REPORT OF THE PORTFOLIO COMMITTEE ON HEALTH ON THE STRATEGIC PLAN (2014/15 – 2018/19), ANNUAL PERFORMANCE PLAN ( 2014/15 ) AND BUDGET VOTE 16 OF THE DEPARTMENT OF HEALTH, DATED 9 JULY 2014

1. Background

The Portfolio Committee on Health, having considered the Strategic Plan, Annual Performance Plan (APP) and budget allocations of the National Department of Health and in terms of the Public Finance Management Act (PFMA) of 1999, reports as follows:

2. Introduction

The Constitution of South Africa (Act No. 108 of 1996) recognizes that Parliament has an important role to play in overseeing the performance of government departments and public entities. In terms of section 10(c) of the Money Bills Amendment Procedure and Related Matters Act (Act No. 9 of 2009), updated strategic plans must be tabled in Parliament after the adoption of the fiscal framework. It is important to ensure that the strategic plan is tabled within the stipulated period as the plan provides information for the budget review process of the Portfolio Committee.

This report details the findings and recommendations of the Committee after engaging the Department.

3. Consideration of tabled strategic plan and annual performance plan and budget allocations

On 2 and 3 July 2014, The Portfolio Committee engaged the Minister of Health, Deputy Minister, the Director General and relevant Executive Managers of the Department on the strategic plan, annual performance plan and budget allocation of the Department.

4. Overview of the Department of Health

The Department of Health derives its mandate from the Constitution of the Republic of South Africa and the National Health Act, No. 61 of 2003. The Department contributes directly to achieving the government outcome which calls for a long and healthy life for all South Africans (Outcome 2). In order to achieve this, the Department is guided by the Health Sector Negotiated Service Delivery Agreement (NSDA), namely:

1. Increasing life expectancy;

2. Decreasing child and maternal mortality rates;

3. Combating HIV and AIDS and STIs, and decreasing the burden of disease from Tuberculosis; and

4. Enhancing health systems effectiveness.

The health sector is also guided by the health sector Ten Point Plan, the National Development Plan (vision 2030), and the United Nations (UN) Millennium Development Goals (MDGs).

The National Development Plan (NDP) identifies demographics, burden of disease, health systems and the social and environmental determinants of health as the key areas for intervention in order to improve the health system in the country. However, a fundamental reform of the country’s health system will be required in order to address these issues. The NDP states that by 2030 South Africa should have achieved the following goals:

• Average male and female life expectancy at birth increased to 70 years;
• Tuberculosis (TB) prevention and cure progressively improved;
• Maternal, infant and child mortality reduced;
• Significantly reduced prevalence of non-communicable chronic diseases;
• Injury, accidents and violence reduced by 50 % from 2010 levels;
• Health system reforms completed;
• Primary health care teams deployed to provide care to families and communities;
• Universal health coverage achieved; and
• Health posts filled with skilled, committed and competent individuals.

The Department of Health is also committed to work towards achieving health-related MDGs, namely:

· MDG 4: to reduce by two thirds the Under-5 mortality ratio;

· MDG 5: to reduce by three quarters the maternal mortality ratio; and

· MDG 6: to combat HIV and AIDS, malaria and other diseases.

4.1 Department of Health Strategic Plan ( 2014-2019)

The Department’s five-year strategic goals are to:

· Prevent disease and reduce its burden and promote health;

· Make progress towards universal health coverage through the development of the National Health Insurance scheme, and improve the readiness of the health facilities for its implementation;

· Re-engineer primary healthcare by: increasing the number of ward based outreach teams, contracting general practitioners, and district specialist teams; and expanding school health services;

· Improve health facility planning by implementing norms and standards;

· Improve financial management by improving capacity, contract management, revenue collection and supply chain management reforms;

· Develop an efficient health management information system for improved decision making;

· Improve the quality of care by setting and monitoring national norms and standards, improving system for user feedback, increasing safety in health care, and by improving clinical governance; and

· Improve human resources for health by ensuring adequate training and accountability measures.

