ATC111021: Report Budgetary Review & Recommendation Report of Portfolio Committee on Health
The Budgetary Review and Recommendation Report of the Portfolio Committee on Health, dated 21 October 2011
The Portfolio Committee on Health having assessed the performance of the Department of Health for 2010/11, reports as follows:
Section 77 (3) of the Constitution of South Africa provides for an Act of Parliament which will provide for a procedure to amend the Money Bills before it. The Money Bills Amendment Procedure and Related Matters Act, 2009 (Act 9 of 2009) thus enables Parliament to amend aspects related to tabled Money Bills. The objectives of this Bill are twofold:
- To establish a procedure to amend Money Bills before Parliament within the context of oversight findings and the adoption of the fiscal framework; and
- To establish a Parliamentary Budget Office to provide research support to Parliament and its Committees pursuant to maintaining oversight of the budget process and the possible amendment to Money Bills.
1.1 The role of the Committee
Parliament conducts its constitutional obligations through the work of Committees. Committees of Parliament facilitate the passing of legislation, approve annual departmental budgets and conduct oversight of departments falling within their perimeters.
Section 5 (1) of the Money Bills Amendment Procedure and Related Matters Bill provides for the National Assembly (NA) through its committees to annually assess the performance of each national department, with reference to the following:
- Medium Term estimates of expenditure, its strategic priorities and measurable objectives;
- Prevailing strategic plans;
- Expenditure report relating to such department published by National Treasury in terms of Section 32 of the Public Finance Management Act;
- Financial statements and annual report of such departments;
- Reports of the Committee on Public Accounts relating to the department; and
- Any other information requested by or presented to a House or Parliament.
Section 5 (2) makes provision for the annual submission of the budgetary review and recommendations report (BRRR) for tabling in the National Assembly for each department. It is expected of the BRRR to report on the following:
- Assessment of the department’s service delivery performance given the available resources;
- Assessment on the effectiveness and efficiency of the department’s use and forward allocation of available resources; and
- May include recommendations on the forward use of resources.
In order to enable the Committee to take an informed decision on the performance of the Department of Health for the financial year 2010/11, the Committee consulted the following reports and/or documents:
- The State-of-the-Nation address
- Reports of the Auditor-General
- Report of the Financial and Fiscal Commission
- Fact-finding visit (or oversight)
- Report on the Millennium Development Goals (MDGs)
- Prior BRR Report
1.2 The Department
The Department of Health derives its mandate from the Constitution. Section 27(1)(a) of the Constitution states that “Everyone has the right to have access to health care services, including reproductive health care”. Section 27(3) further notes that “no one may be refused emergency medical treatment.” Section 28(1)(c) further gives every child the right to “basic nutrition, shelter, basic health care services and social services”. Finally, schedule 4 of the Constitution makes health care services both a national and provincial legislative competence and/or imperative.
In line with its constitutional obligations, the vision of the Department is ‘a long and healthy life for all South Africans’. Its mission is to improve health status through prevention of illness and disease and through the promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equity, efficiency, quality and sustainability.
2. Department’s Strategic Priorities and Measurable Objectives
2.1 Strategic Plan of the Department – Ten Point Plan
Health priorities have been set for different epochs in South Africa. The health sector’ s ’10 Point Plan for 2009-2014 has served as an important overarching and macro framework for overhauling the health system, to enhance its capacity to improve health outcomes, and to harness focused interventions towards the Millennium Development Goals (MDGs).
The priorities comprising the 10 Point Plan are as follows:
- Provision of strategic leadership and creation of social compact for better health outcomes;
- Implementation of the National Health Insurance (NHI);
- Improving the quality of health services;
- Overhauling the healthcare system and improving its management;
- Improved human resources planning development and management;
- Revitalisation of infrastructure;
- Accelerated implementation of HIV and AIDS strategic plan and the increased focus on TB and other Communicable Diseases;
- Mass mobilization for better health for the population;
- Review of the Drug Policy; and
- Strengthening Research and Development.
2.2 Measurable Objectives of the Department
The measurable objectives and outcomes of the Department are stated in accordance with its various programmes. They encapsulate what the Department intends to achieve in each programme in order to achieve its overall health care service delivery mandate:
Programme 1: Administration
The objective of this programme is to conduct overall management of the Department. Activities include policy-making by the offices of the Minister and Director-General, and the provision of centralized support services.
- To ensure effective financial management and accountability.
- To ensure that Information Communication Technology (ICT) supports the business objectives of the Department.
Programme 2: Strategic Health Programmes
The objective is to co-ordinate a range of strategic national health programmes by developing policies and systems, and manages and funds key health programmes
- Accelerate the provision of Cotrimoxazole prophylaxis to HIV exposed infants.
- Implement prevention of Mother to Child Transmission (PMTCT) treatment guidelines.
- Increase routine immunization coverage for children under 1 year of age.
- Conduct a national measles immunization campaign in all nine provinces.
- Improve management of communicable diseases.
- Initiate all eligible MDR and XDR patients on ARV’s.
- Implementation of school health services in health sub-districts.
- Finalise youth health strategy.
Programme 3: Health Planning and Monitoring
This programme plans and monitors health services and co-ordinates health research programmes.
- Prepare and submit South Africa’s report to the United Nations General Assembly Session (UNGASS) on HIV and AIDS.
- Conduct annual national antenatal HIV and syphilis prevalence survey.
- Conduct the South African Demographic Health Survey (SADHS).
- Commission national, provincial and district level estimates for burden of disease.
- Monitor and oversee the conduct of clinical trials and related activities.
- Establish Ministerial advisory Committee for quality.
- Conduct an audit of all health establishments to determine if they meet core standards.
- Implement a national adverse event reporting and response system.
- The establishment of the National Health Insurance (NHI) Fund.
- Review the essential medicines lists.
Programme 4: Human Resource Management and Development
The objective of the programme is to plan and co-oordinate human resources for the health sector.
- Co-ordinate the review of the national human resource for health (HRH) plan and ensure alignment with the 10 Point Plan.
- Increase an annual enrolment of Chief Executive Officers (CEOs) into hospital management training programme.
- Commission audit of public and private nursing colleges and schools in the country.
- Strengthen human resource capacity in district hospitals.
- Strengthen human resource capacity for the delivery of emergency care services.
- Finalise and implement Occupation Specific Dispensation (OSD) for therapeutic, diagnostic and allied health professionals.
- Manage disputes between organized labour and the employer in the PHSDSB.
Programme 5: Health Services
This programme supports the delivery of health services in provinces including primary healthcare, hospitals, emergency medical services and occupational health.
- Implement appropriately decentralized and accountable operational management model.
- Accelerate revitalization of health facilities.
- Determine infrastructure area and cost norms for health facilities based on approved national policies.
- Strengthen health infrastructure delivery capacity in provinces.
- Develop and implement disaster management policy.
- Implement hospital emergency preparedness plan.
- Provide strategic and technical support to emergency services.
- Develop a national technology management system.
- Implement health technology regulations.
- Improve the capacity of hospital board members through the development of a national training manual.
- Develop framework for the delegation of authorities to CEOs.
- Strengthen environmental and municipal heath services.
- Increase numbers of ex-mine workers who undergo benefit medical examination (BMEs)
Programme 6: International Relations, Health Trade and Health Product Regulation
This programme co-ordinates bilateral and multilateral International health relations including donor support, regulations of procurement of medicines and pharmaceutical supplies and regulation and oversight of trade in health products.
- Contribute towards post conflict reconstruction and development.
- Strengthening bilateral relations and SADC integration agenda.
- Contribute towards post conflict reconstruction and development.
- Strengthening multilateral relations (IBSA and SADC)
- Facilitate the implementation of the African Union (AU) campaign on accelerated reduction on maternal mortality in Africa (CARMMA) towards meeting the Millennium Development Goals (MDGs)
3. Analysis of the Department’s Prevailing Strategic and Operational Plan
Vote 15: Department of Health
The aim of the Department of Health is to promote the health of all people in South Africa through an accessible, caring and high quality health system based on the primary health care approach.
3.2 Policy Priorities for 2010/11
The Department identified 10 key strategic priorities for the five-year period 2009-2014. The 10 Point Plan consists of the following priorities:
· Provision of Strategic leadership and creation of a social compact.
· Implementation of National Health Insurance (NHI).
· Improving the Quality of Health Services.
· Overhauling the health care system and improving its management.
· Improving Human Resources Management, Planning and Development.
· Revitalisation of Infrastructure.
· Accelerated implementation of the HIV & AIDS and Sexually Transmitted Infection National. Strategic Plan (NSP) 2007-11 and increase focus on TB and other communicable diseases.
· Mass mobilisation for better health for the population.
· Review of the Drug Policy.
· Strengthening Research and Development.
In 2010, Government adopted a new outcome-based approach to attaining the objectives outlined in the MTSF 2009- 2014. In line with this the health department will focus on four key areas:
1) Increasing life expectancy.
2) Combating HIV and AIDS.
3) Decreasing the burden of diseases from Tuberculosis.
4) Improving Health Systems Effectiveness.
