Department of Health on its 2009/10 Annual Report

Meeting report

Ms Matsoso highlighted the Vision and Mission of the NDoH and linked the National Health Systems Priorities: 10 Point Plan to this. She noted that there was a Service Delivery Agreement signed by the NDoH and the Minister of Health as well as a process in place for making the 10 Point Plan actionable.

Ms Matsoso then focused on the achievements and problem areas of the six programmes within the NDoH. Under Programme 1: Administration, she noted that they had received an unqualified audit opinion from the Auditor-General. Their aim was to move toward a clean audit – both nationally and provincially. She further noted that 57% of the Department’s Senior Management Staff (SMS) members had been vetted, but said that the NDoH was moving toward having all SMS members vetted. Problem areas arose due to a delay in provincial support, but a unit had now been established in order to improve future performance. Provincial support teams had also been set up and each of these teams had an action and improvement plan in place. The Department had also completed a skills audit throughout the NDoH and this report would be available to the Portfolio Committee once it was complete.

Under Programme 2: Strategic Health Programmes, Ms Matsoso noted that Improving Maternal and Child Health was one of the Millenium Development Goals set by the United Nations. This goal needed to be achieved by 2015, but at the moment, it was a key area of concern for the NDoH. The Nursing Training Model had changed and it was hoped that this would be key to improving the current antenatal care received by women and key to imparting the necessary skills and knowledge to frontline health workers. She noted that 30% of women were reviewed within three days post-partum, but NDoH wished to increase this in the future.

The NDoH was working very closely with the provinces to ensure that the immunisation campaign for measles was successful. Thus far 90% measles coverage had been attained, but there were five districts that had not attained the required measles coverage. These were Metsweding (Gauteng), Sisonke (KwaZulu-Natal), UMgungundlovu (KwaZulu-Natal), Dr. K.K. Kaunda (North West) and Dr. Pixley kaSeme (Northern Cape).

Ms Matsoso highlighted the fact that the South African National AIDS Council (SANAC), in conjunction with the NdoH, had reviewed approximately 64 000 community health workers. There had been a move towards concentrating on training members of households on health issues, instead of only focusing on community health centres. The Household Community Component (HHCC) entailed imparting awareness and knowledge to families and community members about good household practices, safe infant feeding practices, identification and referral of children at risk, prevention of injuries, child immunisation, and oral dehydration.

The HIV/Aids targets were exceeded in all respects. Ms Matsoso said that the NDoH would report on the HCT Campaign March in next year. She noted however that TB continued to be a problem. She mentioned that there would be a TB campaign and hoped that this would train and enable more people in educating communities about the prevention and control of TB.

There was a 14% reduction in malaria cases and South Africa would continue to work with neighbouring countries such as Mozambique and Swaziland to keep the numbers down.

Problem areas that were noted by Ms Matsoso included not meeting the targets for infant immunisation; the reduction of Community Health Centres providing Termination of Pregnancy services (CTOP); the turnaround time for TB sputa to be tested; low levels of patients starting ARV treatment; the TB registers not reporting adequately resulting in under-reporting; and the significant delays and backlogs at Forensic Laboratories which in turn affected the Criminal Justice System.

Under Programme 3: Health Planning and Monitoring, Ms Matsoso noted that the Norms and Standards had been approved by the National Health Council and this had provided the NDoH with a basis for coming up with an improved health plan. Health facilities would be supported to develop and implement their integrated quality package.

Ms Matsoso highlighted the plans for the introduction of the National Health Insurance (NHI). A Ministerial Advisory Committee and technical support unit had been established within the Department. A draft policy was under discussion and this would form the basis for public consultation.

Amongst the problems noted were sporadic drug stock-outs. Ms Matsoso said that these stock-outs were identified last year and confirmed that this was not acceptable. She noted that there were many internal and external problems that contributed to this problem and that the NDoH had now set up a task to ensure that this dID not happen again. Another problem area was the collection of data. A new National Indicator Dataset (NIDS) for the District Information System (DHIS) had been developed and implemented across all provinces on 1 April 2010.

