Department of Health 2019/20 Annual Performance Plan; with Minister

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Health

04 July 2019
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Media Statement: Health Committee Hears That NHI Bill ‘is a Must’ 

The meeting was convened to discuss the National Department of Health’s (NDOH) annual performance plan and budget with the Minister of Health and senior officials of the Department.

The Minister said that activities in the Department were guided by the National Development Plan (NDP) adopted in 2012, and the Sustainable Development Goal (SDG) adopted in 2015. The goals related to health advocated a reduction in maternal mortality, as well as under five mortality, the end of tuberculosis (TB) and malaria, a reduction in mortality associated with non-communicable diseases, and achieving universal health coverage. The National Health Insurance (NHI) was the Department’s approach to achieve these goals. The President had asked the Department to expedite the NHI recommendation, so the Department was working on this and would soon be announcing what would happen. The Department was also aware of the challenges within the system, which included a shortage of staff, shortages of medical stock and concerns regarding infrastructure. All these challenges had been attended to, and the annual performance report had indicated some of the progress.

Members asked about the protests related to some DoH buildings in Pretoria; whether the Committee could be advised of the locations of new hospitals being built in future; why little was being heard about the Love Life project; whether they could be invited to future health conferences; what role the DoH could play in reducing accident deaths and injuries; and what the situation was regarding the 361 students that had been dismissed by the Department. A Member asserted that the Department was uninspiring in its approach to addressing unequal distribution in the health sector and showed a lack of enthusiasm to implement universal health coverage.

Other issues raised by Members included the DoH’s approach to dealing with the rise in teenage pregnancies; progress on the Traditional Practitioners Bill; the need for more information on the purchasing of technology against the Fourth Industrial Revolution background; mother tongue advertising being needed to convey the DoH’s messages; some clinics not operating as they should due to crime concerns; provincial governments spending DoH funding on non-health projects; the influence of social environments on mental health; and the need to enhance nursing training in the country.

Meeting report

The Chairperson began with introductions and made apologies for absent Members.

Dr Zweli Mkhize, Minister of Health, introduced members of the delegation, which included Ms Malebona Matsoso, Director General (DG), Dr Yogan Pillay, Deputy Director General (DDG), Dr Anban Pillay, (DDG), and Mr Ian van der Merwe, Chief Financial Officer (CFO). He apologised on behalf of Dr Joe Phaahla, the Deputy Minister, and explained their engagements in other parts of the country.

Dr S Thembekwayo (EFF) asked how long the presentation would be, and how long the Minister could stay to answer Members’ questions.

The Chairperson said the Committee would see how far it could go. Since it was the first meeting, Members did not need to exhaust all their questions at this time.

DoH annual performance plan

Dr Mkhize said that activities in the Department were guided by the National Development Plan (NDP) adopted in 2012, and the Sustainable Development Goal (SDG) adopted in 2015. The NDP had nine goals and the SDG had 17. Goals related to health advocated a reduction in maternal mortality, as well as under five mortality, the end of tuberculosis (TB) and malaria, a reduction in mortality associated with non-communicable diseases, and achieving universal health coverage. The National Health Insurance (NHI) was the Department’s approach to achieve these goals.

The Minister said that the Department was looking for ways to improve performance of the health system, starting with organisational restructuring and institutional reforms. The Department also needed to look at the country’s health system in order to improve audit outcomes and to reduce wastage.

The President had asked the Department to expedite the NHI recommendation, so the Department was working on this and would soon be announcing what would happen.

The Department was also aware of the challenges within the system, which included a shortage of staff, shortages of stock and concerns regarding infrastructure. All these challenges had been attended to, and the annual performance report had indicated some of the progress.

The Department had made some progress with respect to reducing the number of those infected with  TB and HIV. Latest estimates provided by the University of Cape Town (UCT) indicated that the incidence of HIV had declined between 2011/12 to 2017/18.

