The Portfolio Committee on Health (the Committee), having assessed the performance of the Department of Health (the Department) against its mandate and allocated resources, reports as follows:

INTRODUCTION

The Money Bills Procedures and Related Matters Amendment Act (No. 9 of 2009) sets out the process that allows Parliament to make recommendations to the Minister of Finance to amend the budget of a national Department. The Portfolio Committee compiles a Budgetary Review and Recommendation Report (BRRR) which is a performance assessment of how the public health sector has used allocated resources. Based on the assessment, recommendations are made to inform effective, efficient and economic use of allocated resources. The BRRR takes into account the following:

Medium-term estimates of expenditure;
Sector strategic priorities and measurable objectives;
Prevailing strategic plans;
Expenditure reports relating to the Department published by National Treasury in terms of Section 32 of the Public Finance Management Act (PFMA) (No.1 of 1999);
Financial statements and annual reports of the Department;
Reports of the Committee on Public Accounts relating to the Department; and
Any other information requested by or presented to a House or Parliament.

1.1.Purpose of the report

This report summarises a presentation received from the Department focusing on its 2019/20 Annual Report. The report details the deliberations, observations and recommendations made by the Committee relating to the Department’s financial and non-financial performance in the 2019/20 financial year.

1.2.Process

In assessing the performance of the Department of Health and its Entities for the financial year 2019/20, the Committee reviewed and analysed the following reports and/or documents:

2019 Estimates of National Expenditure;
Strategic Plan of the Department of Health (2015/16 – 2019/20);
Annual Performance Plan of the Department of Health (2019/20);
Annual Report of the Department of Health (2019/20); and
Report of the Auditor General South Africa (2019/20).

On 11November 2020, the Portfolio Committee on Health engaged with the Auditor-General of South Africa (AGSA) on the audit outcomes of the Department and its entities.

On 18November 2020, the Portfolio Committee on Health and the Select Committee on Health and Social Services engaged the Department on its 2019/20 Annual Report.

2.STRATEGIC OVERVIEW 2019/20

2.1.Sustainable Development Goals

The health sector is guided by the United Nations (UN) Sustainable Development Goals (SDGs). The SDGs recognise that the health system must ensure healthy lives and promote well-being for all, at all ages (by 2030). It is envisaged that this would be achieved through the following:

Putting in place social protection systems and measures.
Reducing maternal mortality to less than 70% per 100000 live births.
Ending preventable deaths of new-borns and children under-5 years of age; and epidemics such as AIDS, TB and malaria.
Reducing one-third of premature mortality from non-communicable diseases.
Strengthening the prevention and treatment of substance abuse, including the harmful use of alcohol.
Improving road safety for all, and halve the number of deaths and injuries caused by road traffic accidents.
Ensuring access to sexual and reproductive health care services, and rights.
Attaining universal health coverage.
Maintaining ecosystems, and reducing the number of death and illnesses caused by hazardous chemicals and pollution.

2.2.Strategic Priorities of Government

National Development Plan

The National Development Plan (NDP) forms an integral part of policy plans within all government departments, including the Department of Health, charting a path to prosperity and improving the lives of all South Africans within various sectors. The NDP articulates nine health-related goals that broadly endorse a health system that raises life expectancy, reduces infant mortality and the occurrence of HIV and AIDS, and significantly lowers the burden of disease.

The NDPidentifies demographics, burden of disease, health systems and the social and environmental determinants of health as the key areas for intervention required to improve the health system in the country. The nine health goals have been identified in the NDP are as follows:

Raised life expectancy of South Africans to at least 70 years
Progressively improved TB prevention and cure
Reduced maternal, infant and child mortality
Significantly reduced prevalence of non-communicable diseases
Reduced injury, accidents and violence by 50% from 2010 levels
Completed health system reforms
Established primary healthcare teams to provide care to families and communities
Implemented universal health coverage
Filled posts with skilled, committed and competent individuals

State of the Nation Address (SONA)

