Department of Health Strategic Plan and Budget 2008 to 2011

Meeting report

National Department of Health (NDOH) Strategic Plan and budget 2008/09 to 2010/11
Mr Thami Mseleku, Director-General, Department of Health, reminded Members that the strategic plan had been presented at a previous meeting and this discussion was intended to focus more on the budget.

Mr Mseleku started the briefing with Slide 13 of his presentation to contextualise the discussion on the Budget. Members were asked to bear in mind that a report of the summary of achievements and the challenges of the previous year could be found in the presentation. Slide 13 contextualised the Budget in terms of how it was actually structured, and if read with Vote 14 it would refer to the six programmes.

Mr Mseleku reminded Members also that the Department had actually tried to restructure itself in order to enhance capacity to accelerate implementation. There were now six programmes. These were: Administration, including the new branch of Corporate Services; Strategic Health Programmes; Health Planning and Monitoring; Human Resource Development and Management; a special programme on Health Entities Management; and International Relations, which looked at health trade and health product regulation.

Mr Mseleku outlined the National Health System Priorities for 2008/09 – 2010/11, stating that aid issues had a special focus. These priorities included strengthening management and communication within and outside the system, implementing programmes to combat both communicable and non-communicable diseases, with a focus on HIV and AIDs, and a health facilities improvement plan, which particularly focused on hospitals, noting that the relationship between hospitals and primary health care facilities was critical. Standards had been launched and evaluations were being done. Another priority was the implementation of an Integrated National Health Information System. The Department was embarking on a study, starting with a focus on a patient information system and a human resource system, as two of the systems forming part of broader implementation of a viable health information system. Health financing would include the design of the National Health Insurance System. There would be a focus on further reducing the prices of pharmaceutical products. The Department had information on international benchmarking, to influence the broader reduction of health costs in the private and public sector. The Department also aimed to strengthen provision of Human Resources for Health. This would also provide an understanding on improving production and issues of recruitment of health professionals from other countries. The Associates Programme had already started at Walter Sisulu University of Technology. The Department aimed also to strengthen international health relations, dealing particularly with issues that impacted on health trade. One of the key new areas was an investigation into clinical trials and their potential danger and sources of trade. These issues would be dealt with both at national and head office level.

Mr Mseleku dealt with the six budget programmes and indicated the key areas for each of the programmes (see attached presentation for details) Under Programme 1: Administration, Mr Mseleku stated that the Department was prioritising what the Auditor-General and this Committee had identified as areas for attention in administration, such as the monitoring and evaluation of conditional grants with the provinces so that attempts could be made to improve the hitherto-qualified audit opinions. The filling of vacant posts for expansion purposes was also important and was linked to ensuring that processes of planning were strengthened.

Under Programme 2, Mr Mseleku said that there was a focus on communicable and non-communicable diseases, with TB being an important area, and improving immunisation coverage.

For Programme 3, the Department had deliberately moved away from simply constructing facilities to planning for 2008/9. The Department had launched standard criteria and conducted some surveys.

Mr Gerrit Muller, Chief Financial Officer, DOH, then briefed the Committee on the budget in more detail. He noted that the budget of the Department was in the vicinity of R15 billion, much of which consisted of large conditional grants that were channelled via the Department to the provinces. Mr Muller referred the Committee to Slide 14 to show where funding corresponded with the priorities listed.  The R10 million to recapitalise nursing colleges would in turn lead to a bigger allocation in coming years.

He added that a new organogram had been drawn up, which would reduce the span of management’s activities and enable each manager to focus more specially on their portfolio. This would lead to better monitoring and control and enhance capacity to accelerate implementation issues.

Mr Muller drew attention to the item Property Management. He said that presently the Department was renting three buildings in Pretoria but hoped to move to the Civitas building in the second half of this year.

With regard to Programme 2, Mr Muller indicated that the HIV and Aids programme was growing at 26%, and the expenditure was in excess of R3 billion. The restructuring of the Medicine Control Council (MCC) would lead to the loss of this particular expenditure out of this budget line.

In conclusion Mr Muller emphasised that this budget was linked to the President’s State of the Nation Address and apex priorities.

Discussion
The Chairperson said that he was expecting to have heard comments around how the figures in the budget could be used to effect transformation and give better health to South African people. He stated that this budget of R15 billion could not clearly be linked to an issue or issues that ensured that the health services would improve. The Committee on Public Accounts had commented on compliance with conditional grants and asset management, and the Auditor General had informed the Committee that the Department was due for restructuring, although the Committee was not independently aware of this. This was also the first time that the Committee had heard about district health being mainly funded from donor funding, and the Committee should have been alerted to this earlier.