Interventions to address the causes of maternal, child and infant mortality will be implemented by the department over the medium term including the scale-up of family planning services to reduce unplanned pregnancies and improve women’s health.

A national health commission is planned to reduce the burden of non-communicable diseases. The deployment of primary health care teams and the implementation of the integrated school health programme will also improve health promotion and the prevention of diseases.

In order to strengthen the health system, the department is placing emphasis on the quality of health care in South Africa by establishing the independent Office of Health Standards Compliance as a public entity.

The following key actions have been identified for reducing the burden of HIV and AIDS and tuberculosis:

• Improving access to antiretroviral treatment;
• Reducing new infections through expanding medical male circumcision services; and
• Preventing mother to child transmission (PMTCT).

The Department plans to publish a white paper on National Health Insurance. The stated aim of the proposed NHI is that it will ensure that all South Africans, irrespective of their socio-economic status, have access to good quality and affordable health services. In 2014/15, phase 1 of the NHI fund will be implemented. This will include, amongst other things, the preparation of the service delivery platform for the full implementation of the NHI.

The activities of the department are organised in six programmes, comprising Programme 1: Administration; Programme 2: National Health Insurance, Health Planning and Systems Enablement; Programme 3: HIV and AIDS, Tuberculosis, Maternal and Child Health; Programme 4: Primary Health Care Services; Programme 5: Hospitals, Tertiary Health services and Human Resource Development, and; Programme 6: Health Regulation and Compliance Management.

4.2 Department of Health Annual Performance Plan (2014/15)

In achieving its goals, the department has set short term goals which are outlined in the annual performance plan. These goals are as follows:

Goal 1: Make progress towards universal health coverage through the development of the National Health Insurance scheme and improve the readiness of health facilities for its implementation. The National Health Insurance will be implemented as follows:

• Achieve Universal Health Coverage through the phased implementation of the National Health Insurance.

- The National Health Insurance law will be passed by 2015/16

- The National Health Insurance fund will be created by 2016/17

• Regulate health care in the private sector by establishing National Pricing Commission and legislating methodologies for calculating fees.

- Functional National Pricing Commission to regulate health care in the private sector will be established by 2017

- Revise and legislate methodology for the determination of the dispensing fee.

Goal 2: Re-engineer primary healthcare by increasing the number of ward based outreach teams, contracting health care providers and district specialist teams and expanding school health services. This will be achieved as follows:

• Twenty eight percent of the Grade one children and 12% of grade eight are receiving screening by 2014/15 and 50% of Grade one and 25% grade eight by 2018/19.
• Improve access to community based PHC services and quality of services at primary health care facilities. This will be achieved by having 1500 functional ward based primary health care outreach teams by 2014/15 and 3500 by 2018/19.
• Improve access to disability and rehabilitation services through the implementation of the framework and model for rehabilitation and disability services. This will be achieved by developing a disability model which will be costed by 2014/15. There will be 52 districts that will be implementing the framework and model for rehabilitation services by 2018/19.

Goal 3: Improve the quality of care by setting and monitoring national norms and standards, improving system for user feedback, increasing safety in health care and by improving clinical governance. This will be achieved by the following:

• Improve district governance and strengthen management and leadership of the district health system. 3760 primary health care facilities with functional clinic committees/ district hospital must have board by 2018/19.
• Improve access to quality primary health care services. This will be achieved by ensuring that 2325 (75%) primary health care clinics in the 52 districts must qualify as ‘Ideal Clinics’ by 2018/19.
• Twenty ports of entry must be compliant with the International Health Regulations by 2014/15 and all 75 by 2018/19.
• Ensure quality health care by improving compliance with National Core Standards at all levels of care. This will be done by ensuring 100% compliance of the National Core Standards in 17 tertiary services, 46 regional and 63 specialised hospitals by 2018/19.

Goal 4: Improve health facility planning by implementing norms and standards

• Improve quality of health infrastructure in South Africa by ensuring all new health facilities are compliant with health facility norms and standards. This will be achieved by ensuring that provinces comply with norms and standards for health infrastructure.