To address these four areas, the health sector must produce twenty deliverables over the next five years, as described in the Strategic Plan 2010/11- 2012/13:
· Increased Life Expectancy at birth
· Reduced Child Mortality
· Decreased Maternal Mortality Ratio
· Managing HIV Prevalence
· Reduced HIV Incidence
· Expanded access to the Prevention of Mother to Child Transmissions (PMTCT) Programme
· Improved TB Case Finding
· Improved TB outcomes
· Improved access to Antiretroviral Treatment for HIV-TB co-infected patients
· Decreased prevalence of Drug Resistant-TB
· Revitalisation of Primary Health Care
· Improved Patient Care and Satisfaction
· Accreditation of health facilities for quality
· Enhanced operational management of Health Facilities
· Improved access to Human Resources for Health
· Improved Health Care Financing
· Strengthened Health Information Systems (HIS)
· Improved health services for the Youth
· Expanded access to Home Based Care and Community Health Workers.
3.3 Performance and Service Delivery Information
This section briefly highlights performance and service delivery information on the department.
The Department had an under-expenditure of 2.6 per cent which amounts to more than R386 million. This was largely due to under expenditure in Programme 5: Health Services amounting to R344 million or 3.6 per cent of that sub-programme’s budget. The Department attributed this underspending on withheld Hospital Revitalisation Grant for some of the provinces (Western Cape’s Mitchell’s Plain Hospital and Mpumalanga’s Rob Ferreira Hospital in particular) due to delays with construction of approved projects, as well as cash flow problems. A roll-over was requested.
Whilst the National Department of Health addressed issues raised by the Auditor General in the 2007/08 report, the Department received a qualified audit for 2008/09 due to the following
1) Lack of a system to reconcile application forms from pharmaceutical companies to the fees received by the Medicines Control Council (MCC) (R29.7 million).
2) Lack of a system to enable the reconciliation of payments for the use of vehicles under the National Fleet Public Private Partnership (R23.2 million).
According to SCOPA this Department has had eight qualifications in the last nine years.
The Department commissioned and completed a 15-year review of the performance of the health sector. This report also identified key weaknesses in management and leadership across all level of the health system.
The completion of Annual Performance Plans (APPs) were affected by the withdrawal and re-issuing of allocation letters.
The Department experienced great challenges with regards to Information and Technology (ICT). Some of the key challenges were personnel shortages, network availability and dilapidated ICT infrastructure. In response to this, four senior positions were created and advertised to deal with ICT capacity.
The Department introduced a competency assessment system for short-listed senior management services (SMS) candidates to be assessed on.
Performance management agreements (PMAs) were one of the biggest challenges. Only 63 out of the 100 SMS members submitted PMAs. The Department implemented the Public Service Act and its regulations and ensured that SMS members who did not submit PMAs were not considered for both the annual package progression nor performance bonuses.
Programme 2: Strategic Health Programmes reported 88.8 per cent coverage for children under one year of age, up from 85.2 per cent in 2007/08. 44 out of the 52 districts implemented the Reach Every District (RED) strategy, exceeding the 2008/09 target of 30 of the 52 districts. 38 of the districts achieved full immunisation coverage of 80 per cent, not meeting the target of 40 out of 52 districts. Whilst no measles outbreak was reported for the reporting period, the Department identified the need to strengthen the immunisation of South African children against measles.
A total of 734 409 (target: 500 000) people living with HIV and AIDS were provided with nutritional supplements.
Only 50 per cent (target: 70per cent) of primary health care (PHC) facilities implemented youth friendly services.
The department reported a 29.5 per cent decrease in malaria cases from 8 743 in 2007/08 to 6 167 in 2008/09.
93 per cent of facilities provided voluntary (HIV) counselling and testing (VCT) services, however the uptake of VCT services remained a challenge.
95 percent of facilities offered Prevention of Mother- to- Child Transmission (PMCT) facilities compared to a target of 100 per cent. 781, 465 patients were initiated on Antiretroviral Therapy (ART) by the end of April 2009, compared to 483, 084 by the end of April 2008- an increase of 38.2 per cent.
The incidence of tuberculosis (TB) has increased from 739.6 per 100 000 population (2007) to 948 per 100 00, a rate of 1 in 105 people in South Africa. South Africa is therefore one of the 22 countries with the highest burden of TB disease contributing 80 per cent of the global TB burden. A TB cure rate of 64 per cent was achieved against a target of 65 per cent. The defaulter rate was improved from 9.1 per cent to 85 per cent in 2007 (In terms of WHO recommended cohort system for analysis of TB data, treatment data can only be measured a year later).
Only 283.4 million male condoms were distributed, against a target of 450 million. Delays in awarding tenders by National Treasury were forwarded as the reason for this. TB cure rates in three of the four TB crisis management districts were significantly lower than the target of 70 per cent.
The National Antenatal and Syphilis Survey for 2008 reflects stability in HIV prevalence amongst 15- 24 year old age- group, from 22.4 per cent in 2006 to 22.1 per cent in 2007 to 21.7 per cent in 2008. This may suggest that health messages are reaching young South Africans. However the same survey showed a National HIV prevalence rate of 29.3 per cent.
Average waiting period for a wheelchair in the Provinces was 8 weeks or longer, where the target is 6 weeks or less. Data collection for the Demographic and Health Survey (2008) did not commence as planned, due to resources constraints. Tender specifications were developed and a target to conduct the survey by October 2008 was set.
The Health Planning and Monitoring Programme produced national norms and standards for health facilities, and 27 facilities were assessed against these norms and standards and supported to produce Hospital improvement Plans. A National Infection Prevention and Control Manual was produced with support from the University of Kwa-Zulu Natal (UKZN). Technical work for the National Health Insurance (NHI) was completed by a Task Team located outside the Department, but including officials from the Department. The Department contributed to the development of the African Union (AU) Pharmaceutical Manufacturing Plan, with the view that South Africa being one of the locations where this would be run. A draft policy on African Traditional Medicine (ATM) was produced and workshops were held with Traditional Health Practitioner Organisations.
The Human Resources Programme saw 8 out of the 9 provinces produce Human Resources for Health (HRH) plans. South African Dental Technicians Council as well as the South African Nursing Council was inaugurated in 2008 as targeted. A total of 100 Clinical Associate Students were enrolled at University of Pretoria, University of Witwatersrand, and Walter Sisulu University, exceeding the target of 36. 140 Hospital Managers were enrolled for a Hospital Management Training Programme, exceeding the 2008/09 target of 122.
23 Emergency Care Technicians (ECT) students graduated from the North West EMS College. Only 3 of the target of 5 ECT programmes in provincial EMS colleges were implemented. The Community Health Worker (CHW) Policy was revised in collaboration with the Department of Social Development.
Proposals for the Occupation Specific Dispensation (OSD) for doctors, dentists and pharmacists were developed. However, delays were experienced in funding the OSD. A dispute was declared by the Trade Unions on the OSD for nurses, and an interdict was obtained by the Trade Unions to stop the implementation of OSD for nurses.
In the Special Programmes and Health Entities Management Programme, 47 out of the 52 districts produced District Health Plans (with the exception of districts in the Western Cape). Governance committees were established in 60 per cent of PHC facilities, up from 33 per cent in 2007/08. Hospital Boards were established in all 9 Provinces. PHC utilisation rate increased from 2.2 visits per capita per annum in 2007/08 to 2.4 visits in 2008/09. However the utilisation rate was still lower than the target of 2.7 visits per capita. Only 186/286 targeted hospitals out of a total of 381 hospitals, appointed information officers. A draft Disaster Management Policy was produced. The Department reported limited progress with regards the development of Health Technology Regulations, due to a lack of certainty about exact legislation to govern these regulations.
The Medicines and Related Substances Bill and Tobacco Products Control Amendment Bill were passed. The Medical Schemes Amendment Bill and the National Health Amendment Bill were tabled in Parliament. 100 per cent of public institutions were smoke free institutions.
South Africa signed bi-lateral agreements with Namibia, Cameroon and Burundi. Agreements on health matters with Guinea Bissau, Malawi, Sudan and Zambia were finalised and prepared for signature. A Memorandum of Understanding (MoU) was finalised between South Africa and China for Health Sector Cooperation in the area of Traditional Medicine. A surgical team from South Africa performed the first open heart surgical procedures at the new Namibian Cardiac Unit launched at the Windhoek Central Hospital.
The Department assisted the Congolese Ministry of Health with the establishment of the Congo Nursing Council. South Africa provided technical assistance during a WHO sponsored training programme for 13 developing countries on the inspections of clinical trial sites.
3.4 Budget analysis
Nominal Rand change
Real Rand change
Nominal % change
Real % change
2009/10 - 2010/11
2009/10 - 2010/11
Programme 1: Administration
1.69 per cent
-4.70 per cent
Programme 2: Strategic Health Programmes
25.96 per cent
18.05 per cent
Programme 3: Health Planning and Monitoring
2.65 per cent
-3.80 per cent
Programme 4: Health Human Resources Management and Development
5.45 per cent
-1.17 per cent
Programme 5: Health Services
14.30 per cent
7.13 per cent
Programme 6: International Relations, Health Trade and Health Product Regulation
15.85 per cent
8.58 per cent
16.68 per cent
9.36 per cent
The Department of Health receives a total budget of R21.5 billion for the 2010/11 financial year compared to the R18.4 billion received in 2009/10, which is 4.65 percent of the total national budget. This represents an increase of 16.68 per cent in nominal terms, which is an increase of 9.36 per cent in real terms. In terms of economic classification, 94.9 percent of the department’s budget goes to transfers and subsidies, while 4.9 per cent goes to current expenditure and 0.2 per cent goes to Payments for Capital Assets.