As it was an election year, there were two States of the Nation Address in 2019. The February 2019 SONA highlighted the following main health-related issues:

The first Presidential Health Summit, hosted in October 2018 brought together key stakeholders from a wide range of constituencies in the health sector. Participants engaged each other on the crisis in the health system and proposed immediate, short- and medium-term solutions to improve the effectiveness of the health system.
The National Health Insurance (NHI) Bill will be ready to be submitted to Parliament soon. NHI is envisaged to reduce inequality in access to health care by enabling South Africans to receive free services at the point of care in public and private quality-accredited health facilities. An NHI and quality improvement War Room has been established in the Presidency consisting of various key departments to address the crisis in the public health system, while preparing for the implementation of the NHI.
A funded multi-pronged national quality health improvement plan for public health facilities to improve every clinic and hospital, will be contracted by the NHI.

The President identified the following health-related issues in the June 2019 State of the Nation Address:

Address capacity at hospitals and clinics, and long waiting times for medication.
Highlight Human Resources for Health (HRH) issues and shortages of doctors and nurses.
Young people will be employed in social economy jobs such as health care.
Improve ambulance services, including obstetric care.
Complete and use the Presidential Health Summit Compact to address the crisis in clinics and hospitals.
Revise the NHI Implementation Plan, including accelerating quality of care initiatives in public facilities, building human resource capacity, establishing the NHI Fund structure, using technology and remote medicine, and costing the administration of the NHI Fund.
Intensify the 90-90-90 Strategy to end HIV as a public threat and to stem the rising HIV infection rates amongst young women, and low rates of men testing and starting treatment for HIV. The goal is to have at least 2 million more people on treatment by December 2020.

2.3.Strategic Priorities of the Department of Health

The Department’s five-year strategic goals are in line with the SDGs and NDP Goals. They are to:

Prevent disease and reduce its burden and promote health.
Make progress towards universal health coverage through the development of NHI 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.
Improve human resources for health by ensuring adequate training and accountability measures.

3.NATIONAL TREASURY RESPONSE TO THE 2018/19 BRR RECOMMENDATIONS

Recommendation 1: The National Treasury and the Department of Health should allocate part of the 2018/19 MTEF health infrastructure allocations to gradually set-off expenditure accruals which have arisen from unavoidable demands for which allocated budgets were depleted.

In its response the National Treasury, concedes that accruals incurred by provincial health departments have increased significantly in recent years, exceeding R13.3 billion as at 31 March 2019. According to the National Treasury, provincial departments require a more systematic and sustainable way of addressing rising accruals. The National Treasury, together with the NDoH, has developed a Health Action Plan that includes developing accruals intervention strategies and aligning procurement and cash-flow plans.

Recommendation 2: The National Treasury should ensure that the framework for health infrastructure conditional grants accommodate flexibility during periods of protracted fiscal constraint so that provinces can be allowed to re-orientate their package of available capital allocations towards maintenance.

The National Treasury indicated that infrastructure is partly funded through the provincial equitable share, which provinces use at their discretion. The conditional grant framework does not limit redirecting capital allocations to maintenance. National Treasury notes that when redirecting funds to maintenance, it is important to consider the stages and cash flows of currently funded projects to ensure there are funds for contractually committed infrastructure projects.

Recommendation 3: The NDoH and National Treasury should provide adequate funding to the Office of the Health Ombud in line with the recently approved structure for better reporting and functionality.

The National Treasury indicated that it will support reprioritisation from areas that will not negatively affect service delivery.

4.REPORT OF THE AUDITOR GENERAL OF SOUTH AFRICA(AGSA)

4.1.Department and entities

The Auditor General of South Africa reported that overall the health portfolio has regressed from the previous financial year. The Department received an unqualified audit opinion, with material findings. The Department has, for the last nine consecutive years obtained an unqualified audit opinion. Three entities, Council for Medical Schemes (CMS), National Health Laboratory Service (NHLS) and the Office of Health Standards Compliance (OHSC), received unqualified audit opinions with findings. The AGSA indicated that financial statement preparation remains a concern as material adjustments were effected to annual financial statements submitted for audit by the Department and NHLS.