Progress had also been made with medical circumcision, which saw more than four million men – including one million in KwaZulu-Natal (KZN) -- receive medical attention.

The Department oversees the free distribution of condoms for men and women, which aims to reduce infections such as HIV and sexually transmitted diseases (STDs). It had looked at the prevalence of condom usage and conducted studies on their usage and the reduction in cases of AIDs.

The Minister said that South Africa was one of the heaviest spending countries on countering TB. The Department aimed to find 40 000 more patients requiring TB treatment through contact tracing. It intended to eliminate malaria, which required collaboration with South Africa’s neighbouring countries.

The Department planned to employ more psychologists to address mental health issues.

The Minister stated that disease control needed to start at the local district level. The essential part was to improve the delivery of clean water and sanitation, especially to rural areas.

The Department was cooperating with the police to come up with a plan to improve safety at hospitals.

It was looking at quality measures, as well as strategies, to improve infrastructure.

645 Cuban-trained medical students would be returning home, and the DoH would ensure their integration and placement. The training of nursing staff would also be strengthened in the public sector.

The Department needed partnerships, in particular from Parliament, to champion universal health coverage.

The full details of the Department’s activities would be explained by other members of the delegation. The Minister asked permission to withdraw at 2pm, but encouraged Members of the Committee to ask questions.

Director General Ms Matsoso continued the presentation, and drew the Committee’s attention to the slide on South Africa’s Vision 2030. She reiterated the importance of the NDP and SDG, emphasising the alignment between the two sets of policies so that the report could be converged into one. The implementation of policies required collaboration between the district, provincial and national levels.

She highlighted the proposed targets for maternal mortality ratios and neonatal mortality rates, explaining the correlation between the two rates, and expressed her confidence in achieving these goals by 2024.

The DG went through the budget breakdown for 2019/20 and 2020/21. The overall budget for 2019/2020 was R51.46 bn, and it would be increased to R56.69 bn in the 2020/21 financial year.

The purpose of the first programme (administration) was to provide support services to the Department in areas such as human resource development and management, labour relations, information communication technology, property management, security, legal, supply chain management and financial management. The key performance indicators were the audit opinion from the Auditor General (AG), the number of provincial DoHs that demonstrated improvements, and the claim management system.

Programme 2 was National Health Insurance. The purpose of this programme was to improve access to quality health services through the development and implementation of policies to achieve universal health coverage and health financing reform. The key indicators to assess this programme included the legislation for the NHI, the establishment of an NHI office, the number of district health contracting teams trained, the number of health facilities implementing the Health Patient Registration System (HPRS), and the total number of health facilities reporting stock availability.

Programme 3 (Communicable and non-communicable diseases) aimed to develop and support the implementation of national policies, guidelines, norms and standards, and achievement of targets. This programme was also responsible for developing strategies and implementing programmes that reduce maternal and child mortality. The key areas were medical circumcision and the number of undiagnosed TB-infected persons.

The DG commented on the importance of the prevention of these diseases. South Africa was one of the countries identified for malaria elimination. Thus it was not only a South African issue, but also a regional issue. It was therefore important to built capacity to assess South Africa’s level of responsiveness to deal with a disease outbreak.

Moving on to mental health, she predicted that there would be an increase of mental health patients in South Africa, and thus it was important to build up the capacity to deal with the situation. The Department planned to improve community-based health care.

Programme 4 dealt with primary health care. The Department was working with district level hospitals to strengthen direct governance and to improve the oversight function that boards and committees had. The DoH planned to improve the quality of services at primary healthcare facilities through the Ideal Clinic initiative and through the Ideal Hospitals programme at the hospital level. The Department planned to improve the accessibility of primary health care services to people with disabilities, and the feedback system. It would also come to Parliament to present the Traditional Health Practitioners Bill.

Ms Matsoso spoke about the environmental health facilities and the Department’s determination to improve Emergency Medical Services (EMS).