Under Programme 4: Human Resource Management, Ms Matsoso identified several areas of achievement. These areas were: the review of long-term plans of Provincial Human Resources for Health (HRH) plans; improvement of hospital management; auditing of Nursing Colleges and Schools; implementation plan for the Nursing Strategy; establishment of Emergency Care Technician (ECT) Colleges; and managing disputes between orgainsed labour and the state as the employer through the bargaining council.

Under problem areas, Ms Matsoso mentioned that there was a delay by the Northern Cape Province in submitting their HRH plan and this in turn delayed the consolidated plan. The province had since submitted its HRH plan and the development of a revised planning framework was under way. The Health Profession Council of South Africa (HPCSA) accredited only four out of the eight colleges and the number of registered students was below average. The progress with the Data Capturer Project was also slower than anticipated and fewer interns were absorbed into the Public Service. Funding constraints also limited the ability of provinces to absorb the interns. The NDoH was hoping that this would improve in the future.

Under Programme 5: Special Programmes and Health Entities Management, Ms Matsoso identified three areas of improvement. These were: improvement of access to Primary Level Health Facilities; improvement in the implementation of accountable operational management of districts; and improvement of hospital infrastructure. She noted that more needed to be done to improve quality of services and access to primary care facilities. She further noted that thus far, plans for the improvement of hospital infrastructure had been developed for 80 hospitals.

The problem area identified in improvement in implementation of accountable operational management of districts was the lack of achieving set goals. She noted that the NDoH was intent on moving towards achieving set targets. With regard to Hospital Management, the NDoH wanted to link the work being done with the project that had been undertaken with the Department of Public Service and Administration (DPSA).

Under Programme 6: International Relations, Health Trade and Health Product Regulations, Ms Matsoso noted the continued agreements of health matters between South Africa and Zambia, Lesotho, Malawi and Cuba. She spoke about the continued success of the training received by medical students at various levels of medical training in Cuba. Another achievement was the funding agreements signed with the United States of America and the agreement of intent with Sweden. The Department continued to work with the World Health Organisation (WHO). It had also improved the timelines for the registration of medicines and increased the number of clinical trials. Additional to this, three Universities of Technology presented nine training courses to 274 environmental health practitioners (EHPs) on the WHO’s 5 Keys to Safer Foods.

Problem areas identified was the low national coverage of Vitamin A in children aged 12-59 months and the limited progress made in the development of an integrated food production strategy in collaboration with the Departments of Agriculture and Education. She hoped that the targets would be surpassed in the coming financial year.

Ms Tiny Rennie, Acting Chief Financial Officer, reported on the financial statements. She confirmed that the money transfers to the provinces. She explained how the money appropriated was spent in the six different programmes and further explained the underspending for each one.

Programme 1: Administration, showed an under expenditure of R4,738 million. This was due to the delay of moving into the CIVITAS building. The move had now happened and the money had been spent.

Programme 2: Strategic Health Programmes, showed an under expenditure of R24,3 million. This was due to two factors: the delayed portion of the H1N1 vaccines supply and a pending court case for the construction of a mortuary in the Northern Cape.

Programme 3: Health Planning and Monitoring, showed an under expenditure of R10,9 million. This was due to two factors: an initial slow spending for the new cluster of Office of Standard Compliance and a delay in setting up IT equipment in the CIVITAS building.

Programme 4: Human Resources and Management Development, showed an under expenditure of R7,348 million due to the delay in finalising a tender for an audit of the Nursing Colleges project.

Programme 5: Health Services, showed an under expenditure of R402 million due to a conditional grant for Hospital Revilatisation in Mpumulanga being delayed by the audit from National Treasury being conducted before funds could be released. Another reason was unprocessed invoices which could not be paid before year end due to cash flow limitations.

Programme 6: International Relations, Health Trade and Health Products Regulation, showed an under expenditure of R7,572 million due to outstanding accounts that were unclaimed by the Department of International Cooperation and Relations.

Ms Rennie noted that under the Provincial Conditional Grants, there was over spending by some provinces in Forensic Pathology Services. She mentioned that some provinces used core funding whilst others (specifically KwaZulu-Natal) transferred costs from previous years. She also noted that this was a once off grant for 2010.