The SAMRC maintained its clean audit, due to effective controls in place and oversight by the assurance providers. The OHSC has regressed from a clean audit to unqualified with findings, this was due to inadequate controls in recording and reporting its performance information. The South African Health Products Regulatory Authority (SAHPRA) and the Compensation Commissioner for Occupational Diseases (CCOD) did not submit their financial statements for the year under review.

Irregular expenditure increased from R37 million to R69 million this financial year. The main contributors to irregular expenditure was the Department, incurring R54million, followed by the CMS (R14 million), and NHLS (R776 000). The AGSA reported that the nature of irregular expenditure was due to non-compliance with key legislation.

The AGSA reported on the three root causes for poor performance including, slow response or no response to improving key controls and addressing risk areas; inadequate consequences for poor performance and transgressions; and instability or vacancies in key positions The AG recommends that leadership and senior management of the Department and entities, exercise oversight regarding financial and performance reporting and compliance as well as internal controls; implement proper record keeping, prepare accurate and complete financial and performance reports and monitor compliance with applicable legislation relating to Supply Chain Management.

4.2.Provincial Departments

AGSA reported that Provincial Departments of Health did not submit their financial statements for the year under review.

PERFORMANCE OF THE DEPARTMENT2019/20

This section provides an overview and assessment of the reported financial and non-financial performance of the Department for 2019/20.

The Department is structured into six programmes, namely:

Programme 1: Administration
Programme 2: National Health Insurance (NHI)
Programme 3: Communicable and Non-Communicable Diseases
Programme 4: Primary Health Care (PHC)Services
Programme 5: Hospital Systems
Programme 6: Health System Governance and Human Resources

5.1.Financial Performance

For 2019/20, the Department received a budget of R51.195 billion, of which it spent R50.773 billion (as shown in Table 1). This constitutes expenditure of 99.2%, up from 98.1% expenditure rate in the previous financial year. The Department underspent its allocated budget by R422.4 million or 0.8%.

Table 1: Appropriation statement 2019/20

Programme R’000		2019/20			2018/19
Programme R’000		Final Appropriation	Actual Expenditure	Over/under expenditure	Final appropriation	Actual expenditure	Over/under expenditure
1	Administration	588 743	542 426	46 317	610 308	546 981	63 327
2	National Health Insurance	1 999 789	1 840 046	159 743	1 729 397	1 192 205	537 192
3	Communicable & Non-Communicable Diseases	22 851 142	22 713 512	137 630	20 801 184	20 698 172	103 012
4	Primary Health Care	219 651	216 857	2 794	204 552	199 354	5 198
5	Hospital Systems	20 432 634	20 413 709	18 872	19 340 266	19 192 800	147 466
6	Health System Governance and Human Resources	5 103 204	5 046 221	56 983	4 822 667	4 765 073	57 594
	TOTAL	51 195 163	50 772 771	422 392	47 508 374	46 594 585	913 789

Source: Department of Health, adapted

The largest amount of under expenditure, representing 37.8% of the Department’s total under-expenditure, is reported in Programme 2: National Health Insurance which underspent by R159.7 million (7.9 %) of the programme’s budget.

Programme 1: Administration underspent by R46.3 million which is 7.8% of the programme’s available budget, and 10.9% of the total under-expenditure.

Programme 3: Communicable and Non-Communicable Diseases underspent by R137.6 million which is 0.6% of the programme’s budget, representing 32.6% of the total departmental under-expenditure.

Programme 6: Health System Governance & Human Resources underspent by R56.9 million which is 1.2% of the programme’s budget, which is 13.5% of the total under-expenditure.

