Health Budget briefing

Meeting report

SOCIAL SERVICES SELECT COMMITTEE
15 May 2001
HEALTH BUDGET BRIEFING

Chairperson: Ms Loretta Jacobus

Documents handed out
National Department of Health - Directorates (see Appendix 1)
Summary of Vision, Mission Statement & Ten Point Plan for 1999-2004 (see Appendix 2)
Estimates of Expenditure and Programme Objectives 2001: Vote 15 (.pdf file)

SUMMARY
Three Health Department Deputy Directors General addressed the committee on how they are working towards achieving their Ten Point Plan and gave an overview of this year's budget. This was followed by an wide-ranging discussion period.

MINUTES
The Chairperson introduced the three Deputy Directors General from the Department of Health (DOH): Dr K Chetty, Ms N Matsau, and Mr G Muller. The Chairperson explained that the presentation was necessary to prepare for the Health budget debate on June 12. In addition to an overview of the Department's activities, the Committee had also identified areas of concern which had been previously communicated to the DOH.

Department's Vision, Mission and Ten Point Plan
Dr Chetty apologised for the absence of the Minister and the Director General, who were both abroad at the moment. She explained that she would give a short overview of the strategic framework of the department. Mr Muller would then explain the budget to the Committee and Ms Matsau would deal with the issues raised the previous Friday. She then read through the summary of the Department's Vision, Mission and Ten Point Plan.

Ms Matsau explained that she would attempt to lift out of the Ten Point Plan four or five points including: the improvement of quality in health services, decreasing morbidity and mortality, reorganisation of support services, international health, and gender issues.

Improvement of the Quality of Care
The Patients Rights Charter has by now been distributed to every health centre in the country. The DOH would like to ensure compliance and adherence to the charter. This could be achieved by raising awareness in consumers of their rights. The Department has developed a primary care package of a certain standard. At the moment the services offered by different health centres differ geographically, but the department hopes to change this, so that everyone is offered the same level of health care throughout South Africa.

However, because of the content of the primary care package, and due to the limited resources available, the department has to proceed cautiously. The content of the packages demand much consultation with different stakeholders, and this would therefore take time. The focus would be on improving the management of health services. All hospitals should be offering the same standard.

Decreasing Morbidity and Mortality
HIV/AIDS
There are 8 strategies in the DOH's approach to the problem of HIV/AIDS. In terms of public awareness, it has been noticed that some communities still deny the presence of AIDS within their groups. If a person is suffering from HIV/AIDS, the people will deny he is suffering from HIV/AIDS, and will call it something else. This is either due to ignorance or denial. People must first accept that HIV/AIDS exists before any help can be given.

The DOH is aggressively seeking a vaccine to treat HIV/AIDS. They are aware that this work is also been done internationally, so hope to be the first to find a vaccine.

Focus is also been given to the treatment of sexually transmitted diseases and other opportunistic infections. The DOH has adopted the model of home based care, and has examined other countries that are using this model. Condom distribution is still an important strategy of the department. The government would issue guidelines for anti-retroviral medicines.

Tuberculosis
It has been noticed that tuberculosis (TB) is again gaining ground amongst the population. It is beginning to be a problem due to the extent of HIV/AIDS. There is a shortage of drugs to treat TB, plus it is a difficult infection to treat because of the commitment that is needed from the patient. That is why the DOTS strategy, where the patient has someone else who is responsible for the administering of the medication, has been so successful.

A multi-drug resistance to medication for TB has been noted. How serious this problem is has yet to be determined. A countrywide survey will be carried out to gain a better picture of the problem.

Management of TB hospitals by SANTA is currently under review, and there will be a total review of the management of TB. Some outcomes (of treatment) have been very poor, with less than 20% success rate. The relationships with NGOs will also be examined. The time has come when we cannot separate the treatment of TB from AIDS.

Maternal and women's health
The DOH is working with police on violence towards women, including rape. There are still many back street abortions taking place, we do not know why, and we ask if for some reason or services are inaccessible to some.

The issue of maternal deaths will be investigated. We also have noticed that the uptake of contraception has not increased, which is of concern to us, especially the use of condoms.

Child health
Implementation of immunization is only 65% in spite of the money that has been spent, and the department will work on improving this rate. It seems that people misunderstand the importance of the child receiving the 3 full doses. It is estimated that 90-98% of children receive the first dose, but that only 70% of children receive the second dose, and the third dose decreases even more. If the child does not receive the 3 doses, the child is not immunized.

A plan has been recently put together to take care of orphans. It is not possible to separate orphans according to those who come from an AIDS tragedy and those who do not, so a comprehensive plan has been put together.