Ms Rennie confirmed that during the year of review, the South African National Aids Council Trust (SANAT) was dormant and that no transfers were made to the trust.

Ms Matsoso concluded the presentation by emphasising the importance of improving services for the NDoH going forward. She also highlighted the importance of the improved financial management system and the unqualified audit report.

Discussion
The Chairperson noted that some of the provinces seemed to have lots of money, yet they were overspending and asked Ms Matsoso to explain the reasons for both the over- and under-spending.

Ms M Segale-Diswai (ANC) asked if in future reports, a list of all provinces that underspent could be identified and recorded.

Mr M Waters (DA) asked why there was an amount of R11,6 billion of unauthorised expenditure and a bank overdraft of R8 billion in the Provincial Departments of Health.

Ms M Dube (ANC) asked the Department to explain the differences between unauthorised expenditure and the overdraft. She questioned whether the NDoH ever visited the Provincial Departments to check what they were doing with the funds appropriated to them or whether they just accepted that the money was being spent as the Provincial Departments said it was being spent. She also questioned what the Department was doing to curb unauthorised activities and to expose those who were looting the coffers of government.

Ms A Luthuli (ANC) asked what the Department was doing about the under spending in Mpumalanga.

Ms E More (DA) asked whether the Provincial Support Directorate had now been established and whether they were functional. She commented that the overall over- or under- spending was unacceptable. She felt that the DoH needed to plan appropriately and have some systems in place to avoid this situation.

Ms Rennie explained the difference between unauthorised expenditure, over expenditure and overdraft. She explained that six out of the nine provinces did not spend within their budget and that five of the nine provinces had unauthorised expenditure. For the period 2009/10 R8 billion was spent. R11.6 billion was from the previous years and some monies could not be paid before 31 March. This was the reason for the over expenditure. Over expenditure was recorded for one year. Each province managed its own cash flow and the bank overdrafts reflected money that they did not have.

The Chairperson noted that there seemed to be a problem with TB in the mining communities and asked what was being done to address this issue.

Mr Waters also felt that the TB issue was one of great concern. He noted that this was one of the drivers for mortality. He asked the Department to explain why they had not achieved their targets. He asked for how long patients had been without their TB and ARV medication and how many patients were affected. He wanted the Department to explain why there were still some miners who had not received compensation as the Public Protector Report said that there had to be a turnaround time of six months for compensation.

The Chairperson asked Ms Matsoso to explain how it was possible for a person to be on sick leave for an average of five days as this would mean that there was nobody working.

Ms Matsoso said that TB was still a big concern in South Africa. In past years there used to be a bus collecting households who were then treated for TB. The approach had now changed and TB was treated on an individual basis. She felt that this approach needed to be rethought and that South Africa needed to go back to treating households instead of individuals. It would be important that the treatment cycle be completed as well. TB treatment could also be linked to HIV treatment. She assured the Committee that mineworkers were also being looked at.

Dr Yogan Pillay, Chief Director: Strategic Planning, said that the testing of sputa was a priority for the NDoH. There had been some problems with the laboratories testing sputa and the DoH was working with them to decentralise laboratories. This would not only be applicable to TB but to a range of diagnostic tests. Once the process was complete, the DoH would be able to brief the National Health Council and the Portfolio Committee.

Ms Matsoso said that an Advisory Committee looking at injuries and processing of claims had been set up and that they were in consultation with the DoH on how to best deal with unprocessed claims.

She said that the DoH was also looking at the reasons why so many people were off on sick leave and hoped to have a more detailed analysis of the situation so that the true reality of the situation could be gauged.

The Chairperson noted that he could not remember receiving a Human Resources Plan.

Ms Segale-Diswai commented that according to the presentation, 85% of SMS did not submit their Performance Management Agreements (PMAs). She noted this with much disdain and believed that this was unprofessional and did not see how these managers could be compensated, as in her opinion they were not doing what they were employed to do. She asked if there were any measures in place to develop these people.