The department carries out its mandate through six programmes, namely, Administration, Strategic Health Programmes, Health Planning and Monitoring, Health Human Resources Management and Development, Health Services and International Relations, Health Trade, and Health Product Regulation. Three of the programmes, namely Health Services, Strategic Health Programmes, and International Relations, Health Trade and Health Product Regulation received increases in budget allocations, reflecting their importance as strategic priorities. As was the case in the 2009/10 financial year, the Health Services Programme remains the key priority for the Department, receiving 54 per cent of the department’s budget in 2010/11.
Government’s increased commitment to impacting HIV/AIDS is evident in the 25.9 per cent nominal increase in Strategic Health Programmes budget allocation. This translates to an 18.05 per cent increase in real terms, most of which is spent through the HIV and AIDS and STIs Sub-programme.
Departmental receipts for 2010/11 are projected at R31.4 million derived mainly from fees for the registration of medicines by the Medicines Control Council. This figure has decreased by 6.82 percent from the R33.7million received in 2009/10.
3.5 Programme Analysis
Programme 1: Administration
The purpose of the Administration Programme is overall management of the department and providing centralised support services. This Programme is allocated R264.8 million for 2010/11, which is 1.23 per cent of the department’s budget. This represents a 4.4 per cent nominal increase which is a 12.2 per cent decline in real terms, compared to 2009/10. Most of the budget is allocated to the Corporate Services Sub-programme, which receives R181 million or 68.35 per cent of this programme’s budget. This is down 2.65 per cent from the previous year’s budget allocation of R184.9 million.
The bulk of the allocation for this Programme is consumed as current expenditure (97.3 per cent), which includes Goods and Services, which amount to 55.1 per cent of the Programme budget, Compensation of Employees at 42.18 percent of the Programme budget and Lease Payments, which take up 17.78 per cent of the programme budget. In addition, 2.6 per cent of the allocation will be spent as capital expenditure on Machinery and Equipment.
Programme 2: Strategic Health Services
The Strategic Health Programme aims to coordinate, manage and fund strategic national health programmes, including developing policies, systems, norms and standards. The programme receives an increase of 26 per cent, which is the largest increase across programmes in the Health Department. This programme is the second largest programme of the Health budget and is allocated 34 per cent (R7.3 billion) of the department’s overall budget. Overall expenditure in this programme is dominated by transfers and subsidies (93.7 per cent). These include:
· Comprehensive HIV and AIDS grant to provinces and municipalities: R6.0 billion
· Forensic Pathology Services grant to provinces and municipalities: R557.0 million
· National Health Laboratory Services: R77.7 million
· MEDUNSA and University of Cape Town: R1 million
· Council for the Blind: R600 000
· HIV and AIDS: NGOs 65.1 million
· Lifeline: R12.2 million
· LoveLife: R77.4 million
· Soul city: R17 million
· South African AIDS Vaccine Initiative: R11.7 million
· Tuberculosis NGOs: R3.9 million
· Maternal, Child and Women’s Health NGO: 1.1 million
The HIV and AIDS and Sexually Transmitted Infections (STIs) sub-programme received R6.5 billion the largest percentage (89 per cent) of the programme allocation. This represents an increase of 33 per cent compared to the 2009/10 allocation. The allocation to this programme, given the tough economic climate and the resulting fiscal pressure, demonstrates Government’s renewed commitment to reduce the impact of HIV and AIDS in South Africa, a country with one of the highest infection rates in the world. The increase is mainly for additional allocations for the HIV and AIDS conditional grant to expand treatment and to begin treatment for all HIV –infected infants, as well as patients with TB and pregnant women whose CD 4 count is below 350.
At first glance, it would seem that the 37.9 per cent nominal increase, which represents a 29.24 per cent real increase in funding for the TB Control and Management sub-programme, represents the recognition by Government of the importance of treating TB, given the 70 per cent co-infection rate amongst people living with HIV. However, most of the allocation to this sub-programme is to fund a national TB prevalence survey to be conducted in 2009/10 and 2010/11.
The allocation to the Communicable Diseases sub-programme has increased substantially by 74.77 percent in nominal terms. In 2009/10, the department indicated that the increase in this programme budget was due to the new health disaster response (cholera) grant, which has been introduced to contain the cholera outbreak in Limpopo. However, in the 2010 Estimates of National Expenditure, the department has indicated that the huge increase was to address the H1N1 epidemic. The department should therefore explain this contradiction to Parliament. The Department will be rolling out a mass flu vaccine campaign in April 2010. It remains to be seen whether the roll-out will be sufficient to deal with the potential outbreak given that the 2010 FIFA World Cup will be taking place during the flu season.
The Maternal, Child and Women’s Health and Nutrition sub-programme receives R57.3 million, representing a 23 per cent nominal increase and a 15.49 per cent real increase. This is to implement the Mass Immunisation against Measles Campaign from 2009/10 to 2011/12. This is a timeous (some would argue it is perhaps just too late) programme, given the deaths of at least 8 babies from measles early in 2010, and the resultant establishment of special isolation wards, especially in the Western Cape and Gauteng. This outbreak of measles also highlights the importance of providing adequate health care to refugees and migrant workers in South Africa. Given that maternal mortality rates in South Africa have deteriorated and that the Department has prioritised this as a key deliverable, the adequacy of the budget for this sub-programme might be questioned, given that the budget allocation falls to R50 million (2011/12) and R31 million (2012/13) over the MTEF.
The Non-Communicable Diseases sub-programme increased in real terms from R636 million in 2009/10 to R665.4 million in 2010/11. This represents a nominal increase of 4.59 per cent and a decline of 1.98 per cent in real terms. The major part of this programme is the Forensic Pathology Services Grant, which received an allocation of R557 million in 2010/11.
Programme 3: Health Planning and Monitoring
The aim of Health Planning and Monitoring Programme is to plan and monitor health services and coordinate health research programmes. The Programme is divided into four sub-programmes and its allocation increased from R396.4 million in 2009/10 to R406.9 million in 2010/11. This represents a 2.6 per cent nominal increase, in which is a real decrease of 3.8 per cent. 68.27 per cent of the programme budget goes to transfer payments, while 31 per cent goes to current expenditure.
The Health Information Research and Evaluation Sub-programme, which receives 74.71 per cent of the programme allocation aims to maintain health information systems, conduct research and training on disease surveillance and outbreaks and monitors and evaluates health programmes. The allocation for this sub-programme increased from R278.1 million (2009/10) to R304 million (2010/11), which represents a real increase of only 2.45 per cent. Funding for the Medical Research Council is channelled through this sub-programme (R270 million).
The Financial Planning and Health Economics Sub-programme is responsible for conducting health economic research, developing policy for medical schemes, social health insurance and public private partnerships. It also oversees funds for the Council for Medical Schemes. The budget allocation for this sub-programme decreased by 41.67 per cent in nominal terms (45 per cent in real terms) from R62.4 million in 2009/10 to R36.4 million in 2010/11. This decrease in budget is because the 2009/10 budget contained R30 million which was used by provinces in preparation for the 2010 FIFA World Cup, mainly to procure medical equipment for stadiums and Emergency Medical Services. Whilst one would assume that this particular sub-programme would receive increased funds in preparation for the proposed National Health Insurance (NHI) it receives less funds going forward (R36.4 million in 2010/11, R 24.4 million in 2011/12, and R25.3 million in 2012/13).
The Pharmaceutical Policy and Planning Sub-programme aims to monitor the procurement and supply of drugs, and ensure that there are no stock-outs of all essential drugs, especially paediatrics, TB and antiretroviral (ARV) medicines in accredited sites. This sub-programme received a nominal increase of 4.3 per cent, which represents a real decrease of 2.51 per cent. The real decrease in this sub-programme might have serious implications when viewed against the backdrop of stock-outs of ARVs in the Free State Province during 2009.
The Office of Standards Compliance Sub-programme aims to deal with quality assurance, licensing and the certificates of need required in terms of the National Health Act, No. 61 of 2003. It also deals with radiation control. This sub-programme receives 12.56 per cent of the programme budget, which will be used to inspect hospitals countrywide. Funding for this sub-programme will increase at an average annual rate of 22.7 per cent over the medium term to build up all aspects of the functioning of the Office of Standards Compliance. Increasing from R41.1 million (2009/10) to R51.0 million (2010/11) the sub-programme experienced nominal increase of 24.09 per cent, which is 16.3 per cent in real terms. Over the MTEF, the sub-programme aims to increase the number of hospitals audited.
Programme 4: Human Resource Management and Development
The Human Resources Management and Development Programme aims to plan and coordinate human resources for the Department of Health. This Programme receives R1.9 billion in 2010/11, 98.3 per cent of which will be spent through transfers and subsidies.
The Human Resources Policy, Research and Planning Sub-programme aims to plan for the medium to long term human resources needs in the national health system, and received an allocation of R8.9 million in 2010/11. This is a 57.87 per cent decrease compared to the 2009/10 allocation of R19.8 million. In the 2009/10 financial year, the sub-programme received a large increase in expenditure in order to conduct an audit of nursing colleges to inform the recapitalisation process for proposals on the upgrading of colleges, equipment and teaching facilities.
