Department of Health on its 2014 Annual Performance Plan

Meeting report

Chairperson’s Opening Remarks
The Chairperson said that when the meeting adjourned yesterday there were two questions that the Department needed to respond to before it presented its Annual Performance Plan (APP).

Response by Department of Health
Ms Malebona Matsoso, Director-General (DG): Department of Health, said that she would start with the sections that were of relevance to the National Health Act.  Section 36 of the Act provided for the certificate of need, which was about achieving consistency in health services in terms of national, provincial and municipal planning, but also to promote equitable distribution and rationalisation of health services and resources in such way that they could address the problems of inequities that were based on racial, gender, economic, and geographical factors. This was what was provided in the National Health Act. It further stated that they needed to promote an appropriate mix of private and public health services, and the demographics and technological profiles as well as the potential advantages of existing public and private health services, particularly for the affected communities.

The Act also stated that they needed to protect and advance categories of persons designated in terms of the Employment Equity Act and the potential benefits of research and development with respect of improvement of service delivery, but should also ensure that ownership of health facilities did not create perverse incentives for service providers and health workers. It also emphasised the quality of health services as well as the financial sustainability of the health establishment and health agencies. It goes on to say that they needed to ensure the availability and appropriate utilisation of human resources and health technology, and whether the private health establishment was for profit or not, there were Non-Governmental Organisation (NGO) facilities. It also referred to compliance with the requirements of the certificate, or non-compliance.

The DG said that therefore those were the bases on which health services would be provided, but when they made regulations they should consider certain conditions, as it specifically referred to vulnerable populations in terms of people with disabilities, women, older persons, and children. Therefore, their understanding was that when looking at the demographic profile they would have to look at whether disabled people were being affected in accessing health services, or not. Those provisions of the act would apply equality to the public sector, as well as the private sector.

Annual Performance Plan
Programme 1 - Administration
The DG said that the strategic objective of Programme 1, administration, was to ensure effective financial management and accountability by improving audit outcomes. The Department would develop and implement the ICT governance framework by focusing on the ICT continuity plan, inclusive of the ICT disaster recovery plan (DRP). It would provide support for effective communication by developing an integrated communication strategy and implementation plan, and ensure efficient and responsive human resource services through the implementation of efficient recruitment processes and responsive human resource support programmes. It would provide leadership in the health sector by integrating all health sector plans and providing support for developing identified plans.  It would establish a forum for consultation of stakeholders on identified legislation, regulations and policy processes. The DG said that the total budget for programme administration was R399m for the 2014/15 financial year.

Programme 2 -National Health Insurance, Health Planning and Systems Enablement
The purpose of Programme 2, National Health Insurance, Health Planning and Systems Enablement, was to improve access to quality health services through the development and implementation of policies to achieve universal coverage, health financing reform, integrated health systems planning, reporting, monitoring and evaluation and research.

The DG said that the strategic objective of programme 2 was to achieve universal health coverage through the phased implementation of the National Health Insurance (NHI).  The Department’s goals were intended to:
Regulate health care in the private sector, by establishing a National Pricing Commission and legislating methodologies for calculating fees.
Improve Management and control of pharmaceutical services, central chronic medicine dispensing and distribution.
Strengthen revenue collection by incentivizing central hospitals to increase their revenue collection. Develop business and enterprise architecture for E-Health.
Establish a National Health Research observatory.
Develop and implement an integrated monitoring and evaluation plan aligned to health outcomes and outputs contained in the Health Sector Strategy.
Establish a coordinated disease surveillance system for Notifiable Medical conditions (NMC).
Monitor HIV prevalence, domestication of international treaties and implementation of multilateral cooperation on areas of mutual and measurable benefit.  
The implementation of bilateral cooperation on areas of mutual and measurable benefit.

The total budget for this programme was R621m for 2014/15 financial year.

Programme 3 - HIV / AIDS, TB and Maternal and Child Health
The DG said that the purpose of Programme 3: HIV / AIDS, TB and Maternal and Child Health was to decrease the burden of disease related to the HIV and TB epidemics; to minimise maternal and child mortality and morbidity; and to optimise good health for children, adolescents and women. This was done through the three overarching strategies of setting policies, guidelines, norms, standards and targets; supporting the implementation of these; and monitoring and evaluating the outcomes and impact of this implementation.