She questioned whether the Department had a serious view of their human resources deliverables. She also believed that the Department should stop taking a hospi-centric view and focus their energies on developing staff at clinic level. She questioned whether the organisational structures were the same in all the provinces. She believed that clinics were the entry point of health and if they were not well-managed then hospitals would not be well-managed either.

Mr Waters believed that the training received through the hospital management training programme should not be about the number of people that were trained, but about the changes that had occurred at ground level due to this training. He asked what CEOs were doing with regard to pre- and post-assessment and implementation. He was also concerned that nothing was being said about clinic managers.

Ms T Kenye (ANC) asked why the Human Resources for Health (HRH) plan had not been implemented yet.

Mr Waters commented that the previous Minister of Health had launched a National HR plan and wanted to know what happened to this plan.

Ms Matsoso explained that the Department was shocked that so many SMS members had not signed their PMAs. The NDoH had now intervened and all SMSs had now signed. The NDoH would be using letters as a basis of assessing supervisors and that a no bonus scheme had been implemented. She hoped that this would resolve the current situation.

Ms Matsoso said that the NDoH had approached all the Provincial Departments of Health to submit their HR Plans. At the time of doing the Annual Report, the Northern Cape Province had not yet submitted their report. All reports were in now and the NDoH was in the process of consolidating all reports in order to finalise the National HR plan.

She further commented that the number of specialists and super specialists were dropping and that the country needed more nurses and Emergency Services personnel.

Ms Segale-Diswai noted that data management was an issue in all programmes. It seemed as if different programmes collected their own data and there was no consolidation in any of the programmes. She asked the Department to report on what was being done to remedy this situation. She suggested that the DoH go back to the drawing board as they had been experiencing the same issues year after year.

Ms Luthuli felt that the Department should get their foundations right and concentrate on primary health care.

Mr Waters commented that the cancer register was last reviewed in 2001 and asked what the Department would do about this.

Ms Matsoso said that 3 000 data collectors had been trained but these people had not been used aggressively as the Department did not have an integrated system. She hoped that this would be corrected in the future.

Ms Segale-Diswai questioned what happened to the environmental officers and if they were being fully utilised. She asked what happened to the environmental officers once they were sent to the provinces.

Ms Matsoso said that there had been several difficulties in this regard. Local Government was unable to employ the environmental officers due to monetary constraints and constraints in the legislation. The NDoH was looking at the legislation to see how it could be changed.

Mr Waters asked the Department to explain what had happened about the Radiation Control issue as recorded on page 14 of the Annual Report. There were 236 radiation devices missing and he wanted to know what was being done to recover these. What were they doing about filling vacant posts at the Radiation control centres? He also mentioned that some areas such as Durban had not been inspected for more than seven years.

Ms Matsoso explained that she did not have the relevant information available, but she would investigate this matter further and get back to the Portfolio Committee with her findings. She explained that the NDoH had advertised vacant posts and would meet with the Nuclear Regulator. She would then be able to report back on the progress in this regard. She suggested that the Commissioner be present when she did report back.

Mr Waters questioned how accurate the data in the Annual Report was as data from the PERSAL System was not reliable. He asked from where they got the data. He asked if the data included the private sector.

Ms Matsoso explained that their data came from the PERSAL system but the NDoH had a systematic process of cleaning out the data to ensure that it was clean. They had also used data from BASS and LOGIS. The data did not include the private sector.

Mr Waters asked the Department about the NHI. Were they not supposed to investigate the feasibility of this programme first before any member of the task team went to the media? In the Annual Report it said that one consultant was appointed for 163 days and was paid over half a million?

Ms Matsoso said that a report was presented to the Minister of Health and it would now be going to the National Health Council for discussion. This was a separate process and the report had been tabled. She said further than the consultant employed was a senior secretariat member to the task team and she was assisted by officials from the NDoH.

Mr Waters questioned the standards at the Nursing Colleges. He noted that inspections were supposed to be done on a yearly basis yet some were done in 1998 while others were done in 2004. He asked the Department to explain what they were doing in this regard.

Ms E More (DA) commented that there was a high turnover of nursing staff and asked the Department whether there were any interventions in place to address this issue.

