REPORT OF THE PORTFOLIO COMMITTEE ON HEALTH ON THE STRATEGIC PLAN
(2014/15 – 2018/19), ANNUAL PERFORMANCE PLAN (2014/15) AND BUDGET VOTE 16 OF THE DEPARTMENT OF HEALTH,
DATED 9 JULY 2014
1.
Background
The Portfolio
Committee on Health, having considered the Strategic Plan, Annual Performance
Plan (APP) and budget allocations of the National Department of Health and in
terms of the Public Finance Management Act (PFMA) of 1999, reports as follows:
2.
Introduction
The Constitution of
South Africa (Act No. 108 of 1996) recognizes that Parliament has an important
role to play in overseeing the performance of government departments and public
entities. In terms of section 10(c) of the Money Bills Amendment Procedure and
Related Matters Act (Act No. 9 of 2009), updated strategic plans must be tabled
in Parliament after the adoption of the fiscal framework. It is important to
ensure that the strategic plan is tabled within the stipulated period as the
plan provides information for the budget review process of the Portfolio
Committee.
This report details the findings and recommendations of the Committee
after engaging the Department.
3.
Consideration
of tabled strategic plan and annual performance plan and budget allocations
On 2 and 3 July
2014, The Portfolio Committee engaged the Minister of Health, Deputy Minister,
the Director General and relevant Executive Managers of the Department on the
strategic plan, annual performance plan and budget allocation of the
Department.
4.
Overview
of the Department of Health
The Department of Health derives
its mandate from the Constitution of the Republic of South Africa and the National
Health Act, No. 61 of 2003. The Department contributes directly to achieving
the government outcome which calls for a long and healthy life for all South
Africans (Outcome 2). In order to achieve this, the Department is guided
by the Health Sector Negotiated Service Delivery Agreement (NSDA), namely:
1.
Increasing life expectancy;
2.
Decreasing child and maternal mortality rates;
3.
Combating HIV and AIDS and STIs, and decreasing the
burden of disease from Tuberculosis; and
4.
Enhancing health systems effectiveness.
The health
sector is also guided by the health sector Ten Point Plan, the National
Development Plan (vision 2030), and the United Nations (UN) Millennium
Development Goals (MDGs).
The National
Development Plan (NDP) identifies demographics, burden of disease, health
systems and the social and environmental determinants of health as the key
areas for intervention in order to improve the health system in the country.
However, a fundamental reform of the country’s health system will be required
in order to address these issues. The NDP states that by 2030
South Africa should have achieved the following goals:
The Department of Health is also committed to work towards achieving
health-related MDGs, namely:
·
MDG 4: to reduce by two thirds the Under-5
mortality ratio;
·
MDG 5: to reduce by three quarters the maternal
mortality ratio; and
·
MDG 6: to combat HIV and AIDS, malaria and other
diseases.
4.1 Department of Health Strategic Plan (2014-2019)
The Department’s five-year strategic goals are to:
·
Prevent disease and
reduce its burden and promote health;
·
Make progress towards
universal health coverage through the development of the National Health
Insurance scheme, and improve the readiness of the health facilities for its
implementation;
·
Re-engineer primary
healthcare by: increasing the number of ward based outreach teams, contracting
general practitioners, and district specialist teams; and expanding school
health services;
·
Improve health facility
planning by implementing norms and standards;
·
Improve financial
management by improving capacity, contract management, revenue collection and
supply chain management reforms;
·
Develop an efficient
health management information system for improved decision making;
·
Improve the quality of
care by setting and monitoring national norms and standards, improving system
for user feedback, increasing safety in health care, and by improving clinical
governance; and
·
Improve human resources
for health by ensuring adequate training and accountability measures.
Interventions to address the causes of maternal, child and infant
mortality will be implemented by the department over the medium term including
the scale-up of family planning services to reduce unplanned pregnancies and
improve women’s health.
A national health commission is planned to reduce the burden of
non-communicable diseases. The deployment of primary health care teams and the
implementation of the integrated school health programme will also improve health
promotion and the prevention of diseases.