In terms of economic classification, expenditure on Compensation of Employees (COE) amounted to R830.9 million (96.7%) of the COE budget allocation of R859.3 million. This was due to vacancies not being filled. Approximately, 21% of the Goods and Services budget allocation was not spent. This amounted to R345 million of the R1.6 billion budget allocation remaining unspent. Purchase of Capital assets was allocated R835.2 million, but only R794.5 million (95.1%) was spent.

Approval was given for a total of R171.7 million to be veered after the Adjustments budget by the Director General (DG). This included amongst others R104.2 million within Goods and Services, R41.3 million within Purchase of capital assets and R20.8 million from Machinery and Equipment to Goods and Services. National Treasury approved virements including R339.3 million as increase in conditional grants, R25 million from Goods and Services, and R314 300 from Purchase of capital assets, R21 million from Condom allocation towards COVID-19. In terms of roll-overs, R89.3 million in funds were rolled over for medical equipment for hospitals in Limpopo.

5.1.1.Performance perProgramme

Programme 1: Administration –This programme was allocated R588.7 million and spent R542.4 million (92.1%) up from 89.9% expenditure rate in the previous year. Under expenditure totalled R46.3 million.
Programme 2: National Health Insurance (NHI) –This programme recorded improved spending compared to the previous financial year. It was allocated nearly R2.0 billion, of which only R1.84 billion or 92% was spent. This means the programme underspent by approximately R160 million.
Programme 3: Communicable and Non-Communicable Diseases –This programme was allocated R22.851 billion (up from R20.699 billion) and spent R22.714 billion, which is a 99.4% expenditure rate. Under-expenditure amounted to R137.6 million. The vast majority, 98.1% of this programme’s budget (R22.409 billion) was allocated to the HIV and AIDS sub-programme. Only R15.7 million is allocated to Women’s Maternal and Reproductive Health, and R41.0 million is allocated to Health Promotion and Nutrition. The relatively small TB budget declined from R25.2 million in 2018/19 to R24.4 million in 2019/20.
Programme 4: Primary Health Care (PHC)Services –The budget allocation for this programme decreased from R 279.7 million in 2018/19 to R219.7 million in 2019/20 with expenditure of R216.9 million (98.7%).
Programme 5: Hospital Systems –This programme has spent nearly 100% (R20.414 billion) of its R20.433 billion allocated funds. This is in keeping with the previous financial years’ spending pattern.
Programme 6: Health System Governance and Human Resources – This programme has spent 98.9 % of its appropriated funds, amounting to R5.046 billion.

5.2.Non-Financial (Service Delivery) Performance

Table 2, below, provides an overview of the number of targets achieved and not fully achieved. It also indicates the percentage of budget spent. Overall, the Department’s performance appears to have declined compared to the previous financial year. During the 2019/20 financial year, the Department achieved only 33 out of 71 of its set targets (46.5%), compared to the 2018/19 financial year when it achieved 23 out of 53 targets set (49%).

Table2: Programme Performance Overview

	2019/20					2018/19
Programme	Number of targets	Achieved	Not fully achieved	Targets Achieved 2019/20	Budget Spent 2019/20	Targets Achieved 2018/19	Budget Spent 2018/19
Administration	3	1	2	33.3%	92.1%	0%	89.9%
National Health Insurance	12	8	4	66.7%	92.0%	50%	70.5%
Communicable & Non-Communicable Diseases	16	9	7	56.3%	99.4%	33%	99.7%
Primary Health Care	16	7	9	43.8%	98.7%	73%	88.7%
Hospital Systems	8	2	6	25%	99.9%	42%	99.2%
Health System Governance and Human Resources	16	6	10	37.5%	98.9%	67%	98.8%
Total	71	33	38	46.5%	99.2%	49%	98.1%

Source: Department of Health 2020, adapted

5.2.1.Performance per Programme

This section provides an analysis of the performance of the Department under each of its six main programmes. The analysis focuses particularly on the overarching targets and achievements under each programme and highlights some of the challenges that prevented the Department from achieving these target.