The DG said that the strategic objectives of this programme were to:
Reduce the maternal mortality ratio to under 100 per 100 000 live births, reduce the neonatal mortality rate to under six per 1 000 live births, and improve access to sexual and reproductive health services by expanding the availability of contraceptives.
Expand the Prevention of Mother to Child Transmission (PMTCT) coverage to pregnant women by ensuring all HIV positive antenatal clients are placed on ARVs and reducing the positivity rate to below 1%, and reduce the under-five mortality rate to less than 23 per 1,000 live births.
By promoting early childhood development, contribute to health and wellbeing of learners by screening for health barriers to learning.
Improve the effectiveness and efficiency of the routine TB  control programme to increase the identification of TB patients; to ensure that these patients take and complete their treatment, improve the functioning of the MDR-TB control programme, including earlier initiation and decentralised treatment, ensure that all correctional services facilities have appropriate services and that inmates all have access to TB and HIV diagnosis and treatment services and care.
Scale up the combination of prevention interventions to reduce new infections, including HIV Counselling and Testing (HCT), male medical circumcision and condom distribution.
Increase the numbers of HIV positive people who are managed so that they do not contract opportunistic infections, especially TB, and who receive antiretroviral therapy when needed.  

In terms of the total budget, R13bn was allocated for programme 3 in 2014/15 financial year.

Programme 4 - Primary Health Care,
The DG said that the aim of Programme 4, Primary Health Care, was to develop and oversee implementation of legislation, policies, systems, and norms and standards for a uniform district health system, environmental health, communicable and non-communicable diseases, health promotion, and nutrition.

The strategic objectives of programme 4 were to improve district governance and strengthen management and leadership of the district health system.
Establish an inter-sectoral forum that would plan and oversee the implementation of interventions across all sectors.
Improve access to community based Primary Health Care (PHC) services and quality of services at primary health care facilities.
Ensure that the Port Health services are rendered in line with International Health Regulations.
Improve environmental health services in all 52 districts and metropolitan municipalities in the country. Reduce risk factors and improve management for Non-Communicable Diseases (NCDS) by implementing the Strategic Plan for NCDs 2012-2017.
Improve access to, and quality of, mental health services in South Africa.
Improve access to disability and rehabilitation services through the implementation of the framework and model for rehabilitation and disability services.
Improve access to disability and rehabilitation services through the implementation of the framework and model for rehabilitation and disability services.
Eliminate Malaria by 2018, so that there were zero local cases of malaria in South Africa.
Improve Forensic Chemistry Laboratory turnaround times for blood, alcoholic, toxicology and food samples.

The total budget for programme 4 was R93m for 2014/15 financial year.

Programme 5 - Hospital, Tertiary Health Services and Human Resource Development
The DG said the aim of Programme 5: Hospital, Tertiary Health Services and Human Resource Development, was to develop policies, delivery models and clinical protocols for hospitals and emergency medical services and to ensure alignment of academic medical centres with health workforce programmes,the  training of health professionals, and to ensure the planning of health infrastructure to meet the health needs of the country.

The strategic objective of this programme was to increase capacity of central hospitals to strengthen local decision making and accountability to facilitate semi-autonomy of 10 central hospitals. Ensure equitable access to tertiary service through implementation of the National Tertiary Services Plan. Ensure quality health care by improving compliance with National Core Standards at all Central, Tertiary, Regional and Specialized Hospitals. Develop health workforce staffing norms and standards. Ensure that the number, distribution, quality and standard of health facilities were in compliance with norms and standards. Improve quality of Nursing training and practice by ensuring that all Nursing colleges are accredited to offer the new Nursing qualification. Improve quality of health infrastructure in South Africa by ensuring all new health facilities are compliant with health facility norms and standards. The total budget for programme 4 was R18bn for 2014/14 financial year.

Programme 6 - Health Regulation and Compliance Management
The DG said that the purpose of Programme 6: Health Regulation and Compliance Management was to regulate the procurement of medicines and pharmaceutical supplies, including food control, and the trade in health products and health technology. Promote accountability and compliance by regulatory bodies and public entities for effective governance and quality of health care.