Programme 5 (hospital systems) developed national policy on hospital services and responsibilities by level of care, and also provided guidelines. The programme was further responsible for the management of the national tertiary services grant, and ensured that planning for health infrastructure met the health needs of the country. Although the allocated budget for the programme was R20 billion, a significant portion was made up of transfers.

The last programme was governance and human resources. This programme aimed to achieve integrated health systems planning, monitoring and evaluation and research. Its function was to develop and monitor the implementation of health workforce policies and ensure the smooth running of the system. This programme also had the function of overseeing public entities and statutory health professional councils.

The DG spoke about the progress of the National Public Health Institutes of South Africa (NAPHISA) bill, which was approved earlier this year. The government also was devising a handbook to develop a government monitoring system. Furthermore, there were still laws that referred to homelands that had not been repealed, and she appealed to Parliament to repeal them.

Mr Van der Merwe (CFO) took Members through a breakdown of the conditional grants, both direct and indirect allocations.

Discussion

Ms G Tseke (ANC) said she hoped that she and other Members could learn more from them, since they were new in the Committee. Referring to the protests in Pretoria regarding the state of health facilities, she asked about the status of the DoH’s building programmes. If it was building hospitals, would Members be informed of the locations where they were being built? Regarding non-governmental organisations (NGOs), the Department had previously supporting organisations such as Love Life, which used to work well in engaging with young people, but it had recently gone quiet. She asked if the Department was still monitoring them. With regard to community health workers, her constituents had raised the question of whether the proposed system integration intended to de-legitimise community workers.

Dr S Thembakwayo (EFF) also asked about the status of the building under the charge of the DOH in Pretoria. As health had a global context and needed a careful and more collaborative approach, she asked if invitations to conferences related to health could be extended to Members as well. A report which was released by the World Health Organisation (WHO) on SDG 2030 indicated the goal to reduce global deaths and injuries safety on roads by 2020, and she asked how the Department planned to achieve this, given there were only six months left. Referring to her recent travel to Cuba, she asked if South Africa was ready to learn and to move with Cuba in order to research and manufacture medicines, as the previous Minister had never honoured his promises. The Department had mentioned a company that manufactured anti-retrovirals (ARVs) -- was the company still functioning and what was its impact? Regarding the 363 graduates dismissed by the NDoH, she raised doubt that although there was a shortage of staff, whether this matter would be reviewed in a different way by the courts.

Mr M Hendricks (Al Jama-ah) remarked that the health sector of the country also contributed to unequal distribution through its unequal access to healthcare. He asked the Minister if the Department had the power to change that, at least in the health sector. The present situation meant the rich lived longer and the poor lived shorter. He felt that the Department did not have an appetite for the NHI.

Ms S Gwarube (DA) agreed on the importance of universal health coverage. She asked about the NHI pilot project, and suggested that since the report had not been tabled, it would not be wise to ask the Committee to pass the budget for the project. This report needed to be tabled without delay. She asked about the under-spending on the infrastructure budget, and how the Department monitored the  allocation of the budget.

Ms H Ismail (DA) asked what mechanisms were in place to monitor budget allocations and spending. How did the Department plan to monitor the early diagnosis stock availability described in the presentation?

Ms P Dyantyi (ANC) suggested that due to the Minister’s schedule, the Chairperson should pause the questions session and ask the Minister to answer the questions raised so far.

Minister’s response

The Minister said that it was impossible to answer all the questions, and suggested further sessions with Members to go through the issues raised in depth.

In response to the building the Members had mentioned, he said a meeting had been convened between the previous Minister, the current Minister, Deputy Ministers and union members, and a resolution had been reached. The Department was relocating to another building. He therefore considered the outcome satisfactory, and the matter was now closed.

He suggested a date be set to discuss the building and infrastructure of hospitals.

The Minister said that the Members had raised many good points during the session. For instance, how did the Department monitor NGOs? However, he insisted that there were issues of principle that need to be sorted out, such as whether certain facilities should be in government service or under private service, or operate under NGOs. He suggested a discussion on this topic should be scheduled.