Programme 1: Administration –This programme achieved only one (33.3%) of the three planned targets for 2019/20. The notable targets under the programme during the period under review include the following:

The Department met its target of achieving an unqualified audit opinion. The AGSA identified material misstatement of capital commitments in the financial statements and thus the Department received an unqualified audit opinion in 2019/20.
The Eastern Cape, Free State, and Mpumalanga Provincial Departments of Health received qualified audit opinions which meant that the Department failed to reach the target of 5 Provincial DOH that demonstrate improvements in audit with no significant matters for 2018/19. It should be noted that due to COVID-19, a number of Provincial Departments of Health Financial statements are still outstanding and may yet show an improvement in audit outcome.
Only three, not all Provincial Departments of Health as targeted, implemented claim management system to manage medico legal claims. This was attributed to late approval for the Case Management System.
The Department had a vacancy rate of 14.9% due to budget cuts on COE effected by National Treasury. The Department aims to embark on a robust reprioritisation process to ensure that critical posts are filled, and posts that cannot be accommodated are abolished.

Programme 2: National Health Insurance – Out of the 12 planned targets, the Department achieved 8 or 66.7%, up from 50% in 2018/19. The reasons given for this deviation were as follows: (1). Key positions in the NHI office were not filled due to the NHI bill not being finalised; (2). General Practitioners (GPs) Contracting Capacitation model could not be implemented this year due to challenges with the reimbursement model; and (3). Training on the Medicines Stock Out System was halted due to COVID-19 and changes in training approach such that NHI training could not be expanded.

Targets achieved include the following:

A comprehensive package for district hospitals was established as per the planned target. Three thousand seven hundred and seventy-two(3 772) health facilities reported stock availability at national surveillance centre against the set target of 3725.
The Department achieved its target of implementing the early warning system for medicine stock-outs.
Thirty-six facilities with automated e-Prescription and dispensing system was implemented against the planned target of 25 facilities.
A total of 3 381 731 patients were enrolled for receiving medicine through the CCMDD programme and the actual target was 3 million.
The Department planned to maintain 3220 primary health facilities (PHC) and 22 hospitals for the period under review and 3059 PHC facilities and six hospitals were maintained.
The Departmentfurther reported that it will attend the 2020/21 public hearings on the NHI Bill that will be arranged by the respective committees of Parliament. A proposed organogram of the Departmentincluding NHI Office was prepared and submitted to the Department of Public Service and Administration during 2019/20 financial year and that discussions on filling of posts for the NHI Office will continue between Health and the Department of Public Service and Administration (DPSA) during the 2020/21 financial year. The Departmentfurther reported that local training of district teams on NHI will resume once COVID-19 has subsided.

Programme 3: Communicable and Non-Communicable Diseases–In programme 3, the Department fully achieved only 9 out of 16 targets or 56.4%. this is up from its achievement of only 2 out of 6 targets or 33.3% in the previous financial year. The number of targets in this programme has been reduced significantly over the past few years, from 57 in 2015/16 to 6 last financial year, increasing to 16 in 2019/20. The Department spent nearly its entire budget (99.4%), but achieved only a 56.3% of its targets fully.

The Department did not achieve the target related to Medical Male Circumcisions (MMCs) with only 531 988 out of a targeted 600 000 performed. Further, the District Mental Health Teams target of 20 additional districts with mental health teams established was not attained, with only 17 established. A new indicator, the number of patients with mental health problems consulted by contracted psychiatrists or psychologists was not implemented. The reason cited is the contract with the service provider was cancelled.

The TB budget declined from R25.2 million in 2018/19 to R24.4 million. TB is a critical programme as it is regarded as the leading cause of death in South Africa. Failure to treat TB means that patients infect others, and also are liable to contracting drug resistant TB (DR- TB) multi drug resistant (MDR) or extreme drug resistant (XDR) TB which are exponentially more expensive and difficult to treat.

