Department of Health 2020/21 Annual Report; with Deputy Minister

Meeting report

The Chairperson, Ms M Gillion noted apologies from the Minister and Mr E Nchabeleng (ANC, Limpopo).

The Deputy Minister, Dr Sibongiseni Dhlomo, was present at the meeting and led the Department’s presentation.

Input by Deputy Minister

The Deputy Minister said the Department’s efforts to do certain work, was hindered by the impact of COVID-19. The Department had some success stories, such as the creation of Youth Zones across the country, and scaling up the Central Chronic Medicines Dispensing and Distribution (CCMDD). This encouraged citizens to collect medication closer to the areas where the citizens lived. Currently, there are 3.5 million South Africans in this programme. The Health Patients Registration System was also a success. There are 46 million South Africans in the programme to date.

The Deputy Minister acknowledged shortcomings within the Department and said the Acting Director-General, Dr Nicholas Crisp, will address these further.

Department of Health 2020/21 Annual Report

The Acting DG said it was an abnormal year, due to the COVID-19 pandemic. The first two quarters were considerably different to the latter two quarters of the year. Dr Crisp took the Committee through the purpose of the presentation, which was to reflect on the highlights and achievements of the Department in the year under review. He outlined the vision and mission of the Department.

The Acting DG said he will address six programmes related to the performance report, and the Acting Chief Financial Officer (CFO) will address the financials.

Programme 1: Administration

Targets set by the Department which were achieved include reviewing the equitable share formula for Health, and physically following up on patients with issues, within the facilities.

Programme 2: National Health Insurance

There were 46 million registrations targeted on the Health Patient Registration System, and a record 59 million individuals registered in the year under review.

Programme 3: Communicable and Non- communicable Diseases

This programme has been very challenging for the Department because COVID is a communicable disease. Many of the other programmes were heavily impacted by the lockdown and redirection of resources. The quality of safety and care improvement was not implemented. There were no hospital assessments done on the food services. The Department will continue to consult with the World Health Organisation (WHO) for technical support in developing the mass drug administration (MDA) implementation plan.

Programme 4: Primary Health Care

The quality programme received a lot of attention. A total of 16 quality learning centres were identified, and each of these centres has an allocated number of hospitals, both public and private. Traditional medicine did not improve as the Department would have hoped. Nine ports were assessed for compliance. The Department is constantly working on strengthening programmes with performance improvement strategies.

Programme 5: Hospital Systems and Infrastructure

This programme looks specifically at infrastructure development, not just hospitals but all the buildings related to the health sector. The planned target for the previous financial year was to get to 54 primary health care facilities constructed or revitalised. 24 hospitals were targeted, and 25 hospitals were processed through the programme. 150 Health care facilities received attention.

Programme 6: Health Systems Governance and Human Resources

The public health nursing colleges were a challenge which resulted in most of the targets not being met. There were only three nursing colleges for accreditation of an advanced diploma in Mid-Wifery, and one for a diploma in nursing. Clinical government assessments were planned but not all were fulfilled. T

The Acting DG said staff redistribution is an ongoing issue, and handed over to the Acting Chief Financial Officer (CFO), Mr Hadley Nevhutalu

The Acting CFO said said there were challenges in the year under review because of the way things emerged during the COVID-19 pandemic. There were three unusual budget adjustments, which made it difficult for the Department to account for use of funds. The budget adjustment was R58 billion, and by the end of March R57 billion was spent. This was a spent percentage of 99.1%. The COVID-19 Special Appropriation Fund did not go to Parliament for appropriation, and as a result the money never got to the Department.

The under-spending in Programme 1 was because of the Department not paying the Compensation of Employees (COE) for two years. The matter is now being resolved. There was a dispute with Public Works on payments for the building which the Department was evacuated from. Systemic challenges resulted in invoices remaining unpaid.

He gave a summary per Province, indicating the different amounts spent in relation to the grants. He also outlined the expenditure of the National Health Insurance Grant.

See presentation attached for further details

Discussion

Ms A Maleka (ANC, Mpumalanga) asked what efforts were being made by the DoH to ensure a clean audit report; why the targets related to the Department receiving clean audits were removed; what support was provided to the provinces to encourage clean audits; and she asked for the latest update on the North West province.

Ms S Luthuli (EFF, KZN) asked how the COVID-19 pandemic affected the use of interns and unemployed graduates. Gender Based Violence (GBV) is a challenge in South Africa, and Ms Luthuli asked what role the Department played in the fight against GBV. She also asked for an update on the Cuba doctors’ programme.