Mr Mseleku said that it was accepted that there was a gap in the knowledge of the Department and the Committee, but that this really related to how far and deep the Committee expected the Department to go in reporting on all matters.

Mr B Mashile (ANC) said that there were marked increases in the budget amounts related to programmes, but he wanted to know exactly how these increases respond to the challenges on the ground. He asked if this budget was trying to solve the problems reported and seen every day in the national media. He asked further if this budget was responding in a direct way to the needs of beneficiaries.

Ms M Matsemela (ANC) asked how the budget could be divided up to the benefit of the people. She expressed shock at the situation in the Ukhahlemba district. She asked further whether the Department would be faced with any unforeseeable expenditure for this year, and whether this would not put extra strain on the budget. Ms Matsemela asked what was being done with dual therapy when undergoing Prevention of Mother To Child Transmission.

Mr Mseleku stated that the 15 billion was the budget of the National Department, and not for the entire health system. For each of the programmes there was an indication of what the National Department would contribute to provincial levels. Mr Mseleku said that the R15 billion would not be directly linked to issues in the Ukhahlemba district. The bulk of the intervention would come from the province.

Mr M Waters (DA) asked if benchmarking was being done at the same levels at public and private hospitals and, if standards were different, what was the reason for this.

Mr Mseleku said, with regard to the Hospital Improvement Plan, that the Department wanted to start with a few hospitals and evaluate them in order to be able to formulate a set of criteria or standards for the country, as this would then be used for benchmarking purposes. He said the standards were the same for public and private hospitals, but how provinces implemented the plans was dependent on the needs and budget of that province.

Mr Waters pointed out that Slide 15 mentioned vacancy rates, and asked what these vacancies were. He asked why there was a moratorium on the training of nurses in the private sector and why it was taking so long to register foreign nursing professionals.

Mr Mseleku said that the Department of Health had seen a plethora of private nursing colleges training people in different ways, which did not always lead to proper qualifications. Mr Mseleku stated that the Nursing Councils decided to put a stop to this, and instituted a moratorium on training by such colleges, pending a review of the processes that were required to sort out the problem.

With regard to the vacancies, he then said that there was a need for 35 000 nurses. There were problems in the vacancy rates in the provinces, and in addition there were problems in the Nursing Council that the Department was trying to solve, and it was likely that a new Council would be established.

Ms R Mashigo (ANC) asked about the state of hospitals generally and Upington Hospital specifically, where the site existed but no hospital had been built

Mr Mseleku said that Upington Hospital was one of the hospitals referred to in the budget, which had now received a definite budgeted amount, unlike the previous situation.

Ms Mashigo stated that there were many people who had attended courses on community home-based care, and were keen to work in South Africa. They came especially from neighbouring countries, and were willing to be mainstreamed into different professions, especially as qualified health-care givers. She suggested that they be identified by the Department for training and should be given work in South Africa as home-based care workers.

Mr Mseleku responded that there was no specific programme with other countries to upgrade community care-givers, save for a programme with the Tanzanian Department of Health, and save in certain identified strategic areas, like the Eastern Cape. Most countries looked to South Africa for training, and there was a reversal in the trends, showing more people moving out of South Africa with fewer returning. Mr Mseleku added that some nurses were leaving hospitals to go and work at primary healthcare facilities.

Ms Mashigo asked whether there was an audit committee to look into the spending of the Department.

Mr Mseleku responded that the Department did have its own internal audit committee, which was very strong. He commented, in relation to the implementation of the conditional grants, that expenditure on hospital revitalisation had been very good on the whole, but that there were some problems in certain provinces where the province was unable to provide certain information on time.

Mr A Madella (ANC) noted the indications that 312 Tunisian doctors were assessed by the health profession, 258 were deployed, and 54 were sent back home. He asked what happened to those who were sent back. He also asked what the output was of nursing colleges that had been re-opened by the President. He asked further for an indication of the extent to which the country was able to contribute to its own requirement of health professionals.

Mr Mseleku explained that the evaluation of the Health Professions Council of South Africa (HPCSA) was done in South Africa. The Department had sent a team to the country of recruitment that looked at the system, agreed on the compatibility of the system with South Africa and accredited the country for registration. When the country had recruited doctors they undertook their own evaluation before they would come to South Africa, to look at competency. 155 doctors arrived in the country, but 24 were found not suitable for various reasons, one of which was lack of familiarity with the language.