In order to strengthen the health system, the department is placing
emphasis on the quality of health care in South Africa by establishing the
independent Office of Health Standards Compliance as a public entity.
The following key
actions have been identified for reducing the burden of HIV and AIDS and
tuberculosis:
The Department plans
to publish a white paper on National Health Insurance. The stated aim of the
proposed NHI is that it will ensure that all South Africans, irrespective of
their socio-economic status, have access to good quality and affordable health
services. In 2014/15, phase 1 of the NHI fund will be implemented. This will include, amongst other things, the
preparation of the service delivery platform for the full implementation of the
NHI.
The activities of
the department are organised in six programmes, comprising Programme 1:
Administration; Programme 2: National Health Insurance, Health Planning and
Systems Enablement; Programme 3: HIV and AIDS, Tuberculosis, Maternal and Child
Health; Programme 4: Primary Health Care Services; Programme 5: Hospitals,
Tertiary Health services and Human Resource Development, and; Programme 6:
Health Regulation and Compliance Management.
4.2 Department of Health Annual Performance Plan (2014/15)
In achieving its goals, the department has set short
term goals which are outlined in the annual performance plan. These goals are as follows:
Goal
1: Make progress towards universal
health coverage through the development of the National Health Insurance scheme
and improve the readiness of health facilities for its implementation. The
National Health Insurance will be implemented as follows:
- The
National Health Insurance law will be passed by 2015/16
- The
National Health Insurance fund will be created by 2016/17
- Functional
National Pricing Commission to regulate health care in the private sector will
be established by 2017
- Revise
and legislate methodology for the determination of the dispensing fee.
Goal
2: Re-engineer primary healthcare by
increasing the number of ward based outreach teams, contracting health care
providers and district specialist teams and expanding school health
services. This will be achieved as
follows:
Goal
3: Improve the quality of care by
setting and monitoring national norms and standards, improving system for user
feedback, increasing safety in health care and by improving clinical
governance. This will be achieved by the
following:
Goal 4: Improve
health facility planning by implementing norms and standards
Goal
5: Improve financial management by
improving capacity contract management, revenue collection and supply chain
management reforms
Goal
6: Improve human resources for health
by ensuring adequate training and accountability measures
·
Improve turnaround times of recruitment at the
National Department of Health. This will
be reduced by four months in 2014/15 and three months by 2018/19
·
Develop health workforce staffing norms and
standards. Norms for primary health care using Workload Indicator Staffing Need
(WISN) methodology will be determined by 2014/15. Guidelines for human resource norms and
standards will be published for all levels of care by 2018/19.
·
Improve quality of nursing training and practice
by ensuring that all nursing colleges are accredited to offer new nursing
qualification. Five public nursing
colleges will be accredited to offer the new nursing qualification by 2014/15.
·
Establish the health leadership and management
academy in order to develop a training programme
for hospital chief executive officers (CEO’s) and district health managers.
Goal 7: Prevent
disease and reduce its burden and promote health
- Strengthened
regulatory framework (to review current legislation and close gaps).
- Increased
capacity to enforce compliance by mines using multi-disciplinary inspections
that comprise officials from the Departments of Health, Mineral Resources and Labour.
- Effective
surveillance and reporting system.
Goal
8: Develop an efficient health management
information system for improved decision making
- Health
Patient Registration System;
- Patient
Administration to improve efficiency and reducing waiting times; and
- Integrated
electronic Health Data Collection System.
5.
Budget
Analysis
The
department carries out its mandate through six programmes. The department
receives R33.9 billion for 2014/15, up from R30.5 billion in the previous
financial year. This is an increase in nominal terms of 11.2% and 4.7% in real
terms. Table 1 shows the programme allocations for the Department of Health’s
budget.