Goal 5: Improve financial management by improving capacity contract management, revenue collection and supply chain management reforms

• Monitor budgets and expenditure of provinces for non-negotiable items. The non-negotiable items are infection control and cleaning, medical supplies including dry dispensary, medicines, laboratory services, blood services, food services, security services, laundry services, essential equipment and maintenance of equipment, infrastructure maintenance, children’s vaccines, HIV and AIDS and TB.
• Develop and implement a Revenue Retention Model to strengthen revenue collection by incentivizing central hospitals to increase their revenue collection by 2016.

Goal 6: Improve human resources for health by ensuring adequate training and accountability measures

· Improve turnaround times of recruitment at the National Department of Health. This will be reduced by four months in 2014/15 and three months by 2018/19

· Develop health workforce staffing norms and standards. Norms for primary health care using Workload Indicator Staffing Need (WISN) methodology will be determined by 2014/15. Guidelines for human resource norms and standards will be published for all levels of care by 2018/19.

· Improve quality of nursing training and practice by ensuring that all nursing colleges are accredited to offer new nursing qualification. Five public nursing colleges will be accredited to offer the new nursing qualification by 2014/15.

· Establish the health leadership and management academy in order to develop a training programme for hospital chief executive officers (CEO’s) and district health managers.

Goal 7: Prevent disease and reduce its burden and promote health

• Reduce the maternal mortality ratio to under 100 per 100 000 live births by 2018/9. This will be achieved by ensuring that at least 65% of antenatal clients visit primary health care (PHC) facilities before 20 weeks and also to ensure that at least 80% of mothers also visit a PHC facility for a postnatal checkup within six days.
• Reduce the neonatal mortality rate to under six per 1000 live births
• Improve access to sexual and reproductive health services. This will be achieved by ensuring that 55% of women are using a combination of contraceptives by 2014/15 and that 60% of females are screened for cancer of the cervix at least once every ten years by 2014/15. The department will also provide Human Papilloma Virus (HPV) Vaccine to at least 70% of grade four girls to protect them from cancer of the cervix.
• Expand the prevention of mother to child transmission (PMTCT) coverage to pregnant women by ensuring that all HIV positive antenatal clients are placed on ARVs and reducing the positivity rate to below 1% by 2018/19. This will be achieved by ensuring that 93% of HIV positive pregnant mothers receive ARVs by 2014/15 increasing it to 100% by 2018/19.
• Reduce the under- five mortality rate to less than 23 per 1000 live births by promoting early childhood development. This will be done by ensuring that children under five years’ diarrhoea cases fatality rate is at 3.5% in 2014/15 and 2% in 2018/19 and severe acute malnutrition case fatality rate for children under five is at 8% in 2014/15 and 5% in 2018/19. Immunization coverage for under 1 year will be at 90% in 2014/15 and scaled up to 93% in 2018/19.
• Scale up the combination of prevention interventions to reduce new HIV infections. HIV test conducted among the population 15 to 49 years will be targeted at 10 million annually and 50 million over the period of 5 years. One million medical male circumcisions (MMCs) will be conducted annually, 5 million cumulatively by 2018/19. The total number of people remaining on ARVs is targeted at 3 million in 2014/15 and 5.1 million at the end of 2018/19.
• Improve the effectiveness and efficiency of the routine TB control programme to increase the identification of TB patients and to ensure that these take and complete their treatment. The target for the new TB client treatment success at 79% in 2014/15 and 85% by 2018/19 with a TB defaulter rate of 6% for 2014/15 and 5% or less in 2018/19. MDR-TB treatment success rate should improve from 42% to 50% in 2014/15, and to 65% in 2018/19.
• Ensure that all correctional services facilities have appropriate services and that all inmates have access to TB and HIV diagnosis and treatment services. This will be achieved by ensuring that Correctional Services Management Areas that undertake risk assessments for TB and HIV which are targeted at 20 in 2014/15 increase to 48 by 2018/19 and those conducting routine TB screening are at 50% in 2014/15 increase to 95% by 2018/19.
• Ensure access for more than 500 000 miners to regular TB prevention, screening and treatment through:

- Strengthened regulatory framework (to review current legislation and close gaps).