The Sector Labour Relations and Planning Sub-programme aims to provide the resources and expertise for bargaining in the national Public Health and Social Development Sectoral Bargaining Council. It is allocated R3.5 million, 41.6 per cent less than its 2009/10 allocation of R6.0 million.
By far the highest share of the Programme budget goes to the Human Resources Development and Management Sub-programme, which receives R1.9 billion, which is 99.35 percent of the programme budget. This sub-programme is responsible for developing human resource policies, norms and standards, and for the efficient management of employees of the national Department of Health. It funds the Health Professions Training and Development Conditional Grant, which is transferred to provinces, to the amount of R1. 86 billion and represents 98.32 percent of the programme budget.
Programme 5: Health Services
The Health Services programme aims to support health services in provinces including hospitals, emergency medical services and occupational health. This programme receives the largest share (53.6 per cent) of the national Department of Health budget. Its objectives include.
· Strengthening primary health care through an audit of primary health care services and facilities in all provinces by December 2010.
· Expanding access to health infrastructure by developing a plan to add 18 hospitals to the hospital revitalisation project, to be delivered through public private partnerships.
· Improve the delivery of health services in the 18 priority districts through a detailed set of interventions in maternal and child health and other areas by March 2012.
By far the largest portion of this programme’s budget (99.24 per cent) goes to the Hospitals and Health Facilities Management Sub-Programme. This Sub-programme is responsible for national policy on hospitals and emergency medical services (EMS). It is also responsible for funding the Hospital Revitalisation Grant, which takes up R4 billion or 35.3 per cent of the total transfer and subsidy budget within this programme, as well as the Tertiary Services Grant which takes up R7.4 billion or 64.96 per cent of the programme’s transfer budget. Over the MTEF, these grants will take up a total of 99 per cent of the programme budget as transfers to provinces. In addition, the budget allocation increased from R10.0 billion to R11.4 billion, which is an increase of 14.34 per cent in nominal terms and 7.16 per cent in real terms.
Over the MTEF period, the department will continue to develop a comprehensive national infrastructure plan. One of the key aspects of this plan is to collect information on the remaining facilities that are not part of the hospital revitalisation and infrastructure grants that need major upgrades and minor repairs. Another key aspect is that the health facilities maintenance budget per health facility will be monitored in each province and a strategy will be developed to progressively increase the maintenance target to 3- 5 per cent of capital value by March 2011.
The aim of the District Health Services Sub-programme is to promote and coordinate the district health system, monitor primary healthcare and activities related to the Integrated Sustainable Rural Development Programme and the Urban Renewal Programme, as well as deal with policy and monitoring for health promotion and environmental health. This sub-programme received an increase of R4.4 million to total R34.7 million in 2010/11, which is a real increase of 7.33 per cent from the 2009/10 allocation.
The Environmental Health Promotion and Nutrition Sub-programme aims to provide technical support and monitor the delivery of municipal health services by local government, provide port health services and support poison information centres. This Sub-programme received a 6.32 per cent nominal increase (a real decrease of -0.36 percent) from R19 million in 2009/10 to R20.2 million in 2010/11. The sufficiency of this amount is debatable, given the extra burden the 2010 FIFA World Cup poses with the thousands of tourists expected to enter the country’s ports.
Programme 6: International Relations, Health Trade and Health Product Regulation Programme
The International Relations, Health Trade and Health Product Regulations Programme aims to coordinate bilateral and multilateral international health relations, including donor support, regulate procurement of medicines and pharmaceutical supplies, and regulation and oversight of trade in health products. . The budget allocation for this programme increased from R90.2 million in 2009/10 to R104.5 million in 2010/11, which is a real increase of 8.5 per cent.
The purpose of Multilateral Relations sub-programme is to:
· Develop and implement bilateral and multilateral agreements to strengthen the health system.
· Conclude agreements on the recruitment of health workers from other countries.
· Provide technical capacity to South Africa in fields such as health technology management and surveillance systems.
· Mobilise international resources for priority health programmes.
The major portion of this Sub-programme’s budget goes to paying membership fees to international agencies such as the World Health Organisation (WHO) and for activities of health attachés. This sub-programme received a 12.42 per cent nominal increase from R45.1 million in 2009/10 to R50.7 million in 2010/11. South Africa’s multilateral and bilateral cooperation on health matters were strengthened in 2009/10 and should continue to strengthen in 2010/11.
The Food Control and Non-medical Health Product Regulation Sub-programme aims to ensure food safety by developing and implementing food control policies, norms and standards, and regulations. . Its budget allocation increased from R6.5 million in 2009/10 to R 7.2 million in 2010/11, which represents a nominal increase of 10.77 per cent and a real increase of 3.81 per cent.
The aim of the Pharmaceutical and Related Product Regulation and Management Sub-programme is to regulate the trade in medicines and pharmaceutical products through the Medicines Control Council (MCC). Expenditure on this Sub-programme is expected to grow by an average of 10.2 per cent over the MTEF to support the new Medicines Regulatory Agency, develop Information Technology (IT) systems and reduce backlogs. In 2010/11 the department aims to:
· Improve patient safety through a pharmaco-vigilance plan for monitoring extreme resistant drug tuberculosis (XDR-TB) medicines.
· Improve the regulation of medicines and health products through a functional electronic document management system.
· Improve medicine registration timelines from 36 months for new chemical entities and 24 months for generics to 24 to 18 months
· Develop legislation in 2010/11 to establish the functioning of the South African Health Products Regulatory Authority.
This sub-programme increased by R7.9 million from the 2009/10 allocation to receive R46.6 million in 2010/11, a 20.4 per cent nominal increase and a 12.8 percent real increase from 2009/10.
4. Analysis of Section 32 Expenditure Report
In 2010/11, the Department was allocated R21.6 billion which included the adjustment of R164.05 million made by the Department during the period under review. Of this amount, the Department spent R20.9 billion at the end of March 2011. This amounted to an under-expenditure of R742.9 million. This was mainly due to notable under-expenditure in Programme 2 and Programme 5 which amount to R645 million accounting for approximately 86% of the total under-expenditure.
Programme 1: Administration
The administration programme was allocated a total budget of R264.8 million, adjusted to R282.1 million. At the end of the reporting period, the Administration programme had spent R260.0 million, under-spending its budget by 7.75%. This was attributed to no funds being spent on Service Sector Education and Training Authority.
Programme 2: Strategic Health Programmes
The Strategic Health Programme received R7.29 billion which subsequently increased by R106 million to R7.4 billion during the adjustment period. By the end of the financia year 97.7% (R7.232 million) of budget allocation had been spent. The 2.3% under-expenditure was mainly due to funds not being transferred to Love Life non-governmental organization (NGO) and other NGO’s due to non-compliance with the Public Finance Management Act (PFMA) (No.1 of 1999) regulations.
Programme 3: Health Planning and Monitoring
Programme 3 was allocated a total budget of R406.9 million in 2010/11 financial year before the adjustment period. During the adjustment period, an amount of R7.7 million was added to its budget, totaling R414.6 million. At the end of the reporting period, the Health Planning and Monitoring Programme had spent 94.38% of its budget. The reasons given for the under spending were the late commencement of the project for the audit of health facilities in all provinces due to a new approach of a comprehensive, integrated approach from a central point, as well as delays in filling of critical posts.
Programme 4: Human Resource Management and Development
The budget for this programme totaled R1. 897 billion, being adjusted by an additional R500 000. The programme’s actual expenditure totaled R1. 883 billion (99.25%), recording an under-expenditure of R14.6 million or 0.75%. The under-expenditure is related to commitments made in March which will be paid in April for the next financial year, as well as delays in the recruitment process for critical posts.
Programme 5: Health Services
The main appropriation of the Health Services Programme (R11. 528 billion) was adjusted with an additional R28.3 million, giving an available budget totaling R11.557 billion. R11. 072 billion (95.81%) of this amount was spent by the end of the financial year, translating into a 4.19%(R485 million) under-expenditure. The under-expenditure was mainly due to hospital revitalization conditional grants being withheld for certain provinces (the Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo and Northern Cape) due to delays on projects.
Programme 6: International Relations, Health Trade and Health Product Regulation
During the period under review, the budget for the Programme (R104.5 million) was increased by R4 million in the adjustment process. At the end of the financial year, the programme had spent 72.23% (R78. 378 million) of its R108.5 million budget. The 27.77% under-expenditure was mainly related to Goods and Services items and outstanding accounts to be claimed from the Department of International Relations and Co-operation.
5. Analysis of the Annual Report and Financial Statements of the Department
5.1.1. Department's Key Strategic Objectives
The strategic framework used to guide the department is the 10 Point Plan for 2009-14, and the Negotiated Service Delivery Agreement (NSDA) 2010- 2014, which was signed in October 2010. The Department is responsible for Outcome 2: “A long and healthy life for all South Africans.” Four outputs have been identified to achieve Outcome 2, viz.:
1. Increasing life expectancy.
2. Decreasing maternal and child mortality rates.
3. Combating HIV and AIDS and TB.
4. Strengthening health systems effectiveness.
These outputs are broadly in line with the health-related United Nations (UN) Millennium Development Goals (MDGs) 4, 5 and 6 which seek to reduce child and maternal mortality and reduce the spread of HIV and AIDS and TB.
5.2. Programme Performance by Budget Programme
Under-spending of Budget
The Department spent R20.9 billion of the adjusted appropriation budget of R 21.6 billion, recording a 3.4% under expenditure of R 742 million. This represents an increase of approximately 62% from the previous year’s under expenditure of R457 million or 2.5%.