The strategic objectives of this programme were to regulate Complementary and Alternative Medicines (CAMS), Medical Devices, In-vitro Diagnostics and African Traditional Medicines in South Africa.
Improve the efficiency of the Regulator through restructuring, by establishing the South African Health Product Regulation Authority (SAHPRA) as a public entity.
Strengthen food safety through expanding testing capabilities for adulterants (colorants, protein, and allergens).
Improve registration of response times for antiretroviral, oncology, TB medicines and vaccines used to treat high burden diseases.
Improve oversight and corporate governance practices by reviewing the Governance Framework and Implementation Plan biennially.
Monitor the existence of and progress on annual and regular plans that addresss breaches of quality, safety and compliance in all public sector establishments.
Enhance governance and management by establishing all committees at the Compensation Commissioner for Occupational Diseases/ Medical Bureau for Occupational Diseases (CCOD/MBOD). Establish occupational health services within the public health system.
Provide for coordinated disease and injury surveillance and research by establishing the National Public Health Institute of South Africa (NAPHISA).
Iimprove the acceptability, quality and safety of health services by increasing user and community feedback and involvement.

The total budget for Programme 6 was R33bn for 2014/15 financial year.

Discussion
Mr F Mahlalela (ANC) said that one of the general observations of the APP was that the Department was expected to submit quarterly reports and on the basis of that, the Committee would use them to plan its oversight on how the Department was performing in terms of the APP.  Looking at the APP, 50% were annual targets, which confused the situation.  The Committee would not be able to know the performance of the Department until the end of the financial year. He asked the Department to review that scenario so that their oversight work could be simplified.

He asked what the reasons were for the reduction of the budget in programme 1.

He noted that there were a number of pieces of legislation which the APP indicated that the Department would be bringing.  However, the targets were annual, and this meant that they could not plan as to when the bills could be tabled.  However, if there was a timeframe on a quarterly basis when they submitted their report, they would be in a position to ask for the bill to be tabled.

He asked whether it would be possible for the Department to share with the Committee the names of the five central hospitals it would be targeting this year so that that when the Committee planned for oversight, they would know which hospital to visit, as well as the five nursing colleges.

Mr H Volmink (DA) thanked the DG for a very informative presentation. He noted that when they had looked at strategic tools for reducing child health, one of those was Integrated Management of Childhood Illnesses(IMCI) which was developed by the United Nations Children’s Fund (UNICEF) and World Health Organisation (WHO).   This did not appear in the presentation or on targets and indicators, and he wanted to know why it was left out, because it was a vital tool.

He asked why the Department, in terms of indicators, did not align the neonatal strategic objectives with the performance indicators.

In terms of the maternal mortality ratio data, he asked whether the Department was concerned about the data used as statistics so that as a Committee they could have full confidence in the veracity and accuracy of the data, because there was quite a large discrepancy in terms of collected data.

There was oncern with regard to the way the training of emergency personnel was run, where short courses were offered to them and they were actively engaged in service delivery, participating in the economy and developing professionally. He asked if they took those service personnel out of the emergency services for two to four years, would they not experience the same problem as nursing training, where they would actually be taking out people with experience instead of keeping them in?  Was there perhaps an innovative way where they would still be engaged in emergency services, as well as get inside training, instead of going to university for four years?

With regard to integrated health service plans, especially sanitation, he asked how far along those plans were, and when they could envision a mature plan of integration of health services across the board.

Mr N Matiase (EFF) said that they should acknowledge the annual allocation and the positive steps with regard to achieving full medical coverage for all South Africans, regardless of social standing, of which the Government’s approach to the NHI was a positive indication.  He recommended that the Minister and the Department should indicate spending patterns by provinces, in addition to what they had provided to the Committee, so that they would be able to measure and perform an oversight role on what had been allocated and how provinces were spending on a quarterly and annual basis.

He noted that under Programme 6, health regulation and compliance management, they had heard that the Department was planning to establish a new entity called the South African Health Product Regulation Authority. He asked if that would over-burden the Department, because currently there were about 12 entities, together with statutory councils. There should be research to check what the roles and mandates of the entities were, as well as the statutory councils, to come to a determination of whether there was a need for the new entity.

He noted that the ratio between the administrative personnel and specialists was a bit skewed. It would be better if they could do research on what the current ratio was, so as to strike a balance between the non-professional staff and professional staff.  For instance, in Ireland there were five nurses for each doctor, which was something they could learn from.

He recommended that for the benefit of new Members, in order to empower and capacitate them as a Committee, they needed to be provided with the NHI founding or concept paper so that they were able to understand its objectives and measure and evaluate in terms of the milestones the Department had set for itself.

Dr P Maesela (ANC) said there was a need for the National Pricing Commission to regulate health care in the private sector, as the public was calling out for this, and the sooner it happened, the better. The social causes of diseases, and ways of combating them, needed to be listed so society could identify potential problems and try to avoid them.