He said invitations to health conferences depended on the organisers, so he could make no guarantees, as it was not within his power to issue invitations.

Regarding safety on the roads, the Minister said that all the Department could do was to provide doctors and ambulances. The biggest cause of death was perhaps gunshots and stabbing, so perhaps a bigger inter-departmental platform should be established to discuss this issue.

Responding to the perceived lack of enthusiasm for universal coverage that Mr Hendricks had mentioned, he suggested that the Committee could discuss the issue after the budget speech, but reaffirmed that the Department had good appetite for the programme. Despite political differences, universal health coverage would have to be paid for. The issue of the NHI bill lay with the National Treasury, and the Department had shared those budget figures with the Committee. He hoped that Members would go back to their constituents and ask what their concerns were, so everyone could be involved.

Dr Mkhize said the Department recognised the need to monitor expenditure by provinces, and this meant the executive and legislative branches needed to work together. The Department would report and the Committee would perform its oversight function by asking questions.

He asked for permission to leave the meeting, and Members took a tea break.

Discussion resumed

When the meeting reconvened, Ms A Gela (ANC) asked about the progress of the bill for the regulation of traditional practitioners. Regarding teenage pregnancy, prevention was important. The presentation yesterday had shown that there was a challenge and an increase. She therefore suggested the Department should send out a message to the people, maybe in the form of a slogan that said “Sugar Daddy Must Fall!” Referring to the 3% budget overspending in the 2018/19 financial year, she asked if the NDOH had any measures in place to monitor this.

Ms T Munyai (ANC) stressed the importance of universal health care and said it must be the new administration’s central focus to pass the NHI bill. She stressed the huge impact the NHI would have on closing the gaps between the rich and the poor in terms of their access to receiving healthcare services. It should be passed, no matter how much the cost was. Speaking about the fourth industrial revolution in the health sector, she said there needed to be a trustworthy supplier chain to procure technological devices to ensure that these devices were bought at a reasonable cost. 

Ms M Hlengwa (IFP) said that the media often forgot about the non-English speaking patients. Mother-tongue advertising was needed. Secondly, she mentioned the clinics in Western Cape which were not open 24/7 because of crime, and some clinics were even not operating. In KZN, medical supplies came late to some clinics, which resulted in insufficient stock for patient treatments. Did the Department have any solution to resolve this?

Mr K Jacobs (ANC) appreciated the Minister’s proposal that many questions would be discussed in future. Referring to the five provincial programmes which had demonstrated no improvement in 2018/19, he asked what the DoH’s plan of action was to deal with the situation.  What mechanisms did it use to monitor the transfer of funds to provincial departments under Programme 2? He asked if pilot project could be evaluated. Referring to the International Health Regulations and NAPHISA in Programme 3, he asked if they had been incorporated into law. Regarding the severity of mental illness among South Africans, he argued that many mental illnesses were caused by social conditions, so he asked Members to address this issue with the help of a broader spectrum of departments. He asked the DG if water, electricity and sanitation at the municipal level had been incorporated into each of their own mandates. He remembered a time when nurses played an instrumental role in the healthcare sector, and therefore asked if the DoH could navigate through the complex tension between the Department of Higher Education and Training and the DoH to get nurses training in hospitals again, in order to enhance the quality of training. Regarding environmental health, he wanted to know who was responsible for dealing with plastic pollution.

The Chairperson advised the Members to try not to get to know the Department in one day.

Ms N Chirwa (EFF) enquired about the relationship between the DOH and NGOs. What resources migrated between the two entities, since most accomplishments claimed by the Department were done by the NGOs at ground level? She also raised the subject of condom usage, commenting that the topic had not been given adequate attention in trying to determine why certain populations and communities were not using condoms. For example, it was not easy for involved parties to use condoms during transactional sex. Regarding the stock availability system, she asked whether there was an evaluation mechanism to check the performance of the system. She questioned the binary category used in data capturing, since it excluded the trans-gender population.