Under expenditure occurred in several programmes. Two programmes account for R645 million of the under expenditure. The most significant in terms of actual variance was R484 million (up from R402 million or 4% in the previous financial year), which was under-spent in Programme 5: Health Services due to the withholding of Hospital Revitalisation Conditional Grant funds for some provinces. This amount is 4.2% below the allocated funds of R11, 557 billion. The reasons forwarded for the under spending were delays in construction and poor monitoring of projects, as well as delays in commencing the national facilities audit.
The second amount is R160 million (2.2%) which was underspent in the Strategic Health Programmes. The reasons given for the under spending were the delayed finalisation of the condom tender by National Treasury, delayed transfers to certain NGOs due to non-compliance with the Public Finance Management Act, as well as late commitment for capital expenditure for Forensic Chemistry Laboratories equipment.
Three of the six programmes recorded under spending of more than 7%, namely Programme 1: Administration (7.8%), Programme 3: Health Planning and Monitoring (7.4%) and Programme 6: International Relations, Health Trade and Health Product Regulation (27.8%).
The Department of Health consists of six main programmes that include various sub-programmes. These programmes will now be reviewed.
5.2.1 Programme 1: Administration
The Administration programme aims to conduct overall management of the department. The programme had an under expenditure of 7.8% (R21.8 million) of its budget of R282.1 million.
The Administration programme consists of the following sub-programmes:
· Strategic Planning.
· Financial Services and Deputy Chief Financial Officer (CFO).
· Legal Services.
· Human Resource Management.
· Information and Communication Technology (ICT) Services.
· Gender Focal Point.
The Strategic Planning sub-programme achieved its target, amongst others, of producing an Annual National Health Plan (ANHP), supporting all 9 provinces with the development of their respective Annual Performance Plans (APPs). However, the goal of producing 9 provincial and 1 national Service Transformation Plans (STPs) for 2010- 2020, was not achieved (2 provincial and 1 national STPs are outstanding). The production of STPs is important for the delivery of effective healthcare services over the long term, and for shaping short- and medium- term plans. Also, 3 of the 18 District Health Plans (DHPs) were not reviewed as these were submitted late to the Department.
Whilst the Department in 2009/10 received an unqualified audit opinion from the Auditor-General for the first time in seven years, it was unable to repeat the achievement this year. Two of the 9 provinces (KwaZulu-Natal and the Western Cape) were in the process of implementing their own financial improvement plans. Only 2 provinces (North West and Western Cape) achieved unqualified audit opinions. The Auditor-General reports that 3 provinces improved their audit outcomes, 5 were unchanged and 2, including the national department, regressed.
Legal Services reports a comprehensive review of health legislation as the reason for the Health Laws Amendment Bill not being drafted.
The Communication policy and five-year communication strategy has not been published to date. The reason given was that these had to be aligned to the government policy produced by Government Communication and Information Services (GCIS).
The ICT Services of the department reports 30% downtime in July and August 2010 in network availability and 40% downtime in accessing transversal systems, due to the relocation of data lines to the Civitas Building and the reconfiguration of systems.
The Human Resources Management reports that the revised organisational structure was approved by the Minister and submitted to the Department of Public Service and Administration (DPSA).
The Gender Focal Point sub-programme did not produce the 4 quarterly gender audit reports, nor the 9 provincial gender audit reports it aimed to achieve. However, interviews with senior management and focus groups with officials were conducted.
5.2.2 Programme 2: Strategic Health Programmes
The Strategic Health Programmes co-ordinates a range of strategic national health programmes by developing policies and systems, and by managing and funding key health programmes. These sub-programmes relate directly to the health MDGs 4, 5, and 6 which address child and maternal mortality and HIV and AIDS and Tuberculosis. Programme 2 consists of the following sub-programmes:
- Maternal, Child and Women’s Health and Nutrition.
- HIV and AIDS and STI Management.
- TB Control and Management.
- Communicable Disease Control.
- Non-Communicable Diseases.
The programme achieved a 97.8% expenditure of its budget of R7,393 billion, with 2.2% under-expenditure. This under-expenditure, which amounts to approximately R160 million, was largely attributed to the delayed finalisation of the condom tender by National Treasury, delayed transfers to some NGOs due to non-compliance with the PFMA and departmental priorities, as well as late commitment of capital expenditure for Forensic Chemical Laboratories equipment.
Some of the significant achievements with regards to the maternal and child health programmes, which relate to the child and maternal MDGs, include:
· 69.1% from a set target of 60% of HIV-exposed infants were initiated on Cotrimoxazole prophylaxis therapy (CPT) from 6 weeks. CPT is important to reduce opportunistic infections.
· More than 72.8% of children were immunised, an increase of 12.8% from the set target of 60%.
· Measles immunisation campaigns were conducted in all 9 provinces.
· 72% (target 60%) of primary health care facilities provided basic antenatal care (BANC).
· 79.4% (target 70%) of pregnant women who are HIV positive were initiated on Highly Active Antiretroviral Treatment (HAART).
However challenges were experienced in a number of areas, including:
- 29.9% (target 40%) of newborn babies and 27% (target 40%) of mothers were reviewed within 6 days post natal.
- Only 81% (target 100%) of maternal facilities conducted peri-natal review meetings.
- 96.9 % (target 100%) of pregnant women were tested for HIV.
- Data on the actual proportion of primary level care facilities with health care providers trained in EmOC (emergency obstetric care) and CEmOC (Comprehensive emergency obstetric care) were not available, though an audit had commenced and will be completed in 2011/12.
The sub-programme: HIV and STI management encompasses government’s response to the HIV and AIDS pandemic, and addresses its efforts to achieving MDG 6. As noted above, significant changes to the government’s HIV and AIDS policy, announced in the President’s National AIDS Day speech on the 1st of December 2009, were implemented as from the 1st of April 2010. The HIV Counselling and Testing (HCT) aimed to increase the number of people testing for TB, diabetes hypertension and HIV and AIDS. At the end of the financial year, 11.4 million people had been counselled with 9.7 million agreed to be tested. Other significant achievements include:
· 42 756 community care givers (target 36 106) received stipends- all programmes which have community based projects and were funded from the Expanded Public Works Programme (EPWP) and conditional grants were included.
· 99 % of TB/HIV co-infected patients were provided with Cotrimoxazole prophylaxis therapy (CPT).
However, despite some improvements compared to the previous financial year, a number of targets were not achieved:
- 381 612 (target 400 000) new adults were initiated on anti-retroviral treatment (ART).
- 37 065 (target 40 000) new children initiated on ART. The strike during July and August 2010 were cited as having affected service delivery in both cases.
- 1 603 (target 2000) peer educators were trained.
- 54% (target 60%) of TB/HIV co-infected patients eligible for ART were initiated on treatment.
- 67% of TB patients tested for HIV (target 90%).
- 492 million male condoms (target 1 billion) were distributed.
- 4.9 million female condoms (target 6 million) were distributed. Whilst the numbers of both male and female condoms distributed represent an increase compared to the previous financial year, they fall short of the new targets set by the HCT campaign.
The FIFA 2010 Strategic Plan for Communicable Disease Control was implemented and achieved. Malaria incidence reduced to 0.66 per 1000 population local incidence, but was 1.65 per 1000 population when so-called “imported” cases were included. 90% coverage of indoor residual structure spraying (target 80%) was one of the key interventions against malaria.
Non-communicable diseases, including hypertension, diabetes and obesity are part of the quadruple burden of diseases that confronts South Africa. However, many of the targets were not achieved:
- A study to establish the baseline of persons with controlled diabetes was not undertaken.
- 7 out of the 9 provinces report not reaching the 40% target of primary schools in health priority districts implementing preventative school oral health service programmes due to the FIFA World Cup and public sector strikes.
- Turn-around times for blood alcohol, toxicology and food specimens are still significantly below the set targets set.
TB control and management recorded a limited number of successes:
- 71.1% (target 70%) TB cure rate, increasing from 63.4% in 2009.
- 19 (target 15) drug resistant (DR) TB facilities diagnosing and putting DRTB patients on appropriate treatment regimens.
- 11 379 professionals (target 3 500) and 7 128 non-professional workers (target 2 500) were trained in TB management control.
The following targets were not achieved:
- 401 048 (target 405 512) new cases of TB were reported.
- 74% (target 80%) of patients successfully completing their treatment. This does not appear to tally with the 71.1% cure rate reported above.
- TB default rate 7.9% (target 7%).
- 48 (target 80) treated TB patients serving as ambassadors for TB.
- 69% (target 100%) of HIV positive multi-drug resistant (MDR) patients and 84% (target 100%) of HIV positive extreme drug resistant (XDR) patients were started on ARVs.
5.2.3 Programme 3: Health Planning and Monitoring
The Health Planning and Monitoring Programme supports the delivery of health services primarily in the provincial and local spheres. It consists of the following four sub-programmes:
· Health Information, Epidemiology, Research and Evaluation.
· Office of Standard Compliance.
· Health Financial Planning and Economics.
· Pharmaceutical Policy and Planning.
This programme spent R391 million (92.6%) of its total budget of R422 million, with an under-expenditure of R31 million or 7.4%. The under expenditure was related to vacancies due to recruitment processes which could not be completed before the end of the financial year.