- Increased capacity to enforce compliance by mines using multi-disciplinary inspections that comprise officials from the Departments of Health, Mineral Resources and Labour .

- Effective surveillance and reporting system.

• Increase TB and HIV awareness in peri-mining areas in six districts with high concentrations of mines.
• Increase access to TB and HIV prevention, diagnosis and treatment in peri-mining communities in six districts with high concentration of mines by screening, counselling , testing for TB and HIV using mobile units.
• Establish the National Health Commission by 2016/17.
• Reduce risk factors and improve the management of Non-Communicable Diseases (NCDs) by reducing obesity by 55% in women and 21% in men by 2018/19. Counsel and screen people for high blood pressure with a target of 500 000 in 2014/15 and 5 million by 2018/19 and similarly, 500 000 for raised blood glucose in 2014/15 and 5 million by 2018/19.
• Improve access to and quality of mental health services. This will be achieved by increasing the percentage of people screened for mental disorders and also an increased percentage of prevalent population access to mental health treatment from 28% to 35% over the five year term.

Goal 8: Develop an efficient health management information system for improved decision making

• Appointment of the Ministerial Advisory Committee on E-Health.
• Implementation of the Health Information Normative Standards Framework.
• Health facilities will have IT infrastructure. Seven hundred primary health care facilities in the NHI pilot districts will be part of the project’s first phase. The IT infrastructure will be done by implementing :

- Health Patient Registration System;

- Patient Administration to improve efficiency and reducing waiting times; and

- Integrated electronic Health Data Collection System.

• Finalization of mHealth Strategy and policy guidelines. This will be achieved by ensuring that the Mom Connect Project, which is a mobile messaging to pregnant women, is functioning. All pregnant women will have to be registered to Mom Connect so that they can communicate with a health facility.
• Implementation of recommendation on primary health care patient information systems assessment.

5. Budget Analysis

The department carries out its mandate through six programmes . The department receives R33.9 billion for 2014/15, up from R30.5 billion in the previous financial year. This is an increase in nominal terms of 11.2% and 4.7% in real terms. Table 1 shows the programme allocations for the Department of Health’s budget.

Table 1 : Health Budget for 2014/15 medium term

Programme	Adjusted 2013/14	Estimate 2014/15	Real Percent change in 2014/15
R million
Programme 1: Administration	405.7	399.7	-7.23%
Programme 2: NHI, Health Planning and Systems Enablement	491.8	621.3	18.96%
Programme 3: HIV and AIDS, TB and Maternal and Child Health	11 042.0	13 049.9	11.28%
Programme 4: Primary Health Care Services	102.6	93.5	-14.19%
Programme 5: Hospitals, Tertiary Services and Human Resource Development	17 722.4	18 925.8	0.56%
Programme 6: Health Regulation and Compliance Management	763.7	865.3	6.69%
TOTAL	30 528.2	33 955.5	4.73%

The two largest programmes namely Programme 5: Hospitals, Tertiary Services and Human Resource Development and Programme 3: HIV and AIDS, TB, Maternal and Child Health jointly constitutes almost 94% of the total budget.

The allocation for Programme 4: Primary Health Care Services again declines in both nominal (-8.87%) and real terms (-14.19%) in 2014/15. Less than one per cent (0.28%) is allocated to this programme (R93.5 million), which is less than it received in the previous year, both as a percentage (previously 0.34%) and in Rand value (R102.6 million).

In terms of economic classification, the bulk of the Health Budget (R30.9 billion or 91.0%) consists of transfers and subsidies to provinces and municipalities, and departmental agencies and accounts. This figure includes R206.1 million to non- profit institutions and R596 million to departmental agencies and accounts.