Mr Madella asked to what extent this budget would contribute to the alleviation of the long queues people were confronted with on a daily basis, and the lack of available medications at many public health centres.

Mr Mseleku said that queues and availability were included in the standards for hospitals and clinics so this could be closely monitored. The Department had started programmes to deal with queues in some clinics, and had been able to intervene and see improvements with the supply of medicines as well. Mr Mseleku stated that one of the challenges identified was the relationship between chronic medication and the capacity of clinics to keep that medication because of the scheduling issues. There had been successes where the clinics had set up systems to make the community understand the impacts of not coming to collect medicines on the due dates.

Mr Madella said that this budget was silent on a disability strategy, particularly providing devices to assist the disabled, or doing an audit to find out whether health facilities were accessible to people with disabilities. He asked what was being done about the absence of these facilities.

Mr Mseleku said that the National budget did not actually outline issues related to the disability strategy, and there was a need to unpack and monitor it.

Mr Madella said that from a labour relations point of view, a phenomenon in the Department of Health was that where there were disciplinary matters, the Department seemed to want to refuse settlement offers and proceed with hearings, and even then, if the findings were against the Department, it was prepared to go to review of these decisions at the Labour Court, and even then, when a finding was given against the Department, it would still not comply with its obligations. This was very costly.

Mr Mseleku said he would have to refer to Human Resources to investigate. He said that this had never happened at National level. This may be the case in the provinces, and the National Department would have to check whether it was not losing money through suspensions, and undue amounts being spent on labour issues.

Mr Madella asked if the Department was happy with the allocation, and asked if it could cope with the money allocated, given the crisis within the health care system. 

Mr Mseleku indicated unhappiness with certain areas of the budget, especially the amounts budgeted for the information system, as some people were still using paper records, and there was a need to make them electronic.

Ms Madumise asked if the increase in the budget for Anti retroviral treatment (ARVs) would allow more patients to be on ARVs, and whether it would allow the Department to be able to monitor the patients on these drugs.

Mr Mseleku stated that the HIV and Aids budgetary increase allowed for more people to be accommodated in the treatment programme and there was improved monitoring at these centres.

Ms Madumise asked if there was any progress as far as the treatment-default rate was concerned, and whether the R15 billion departmental budget includes the Minister’s and Deputy Minister’s allocations.

Mr Mseleku said that staff had been redeployed from the office of the Deputy Minister, pending information on how this matter would be resolved. It seemed that eventually the office would have to be dissolved. Currently people were still being paid as they were still attached to that office.

Mr Yogan Pillay, Cluster Manager:Strategic Planning, Department of Health responded that  the default rate, having remained at 10% for a number of years, had now come down to 8.9% and there was confidence that it would reach the President’s target of 7% by the end of this year. The Department was putting in additional effort to trace defaulters, and in high burden areas had appointed defaulter-tracing teams made up of a nurse and two community health workers to track defaulters and get them back on their treatment. If the defaulter rate could be decreased then the multiple-drug resistant TB rate in the country would be decreased as well.

Ms C Dudley (ACDP) said that the impact of the two year medical internship was mentioned as a challenge. She asked how this was going to be addressed and whether the budget was going to assist in this process.

Mr Mseleku stated that the Department had minimal impact, but had tried to ensure that those doctors doing community service would be retained, and all provinces had put contingency plans in place.

Ms Dudley asked how safety in hospitals was being addressed.

Mr Mseleku stated that safety in hospitals and training were catered for in the budget, which included training in colleges and the colleges themselves. Provincial budgets addressed this, while the national budget addressed matters related to developing policies, monitoring and evaluation. The standards document launched would be circulated at hospitals.

Ms Dudley asked how the budget would address nursing colleges and facilities for the training of nurses.

Ms Dudley asked how the problem of too few beds was going to be addressed in relation to infrastructural spending.

Mr Mseleku responded that South Africa had enough beds, and that the Department was reconfirming the needs so that at a later stage it would be able to reconcile numbers.

Ms Madumise asked if the Department was prepared to assist in those refugee camps where there were health problems, where would the help come from, and was there a budget for assistance.

Mr Mseleku responded that the Department of Health was represented on a national task team established by Cabinet to look into the refugee problem. The Department was looking at sending a response team with epidemiologists to assess the potential for outbreaks at the camps. He added that one of concerns under discussion was the consequences of any health outbreaks, such as people not being able to go to work and assist their families. The Department was also encouraging volunteer work.