Ms Matsoso said that the NDoH was busy working on how to resolve the issues around the Nursing Colleges and that they would inform the Portfolio Committee on the progress in future meetings. In the past, colleges provided care and technical services and had a service oriented approach. This had since been replaced by a training oriented approach. She felt that the NDoH need to look at how they could bring back the service oriented approach to the training offered.

Mr Waters asked if there were any timeframes set for the improvement of antenatal care. This should be monitored. Where were the 30% of women reviewed within three days post-partum being monitored?

Ms Luthuli felt that 30% was not enough and that the Department needed to do more.

Dr Nikki Padayache from the DoH said that in order to achieve appropriate primary health care, training needed to start at management level and then be filtered down to staff at community level. There needed to be a shift from concentrating on individuals to concentrating on families. Thus far, 98% of community health workers had been trained and the focus was shifted from offering only training, to also services. This covered the six major areas as outlined. Thus far 2 800 health centres had been supervised and visited and 43% of District Health Services Councils had been established. There had been a gradual increase on expenditure in primary health care. NDoH now need to concentrate on all 42 districts instead of just 18 districts.

Dr Y Pillay from the DoH commented that primary health care had been prioritised. The NDoH had investigated different models around the world that would assist in strengthening SA’s current health model. They had found the model in Brazil to be the best and the Minister of Health and the MECs for Health had visited Brazil. This model focused on geographic areas and used a team that was led by one specific person, such as a nurse. It combined a new package of services and concentrated on households and communities. It also offered a good referral system. In this model, all Government Departments worked together on all levels. It had a good evaluation, monitoring and information system. The DoH would be presenting a detailed programme to the Minister of Health.

He continued that the target for the DoH was for expectant mothers to receive best quality care and there were guidelines available for this. There was additional assistance available to specific facilities but the DoH found that only one third of expectant mothers received antenatal care within their first trimester. He said that the challenge was to get expectant mothers to come to the antenatal facilities.

Ms Matsoso said that the DoH should spend more time at the facilities to help them assess what was happening. She felt that there was a top-heavy structure and not sufficient nursing staff. She hoped that in spending more time at the facilities, the DoH could assess what needed to be done and in this way start improving services at these facilities.

Mr Waters asked if it was worthwhile distributing so many condoms. He questioned whether it would not make better sense to concentrate on changing behaviours in terms of the impact of HIV/Aids rather that concentrating so much effort into the distribution of condoms.

Ms Luthuli felt that the Department was leaving the men behind. She felt that men were a critical link in the spread of HIV infections and that they needed to educated on their role in the spread of the virus.

Ms Kenye asked why the Department did not avail the female condoms to communities but concentrated solely on male condoms. She also felt that there was some corruption in the rural areas because they were not getting formula that was sent to the clinics for babies of HIV positive mothers. These mothers then had no option but to breastfeed their babies and infect their HIV negative babies. What were they doing to reverse this situation?

Ms Matsoso commented that implementing behaviour change within communities was a very difficult task and the messaging would depend on the target audience. The DoH had put preventative measures in place but she could not say how they could account for the impact of these.

Dr Y Pillay said that the impact of condom distribution was recorded in the HSRC Report. According to the report, there had been a reduction. They hoped this number would increase in the next financial year. In one example, the distribution of condoms had made a significant impact in the prevention of STIs.

Ms Matsoso said that corruption was a big problem in the different provinces as it happened on a daily basis. She suggested that the DoH should perhaps look into having a special unit set up to co-ordinate and investigate any allegations of corruption.

Mr Waters wanted to know when there would be visible changes in terms of the Quality Improvement Plans. He felt that at the moment there were no changes.

Ms Matsoso said that quality was not just about standards but about change in behaviour and approach. The Quality Improvement Plans would be based on improved outcomes and include things such as clean clinical excellence matching up with clean hospitals, shorter queues, etc. There was a general concern about the quality of the training of doctors and the NDoH would focus on this as well as training of managers. In this way they would ensure that hospital staff were adequately trained and in this way it would strengthen staff at clinic and primary level. The NDoH was also looking at why feeder clinics were being bypassed as this added to the pressure on clinics. She said that there were many issues that need to be addressed and answered.