Current payments constitute a total value of R2.0 billion, which represent 5.9% of the total budget allocation. Most of the current expenditure is allocated to Goods and Services, taking up 70.3% of the total current payments. Expenditure items that receive the largest share of the goods and services budget are Contractors at R416.0 million (up from R313.8 million in the previous year), Consultants and professional services: Business and advisory services at R126.5 million, Medical Supplies at R149.2 million and Medicine at R201.2 million. Stationery and printing receive R41.3 million, down from R46.1 million in 2013/4, whilst advertising more than doubles from R23.4 million to R58.5 million.

A significant increase in payments for capital assets is reported, from R466.4 million in 2013/14 to over one billion rand (R1 025 million) in 2014/15. Buildings and other fixed structures more than doubles from R440.0 million to R979.9 million. Machinery and equipment also increased significantly from R26.3 million to R45.2 million.

The focus over the medium term will continue to be on increasing life expectancy and reducing the burden of disease by revitalising hospitals, providing specialised tertiary services, and preventing and treating HIV and AIDS. The following additional allocations have been made in the 2014/15-2016/17 financial years:

• R1 billion in 2016/17 for the department to continue to provide greater access to antiretroviral treatment.
• An additional R200.0 million in both 2014/15 and 2015/16 has been allocated through a newly formed component of the national health grant for the roll-out of the HPV vaccine which protects women and girls from cervical cancer.
• R30.0 million for a national survey on health demographics.
• Increase in the NHI grant for the expansion of the NHI programme in the pilot sites, including for the contracting of General Practitioners (GPs).
• R70.0 million over the MTEF period for capital assets for the forensic chemistry laboratories and for commissioning the new laboratory in Durban.
• Spending in the Health Regulation and Compliance Management programme is projected to increase significantly over the medium term to strengthen the Medical Research Council’s research programmes, and to allow the Office of Standards Compliance, which is currently a sub-programme in the department, to employ additional staff to establish itself and build its inspectorate function. This is set to increase the Department’s establishment from 1 500 in 2013/14 to 1 535 in 2014/15. From 2014/15, the Office of Standards Compliance is set to become a standalone public entity.

The following reductions in Conditional Grants also come into effect:

• The department’s infrastructure spending is funded through two conditional grants: the provincially delivered health facilities revitalisation grant and the nationally delivered health facility revitalisation component of the national health grant.
• The health facilities revitalisation component of the national health grant is set to continue increasing this programme’s expenditure over the medium term as the department continues to revitalise hospitals. However, allocations are reduced as a result of Cabinet approved reductions of R200.0 million, R254.8 million and R249.5 million over the medium term due to slow spending. These allocations will be reviewed as capacity improves.

• There are currently 7 mega projects being implemented by national or provincial departments, each with a cost of over R1 billion, funded by conditional grants.
• There are currently 50 large infrastructure projects being implemented by the national or provincial departments funded by the conditional grants. Each project has a total estimated cost of more than R250.0 million, but less than R1 billion.

6. Programme Allocations

6.1.1 Programme 1: Administration

The purpose of the Administration Programme is overall management of the department and providing centralised support services. The Programme budget decreases by 1.5% in nominal terms from R405.7 million in 2013/14 to R399.7 million in 2014/15 (but in real terms by 7.2%). The largest sub-programme is Corporate Services, of which the allocation decreases by 3.5% in nominal terms and by 9.1% in real terms. Office Accommodation receives 26.5% of the Programme budget, and is the only sub-programme allocation to increase, from R97.5 million in 2013/14 to R105.8 million (up nominally by 8.5% or 2.2% in real terms).

In terms of economic classification, 98.2 % of the budget is allocated to current payments. Compensation of Employees amounts to R161.6 million (41.2%) while R230.8 million is allocated to Goods and Services. This includes R103 million for Operating leases.

6.1.2 Programme 2: National Health Insurance, Health Planning and Systems Enablement

The National Health Insurance, Health Planning and Systems Enablement Programme aims to improve access to quality health services through planning, integration of health systems, reporting, monitoring and evaluation, and research.