Table 1: Health Budget for 2014/15 medium term
Programme |
Adjusted 2013/14 |
Estimate 2014/15 |
Real Percent change in 2014/15 |
R million |
|||
Programme 1: Administration |
405.7 |
399.7 |
-7.23% |
Programme 2: NHI, Health Planning and Systems Enablement |
491.8 |
621.3 |
18.96% |
Programme 3: HIV and AIDS, TB and Maternal and Child Health |
11 042.0 |
13 049.9 |
11.28% |
Programme 4: Primary Health Care Services |
102.6 |
93.5 |
-14.19% |
Programme 5: Hospitals, Tertiary Services and Human Resource
Development |
17 722.4 |
18 925.8 |
0.56% |
Programme 6: Health Regulation and Compliance Management |
763.7 |
865.3 |
6.69% |
TOTAL |
30 528.2 |
33 955.5 |
4.73% |
The two largest
programmes namely Programme 5: Hospitals, Tertiary Services and Human Resource
Development and Programme 3: HIV and AIDS, TB, Maternal and Child Health
jointly constitutes almost 94% of the total budget.
The allocation
for Programme 4: Primary Health Care Services again declines in both nominal
(-8.87%) and real terms (-14.19%) in 2014/15. Less than one per cent (0.28%) is allocated to this programme (R93.5 million), which is less
than it received in the previous year, both as a percentage (previously 0.34%)
and in Rand value (R102.6 million).
In terms of
economic classification, the bulk of the Health Budget (R30.9 billion or 91.0%)
consists of transfers and subsidies to provinces and municipalities, and
departmental agencies and accounts. This figure includes R206.1 million to non-
profit institutions and R596 million to departmental agencies and accounts.
Current payments
constitute a total value of R2.0 billion, which represent 5.9% of the total
budget allocation. Most of the current expenditure is allocated to Goods and
Services, taking up 70.3% of the total current payments. Expenditure items that
receive the largest share of the goods and services budget are Contractors at
R416.0 million (up from R313.8 million in the previous year), Consultants and
professional services: Business and advisory services at R126.5 million,
Medical Supplies at R149.2 million and Medicine at R201.2 million. Stationery
and printing receive R41.3 million, down from R46.1 million in 2013/4, whilst advertising
more than doubles from R23.4 million to R58.5 million.
A significant
increase in payments for capital assets is reported, from R466.4 million in
2013/14 to over one billion rand (R1 025 million) in 2014/15. Buildings
and other fixed structures more than doubles from R440.0 million to R979.9
million. Machinery and equipment also increased significantly from R26.3
million to R45.2 million.
The focus over
the medium term will continue to be on increasing life expectancy and reducing
the burden of disease by revitalising hospitals, providing specialised tertiary
services, and preventing and treating HIV and AIDS. The following additional allocations have
been made in the 2014/15-2016/17 financial years:
The following reductions
in Conditional Grants also come into effect:
6.
Programme Allocations
The purpose of
the Administration Programme is overall management of the department and
providing centralised support services. The Programme budget decreases by 1.5%
in nominal terms from R405.7 million in 2013/14 to R399.7 million in 2014/15
(but in real terms by 7.2%). The largest sub-programme is Corporate Services,
of which the allocation decreases by 3.5% in nominal terms and by 9.1% in real
terms. Office Accommodation receives 26.5% of the Programme budget, and is the
only sub-programme allocation to increase, from R97.5 million in 2013/14 to
R105.8 million (up nominally by 8.5% or 2.2% in real terms).
In terms of
economic classification, 98.2 % of the budget is allocated to current payments.
Compensation of Employees amounts to R161.6 million (41.2%) while R230.8
million is allocated to Goods and Services. This includes R103 million for
Operating leases.
The National
Health Insurance, Health Planning and Systems Enablement Programme aims to
improve access to quality health services through planning, integration of
health systems, reporting, monitoring and evaluation, and research.
This Programme
budget increases by 26.3% in nominal terms (or 19.0% in real terms) from the
2013/14 financial year, due to increased funding to the NHI sub-programme. The
NHI sub-programme increased with 31.6% nominally and 23.9% in real terms. The
NHI sub-programme receives the largest portion of the Programme 2’s budget, at 78.4%
(R487.2 million) to develop and implement policies, legislation and frameworks
for expansion of health insurance to the broader population, amongst other
things. The increase in this sub-programme is to ensure that General Practitioners
(GPs) are contracted for the NHI.