Ms S Lehihi (EFF, North West) asked if the Department did an audit on human resources capacity in local clinic services. She asked when the Department plans to extend its assistance to less resourced clinics to improve services. Several clinics are using revolving doctors, which is a disadvantage to the community.

Ms N Ndongeni (ANC, Eastern Cape) said in October 2021 South Africa entered its twentieth month of lockdown as a response to the global COVID-19 pandemic. Various stages of lockdown were enforced during this period with hopes of reducing the spread of COVID-19, and to prepare public and private facilities for the surge of infections which may arise. She asked how COVID-19 impacted all the targets set out in this programme.

She asked for an update on the use of patent laws to produce vaccines, ARV’s and TB medication in the country, and said the performance of Programme 3 appears poor, as it achieved only 33.3% of its set targets, despite spending the entire budget. She wanted to know what is being done to improve this, other than reducing the number of indicators.

She also asked for an update on the new Mental Health Strategy Framework, and asked how the Department is improving and monitoring mental health services across the country. The Department should provide a comprehensive report on mental health services in the country.

The Mental Health Strategy Framework comes to an end in the current financial year. Ms Ndongeni said the Department should brief the Committee on the policy to replace it.

She wanted to know which health promotion interventions were implemented, especially in the rural areas. The Department should provide the Committee with a report on drugs in stock across the provinces for the year under review. She asked how the Department is planning to address the challenge of drug stock.

Ms D Christians (DA, Northern Cape) asked for an update on the medical legal claims which were outstanding in the last report. She asked what the role of the Department is in the fight against GBV, focusing on the patient admission process; what these processes are, and if the processes are in line with the COVID-19 restrictions in hospitals. She asked if these processes impacted GBV victims in any way, and she asked about progress with filling the deputy director general (DDG) positions in hospitals.

She also asked about restrictions on hospital visits, as this is denying families of patients the opportunity to ensure the patient receives adequate treatment. This is an issue the provincial government needs to look into.

Mr M Bara (DA, Gauteng) asked when all the ports of entry will be compliant with the international health regulations; how clinical boards and hospital boards are capacitated; how the functionality of clinic committees are assessed, and if these committees were impactful.

He also asked how the Department plans to address the drug shortage. It seemed more resources were channeled into responding to the COVID-19 pandemic, while leaving a gap in other facilities.

The Committee Chairperson raised concerns about the accommodation issues the Department had at Civitas building. She asked for an update on the new accommodation, and asked what the staff morale was currently.

She asked the Department to provide a report on the rollout of the Health Patient Registration System, and asked if this system linked the Department of Home Affairs to any other department systems, or perhaps the medical aid system.

She asked how the Department is implementing recommendations from the National Health Insurance (NHI) evaluation; and wanted to know what is being done to improve the performance of Programme 3. The Department should update the Committee on the track and trace system for COVID-19.

DoH response

The Deputy Minister of Health handed over to the Acting DG to lead the responses.

Dr Crisp said the Department has a grant within the NHI which pays general practitioners to visit patients. This was meant to address the challenges faced by the primary health care system, where doctors are not always easily available, especially in rural areas.  He said the questions around the rotation of doctors would be better answered by Mr Ramphelane Morewane, Chief Director of the National Department of Health.

Dr Crisp said during 2020 there were no available vaccines and the Department was dealing with the matter of inpatient space. The three waves each had a different impact. In the first wave the Department did not have much insight into the treatment of COVID-19, but quickly learnt ventilation is less important than what is referred to as Constant Positive Airwave Pressure (CPAP).

Treatment was not as good when the patient was nursed on the patient’s back. Treatment worked better when the patient was positioned on the patient’s front. The Department learnt a lot about the use of different medicines, including the use of steroids. A lot of learning happened in the first wave. The second wave was an opportunity to adapt much of the learning to care for patients in the wards. There were many improvements in the third wave, and the introduction of vaccinations as well. In the beginning the staff did not know what to expect. It was not clear how the workday would operate, and the use of Personal Protective Equipment (PPE), for example.

In the primary health care system many patients stayed away from hospitals out of the fear of contracting the virus. There had to be a change in the way care was provided. Community Health Care Workers (CHCW) had to go into communities and operate door-to-door. The Department lost over 1300 colleagues during the pandemic and this has had a psychological impact on all the staff. There is no question the entire health system took a huge blow during the year under review.

The Acting DG said through various engagements with other departments, it is understood mental health is an increasing challenge. There have been presentations on how to approach mental health. The Department was looking at a long-term approach, a 15-year programme on ways to improve the strategies of mental health. There has been a lot of activity in preparing policies going forward.