Programme 4: Primary Health Care–In terms of performance, eight (8) out of 11 targets or 72.7% (previous financial year 20 out of the 25 targets or 80%) were fully achieved. About 118 (target 80) District Hospital Boards were trained to implement the handbook for governance structures. Provinces with dedicated resources for recruitment, orientation, and training of hospital boards performed better than those without. About 41% of 3400 Primary Health Care (PHC) facilities (target 45%) were accessible to people with disabilities. Approximately 1 906 PHC facilities (target 1 800) qualify as Ideal Clinics.

Only 10 (target 20) points of entry were compliant with International Health Regulations (IHR) 2005 core capacity requirements. This is a critical indicator as evidenced by the COVID-19 pandemic, and needs to be monitored closely.

All 9 provinces were monitored for compliance with the EMS regulations using the approved checklist annually and 9 EMS improvement plans revised accordingly.

Only 4559 (target 1 000 000) chronic patients provided feedback via the Patient Satisfaction Assessment App. The reason for deviation is that the Application (App) is not fully implemented at all health facilities with only the Proof of Concept implemented at 388 facilities.

Programme 5: Hospital Systems – The number of targets for this programme has decreased from 29 in 2017/18, 19 in 2018/19 to only 8 in 2019/20. Only two (2) of the eight (8) targets (25%) were achieved. This is despite having spent nearly the entire budget for the programme. The two indicators which were achieved are, 37 facilities compliant with Infrastructure Norms and Standards; and 100 facilities maintained, repaired and/or refurbished through the Equitable Share and HFRG in Districts.

In 2019/20, the AGSA did not find any material findings on the usefulness and reliability of the reported performance information in Programme 5. This has been a long-standing challenge in this programme and must be noted as an achievement.

Indicators not achieved include, amongst others:

Baseline assessments at only 49 hospitals (target 61) conducted using the Ideal Hospital Framework;
Only 41 clinics and CHCs constructed or revitalised (target 60);
Only 20 hospitals revitalised (target 36); and
The Draft implementation plans for improvement of 10 Central hospitals organisational structures were not costed as planned.

Programme 6: Health System Governance and Human Resources–The number of targets for this programme has increased from 3 in 2018/19 to 16 in the year under review. Six (6) of the 16 targets (37.5%) were achieved.

The eHealth Strategy 2020-2025 was published as targeted. A handbook for Board members serving on public health entities and statutory professional council which was developed in 2018/19 was not implemented as planned.

The NAPHISA (National Public Health Institutes of South Africa) Bill was processed by both houses of Parliament on 25 February 2020 and sent to the President for assent. The policy for community service was not reviewed.

5.2.2.Human Resources

The Department reports that it had a total of 1 434 permanent posts filled, out of 1 755 approved posts which represents a vacancy rate of 14.9% (compared to previous year’s vacancy rate of 13.3%). In the Senior Management Services (SMS), the highest vacancy rates were experienced at level 14 (35.3%, n= 12) and level 13 (18%, n=24, up from 10 in 2018/19).

COMMITTEE OBSERVATIONS AND FINDINGS

The Committee made its observations and raised key concerns during its deliberations, including:

Overall performance and reporting

The Committee welcomed the 2019/20 Annual Report of the Department, acknowledging that the COVID-19 pandemic has brought an unprecedented crisis which had implications on the work of the Department, coupled with the challenges related to the Civitas building.
The Committee is however concerned that the performance of the Department in meeting its set targets has declined from achieving 49% in 2018/19 to achieving 45% in 2019/20 financial year. Expenditure spending of the Department has increased from 98.1% in 2018/19 to 99.2% in 2019/20.
The Committee is of the view that there is a lack of correlation between the budget spent and achievement of set targets. The Committee noted its concern in relation to Programme 2, that the number of targets have been reduced from 27 to 12 in 2018/19 and only 8 of these were achieved and spent 92% of its budget.

Audit Outcomes

The Committee appreciates that the Department has obtained an unqualified audit opinion for nine consecutive years. However, urged the Department to move from an unqualified report to a clean audit.