In terms of
economic classification, 87.5 % of the budget (R 543.8 million) is allocated to
current payments. Compensation of Employees amounts to R67.2 million while R476.6
million is allocated to Goods and Services, R395.8 million of which is for
Contractors and R7.0 million for Business and Advisory Services.
The aim of this
programme is to coordinate, manage and fund HIV and AIDS, Tuberculosis (TB) and
maternal and child health programmes. It aims to reduce infant, child and youth
morbidity as well as maternal mortality. It also aims to increase the TB cure rate.
A large
proportion, 98.0% of this programme’s budget is allocated to the HIV and AIDS
sub-programme, amounting to R12.8 billion in 2014/15. This represents a nominal
increase of 16.4% or 9.6% in real terms compared to the 2013/14 allocation. The
four remaining sub-programmes combined receive less than 2.0% of the
programme’s budget.
The Women’s
Maternal and Reproductive Health sub-programme is responsible for amongst other
interventions, deploying obstetric ambulances, establishing Kangaroo Mother Care
facilities, midwifery education and training, and strengthening infant feeding
practices. This sub-programme received less than 1% (0.13%) of the programme
budget and the allocation declined by 5.2% in real terms in 2014/15.
The Child, Youth
and School Health sub-programme increases from R17 million to R218.4 million
mainly due to roll-out of the HPV Vaccine. This sub-programme develops and
monitors policies and guidelines, and sets norms and standards for child
health.
Over the medium
term, key initiatives will be implemented in line with the maternal and child
health strategic plan. These include the continued rollout of the integrated
school health programme to cover all learning phases, prioritising under-served
and under-resourced schools, and strengthening the immunisation programme.
Empirical evidence shows that South Africa has managed to reduce child
mortality in the last five years. This is a positive outcome emanating from the
scale-up of prevention of mother to child transmission of HIV, the rollout of
antiretroviral therapy, new child vaccines (pneumococcus and rotavirus) and
other child survival programmes.
In 2012/13, the
President launched a multi-sectoral school health programme. To support its
implementation, a communication strategy, a recording and reporting system, a
toolkit for school governing bodies and a memorandum of understanding between
the Departments of Basic Education, Health and Social Development are being
developed. In addition, a training package was developed for school health
nurses, with training taking place in all provinces. In 2014/15, the fight
against cervical cancer will be intensified through the provision of human
papilloma virus vaccinations to Grade 4 girls.
In terms of
economic classification, R533.1 million (4.1%) of the budget is allocated to
current payments. Compensation of Employees amounts to R64.4 million while R468.7
million is allocated to Goods and Services, R148.4 million of which is for Inventory:
Medical Supplies and R200.0 million for Inventory: Medicine.
Table 5: Programme 4: Primary Health Care Services
The Primary
Health Care Services programme aims to develop and implement a uniform district
health system and to develop policy for district health services. The Non-
Communicable Diseases sub-programme receives R25.7 million in 2014/15
representing 27.5% of the programme’s budget allocation. This sub-programme,
amongst others, assists provinces in implementing and monitoring chronic
diseases, disability, elderly people, oral health, mental health and substance
abuse.
This Programme’s
budget decreased by 8.9% in nominal terms in 2014/15, this translates into a
decrease of 14.2% in real terms. This is despite the Department’s stated aim of
providing health services based on the primary health care approach.
In terms of
economic classification, R87.6 million (93.7%) of the budget is allocated to
current payments. Compensation of Employees amounts to R50.6 million while R37.0
million is allocated to Goods and Services.
The aim of the
Hospitals, Tertiary Health Services and Human Resources Development Programme
is to accelerate the delivery of health infrastructure. It also aims to
strengthen human resource capacity in the health sector. The budget for this
programme has increased by 6.8% (nominal) in 2014/15 compared to the previous
year, but with 0.6 % in real terms.
