Intergovernmental Fiscal Review: Health

Meeting report

SELECT COMMITTEE ON SOCIAL SERVICES (NATIONAL COUNCIL OF PROVINCES)
16 October 2001
INTERGOVERNMENTAL FISCAL REVIEW: HEALTH

Chairperson: L Jacobus

Documents handed out
Intergovernmental Fiscal Review - Health (Powerpoint presentation)
Intergovernmental Fiscal Review 2001 [Chapter 4: Health]

SUMMARY
The meeting focused on the chapter on health within the IGFR 2001. Many of the presentations used the data and statistics found in this document.

A number of general issues prevailed throughout the meeting:
- the inequality in health care spending across the provinces was a constant theme.
- service delivery and the quality of care.
- the recruitment of trained health care personal was widely discussed.
- the fiscal implications of the HIV/AIDS epidemic.

Other issues discussed included: the maintenance of hospitals and clinics; human resource development and management; the need for more public-private partnerships (PPPs) and the need to rethink the system of conditional grants allocated to the provinces.

Input of Minister of Health - Manto Tshabalala-Msimang
- The Minister acknowledged that the IGFR was an important document as it showed the trends, constraints and delivery of services across all the provinces.
- She highlighted the success of the Department of Health in providing Primary Health Care (PHC). Since 1995 over five million South Africans have gained access to PHC. Despite this, she pointed out that the task was far from complete.
- One of the problems for the department was human resources. Primarily these problems were caused by an unequal distribution of health professionals. Large numbers of professionals are based in the urban centres. The introduction of compulsory community service has ensured that health professionals are placed in the areas where they are most needed.
- The IGFR highlighted a number of challenges facing the health department. The first of these was the financial pressures facing the department. The Minister commented that the IGFR underestimated these pressures. A second major problem was the increase in emerging and reemerging diseases - the top two being HIV/AIDS and TB. The Minister mentioned that there needed to be an improvement in the reliability of the statistics and data in this regard. The department was currently developing a document on enhanced responses to HIV/AIDS and TB. This document in particular focused on the funding requirements to improve the government response. Two of the priorities of the department in fighting HIV/AIDS are the treatment of STDs, which could reduce the possibility of infection by 40%, and the promotion of condoms.
- In conclusion the Minister said that the health department was constantly seeking improvement through new and updated managerial systems. She thanked the Treasury for its work in compiling the IGFR and mentioned that Treasury must continue to move rapidly in assisting with budgetary issues.

Presentation on Health Chapter in the IGFR
Mr M. Bletcher (Treasury) went through the Powerpoint presentation (see document).

Discussion
A number of questions and points of discussion emerged:
- The provincial health departments complained that at the end of the financial year the national government simply dumped its excess funds onto the provincial departments. This was unfair as it did not give the provinces enough time to spend the excess money. An official from the national department responded that this was not the case as money was allocated on a monthly or quarterly basis. Furthermore, the problem was that many of the provinces did not produce timeous financial reports. The official also pointed out that there should be a rollover of funding within the departments.
- Government policy on the HIV/AIDS epidemic was discussed. Ms Tshabalala-Msimang outlined the government's strategic plan which she said had been successful. Firstly, she estimated that 90% of the population was now aware of the prevalence of AIDS. The challenge was now to convert this awareness into a change in sexual and social behaviour. She made an appeal to communities to look after their loved ones. Secondly, the Minister mentioned the increase in usage of condoms, which had doubled in two years. The demand for female condoms had also doubled over the last two years. The Minister said it was difficult to say if the department was winning in its fight against AIDS as a number of programmes would take awhile to reach fruition.
- The issue of Primary Health Care was discussed. The Minister outlined government policy saying that there was free health care for pregnant women and children under the age of six. However, she acknowledged that the government was reluctant to turn away people because of lack of funds. Therefore, to some extent, policy was dictated by realities on the ground.
- A representative from the Northern Province asked if the national department was offering any incentives to curb the loss of capable nurses. The Minister replied that over the last few years the salaries of nurses had improved. She pointed out that the issue of migration was a global phenomenon. The issue was not only about financial incentives, but also the state of facilities and equipment. The national department regretted the loss of skilled health professionals, but commented that the policy of community service was countering these losses.
- Dr Nel (NNP) asked the Minister as to why there was a reduction of hospital beds in some provinces. The Minister replied that the policy of the department was to rationalise hospital beds across all provinces. The department aimed to ensure patients moved out of beds and went to step-down facilities like community health centres.