On the drug stock issue, he said stock visibility was very robust during the COVID-19 period. There were fewer stock shortages despite challenges such as lockdown, shutdown of ports, and delayed ships. All the provinces did remarkably well to ensure there was adequate stock of medicine, although there were some shortages. The stock visibility system made it easier for management to move stock around the provinces when the need arises.

There were a lot of efforts going into developing the plan for dealing with medical legal claims, particularly harmonising the reporting of these claims across the country. The Department discovered there were claims being lodged in more than one province for the same patient and the same incident. The DDG would give more insight on this matter.

The Acting DG said the issue of visits in medical wards remains a problem for the medical practitioners. The Department would like patients to be visited by family members, but must however consider safety first. The hospitals must observe protocols of safety when it comes to this to ensure visitors are not unnecessarily exposed to the virus. He said he is confident these protocols are followed strictly. In the first part of the lockdown there were strict measures put in place. No visiting whatsoever was allowed, however there were still outbreaks happening inside the hospitals.

There were times during the pandemic when the Department did not have enough in its budget for staff. Additional personnel brought in through portal services, terminated contracts, which compromised the ability to deal with ports in an efficient manner. This has fortunately been stabilised and all ports of entry are now open.

There has been a concerted effort in the last couple of months from all provinces to catch up. Specific reporting took place at the National Health Council on the plans each province has for catching up. These plans include catching up on child vaccination, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (Aids), tubercolosis (TB) treatments, and patient follow up. It also included inpatient care in instances where many elective surgeries were delayed because staff had a particular focus on patients with COVID-19. This is not easy because of budget constraints and staff have not had any breaks. Staff members were encouraged to take leave on rotation during this period to facilitate mental health safety.

There were massive challenges with the Civitas building and the morale of patients in the National Department was suffering as a result. The building deteriorated to a point where it was declared unsafe and staff had to work from other government buildings. This went on for more than a year. There was a flood in the building, which eventually led to staff moving out completely. There was a process of finding a new building and ensuring it was ready for occupancy. The Department settled into the new building, and staff morale is now quite upbeat. Currently, staff are on rotation. There are still some outstanding challenges in the health and safety of the physical environment.

The Health and Safety Committee are working well with the Executive Management to address these challenges. The Department sets targets every week for fire escape and evacuation around the building. The general progress is good.

The Acting DG said the Department currently has several suspensions, and this created vacant senior positions. There is a programme running to fill these senior vacancies. Interviews are underway and some of the positions already have candidates. In due time candidates will be shortlisted and vacancies will be filled. The Department is on an upward trajectory.

The relationship between HPRS and the Department of Home Affairs (DHA) is very formal and structured. The departments work quite closely to ensure what is picked up in the health environment is reported to DHA, to work on any potential fraud challenges which may arise in the health sector. This is an ongoing arrangement. The Department currently has a challenge with the medical aid systems, which does not necessarily provide a direct link to its members.

There is a medical aid system called ‘Switchers’. It occurs when the medical practitioner sees a patient and needs to access the patient’s medical aid details, which is done through a computer system enabling the practitioner to access the information without hacking into the medical aid system. Medical schemes, the ‘Switchers’, and the Department can identify patients on medical aid schemes for the purpose of COVID-19, through a series of agreements between the National Department of Health and the Council for Medical Schemes. According to this agreement with the private sector, the public sector will not pay for patients on medical schemes.

The Acting CFO said clean audits for the Department are within reach, but there needs to be unqualified audits on the financial objectives and the performance objectives. The financial sector has a challenge of procurement, supply chain, and contract management. The Department does not have the adequate capacity, but there is progress being made to obtain additional capacity on a contract basis. This is to ensure there is compliance with legislation. The performance objectives obtained a qualified audit outcome, but auditors need to get sufficient audit evidence showing systems and processes were established to enable consistent measurement. There was a target for provinces to improve audits.

It is encouraging to see the qualification findings from the Auditor General (AG), which reduced over the past five years. The challenge remains with the medical legal claims and accruals. The problem remains with some provincial treasuries not allowing the provincial department of health to budget for medical legal claims. This results in claims being paid from an unavailable budget. National Treasury engaged on the matter. The health sector budget was cut by R76 billion, and this cut increases the accruals, in turn affecting audit opinions. National Treasury was made aware of this.

There is a challenge within the provinces related to reporting capital assets. The AG made a presentation before the Minister and the Deputy Minister in preparation for the presentation to the Portfolio Committee and there was an indication there were improvements in KwaZulu-Natal.