Ms Matsemela asked what the budget was being used for since there are many challenges in the country. She asked Mr Muller if this did not complicate consolidation of the budget because it could have implications as far as the Auditor General was concerned.

Ms Matsemela asked further what was the best mechanism for monitoring for the Department in relation to progress towards the Millennium Development Goals (MDGs), which was slower than anticipated.  She asked also about the prediction that by 2015 babies and mothers would be dying from strategic health problems.

Mr Mseleku responded that in regard to the MDGs, objectives were delayed due to some interventions being made but other interventions not being made, particularly in regard to Child Health and Maternal Health. Child and Maternal health programmes had to be strengthened. There were major challenges because some of the issues were linked to monitoring and evaluation.

Dr R Rabinowitz (IFP) noted that very little was said about the MCC in this budget. It was supposed to be restructured, but there was no clarity as to how this was going to be done.

Mr Mseleku reiterated that many of these questions could only be answered through a written response, but the MCC restructuring proposals would be presented together with the Bill and the report on the suggested restructure. He added that the Health Professions Council had its own budget. The report on restructuring of the MCC was available on the website.

Dr Rabinowitz stated that there was a lack of clarity about how many medicines were registered per year, how many were still waiting to be registered, the average time and cost for medicines to be registered, and what amount of money was being spent on the MCC.

She also asked questions about the pricing committee, where this budget came from and how much it would cost to do the pricing and detailed work around the structure of medicines. In regard to indigenous medicines, she said that there was a centre run under the Medical Research Council, and asked where its budget was reflected, and whether there was enough money for research. Dr Rabinowitz stated that there was very little information in the budget about how much it cost the Health Professions Council to hold doctors accountable for standards and to discipline them.

Mr Mseleku noted that slide 30 showed indirectly that the Pharmaceutical Policy and Planning Unit actually managed the secretarial and analytical work for the pricing committee. The specific amount allocated could be given at a later stage. He added that the pricing committee was a very useful committee because without it the reduction in medicine prices would not have been achieved. He added further that restructuring of the MCC would not destroy the pricing committee.

Mr Mseleku said, in regard to the other questions, that the Department did not have statistics at hand but that the details could be provided in writing.

Dr Rabinowitz asked how the Red Cross was supported in the work it was now doing with immigrants.

Mr Mseleku said that the Department was entering into agreements with the Red Cross Hospital, including a more formal arrangement. 

The Chairperson asked for clarity around the challenges of the impact of the two year internship.

Mr Mseleku said that the slides preceding slide 12 related to the 2007/08 budget and a report on the summary of achievements was provided. Slide 6 dealt with the challenges for the 2007/08 year, which had included the public sector strike and the inadequate number of workers available. The impact of the two year internship programme was a challenge, but in 2008 this should be able to be addressed simply because it had been earlier identified and planned for.

The Chairperson asked if Mr Mseleku was suggesting that the medical fraternity would answer that the two year internship programme had been attended to.

Mr Mseleku stated that details could be provided but that there had not been a major collapse of the system.

The Chairperson asked further if the same applied to safety in schools, and whether this issue had been addressed. 

Mr Mseleku said that the same principle would not apply to all challenges, as some had been addressed but others not.

The Chairperson asked the Department to respond to the specific problems in Mpumalanga around psychiatric hospitals.

Mr Mseleku stated that certain steps were taken with regard to safety in certain hospitals, such as an increase in security personnel and better management of people coming in and out of hospitals. He added that there was a need for general steps to be taken to ensure safety, and this was still an issue, even though safety had improved by these measures being taken.

Mr Mseleku added that the Standing Committee on Public Accounts (SCOPA) had reached a point where it concluded that in order to get a fuller picture on all matters it would have to invite the provincial heads to answer specific questions.

Ms Dudley asked if the National Department would then be responsible for those general guidelines on security and how would this proceed.

Mr Mseleku said that when the issue arose, the National Health Council had provided general guidelines, which were adopted and carried out.

The Chairperson said that page 261 of the Budget Vote 14 document contained a statement that there had been significant milestones in eradicating malnutrition in South African children. A Parliamentary team had visited Ukhahlemba to look into the problem. The report, which was seemingly being held back by the Department in the Eastern Cape, stated that children were still dying from malnutrition. He therefore asked whether the statement in the first document was to be considered categorical, or general. The Department had a defined role to play in the delivery of health. If issues like this arose in Ukhahlemba, the Department had to act quickly and demand a response in order to interact and deal with the problem. Perhaps the Department should itself be visiting Ukhahlemba to investigate.