This Programme budget increases by 26.3% in nominal terms (or 19.0% in real terms) from the 2013/14 financial year, due to increased funding to the NHI sub-programme. The NHI sub-programme increased with 31.6% nominally and 23.9% in real terms. The NHI sub-programme receives the largest portion of the Programme 2’s budget, at 78.4% (R487.2 million) to develop and implement policies, legislation and frameworks for expansion of health insurance to the broader population, amongst other things. The increase in this sub-programme is to ensure that General Practitioners (GPs) are contracted for the NHI.

In terms of economic classification, 87.5 % of the budget (R 543.8 million) is allocated to current payments. Compensation of Employees amounts to R67.2 million while R476.6 million is allocated to Goods and Services, R395.8 million of which is for Contractors and R7.0 million for Business and Advisory Services.

6.1.3 Programme 3: HIV and AIDS, TB, Maternal and Child Health

The aim of this programme is to coordinate, manage and fund HIV and AIDS, Tuberculosis (TB) and maternal and child health programmes. It aims to reduce infant, child and youth morbidity as well as maternal mortality. It also aims to increase the TB cure rate.

A large proportion, 98.0% of this programme’s budget is allocated to the HIV and AIDS sub-programme, amounting to R12.8 billion in 2014/15. This represents a nominal increase of 16.4% or 9.6% in real terms compared to the 2013/14 allocation. The four remaining sub-programmes combined receive less than 2.0% of the programme’s budget.

The Women’s Maternal and Reproductive Health sub-programme is responsible for amongst other interventions, deploying obstetric ambulances, establishing Kangaroo Mother Care facilities, midwifery education and training, and strengthening infant feeding practices. This sub-programme received less than 1% (0.13%) of the programme budget and the allocation declined by 5.2% in real terms in 2014/15.

The Child, Youth and School Health sub-programme increases from R17 million to R218.4 million mainly due to roll-out of the HPV Vaccine. This sub-programme develops and monitors policies and guidelines, and sets norms and standards for child health.

Over the medium term, key initiatives will be implemented in line with the maternal and child health strategic plan. These include the continued rollout of the integrated school health programme to cover all learning phases, prioritising under-served and under-resourced schools, and strengthening the immunisation programme. Empirical evidence shows that South Africa has managed to reduce child mortality in the last five years. This is a positive outcome emanating from the scale-up of prevention of mother to child transmission of HIV, the rollout of antiretroviral therapy, new child vaccines (pneumococcus and rotavirus) and other child survival programmes.

In 2012/13, the President launched a multi-sectoral school health programme. To support its implementation, a communication strategy, a recording and reporting system, a toolkit for school governing bodies and a memorandum of understanding between the Departments of Basic Education, Health and Social Development are being developed. In addition, a training package was developed for school health nurses, with training taking place in all provinces. In 2014/15, the fight against cervical cancer will be intensified through the provision of human papilloma virus vaccinations to Grade 4 girls.

In terms of economic classification, R533.1 million (4.1%) of the budget is allocated to current payments. Compensation of Employees amounts to R64.4 million while R468.7 million is allocated to Goods and Services, R148.4 million of which is for Inventory: Medical Supplies and R200.0 million for Inventory: Medicine.

6.1.4 Programme 4: Primary Health Care Services

Table 5 : Programme 4: Primary Health Care Services

The Primary Health Care Services programme aims to develop and implement a uniform district health system and to develop policy for district health services. The Non- Communicable Diseases sub-programme receives R25.7 million in 2014/15 representing 27.5% of the programme’s budget allocation. This sub-programme, amongst others, assists provinces in implementing and monitoring chronic diseases, disability, elderly people, oral health, mental health and substance abuse.

This Programme’s budget decreased by 8.9% in nominal terms in 2014/15, this translates into a decrease of 14.2% in real terms. This is despite the Department’s stated aim of providing health services based on the primary health care approach.