There has also been an improvement in the North West. For the financial year 20202/21 the North West received an unqualified audit opinion on the financials. The Department still needs to work hard on the performance indicators. Moving forward, proper record systems need to be put in place to strengthen monitoring from a national point of view.

The Chief Director replied on the effectiveness of the Clinic Committee. These committees are established on the instruction of the Member of Executive Council (MEC) in the provinces. The Department discovered three major weaknesses related to the structuring, the composition, terms of office, and generally its day to day functioning to do the work necessary. It developed a concept which led to the guidelines which were tested to ensure a standard way the Clinic Committees should operate.

The Mental Health Strategy (MHS) is coming to an end in this financial year. The Department already established a multi-sectoral committee to review the policy and inputs received. The policy aligned with the investment case released in August this year. Stakeholders will meet to work on strategies to refine this policy.

There is a challenge regarding the capacity of port health services. The pandemic has greatly exposed this. The Department was able to shift money around to be able to buy at least 23 of the services of port health officers on the ground. The stimulus package favoured the Department as it was able to increase capacity in this area.

He also touched on the limited number of doctors in clinics currently, which is disadvantaging patients. Primary health care is a nurse driven service, however there is an indication in the Department which shows there could be additional support for a medical practitioner at this level of care. The number of patients who get referred is quite small. The Department has not been able to cover as many clinics to address this. Nurses are equipped with the necessary skills to care for the patient at certain levels.

The principle of contact tracing is embedded in the management of all communicable diseases. As soon as the results are received in the system, tracers are contacted and assigned immediately. This is in line with the response plan People who have been in contact with the positive case are found and captured. If necessary, these people are quarantined. The Department accepts there has been a margin of error, as indicated by the communities. In preparation for the fourth wave the Department has been strengthening contact tracing.

Ms Valerie Rennie, Head: Corporate Services; National Department of Health, told the Committee the Minister said the Department would like the Administrator to come back. She already prepared a handover report. The Department is currently waiting for the normal legislation process through the National Council of Provinces (NCOP), after which the Administrator can be released. The Administrator must first relinquish her duties as an accounting officer before heading back to the Department.

The interns within the Department were encouraged to continue working during the pandemic, to continue gaining the required experience and hours. The intern “term of office” is a 12-month period, and therefore interns were not able to continue working from home. The programme for unemployed graduates was implemented by the national government about four years ago. The programme was decentralised to the provinces, as the provinces are the beneficiaries for the unemployed graduates. Some provinces, such as Limpopo took over, and some did not have the funds to do so.

Currently, National does not have a programme related to unemployed graduates.

On the question of medical legal claims, Ms Rennie said the South African Law Reform Commission (SALRC) published its discussion paper; the first paper was in July 2017 but now the second discussion paper had been published. This discussion paper will assist the Department to ensure there is a legal basis to address medical legal issues. The SALRC said it does not support the no fault Compensation Fund. The matter will be taken forward after 31 January 2022. Provinces are bearing the brunt of budget pressures and have to balance allocated funding marked for service delivery with the unfunded high cost of litigation.

On the matter of Investigations, Ms Rennie said the information was shared with the Special Investigation Unit (SIU) to deal with the perpetrators.

Answering the question on GBV, the Acting DG said all departments are involved in various forms of GBV related forums, responsibilities, and activities. In the recent weeks there were discussions with the Department of Social Development around GBV related matters. The Department has also been involved in international discussions on GBV. There are constant efforts to improve the facilities in hospitals dealing with women who are raped, and children who are abused. The efforts are to improve the environment and the immediate post trauma response.

The North West is slowly going back to normality, following the meeting between the Minister and the Premier.

The Deputy Minister addressed the question on Cuban doctors, but had connectivity issues and could not continue.

The Acting DG said the Department has an ongoing programme with the Cuban government to train South African students in Cuba. This year there are over 1200 students graduating from the programme. The training session is slightly different this year. Students get orientation in the country for one year, and one of the Cuban trainers who is a senior doctor, supervises the student’s final year before the student writes exams. The graduation ceremony is scheduled to take place at the University of Limpopo. The provinces sponsor the students. It is hoped the students will return to the provinces as young doctors. Many of these young doctors are now working in the primary health care sectors around the country. There are still students in the junior years who need to go through the programme. A notice was sent out to the provinces to nominate students for the next round of training.The Chairperson thanked the Department and the Deputy Minister for an informative briefing session. She wished the Department well in the work it is currently doing during these trying times.

Committee minutes dated 9 November 2021

The minutes were considered and adopted.

The meeting was adjourned.