Mr Waters wanted to know who managed the cost centres, who drove these in the different provinces and what was happening to the cost centres.

Ms Matsoso said that the Chief Financial Officers in the provinces needed to be trained to provide support to clinics and hospitals. DoH was working on this and training should take place during the next few months. She hoped that this would build on the wellness of the facilities.

Mr Waters asked the Department to provide the number of students who were being trained in Cuba, the timeframes during which they were trained and the cost of training.

Ms Luthuli asked if South Africa was not able to train students here instead of sending them to Cuba as she felt that was an unnecessary expense.

The Chairperson commented that the Cuban training was done in conjunction with the Department of Education and felt that a meeting needed to be called between the Deans and the Council on Higher Education in order to give the Portfolio Committee deeper insight into this training.

Ms Matsoso added that DoH would reflect the number of students doing training in Cuba in all future reports.

Ms M Dube (ANC) commented that on the final concluding slide, Ms Matsoso mentioned that the Department had met all their priorities for 2009/10, but she could not agree with this statement as she felt that the Department had not done so. She asked the Department officials to reflect on what they were doing wrong and how the DoH would go about achieving its mission.

The Chairperson commented that he felt that Health was not in a healthy state in South Africa. He also commented that Health in South Africa was not completely transformed.

Ms Matsoso commented that the conclusion should reflect both achievements and problem areas and said they would do so in future reports.

Ms Luthuli felt that measles coverage was a big concern and that the Department should look into why the set goals were not achieved. Due to the non-achievement of measles coverage, other people were put at risk.

Ms Segale-Diswai asked the Department what the costs and interventions were for the six districts that could not attain the required measles coverage.

Ms Kenye commented that the rate of infections of measles in the Northern Cape had affected more than 10 000 babies and asked the Department whether they had done anything about this.

Mr Waters asked what the guidelines were for infection control in hospitals and when the Committee would get a copy of the guidelines. He believed that the country was not achieving its Millennium Goals and felt that the Committee also needed to be briefed on this.

Ms Luthuli and Ms C Dudley (ACDP) asked the Department what the reasons were for the shortfall in immunisation and whether there were any plans in place to address these.

Ms Kenye asked the Department what their plans were for reaching their goals for immunisation.

Ms Matsoso said that they were beginning to see a trend developing, not only in child health, but in all preventable diseases. The DoH would look at these collectively.

She further commented that infection control guidelines would be in every hospital. She raised the question about which indicators should be used and suggested a review of the current indicators and the acceptable levels of indicators.

Mr Waters asked the Department to explain whether there were stock-outs or low stock of the ARV and TB medication.

Dr Andrew Pillay from the NDoH said that patients were never without treatment. The problem with the TB medication was that there was only one supplier. This supplier then experienced some problems with medication registration and they had to contact international suppliers to supply the medication until the issue was sorted out. The ARV supplier could not cope with the large amounts of medication needed and ran short. No patient was ever without treatment.

A task team was established by the NDoH to investigate this situation and a report had been commissioned.

Due to time constraints, the Chairperson asked the Committee members to send any unanswered or further questions to the secretary, who would forward these to the Director-General. He asked the Director-General to have the answers ready when they met again.

Ms Luthuli asked whether South Africa was sharing the cost of malaria control with the other countries such as Swaziland and Mozambique. She felt that as a country, we tend to carry others.

Mr Waters asked the Department to indicate the number of terminations that had not taken place.

Ms Dudley asked what the public process was in regard to termination of pregnancies and asked the Department to explain the progress of this process.

Ms Luthuli wanted to know what the Department was doing about those Districts who had not submitted their District Health Plans.

Mr Waters asked the Department about the Medical Research Council research on vaccines and what the progress was.

Ms Dudley asked how the under performance of the distribution of Vitamin A impacted on child mortality.

Mr E Sulliman (ANC) asked the Department to explain the cost of travel and subsistence, whether they had any cost saving measures in place and what they would do in the future to address this issue.

The meeting was adjourned.