In terms of economic classification, R87.6 million (93.7%) of the budget is allocated to current payments. Compensation of Employees amounts to R50.6 million while R37.0 million is allocated to Goods and Services.

6.1.5 Programme 5: Hospitals, Tertiary Health Services and Human Resources Development

The aim of the Hospitals, Tertiary Health Services and Human Resources Development Programme is to accelerate the delivery of health infrastructure. It also aims to strengthen human resource capacity in the health sector. The budget for this programme has increased by 6.8% (nominal) in 2014/15 compared to the previous year, but with 0.6 % in real terms.

The Forensic Chemistry Laboratories sub-programme allocation increases by 55.8% in nominal terms in the 2014/15 financial year, and in real terms by 46.7% from R78.9 million to R122.9 million.

The Hospital Management sub-programme allocation declined in both nominal (1.8%) and real terms (7.6%) in 2014/15. Similarly in 2014/15, the Nursing sub-programme allocation also declined in both nominal (34.2%) and real terms (38.1%).

In terms of economic classification, 0.01 % of the budget (R 185.9 million) is allocated to current payments. Compensation of Employees amounts to R104.7 million while R81.2 million is allocated to Goods and Services, R46.9 million of which is for Consultants and Professional Services: Business and Advisory Services.

6.1.6 Programme 6: Health Regulation and Compliance Management

	Table 7 : Programme 6: Health Regulation and Compliance Management

The Health Regulation and Compliance Management programme aims to, amongst other things, reduce the time taken for medicines to reach the market, establish the Office of Health Standards Compliance and establish a National Public Health Institute. The programme budget has increased by 13.3% in nominal terms from R763.7 million in 2013/14 to R865.3 million in 2014/15.

Most of the funds (68.5%) that is R592.5 million of this programme budget is allocated to the Public Entities Management sub-programme. The Office for Health Standards Compliance sub-programme increases by 87.4% nominally (or 76.5% in real terms) to employ additional staff to establish itself and build its inspectorate function.

In terms of economic classification, 8.2 % of the budget (R271.2 million) is allocated to current payments. Compensation of Employees amounts to R148.7 million while R122.4 million is allocated to Goods and Services, R43.6 million of which is for Consultants and Professional Services: Business and Advisory Services.

7. Committee findings

Having considered the strategic plan, the annual performance plan and the budget of the Department, this section summarizes the Committee’s observations:

• Primary health care is at the heart of the plans to transform the health system. The Committee raised a concern regarding the reduction of the budget towards PHC services.
• The Committee noted that there was a lack of certainty around the role of Community Health Workers (CHWs) when this category of workers could assist in improving access to PHC services. It was also noted that the services rendered by CHWs were not integrated.

• The Department does not have mechanisms of ensuring that public health facilities collect revenue from medical aid patients who use public health facilities.
• On revitalization grants, the Committee noted with concern that the Department does not have any monitoring mechanism to monitor and evaluate the lists that get submitted by provinces for revitalization.
• The Department is faced with the burden of citizens of neighboring countries especially in the Southern African Development Community (SADC) region coming to South Africa for health services. There are no strategies for dealing with the overflow and this puts pressure on the provinces bordering these countries.
• The Department continues to be faced with human resource shortages, specifically health care workers.
• Mental health care is not receiving the much needed attention with regards to access, infrastructure, training, human resources, and budget and community awareness strategies.
• The rate of breastfeeding mothers is very low, currently at 8%. The Committee was concerned about health risks associated with babies who have not been breastfed.
• The Committee also noted with concern the shortage of laboratory services in the country which may impact negatively on service delivery.
• The issue of outsourcing or tendering for health care services like linen, cleaning, catering and security was also noted as a concern as this leads to poor service delivery.
• There were no strategies on how the Department intends to accredit 220 public nursing colleges by 2018/19. This will lead to the Committee not being able to monitor progress of this particular indicator.
• The lack of financial contribution of the mining sector to the burden of TB-affected miners or ex-miners is also a concern to the Committee.
• In terms of health access particularly for people living in rural areas and in farms, the issue of mobile clinics remains a challenge, 20 years into democracy.
• The Committee raised its concern regarding the lack of targets set pertaining to norms and standards for health facilities compliance. This will pose a challenge on the department in ensuring that provinces conform to these norms and standards.
• With regards to the NHI, the Committee raised a concern pertaining to the timeframes in terms of the duration of the piloting phase to actual roll-out to all districts. In addition, the Committee also questioned whether the establishment of the NHI fund will mean the actual implementation of the scheme.