The Chairperson asked for further clarity on the same page of the same document, which also gave selected performance indicators. He said that the percentage for national immunisation was projected to rise from 84% to 90%. The Department could not just use mathematical postulations. He wanted to know how this level was reached.

Mr Mseleku stated that it was a figure of not less than 90%, and was not the actual target, as the 90% was a World Health Organisation (WHO) target.

The Chairperson asked for an explanation regarding the decline in the figures for full immunization, from 69% to 37%, in health districts. He said it would be useful for the Committee to be given a full breakdown per district, as this might also alert the Committee to the Ukhahlemba question.

Mr Mseleku said that the problem was one of counting, and in his personal opinion a report was not available for that district.

Mr Pillay said that data issues were a general challenge in the country. There had been significant decentralisation, and strong national mechanisms were needed to ensure good coherence and collection of data. He added that if the boundaries were changed, the numbers changed, and there were a number of issues around denominators in districts. The consolidated effect of immunisation in districts was lagging behind.

The  Chairperson argued that he did not agree with these postulations and did not think that they should have been put in this document.

Mr Mseleku said that there may be other explanations and the Department should bring an epidemiologist to account for the problem. He added that a whole range of issues was being covered and the Department was unable to explain all in detail.

The Chairperson asked what a cure rate of 57% and a TB defaulter rate of 7% meant, in relation to the extremely drug resistant (XDR) cases.

Mr Mseleku said that the cure rate was moving up. The defaulter rate had been 10.1% and had worsened.  The Department had then intervened in 2006, and the Multi Drug Resistant (MDR) cases were currently less than 1%.

Mr Mashile stated that he did not understand the explanation given, as this raised some other questions. When the defaulter rate was improving by 3%, then one would expect the TB cure rate to improve as well. However, he had noted a marked decrease in the defaulter rate. 

Ms Mseleku said that the Department did not understand what the Committee was suggesting with regard to TB cure rates, because one was not a function of the other, and there was no correlation between the two.

Dr Rabinowitz asked how much of the National Health Act had been enacted. She asked what percentage of the district health centers were fully operational, with fully operational information systems.

Mr Mseleku said that a substantial part of the National Health Act was being implemented, except for one section which was not yet promulgated by the President, as this dealt with issues of certification. There were regulations in place for about 40 to 60 percent of the Act’s sections and these would be presented to the Committee.  He added that in regard to the district health care system, the Department would have to provide a written response, as this was a case of functionality versus the electronic health information system.

Mr Mashile expressed concern with the answers received, which seemed to show a gap between the provincial and national departments in terms of authority. He asked if there were any policy gaps that needed to be looked at in respect of relationships between the provincial and national departments of health, to ensure that decisions taken by the national department became mandatory for provincial departments.

Mr Mseleku said that the policy gaps between the national and provincial departments were part of an ongoing discussion at national level.

Ms Madumise referred to bullet 6 on page 6 of the Budget Vote document, relating to the MDGs. She said that she had seen the Report, and South Africa was rated the worst among all developing countries. In 2006/7 the Department had trained 70% of health workers and the figure still remained at 70%. She asked how the Department was envisaging an improvement if the figures stayed at that level.

Mr Mseleku stated that the MDGs were a challenge for South Africa. He stated that 80% of personnel were trained in the integrated childhood management issues, but this was not the only thing impacting on numbers. The issue was around integrated service delivery, as there were other social issues in health, like sanitation.

Mr Madella stated that he would have expected to see an indicator that dealt with the infant mortality rate. He asked why the indicator was missing.

Mr Mseleku stated that infant mortality rates would improve if systems improved.

Mr Madella added that he was pleased to see that South Africa was malaria free, and asked if provision was made for malaria fatalities.

Mr Mseleku confirmed that according to the WHO definition, South Africa was malaria free.

Ms Mashigo asked for an explanation regarding the huge costs for consultants.

The Chairperson said that there were a number of issues that needed to be followed up, some by the Committee and others by the Department. The Ukhahlemba issue was one. He added that there was agreement regarding an invitation to be sent to provinces to speak to the Committee and to sort out oversight work. The issues raised by the Auditor-General also had to be attended to, including district health services. However, the Committee had run out of time at this meeting.

The meeting was adjourned.