Provincial Presentations from MECs for Health or Representatives from Department

KZN - MEC for Health
- The MEC pointed out that the national policy of PHC was improving in the province despite financial constraints. There were also significant moves towards home-based care and step-down facilities.
- The focus of the department was ensuring improved quality service and HIV/AIDS and TB. In particular, HIV/AIDS had created enormous pressures on hospitals as well as increased mortality and a rise in the cost of care.
- The MEC stated that more community health workers were needed.
- The outbreak of cholera was also identified as a problem area. The department spent a huge amount of resources controlling the outbreak and recommended that in future there needed to be closer collaboration across a number of departments.
- The MEC said the department appreciated the support of national government and Treasury in countering malaria.
- In terms of migration, the MEC mentioned that the departure of qualified nurses was proving problematic. To counter this exodus the province had doubled its intake of newly qualified nurses.
- Another problem was that foreign doctors appointed to the province were having problems getting their work permits. There was greater need for cooperation with the Department of Home Affairs in this regard.
In conclusion the MEC stated that the main issues in the province were the need for more support to fight the HIV/AIDS epidemic and increased equity in the conditional grant allocation process.

Free State - MEC for Health
- The MEC began by mentioning the impressive strides the department had made in reversing the cash flow problems. Steps taken included: a human resources plan that allowed for a reduction of personnel; the passing of the Free State Nursing Act that allowed for the creation of one nursing college in the province.
- Priorities for the department were: ensuring that drugs and medicines were more readily available and a general improvement in the Emergency Medical Services (EMS).
- In terms of EMS the department ensured that two new control rooms were opened and it also facilitated the purchasing of more vehicles and ambulances.
- A major focus area was the fight against the spread of HIV/AIDS. Policies adopted included; extensive door to door AIDS awareness; the distribution of one million condoms; training about STDs; the establishment of two pilot sites for the distribution of anti-retroviral drugs and free voluntary testing and counseling for all citizens.
- TB was also identified as a high priority area. The objectives were; improvement of cure rate; all districts having a TB coordinator and the establishment of a multi-drug resistant unit by 2002.
- Other policies included; outsourcing of transport services to ensure more efficient transportation of drugs and medicines; acceleration of training of PHC nurses; improvement in the collection of revenue and the ordering of 28 mobile clinics.
- The MEC concluded by recommending that, in terms of PHC, the national department must ensure that patients are treated at the right levels. Secondly, it was recommended that conditional grants must be issued for fighting HIV/AIDS.

Mpumalanga - HOD of Health Department
- Major challenges facing the department were the fact that demand outweighed resources and the growth in HIV/AIDS infections. A survey conducted in 1999 indicated that 27% of women attending anti-natal clinics in the province were infected. The same survey in 2000 reflected an increase to 29,3%. Measures to counter the spread of HIV/AIDS included expanding free testing sites as well as implementing life skills programmes.
- Budgetary limitations were also identified as a major problem. The conditional grant allocation from national government was inadequate for the provinces needs. A major strain on the budget was cross-boundary demands e.g. the treatment of patients from Swaziland, Mozambique and other provinces.
- The lack of adequate equipment was cited as a major problem. The HOD estimated that R300 million was needed for the upgrading of medical equipment. No infrastructure grant had been received in this regard.
- Another problem was the lack of skills amongst personnel. This was as a result of the lack of training as well as the exodus of staff. Adding to this, many foreign doctors were struggling to secure work permits.
- In conclusion the HOD recommended a major funding increase as well as more equitable conditional grant allocation.

Northern Cape - MEC for Health
- The aim of the department was to render optimal efficient service across the province.
- A number of challenges faced the province. Firstly, cross-boundary issues - giving care to citizens of the Free State and North-West provinces. It was estimated that this cost the department R12 million per annum. It was recommended that better communication was needed with the respective provincial health departments.
- A second major challenge identified was the need to increase revenue collection.
- It was also mentioned that more community service staff was needed in the remote areas.
- In conclusion the MEC stated that the departments goals were to pursue improved service and also to gain a more equitable share of conditional grant allocations.

Western Cape - Director of Policy and Planning from Department of Health
- The fiscal constraints facing the department meant there was a need for downsizing. Over the last two years the department had manage to stabilise financially.
- The introduction of free PHC had been managed successfully despite the increase in needs.
- Major improvements were needed in the strengthening of skills at district hospitals and in the upgrading of rural regional hospitals.
- There was success with the single consolidation of the Western Cape Nursing College. However, there was a need to implement a viable bursary system at the college and at universities for nursing training specifically.
- The top three priorities for the department were identified as HIV/AIDS, TB and trauma. For HIV/AIDS the focus was on a home-based care system. The strategy for TB was strengthening the DOTS programme and increasing the cure rate.
- Other more general priorities included; improvement of quality of care; decent management practices; correction of major human resource issues and increased revenue regeneration possiblities.

North-West - Chairperson of Standing Committee on Health
- One of the major objectives of the department was the establishment of a fully-fledged emergency service.
- Other objectives included transformation and job creation.
- The realignment of districts to new boundaries was one of the department successes.
- In terms of hospitals, the province aimed to implement sound management principals through the appointment of CEOs. The overall objective was to provide more modern services in some hospitals.
- The major challenges facing the department were the need for more funding for HIV/AIDS and funding for hospital maintenance.

Closing remarks
The chairperson had to call the meeting to a halt as a number of committee members had other engagements. Before closing the chairperson encouraged all committee members, MECs and provincial representatives to think about the challenges facing the health departments, both provincially and nationally.