· The Committee raised concerns about the accuracy and quality of data used in the monitoring and evaluation of the department’s targets. Apparent discrepancies in the data related to maternal mortality ratios was used as an example.

· The Committee noted that most of the indicators had annual targets as opposed

to quarterly targets as required.

· There is no indication in the strategic and annual performance plans on how the Department will integrate its activities with other departments with regards to tackling the social determinants of health.

Recommendations

· The National Department of Health should work with Treasury in ensuring that provincial health facilities collect revenue from medical aid patients and that they retain a portion of the revenue. Central to this, is to develop a revenue recovery strategy with a clear monitoring system and ensure that recovered funds are effectively utilized for the benefit of communities.

· The department should ensure that there are regulations on running emergency medical services (EMS) and they should report to the Committee on those regulations in six months’ time.

· The Committee recommends that EMS response times be improved, paramedics and ambulance assistants are properly trained and basic qualifications be reviewed, without unduly interfering in the provision of services.

· The department should ensure that mechanisms are in place for monitoring and evaluating lists submitted by provinces for revitalization before approving and gazetting them.

· The department should present to the Committee strategies on mental health, particularly on issues like budget, access, infrastructure, human resources and training of health personnel for mental health.

· The department should brief the Committee on progress and challenges related to the National Health Insurance pilots. The department should also submit quarterly reports to the Committee in order to monitor the spending patterns of the piloting districts in provinces.

· To cut costs related to laboratory services, security, linen and catering, the department should ensure that all these services are procured by the provincial departments of health in preparation for NHI.

· The department should also ensure that there are more regulations and enforcement on food safety standards and ensure interdepartmental collaborations with the Departments of Agriculture Forestry and Fisheries, and Trade and Industry.

· The department should work with the Department of Science and Technology with regards to health technology.

· The department should work with the Department of Education in ensuring that children at a very young age are exposed to the health sector and enhance the school health programme.

· The department should develop norms and standards regarding the provision of mobile clinics in rural areas and in farming communities to ensure access to health services.

• In order to address human resource shortages, the department should ensure that the provincial departments of health speed up the filling of vacant posts with suitably qualified personnel.
• In devising recruitment and retention strategies for health professionals in rural areas, the department should consider factors such as basic working conditions, supervision and mentoring, and further training and specialization of registrars and allied health professionals in rural areas. Innovative incentives should also be looked at.
• The department should provide data on the number of health care workers that are in the country, define their roles and their level of training.
• The department should devise proper training guidelines for health care workers.
• The department should undertake rigorous research on the issue of cross border patients who are using public health facilities in order for the committee to influence the budget allocation for health appropriately.
• The department should devise vigorous public education strategies to educate communities about the importance of breastfeeding and also ensure that all public health facilities have milk banks.
• A sustained public education strategy should be implemented to raise awareness in the community on the HPV Vaccine.
• The department should provide the committee with strategies for accrediting nursing colleges and also a revised curriculum for nursing training.
• The department should devise means of ensuring that the mining sector contributes to the TB pandemic in the mining industry.
• The department should provide the committee with quarterly reports on planned indicators.
• The department should accelerate the process of direct delivery of pharmaceuticals, dry dispensary and related supplies to health facilities by suppliers to ensure improved turnaround times and prompt payment of suppliers.
• The department should present plans taken on collaborations with other government departments in order to tackle the social determinants of health, as outlined in the NDP.

Unless otherwise indicated, the National Department of Health should respond to the recommendations in three months from the day the report is adopted by the House.

Report to be considered.