In terms of entities, the Committee notes and commends the SAMRC for maintaining a clean audit. The Committee noted with concern the regression of the OHSC as well as outstanding audit reports of the CCOD and SAHPRA.

The Committee noted the shortcomings identified by the AGSA in the 2019/20 audit outcomes. Specific concerns include the following:

the reliability of performance information;
findings on irregular expenditure;
non-compliance issues around annual financial statements;
internal controls deficiencies;
inadequate record keeping;
procurement processes not being followed;and
inadequate consequence management.

The Committee raised concern in relation to the outstanding financial statements of Provincial Departments of Health and emphasised the need for the Department to monitor how the grants and transfers to the provinces were spent.

Financial matters

The Committee expressed concern overunder-expenditurewhich amounted to R422.4 million, given thatsome public health facilities are not in good condition.
The Committee noted with concern theirregular expenditure amounting to R69 million, which was incurred due to procurement processes not being followed.

Observations per Programme

Programme 1: Administration

The Committee noted with concern that six Provincial Departments of Health did not implement the claim management system to manage medico-legal claims.
The Department had a vacancy rate of 14.9%due to funding constraints and the shifting of funds, the Committee expressed concern over the high vacancy rate.
The Committee noted with concern that some of the entities and Provincial Departments of Health were lagging behind in terms of performance.
The Committee sought an update on the recruitment of unemployed university graduates.

Programme 2: National Health Insurance (NHI)

The CCMDD programme was lauded by the Committee as a step in the right direction towards the NHI, noting that nearly 3.4 million patients have been enrolled on the programme.
The Committee noted the implementation of the NHI patient beneficiary registry and highlighted the need for a national electronic registration system.
In relation to the NHI Phase 1 Evaluation Report, the Committee enquired on whether the Department was implementing the lessons identified in the report.

Programme 3: Communicable & Non-Communicable Diseases

The Committee was concerned that under the mental health programme, 99% of the budget had been spent, yet not a single target was achieved.The Committee indicated that mental health remains one of the key areas of healthcare because of the consequences and impact of COVID-19 andin light of what had happened at Life Esidimeni.
The Committee brought to the attention of the Department the need to address the findings of the Commission for Gender Equality (CGE) on forced sterilisation of women living with HIV/AIDS.

Programme 4: Primary Health Care

The Committee was concerned that only 12.8% of the targets were achieved under the Primary Health Care programme. The Committee highlighted that primary healthcare was a key and optimal arena of healthcare service delivery, however, it was concerning that primary health care infrastructure remains dilapidated coupledwith alack of mobile units (particularly in the Northern Cape).
The Committee expressed concern that somecommunity health workers had not received stipends, and there were promises of increases and permanent positions that the Department had not delivered on.
The Committee stated that EMS was the backbone of a successful healthcare system, however, improvements in this area had not fully permeated on the ground. Disparities remain in service provision in rural versus urban areas.
The Committee was concerned that targets relating to the Human papilloma virus (HPV)programme were not achieved and that budgets were significantly cut,impacting the roll-out of awareness campaigns.

Programme 5: Hospital Systems

The Committee noted with concern, that there was slow progress in theconstruction of new hospitals, only one hospital was constructed (in KwaZulu-Natal).
On the delaysin the revitalisation andrefurbishment of healthcare facilities, the Committee noted this with concern and enquired about the reasons for these delays.
In relation to the infrastructure that had been built for Covid-19, the Committee enquired whether the Department hadplans to repurpose some of the infrastructure to bereintegrated into the health system to ensure seamless healthcare services. The Committee was of the view that this could be used as an opportunity to improve access and infrastructure in many of the areas that were lacking in healthservices.

Programme 6: Health System Governance and Human Resources

In relation to the delays in the internship placement of foreign-trained health professionals, the Committee said this was concerning considering thedire need for health professional at hospitals and clinics, and that these delays were causing further delays in essential service delivery to communities.
Inadequate safety and security for health workers and patients in public health facilities, was raised sharply by the Committee.
The Committee expressed concern aroundinadequate access to DNA laboratories for victims of gender-based violence and other crimes,thus denying them a recourse to justice.

