the Health Committee dealing with this issue.

In dealing with the XDR TB the patient needed to be isolated and treated. However the patient results were usually available later, so the patient could not at first necessarily be isolated.  Additional beds were needed as well for these patients.  The XDR TB strain had developed because the patients had not finished their treatment and so the TB would adapt to the medication.

The Human Resource matters would be further discussed in the report and meeting concerning that specific matter with the Committee.

In the preceding year too many pharmacists and dentists were trained. For the nurses a normative planning model had not been helpful and it was now suggested to follow with workload based assessments for the nurses, as most nurses had to attend to about 40 patients a day and this included those that were chronic, to the more treatable illnesses.

With regard to the “brain drain” experienced, this had been a long ongoing debate and would continue to be as other countries were experiencing this as well.  The issues were also around the skills need of the country.

In regard to the other debate of whether to issue a stipend or use the bursary system, Dr Pillay noted that both of these were currently being maintained as historically the State employed and trained nurses as well.  It had to be accepted that training university graduates in nursing was also contributing to the international market.

The access to Choice of Termination of Pregnancy (CTOP) was always limited in expansion in that health workers could choose to do this or refer clients to a different hospital or clinic.  However this had resulted in fewer abortions.

The meeting was adjourned.