Health Information, research and evaluation experienced a number of challenges:
- The final Annual National HIV prevalence estimates and trends report was not published by March 2011.
- The South African Demographic Health Survey (SADHS) was not conducted since 2008, due to budgetary constraints.
- Cancer registry is still not operational.
- Disease control hub not established.
- Burden of Disease study not conducted.
- 75 (target 86) telemedicine sites functional.
The Office of Standards Compliance was not established and therefore failed to meet a number of its targets. These include:
- Ministerial Advisory Committee on quality was not established.
- External audits of health facilities were not conducted
- Accreditations of health facilities were not conducted.
- No national adverse event reporting system was in place.
- A national survey to establish baseline and targets was not commissioned.
- National ombudsman office was not established.
- No assessment of hospitals conducting at least 1 satisfaction survey per year was conducted.
However, the Department did report that 60% (target 40%) of complaints were resolved within 25 days.
The Health Financial Planning and Economics sub-programme reported successes include:
- The tabling of the NHI draft policy at Cabinet level.
- Business plan developed to implement a turnaround strategy for improving the management of tertiary services.
- Draft revenue policy was produced and shared with provinces for input.
The Pharmaceutical Policy and Planning sub-programme reported that stock-outs of ARVs was at 2.6% on average, which was an improvement on the <5% threshold targeted. However, the stock-outs for TB medication averaged 5% (target <5%), with the Northern Cape reporting 8.6% stock-outs.
5.2.4 Programme 4: Human Resource Management and Development
The Human Resources Management and Development programme plans and co-ordinates human resources for the health sector. The programme consists of the following sub-programmes:
· Human Resources (HR) Policy Research & Planning.
· Human Resource Development and Management.
· Sector Labour Relations and Planning.
The following challenges were experienced during the period under review:
- 143/400 (target 150/400) hospital managers were enrolled for a hospital management training programme.
- A feasibility study for the management and leadership academy for health managers was not conducted.
- 3 out of 4 (target 4/4) collective agreements reviews were commenced.
The Department reports a number of successes in this programme, including:
- A business plan for the revitalisation of public sector nursing colleges was developed.
- 183 (target 125) clinical associates enrolled within the degree programme, thereby strengthening the human resource capacity in district hospitals.
- 6 additional colleges (target 5) are offering the emergency care technician (ECT) programme.
- The Occupational Specific Dispensation (OSD) agreement for diagnostic, therapeutic and related allied health professionals was signed.
5.2.5 Programme 5: Health Services
The purpose of the Health Services programme is to support the delivery of health services in provinces including primary healthcare, hospitals, emergency medical services and occupational health. The programme consists of the following sub-programmes:
- District Health Services.
- Hospital Services and Health Facilities Management.
- Environmental Health, Health Promotion and Nutrition.
- Occupational Health Services.
District Health Services recorded a limited number of successes which were concentrated in the area of implementing appropriately decentralised and accountable operational management model. In particular, these successes were:
· Revised the Primary Health Care (PHC) package.
· Developed the PHC multi-disciplinary team outreach strategy.
· Developed the PHC service delivery model.
However, a number of challenges were experienced in this sub-programme:
· PHC audit was not conducted.
· PHC utilisation: 2.4 (target 2.6) visits per person per capita to a PHC facility. This is also below the 2.5 visits achieved in the previous year.
· 40 (target 52) districts with a full complement of District Management Teams.
· 46 (target 52) districts with district health plans (DHPs) received from provinces. This was due to one province (Western Cape) not submitting DHPs for verification.
· 32 (target 52) district health councils (DHCs) were established and are functioning. Mpumalanga, KwaZulu- Natal and Western Cape reported that no DHCs were established.
· 68.4% (target 80%) of PHC facilities were visited by a supervisor once a month. Some districts lack PHC supervisors and/or vehicles.
In terms of the Hospital Services sub-programme, a number of targets were not achieved:
· A number of delays were experienced with the revitalisation of hospitals.
· Plans on preventative maintenance were not implemented and “all provinces are far away from the set target”.
· None of the provinces (target 3) implemented disaster management plans.
· None of the provinces (target 4) implemented a standardised data management system, due to the FIFA 2010 World Cup.
· Only 1 out of 9 provinces’ health technology acquisition systems was analysed due to a lack of asset management systems as well as insufficient data provided by hospitals.
· 55.5% (target 80%) of hospital boards have been trained. The appointment of some of the hospital boards was delayed and, therefore, training was postponed.
· 67% (target 100%) of hospital CEOs have signed delegations of authority – some provinces, such as Mpumalanga, Northern Cape and Eastern Cape have withdrawn their delegations to hospital managers.
5.2.6 Programme 6: International Relations, Health Trade & Health Product Regulation
This programme co-ordinates bilateral and multilateral international health relation, including donor support and provide oversight over health trade and the development of health products. This programme consists of the following sub-programmes:
- Multilateral Relations.
- Pharmaceutical and Related Product Regulation and Management (MRA).
- Food Control and Non-Medical Health Product Regulation.
The Department achieved most of its targets in the Multilateral Relations sub-programme including:
· 80 (target 80) South African students recruited and retained in the SA-Cuba programme.
· 6 (target 2) cross border initiatives facilitated to manage communicable disease along border areas.
· 6 (target 6) initiatives were facilitated to strengthen health systems South African Development Community? (SADC)
· Signed and implemented 7 (target 7) agreements to mobilise financial and technical resources for the implementation of the 10 Point Plan.
The Department was unable to achieve any of the targets it set for the Pharmaceutical and Related Product Regulation and Management sub-programme:
· Average time for registration of new chemical entities (NCE) was 32 months (target 24 months) and 30 months (target 12 months) for generics.
Electronic document management system (EDMS) could not be implemented due to the move to the Civitas building.
4. Human Resources
During the period under review, the Department had a total of 1 277 posts filled out of the 1 912 posts available on its staff establishment and 95 posts filled, were additional to the establishment. This translates to an average vacancy rate of 33.2% by the end of the financial year. The highest vacancy rates were experienced in the Contracts (levels 3-5) Permanent which had a vacancy rate of 68.5%. This was followed by highly skilled supervision at 37.9% and highly skilled production at 32.1%. It is noted that from Contract (levels 6-8), Contract (levels 9- 12) and Contract (levels 13 -16) reported only 1 vacancy at (Contract level 9-12). The Department is experiencing its highest turnover rate in the Contract (levels 1 -2) 93.75 %, Contract (levels3 -4) 50%, and Contract (levels 6-8) 36.36%.
6. Consideration of Reports of Committee on Public Accounts
The Department did not appear before the Committee on Public Accounts for the period under review.
7. Consideration of other Sources
7.1 The State of the Nation Address
The health sector was specifically highlighted in the 2011 State of the Nation Address as one of the four main priority areas of government. In line with the President’s directive that all government departments should align their programmes with the job creation initiative and to ensure improved access to Human Resources for Health, one of the most important focus areas for the Department of Health will be the appointment of appropriate and qualified personnel to the right positions.
The State of the Nation Address further emphasized the training of doctors and nurses, as well as the revitalization of 105 nursing colleges and refurbishment and renovations of hospitals and clinics. This is important in order to achieve the Department’s priority of improving patient care and satisfaction and improve the quality of health facilities.
7.2 Report of the Auditor-General of South Africa
The Auditor-General having considered different sources of information on the Health Sector made the following findings:
Findings from audit of human resource management
- Lack of proper application of human resource management procedures which resulted in staff without the required skills being employed.
- Staff not held accountable for poor performance.
- Slow rate of filling of vacancies.
- Lack of or inadequate policies and procedures within the department and its entities.
- Indicators and targets contained in the planning documents not always forming the basis of the performance agreements of senior managers and their subordinates. In some cases senior management have not signed performance agreements at all.
- Poor key control monitoring by leadership.
Findings on supply chain management/procurement
- The tender process was not fair which sometimes resulted in the Department awarding a tender without getting quotations.
- Tenders were sometimes awarded to close friends.
- Tenders were sometimes awarded to persons in service of state and prohibited suppliers.
Findings on the audit of infrastructure
- The process of needs determination and planning was not effective which resulted to unused and underutilization of completed infrastructure.
- A robust procurement system was not consistently applied thus compromising the transparency, accountability and economy with which decisions/commitments were made.
- Project management was not effective resulting in projects that were not completed on time and at the required level of quality and cost.
- The needs determination, planning and prioritizing for infrastructure projects were not completed on time. The needs were identified up to 13 years prior to the acquisition of resources through tenders being awarded.
- The communication and coordination between the departments, management, local authorities and/or communities were ineffective to ensure comprehensive infrastructure delivery, as all the role players were not properly engaged during the planning of the projects.
- Service delivery was negatively affected as the projects were put on hold or were delayed due to scope changes.
- Project management was not effective to ensure that projects are completed on time and at the required level of quality.
- Projects were not always supervised and monitored and timely action was not taken against defaulting contractors and consultants.
- Penalties for unsatisfactory progress and the late completion of projects were not consistently enforced.
- Contractors were not always paid on time to enable them to progress as required.
- Timely, accurate and complete management information was not available in all projects to ensure accurate decision-making.
- The project manager did not always inspect the facilities at completion to ensure that all issues were rectified by the contractor before the final account was settled.