He noted that the National Nutrition Supplementary Plan was not what it was supposed to be.   Although it was the competency of the Department of Education, the health of children and what they ate was of paramount importance, because lack of nutrition affected children’s development, and there should be an intervention in this regard.

He also referred to the diagnostic laboratories in hospitals, where the current norm was to outsource to private consultants who were making money and charging exorbitant amounts, because the Department had abrogated the regulatory mechanisms. The Department should take steps to reduce this by half, as this would cut costs tremendously and create jobs, because people would be trained to do it -- not for profit, but to help reinforce the diagnostic part of the national health service in preparation for the NHI.

There was also the question of food safety.  He was not sure which department had competency on the matter, because there was nobody who actually owned it.  The Health Department had competency to ensure that food safety and standards were maintained.  In many foodstuffs there were colorants that were sold to children, and people bought without knowing they were buying diseases.

The Chairperson asked, with regard to Programme 4 (primary health), what the role of health inspectors was, because most local hospitals were filthy and dirty.

She asked why there was a shortage of specialists.  Was it because of the “brain drain,” or leaving the country because remuneration, or was lack of training the cause?

She asked how many mental institutions there were in the country, province by province.

The DG thanked the Chairperson and Members of the Committee for their questions, comments, and recommendations.

The DG said that in terms of the reduction of the budget, they had been engaging the Treasury, which had done an analysis that showed that because of the fiscal strain, all the departments’ budgets had been reviewed, and for Health they had made a cut in Programme 1, because that was administrative. They had avoided cutting budgets on programmes that were service delivery oriented.

The DG said that they are requested on an annual basis by the Head of Government Business, the Deputy President, to submit their legislative programme for the year.  When they do that, they look at the number of laws they think it is feasible to table in Parliament.  However, they also recognise that there are certain processes that should be followed before the bill goes to Parliament. It was those processes which they had control over and set targets for.

Dr Terence Carter, DDG: NDOH said that the five hospitals targeted were Nkosi Albert Luthuli Hospital, Steve Biko Academic Hospital, Universitas Hospital, Groote Schuur Hospital and Tygerburg Hospital. Unfortunately, as far as nursing colleges were concerned, they had t no names for now but would provide them to the Committee.

The DG said that with regard to the burden of neighbouring countries, she had spoken to the DG of the Department of International Relations and Cooperation (DIRCO). Provinces were not affected the same way – some were affected more than the others. Gauteng, for instance, was incredible because between 30% and 40% of the people using health services came from the neighbouring states.  It was a big challenge.  Statistics South Africa data did not provide information about the inflow of patients from neighbouring states, but their facilities did reveal the data, because when they had looked at the process of patient identification, they looked at the identity number.  Those that came from neighbouring countries would not have an ID number.  However, at the moment the provinces were using tick lists which did not distinguish between foreign and local residents.   Currently they could get the actual data, however, and that would be the basis on which they could approach DIRCO.

Since Mpumalanga had become number two in terms of HIV figures, the Department should re-allocate funds to accommodate the increase in the burden of disease on the population. They had been discussing the revision of the Equitable Share Formula with Treasury, and the principle of equity as a basis for allocation, but it had not worked since there were inter-provincial disparities and inequities. The Department therefore wanted the formula revised.

The DG said the provinces had given them a list of facilities they wanted to build, or which needed maintenance, and this had then been gazetted by the Department. However, the Department did not have a mechanism by which to interrogate the list, and could only trust what had been given to them.  Although the system should probably be reviewed, it should be noted that because the Department had audited all the facilities, they had now rated them in terms of the condition of their infrastructure in a dashboard in all provinces. They also had a formal process with the provinces, whereby the DG met with all the heads of departments to discuss infrastructure and other policy issues.   They had set up Project Management Units in the provinces which were supposed to have engineers, but these were not performing at the required level.

The DG said that norms and standards were already gazetted for any province to implement.  The Department would play a supportive role and develop tools to train them to use the norms and standards, because their view was that it would be easier for them to comply if they understood them.   The norms and standards had been provided on a CD which was detailed and elaborate, and the CD would be forwarded to the Committee so that Members could read and follow them.

The Chairperson said that the Department should try to work with the Department of Education in order to help and assist the youth, who were going to be the leaders of tomorrow. She thanked the DG and her team for a very detailed and informative presentation. She would check with the Department with regard to the information it had promised to provide to the Committee.

The DG thanked the Committee for the comments and advice it had given the Department.

The meeting was adjourned.