Ms E Wilson (DA) suggested the Committee should invite Love Life to present their case at this Committee, considering the government was funding them. Referring to the huge amount of funds that were meant to fund the pilot projects at the provincial level, she said that R243 million had been allocated to the provinces, but the provincial governments were diverting these funds to pay for other purposes. With regard to property management, she wanted an explanation for why there had been a 23,3% increase nominally over a short period of time. She also commented on the low percentage of targets achieved. She asked the Department to explain the disparity between the mortality rate from the researchers in Parliament, and the one that the Department provided. She indicated her disappointment of the Emergency Medical Services (EMS) in the country, calling it “a disaster.” Lastly, she asked what changes had taken place in respect of mental health, and what progress had been made.

The Chairperson again requested the Department to answer the question about the stock availability system.

Department’s response

Ms Matsoso commented on the medicine stock availability situation, and recognised the urgency of stock outages. Dr A Pillay would respond to that question, and the local pharmaceutical production issue would be answered by Dr Y Pillay.

In response to the disparity in the data, she said that the Department had a portfolio consisting of experts from universities and hospitals to conduct research work, using first-hand actual records. They did not rely on statistics. She was uncertain whether the researchers from Parliament also had their own records.

Regarding the health mandates at municipalities, the Department was working on aligning the different mandates at the municipal, provincial and national levels. Since National Healthcare Act clearly stipulates the responsibilities of care at each level of government, it was fundamental to align these different levels. 

The Department agreed with Ms Chirwa’s view on socio-economic and cultural issues affecting condom usage. The Department had processes and tools to assist people from marginalised populations to get access to condoms. To deal with the increase in teenage pregnancies, the Department would start working on making contraceptive pills more accessible.

Regarding nursing and training colleges, she remarked that there was tension between the Department of Higher Education (DHET) and the DoH. The key issue was to navigate a way to resolve the situation without antagonising the DHET, since nurses were still being produced by these colleges.

With regard to NAPHISA, the secretariat would be the best source to answer the question. 

Dr A Pillay began first with the medicine shortage situation. He called the problem a global issue and said that the problem often lay with the manufacturers. The Department had put in place two precautionary measures. Firstly, they indicated in the contract that if manufacturers were unable to produce, they needed to inform the DoH to allow it to seek an alternative solution -- which had not been done. Secondly, the Department imposes a penalty on manufacturers who cannot meet a deadline. The Department also used supplier performance to evaluate pharmaceutical manufacturers. Late tender awarding was a concern for stock availability, as it did not allow manufacturers sufficient time to produce medicines. Clinics and hospitals were all equipped with technology devices to update stock availability weekly. Katelepela was the pharmaceutical company that partnered with the Department to produce ARVs. He explained the emergence of the company’s partnership with the Department of Science and Technology and National Treasury.

Dr Y Pillay referred to oncology data, and said the Department gets data from global estimates as well as the National Cancer register. A number of policies had been adopted to raise awareness of cancer detection and treatments. Regarding mental health, the DoH had formed a committee on mental health services. It had done a cost estimate on mental health issues, which amounted to about R8 billion. Training had been under way at the district level, which linked medical officers to psychiatrists. Condom use was being promoted, but the Department could not indicated the number of condoms being distributed.

Mr Van der Merwe responded on the property management increases, indicating that some increases were due to increases in water, electricity and rates, as well as the maintenance of some properties that the Department needed to pay for. Regarding the dispersal of conditional fund monitoring, he assured the Committee that measures were in place to monitor the funds on a monthly basis.

Ms Matsoso said that she could confirm that there was a need to collaborate with the Cubans on pharmaceutical production. The bill dealing with traditional medicines still needed to be dealt with, and would involve the Department of Energy. Regarding the Health Patient Registration System (HPRS) in reference to Fourth Industrial Revolution, patients were identified with their identity document (ID) numbers.

The meeting was adjourned. 

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