Recommendations

The Portfolio Committee recommends that the Ministerof Health should considerthe following:

Improve audit outcomes -

Ensure that all provincial department submit their annual financial statements to the AGSA for the 2019/20 audit.

Institute measures to address the root causes identified by the AGSA in order to obtain a clean audit.
Present to the Committee a turnaround plan to address the recurring issue related to quality and reliability of data as reported by the Auditor General for the past several years.
Provide a detailed plan to the Committee demonstrating how it will assist provinces toimprove audit outcomes. The detailed plan should be provided to the Committee on a quarterly basis.
Provide systems to assist provincial departments to develop internal controls and instruments to monitor and eliminate irregular, wasteful and fruitless expenditure in reducing inefficiencies.

Strengthen financial management -

The Department should provide the Committee with a quarterly report on consequence management arising from non-compliance with PFMA regulations.

Invest in electronicsystems to improve efficiency in health establishments -

Ensure greater investment in Information Technology (IT)personnel and infrastructure in order to move towards a national electronic information system.

Strengthen health care services

The Department should prioritisemental health care and have clear programmes aimed at strengthening the provision of mental health care services.
The Department should get additional funding to ensure continuity of the HPV programme.
Ensure that HIV positive patients get their medication on time at public health facilities.
Ensure that provinces expand and strengthen EMS staff complement and build capacity, increase ambulance fleet and vehicles, in order to improve on the waiting time.
Ensure that safety and security measures are strengthened in public health facilities to ensure the safety of health professionals and patients.
Strengthen and expand access to DNA laboratories for victims of gender-based violence and other crimes.
Present to the Committee a progress report on all infrastructure revitalisation and refurbishment projects.
The Department should fast-track the placement of foreign-trained health professionals.
Provide the Committee with a progress report on the provincial implementation of the National Community Health Care Workers Policy.
Ensure that all Community Health Workers are permanently employed by the Department, across the country.
The Department should submit a comprehensive report on progress made in the implementation of the NHI, successes and challenges thereof, as well as to ascertain the country’s readiness for its roll-out.
Implement the recommendations of the CGE’s report on forced sterilisation of women living with HIV/AIDS and that a progress report is submitted to the Committee on a quarterly basis, on how the Department is addressing this issue.

Strengthen support provided to the CCOD to enhance its functionality -

Ensure that the CCOD improves on the submission of annual reports and financial statements to the AGSA.

Reduce the number of medico-legal cases and costs thereof -

Improve on patient care experience.
Ensure there is appropriate and adequate professional staffing in health establishments.
National and provincial Treasuries should assist provincial departments in dealing with accruals and medico-legal claims which are depleting departments’ budgets.

Ensure alignment of spending trends with performance –

The Department should present an analysis of the cost-effectiveness of its performance, given that on many measures, nearly the entire budget is spent, but performance is poor. Targets should be designed with a clear idea of the most accurate data source for that measure. If the Department cannot accurately measure the impact of a particular programme, it will not know if it is having a positive impact on health in the country. Furthermore, targets should be designed taking into account the method of data collection and its reliability.

coNCLUSION

The Portfolio Committee is deeply concerned about the misalignment in the reporting of the Department’s annual report targets read against their financial reports. The AGSA made some concerning assertions about the Department’s audit regression and the department themselves admitted to a regression in some of their own targets. The Portfolio Committee will seek to have separate joint meetings with the AGSA and theDepartment in order to scrutinise its performance against the audit outcomes and actual targets and priorities.

The role of the Portfolio Committee is to hold the executive to account to word and deed.

Report to be considered.

Documents

No related documents

ATC201204: Budgetary Review and Recommendations Report (BRRR)of the Portfolio Committee on Health, dated 2 December 2020

Health