- Insufficient coordination and liaison between officials at the departments or the other implementing agents resulted in newly constructed hospitals and clinics or sections thereof, not being optimally used at the time of commissioning. The completion of times of the contractors, the appointment of staff and the availability of equipment and municipal services were not sufficiently synchronized. This led to facilities that were commissioned, but not used for as long as 12 months due to staff shortages and a lack of equipment.
- Employees and political office bearers employed by the institutions has a business or private interest on suppliers.
Findings on Financial Statements
- Seven out of nine provinces received a qualified audit opinion.
- Financial reporting systems limitations are not addressed.
- There is poor key control monitoring by leadership.
- The Department of Health is accountable for 25% of Government’s irregular expenditure.
7.2.1 Comments from the National Department of Health
The following remedial action has been put in place and is underway to address the challenges related to the management and planning for health infrastructure:
- An engineer has been appointed at the National Department of Health to oversee all aspects of infrastructure including the hospital revitalization grant. Furthermore, the National Health Council has approved that all provincial departments of Health should appoint resident engineers;
- Support to the provincial departments of Health by the National Department has been strengthened;
- An integrated approach is being implemented to address health technology and infrastructure as one programme to ensure efficiency and better planning;
- Improved planning is being implemented to ensure that funding is aligned to the milestones and phases of the infrastructure plans, including maintenance and efficient management of professional fees per project;
- Expenditure per project is being monitored on a monthly basis to address possible under expenditure in advance and intervene where applicable. This applies to the management of cash flow too, as well as avoiding late payments and interest charged;
- Consultation with provinces has improved through the newly established Provincial Progress Review Committee meetings chaired by the national Department of Health and
- As part of the strengthening capacity and monitoring of projects, Service Level Agreements will be signed with all provincial departments of Health and Public works with the intention to clearly define the role of the various service providers providing coordination functions.
- The National Department of Health intends developing standard and uniform designs of health facilities to reduce the professional fees in this area and to standardize the format of consultant appointments, with clear descriptions of scope of work and their roles in the professional teams.
7.3 Report of the Financial and Fiscal Commission (FFC)
- The Department received a qualified audit opinion for 2010/11 financial year and the basis for the opinion was
ü Movable tangible capital assets
The asset register used to account for assets was not properly maintained.
ü Matters of emphasis
Irregular expenditure to the amount of R43.3 million was incurred due to non-compliance with the supply chain management procedures.
ü Conditional Grants
The Transferring Officer did not adequately monitor expenditure and non-financial performance information as required by the DORA.
7.3.1 Provincial Health Expenditure outcomes
- KwaZulu-Natal and Free State provinces spent the lowest share of their health adjusted at 93.4% and 95.4% respectively. The highest expenditure shares were recorded by Gauteng Province at 100.5% and North West at 100.2%
- Average provincial health expenditure was at 38.9% as at 31 August 2011.
- Only the Eastern Cape spent above the National Treasury which is expenditure benchmark of 41.7% by August 2011.
7.3.2 Health Conditional Grants Expenditure Outcomes
· Provinces are struggling to spend on Forensic Pathology Services and Hospital Revitalisation grants.
· Only the Health Professions Training and Development Grant and National Treasury are spending at 41%.
· HIV and AIDS, infrastructure and Revitalisation Grants reported slow expenditure.
7.3.3 FFC Recommendations
· The government must develop norms and standards for the public hospital system.
· The government must develop norms and standards that should address issues in relation to the public health system.
7.4 Fact-finding visit
The following findings are drawn from most of the health institutions the Committee visited:
- Primary Health Care not functioning well.
- Human Resources shortages and the prolonged process to fill vacancies.
- The department did not have any recruitment and retention strategies.
- Equipment shortages and bad quality.
- Health institutions do not have maintenance budget.
- Poor ambulance services
- There are no asset registers in all visited institutions.
- No standardized infection control strategies.
- There is lack or poor security in all visited institutions.
- The quality of services have not improved in health institutions.
- Community service doctors were not supervised.
8. Report on Millennium Development Goals
The United Nations (UN) Millennium Development Goals (MDGs) are a series of eight time-bound goals with a target of 2015 that respond to the world’s main development challenges. The three goals relevant to the Department aim to: (4) reduce child mortality, (5) improve maternal health, and (6) combat HIV and AIDS, malaria and other diseases. The Department of Health plays a critical role in achieving these MDGs.
Goal 4: Reduce Child Mortality
The “Under-5 Mortality Rate” (U5MR) refers to the chance of a newborn baby dying before the age of five, and is represented out of every 1000 live births. In 2008, 69 out of every 1000 newborn babies died in South Africa. The Medical Research Council (MRC) estimates that children under five account for over 80% of all child deaths in South Africa. The under-five mortality is driven primarily by the Human immunodeficiency virus pandemic, poor diets and living conditions, and a shortage of staff within the South African health care sector.
Infant Mortality is defined as the probability of a child born in a particular year dying before reaching the age of one year. The infant mortality rate has declined from 54 death per 1 000 live births in 2001, to 53 in 2007.
South Africa is among the African countries that adopted well-known, recognised and effective anti-measles strategies that have reduced measles death to near zero. South Africa launched a mass immunisation campaign aimed administering booster doses to children, which provide them with extra protection against polio and measles. To date, this immunisation campaign has been very successful, and was recognised by the United Nations in its 2008 report on child mortality. Immunisation coverage increased from 68.5% of children under the age of 1 year in 2001, to 98.3% in 2009. The South African government managed to attain its target of 47 out of 52 districts with 80% coverage for children under-1 years of age. In 2010/11, government embarked on an extensive immunisation campaign. Pneumococcal vaccine and Rota virus vaccine were added to the expanded immunisation programme (EPI). In 2009/10 period, the immunisation against measles coverage of 22.8% and 34.6 % was achieved respectively, against a target of 40% coverage. However, challenges of data management were reported.
Goal 5: Improve Maternal Mortality
The maternal mortality ratio is defined as the number of women who die as a result of childbearing, during pregnancy or within 6 weeks of delivery or termination of pregnancy in one year. South Africa’s maternal mortality has increased from 369 per 100 000 in 2001 to 625 per 100 000 in 2007. At the current rate, South Africa is unlikely to meet the target of 38 per 100 000 by 2015.
The proportion of births attended by skilled health personnel is defined as the percentage of women whose live birth occurred in a health facility. This figure has increased from 76.6% in 2001, to 94.3% in 2009. Therefore, achieving the target of approximately 100% births attended by skilled health personnel by 2015, is regarded as possible. South Africa’s contraceptive prevalence rate has increased from 25.2% in 2001 to 33.4% in 2009. However, the target rate of approximately 100% is unlikely to be achieved by 2015. South Africa’ 2010 country report did not include a target data or any data for the adolescent birth rate, and target achievability is therefore reported as unknown.
The antenatal care coverage refers to the between one and four visits to a health facility during pregnancy. In 2001, the antenatal care coverage was calculated at 76.6% against a target of 100%. This number has significantly increased since, and it is reported that in 2009 South Africa achieved the target.
The use of modern contraceptive methods by sexually active women increased from 61.2% in 1998, to 64.6% in 2003. which is below the 70% target set. Achieving this target is deemed unlikely. No data and no target were reported by South Africa for unmet need for family planning and target achievability is regarded as unknown.
It is suggested that non-pregnancy related infections, mainly HIV and AIDS, Tuberculosis (TB) and pneumonia accounts for 38% of all maternal deaths in South Africa.
Goal 6: Combat HIV and AIDS, Malaria and other diseases
The HIV prevalence rate amongst persons 2 years and older has not changed significantly since 2002, suggesting that the epidemic may be stabilising in South Africa. However, the prevalence rate of 11% amongst this group is still considered high. The HIV prevalence rate amongst person 15 – 24 years have declined from 9.3% in 2002 to 8.7% in 2008. Trends in prevalence rate within this group are regarded as a good indicator of new infections.
Research indicates that condom use is lowest in stable relationships (married or persons living together) and highest among persons with less stable relationships. About 74-83% of men and 56-66% of women reported condom use at their last high-risk sexual encounter. On average, condom use at last high-risk sexual encounter is about 62.4%, compared to 100% target set for 2015. Based on current statistics, it is unlikely that South Africa will meet this target.
Awareness and knowledge of HIV prevention methods are generally high, with an 87% on average knowledge level for condoms across all age groups. However, knowledge on prevention methods such as faithfulness, partner reduction and abstinence is lower (thought it had increased significantly since 2006).
The proportion of the population with advanced HIV infection with access to antiretroviral drugs increased significantly from 13.9% in 2005 to 41.6% in 2009. However, South Africa still has some distance to go to meet the 100% by 2015, and is unlikely to do so by the required timeframe. To date, South Africa has the largest antiretroviral therapy programme globally, which may have contributed towards stabilising HIV prevalence (as indicated previously).During 2009/10, an estimated 76.9% of HIV-positive pregnant women were initiated on highly active antiretroviral therapy (HAART), which exceeded the target of 30%. The Prevention of Mother-to-Child-Transmission (PMTCT) programme is almost universally available in public primary health facilities. As such, the proportion of HIV positive babies declined from an estimated 15.2% in 2008/09 to 9.4% in 2009/10. Furthermore 91.7% of HIV-exposed infants received Nevirapine, which exceeded the 2009/10 target of 80%. A total of 494 775 new adult patients were initiated on antiretroviral therapy during 2009/10, which exceeded the target of 215 000. A total of 45 044 new child patients under the age of 15 years were initiated on antiretroviral therapy, which exceeded the target of 33 000. Cumulatively, over 1, 1 million people were initiated on treatment by the end of March 2010.
The ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years is almost 1:1. This suggests that school attendance of orphaned children is on par with non-orphaned children.
Malaria is not endemic in South Africa, and subsequently does not present a major health risk (except in some of the northern regions). Affected provinces are mainly Limpopo, KwaZulu-Natal and Mpumalanga. The death rate due to malaria in South Africa has remained very low at 4-10 per thousand since 1999. A 14% reduction in malaria was achieved between 2008/09 and 2009/10. This exceeded the 2009/10 set target of 5%. The number of cases of children under the age of 5 years with fever who are treated with appropriate anti-malaria medication declined from 9 513 (in 2000) to 603 (in 2009). South Africa has therefore effectively achieved this MDG target.
South Africa faces a high level of TB-HIV co-infection, estimated at 73%. Since 2004, both the incidence and prevalence rates of Tuberculosis (TB) increased, and South Africa is unlikely meet the target for reduction by 2015. Further, the death rates associated with TB per 100 000 of the population increased from 147 (in 2002) to 179 (in 2007). However, the proportion of TB cases detected and cured under the DIRECTLY Observed Treatment Short course (DOTS) increased from 65.5% (in 2004) to 76.4% (in 2008). As a country, it may still be possible for South Africa to achieve a 100% target by 2015.
9. Prior BRRR’s Recommendations that were made by the Committee and were not implemented by the Department
- Corruption and fraud should be dealt with immediately and appropriately (through crime investigation units) and people involved should be dealt with accordingly and money recovered.
- The Department must focus more on Maternal, Child and Women’s Health and nutrition sub-programme as South Africa is one of a few countries in the world where child and maternal mortality rates are increasing. The Department must report back to the Portfolio Committee every six months on progress made and steps taken towards reaching the MDG goals.
- The Department needs to encourage all hospitals and clinics to review the cleanliness of health facilities and also include good hygiene measures to enhance infection control. The Department must update its national infection control policy and report back to the Portfolio Committee on Health within six months on how this infection policy is being implemented and monitored.
- The Office of the Standards Compliance should be fully functional within six months and all critical posts filled. The Department should report to the Portfolio Committee on progress made.
- A patient satisfaction survey should be done every four months to assess the functioning of institutions in terms of service delivery plans and corrective measures to be undertaken.
- The Provincial Departments of Health need to do proper stock control measures to ensure that medication is available at all times and also play their supportive role and provide administrative support in ensuring that medical suppliers are paid on time as per agreement.
- The Department needs to prioritise Human Resources Management and development before infrastructural revitalization of hospitals. To this end the Department must finalise its Human Resources strategy within six months. It must report back to the Portfolio Committee within six months on the progress made with regard to the adequate resourcing of existing nursing colleges (including lecturing staff numbers), the re-opening of closed nursing colleges, the lifting of the artificial limit placed on the private sector on the number of nurses they can train, increasing of the number of medical students, and the involvement of the private sector in training doctors, and the streamlining of the application process by individual foreign medical professionals.
- The Department should develop a recruitment and retention strategy.
- The Department should make primary healthcare a priority as this will assist in reducing the burden in hospitals.
- The Revitalisation grant should be monitored by the National Department of Health on quarterly basis and a report should be submitted to the Portfolio Committee on Health.
- Hospitals should be given a budget for maintenance.
10. Committee’s Observations
- There are no monitoring and control mechanisms of Provinces by the National Department of Health.
- The Committee was of the view that provinces were operating their own way.There was no uniformity and there were no norms and standards on how they operate.
- There are still discrepancies in the distribution of female condoms as opposed to male condoms and this was raised by the Committee during the consideration of the budget vote report.
- Too much money is spent on termination of pregnancy instead of spending it on prevention.
- The data used by the Department is not reliable as some numbers do not tally and this was reflected on page 144, paragraph 19 and 20 of the Department’s annual report.
- The staff shortages which resulted in backlogs in the forensic chemistry laboratories was also raised as a serious concern by the Committee during the consideration of the budget vote report was still not adequately addressed and this leads to delays in the processing of cases.
- Security in health institutions was still a challenge which the Committee raised even during the consideration of the budget vote report.
- There are still Human Resources shortages in the Department especially skilled people.
- The use of the Department of Public Works for infrastructure in health institutions was raised as a serious problem which contributes to some of the challenges the department is faced with.
- There are no clear strategies on how the Department is using the Occupational Specific Dispensation (OSD) as a retention strategy.
- The public sector strike in 2010 was also raised as a serious challenge to the department as it affected service delivery.
11. Committee’s observations on Programme by Programme
- The National Department of Health together with seven Provinces (except the Western Cape and the North West) received a qualified audit opinion from the Auditor-General of South Africa. The target for 2010/11 was that at least four provinces would obtain an unqualified audit opinion. The major reason for this is the asset register with regard to the valuation of assets.
- The issue of corruption was also raised as a serious concern which was evident in the report of the Auditor-General whereby employees had businesses or private interests in suppliers.
- 29.9% of mothers and 27% of babies were reviewed within six post-partum days, which was lower than the 2010/11 target of 40%. This was also lower than the 30% which was achieved in 2009/10.
- Personnel shortages and inadequate clinical facilitation skills contributed to the Department not meeting the target of reaching 100% of maternity facilities conducting perinatal review meetings, instead it was 81%.
- 61% of Primary care facilities had providers trained in the integrated Management of Childhood illness (IMCI), which was lower than the set target of 75% as well as the actual performance of 74% during 2010/11.
- The Occupational Specific Dispensation (OSD) was still a challenge as some health workers were migrating towards provided paediatric Anteritroviral Treatment (ART) services.
- Delays in procurement processes resulted affected the distribution of both male and female condoms in 2010/11.
- Although access to ART was expanded to 418,677 people living with HIV and AIDS in 2010/11 but these figures were lower than the set target of placing 400, 000 new adult and 40, 000 new child patients on ART.
- The department did not meet the set target of 80% of TB patients who completed their treatment only reaching 74%.
- Only 69% of HIV positive MDR patients were initiated on ART against the target of 100%.
- The target of 100% of HIV positive XDR patients who were initiated on ART was not reached as the department only achieved 84%.
- There were challenges on the audit of the implementation of Chronic Diseases Management Register.
- The forensic Laboratories were faced with significant backlogs due to staff shortages and the refurbishment of the Johannesburg laboratory.
- Accreditation and external audit of health facilities did not take place during the reporting period.
- The office of the Ombuds Office was not established.
- Only 143 hospital managers instead of 400 were enrolled for a hospital management training programme.
- There was not progress made on the Management and Leadership Feasibility Study for the Management and Leadership Academy which was supposed to be completed by March 2011.
- With respect to the functioning of the District Health System (DHS) not al targets were completely reached.
- District Management Teams (DMTs) were only established in 40 of the 52 districts across provinces.
- Of the 40 DMTs established, 32 had written HR delegations, 11 had financial management delegations and seven had supply chain management delegations. The Department did not meet its target of 52 districts.
- 32 Districts Health Councils were established instead of the 52 which was the target.
- 43 Primary Health Care facility committees were established against the target of 52.
- There were no health care workers recruited to work in Sierra Leone due to delays in the finalization of the Memorandum of Understanding between Cuba and Sierra Leone on recruitment of Cuban doctors, as well as in the signing off for the transfer of funds to Sierra Leone for the implementation of the Trilateral Project.
- The Department did not meet its target with regard to the registration of medicines which was 24 months for Non-Chemical Entities (NCE) and 18 months for generics. During the reporting period, the average time for registration of medicines was 32 months for NCEs and 30 months for generics. This was due to the Medicines Control Council (MCC) shortage of evaluators and the delays by applicants to respond to resolutions of the MCC.
The Department of Health received a qualified opinion. The overall performance of the Department in the reporting year has been unsatisfactory in most programmes.
The Department experienced financially driven challenges during this period of reporting, especially in the delay of some projects. It also continues to face challenges in terms of under spending especially on the hospital revitalisation programme. However, a notable success is the Department’s implementation of the HCT campaign in which over 11 million people were counselled and over 9.7 million people have been tested for HIV and AIDS. In addition the PMTCT programme continues to be run successfully.
In addressing some of the challenges that were raised in the Auditor-General’s report, the Department is going to conduct a workshop with the AG on the 26 October 2011.
The Committee, however, was impressed with the Kopano MDR unit and the MDR unit at the Dr J.S Moroka Hospital in the Free State Province
The Committee adopted the BRR Report without getting outstanding responses to the questions that were raised by the Committee from the Department.
- The National Department of Health and the transferring officer should ensure that provinces have the capacity and skills to spend their allocated budget on grants.
- The National Department of Health should develop norms and standards on how provinces operate and provinces should adhere to those norms and standards.
- The Department should report to the Committee on interventions it is going to take in making sure that there are no discrepancies in the distribution of condoms as this was also raised during the consideration of the budget vote.
- The Committee recommended that all critical posts be filled within six months. A plan of action must be developed on how to address the backlogs with regards to food sampling, toxicology reports and blood tests.
- An addendum to the Annual Report to be submitted to the Committee with regards to the current situation of the Medicines Control Council and progress made with regards to restructuring.
Report to be considered
No related documents