The Forensic
Chemistry Laboratories sub-programme allocation increases by 55.8% in nominal
terms in the 2014/15 financial year, and in real terms by 46.7% from R78.9
million to R122.9 million.
The Hospital
Management sub-programme allocation declined in both nominal (1.8%) and real
terms (7.6%) in 2014/15. Similarly in 2014/15, the Nursing sub-programme
allocation also declined in both nominal (34.2%) and real terms (38.1%).
In terms of
economic classification, 0.01 % of the budget (R 185.9 million) is allocated to
current payments. Compensation of Employees amounts to R104.7 million while R81.2
million is allocated to Goods and Services, R46.9 million of which is for Consultants
and Professional Services: Business and Advisory Services.
Table 7: Programme 6: Health Regulation and Compliance Management
The Health
Regulation and Compliance Management programme aims to, amongst other things,
reduce the time taken for medicines to reach the market, establish the Office
of Health Standards Compliance and establish a National Public Health
Institute. The programme budget has increased by 13.3% in nominal terms from
R763.7 million in 2013/14 to R865.3 million in 2014/15.
Most of the
funds (68.5%) that is R592.5 million of this programme budget is allocated to
the Public Entities Management sub-programme. The Office for Health Standards
Compliance sub-programme increases by 87.4% nominally (or 76.5% in real terms) to
employ additional staff to establish itself and build its inspectorate
function.
In terms of
economic classification, 8.2 % of the budget (R271.2 million) is allocated to
current payments. Compensation of Employees amounts to R148.7 million while R122.4
million is allocated to Goods and Services, R43.6 million of which is for Consultants
and Professional Services: Business and Advisory Services.
7.
Committee
findings
Having
considered the strategic plan, the annual performance plan and the budget of
the Department, this section summarizes the Committee’s observations:
·
The Committee raised concerns about the accuracy
and quality of data used in the monitoring and evaluation of the department’s
targets. Apparent discrepancies in the data related to maternal mortality
ratios was used as an example.
·
The Committee noted that most of the indicators
had annual targets as opposed
to quarterly targets as required.
·
There is no indication in the strategic and
annual performance plans on how the Department will integrate its activities
with other departments with regards to tackling the social determinants of
health.
Recommendations
·
The National Department of Health should work
with Treasury in ensuring that provincial health facilities collect revenue
from medical aid patients and that they retain a portion of the revenue. Central
to this, is to develop a revenue recovery strategy with a clear monitoring
system and ensure that recovered funds are effectively utilized for the benefit
of communities.
·
The department should ensure that there are
regulations on running emergency medical services (EMS) and they should report
to the Committee on those regulations in six months’ time.
·
The Committee recommends that EMS response times
be improved, paramedics and ambulance assistants are properly trained and basic
qualifications be reviewed, without unduly interfering in the provision of
services.
·
The department should ensure that mechanisms are
in place for monitoring and evaluating lists submitted by provinces for
revitalization before approving and gazetting them.
·
The department should present to the Committee
strategies on mental health, particularly on issues like budget, access,
infrastructure, human resources and training of health personnel for mental
health.
·
The department should brief the Committee on
progress and challenges related to the National Health Insurance pilots. The department should also submit quarterly
reports to the Committee in order to monitor the spending patterns of the
piloting districts in provinces.
·
To cut costs related to laboratory services,
security, linen and catering, the department should ensure that all these
services are procured by the provincial departments of health in preparation
for NHI.
·
The department should also ensure that there are
more regulations and enforcement on food safety standards and ensure
interdepartmental collaborations with the Departments of Agriculture Forestry
and Fisheries, and Trade and Industry.
·
The department should work with the Department
of Science and Technology with regards to health technology.
·
The department should work with the Department
of Education in ensuring that children at a very young age are exposed to the
health sector and enhance the school health programme.
·
The department should develop norms and
standards regarding the provision of mobile clinics in rural areas and in
farming communities to ensure access to health services.
Unless
otherwise indicated, the National Department of Health should respond to the
recommendations in three months from the day the report is adopted by the
House.