Youth and Adolescent Health
The age groups 15-19 and 20-29 still have the highest risk of contracting HIV/AIDS. Health services in the past have abused young people who ask for help concerning their sexuality. We have decided to focus then on providing youth friendly facilities, places that do not intimidate young people, to encourage them to take charge of their sexuality.

Mental Health and Substance Abuse
Mental health facilities do not differentiate according to age, which means that young children are often lumped together with older patients, and suffer because of this. Psychiatric patients are open to abuse. There is presently legislation that will be tabled around this care. The department is looking into the process of de-institutionalization of psychiatric patients, and to discover what their needs are. So far there have been three pilot schemes around this. Two have been successful, and one has failed. The failure happened, we believe, due to lack of support.

It is estimated that 37% of patients should be at home where they have a better chance of recovery and reintegration.

Food Security and Nutrition
The Department is concerned about the issue of food security and have instituted specific programmes.

Reorganisation of support services
The DOH is striving to improve the access to drugs for people, and the legal wrangles around this will be addressed. Other countries have units called Pharmaceutical Intelligence Units, which the DOH will also institute. These units inform the health system of different kinds of drugs, and issues of co-operation. They also research into the different drugs that are available, and new drugs coming onto the market.

There is also a growing awareness around ethics of research. The DOH has developed guiding principles that inform any national, as well as international, agents wishing to use South Africans for research.

International Health
The DOH is taking the cue from the Presidency and from the Office of Foreign Affairs. There is ongoing interaction on an international basis with the SADC community, and health protocols have been developed that are driving the health strategies of SADC forward. The Department is involved in joint projects. Brazil and India are being examined as potential partners in producing pharmaceuticals.

Gender
The Department is concerned that issues have not progressed as they should. A gender audit is needed and there needs to be a greater sensitivity on gender issues.

The Chairperson interjected at this point that this point may need further clarification, and that the team may need to come back at a later stage to explain this in detail.

Department Budget 2001/2
Mr Muller first highlighted the areas where there is a rollover and explained why such a rollover had occurred. In the case of the rollover for International Health Liaison, the invoices had not yet been sent out. Maternal Child & Women's health: on the vaccine programme, the assumed price was higher than the actual price, and the assumed exchange rate was lower than the actual exchange rate, so that the price of the medication was much cheaper than they had anticipated.

For AIDS, there were rollovers of R10 million and R15 million, which included purchase of condoms, the EU funding was channelled through the adjustment budget. The DOH had received an additional grant of R16 million, of which little had been spent as it had only been made available late last year. This money was aimed at the youth but had been made available at a difficult time of the year. September was the month that many teachers were preparing their students for exams, so school programmes had been running slowly. Also, condoms were bought internationally, but subjected to a stringent SABS test. The SABS has a bottleneck at the moment, and quality has to be assured before payment can be made, so that was the reason for the rollover.

The DOH has not done well with poverty relief programmes, and had received only R3 million from the provinces, but had heard in the meantime that another R6 million had been spent by the provinces, although had yet to receive the documentation.

In the case of conditional grants, all money had been transferred to the various provinces, the unallocated amount was meant for dental equipment and health technology equipment.

Mr Muller reported that the DOH has received a larger share of the national budget. There is now an increase in spending on international health with international health issues becoming a priority. HIV/AIDS spending has increased by R10 million. The spending on disease prevention and control has increased. The Medical Research Council is to receive more money for research, so their budget has increased from R108 211 million to R127 221 million. Medico Legal Services will receive R10 million. Conditional grants are now entrenched. No funds are available for the Umtata hospital and the province will fund the balance. The Pretoria Academic Hospital is receiving some funding at the moment as they require some money to finish a certain project.

Impact of Conditional Grants on Provincial Spending
It can be seen that the biggest increase on spending on health by the provinces is in the Free State, Gauteng, KwaZulu Natal and the Western Cape.

There is a dividing line between those who spend more than 20% on health, and those who spend less than 20% on health.

Total Provincial Budgets and Health 2001/02
Another 20% dividing line between provinces can be seen here. Some provinces can be seen to spend more than 600 per capita while the others spend less than 600 per capita. The DOH will look into this pattern of spending.

Discussion
Dr Nel (NNP) enquired about the decrease in morbidity. It was mentioned that guidelines were being developed, and Dr Nel wished to receive these guidelines in writing. He also wished to receive the recent survey on HIV/AIDS prevalence .

Ms Gouws (DP) asked how the DOH can be assured that the blood transfusions were clean. Ms Gouws raised the issue of psychiatric hospitals, she had recently heard of a story in the Eastern Cape where a psychiatric patient had come out on a weekend pass, and had not gone back into hospital. There was no follow-up and he murdered someone. The fact that the hospital was not up-to-date is a bit disturbing.

The Chairperson reminded members that the meeting was about the budget, and that the focus should remain on this.

Mr B Willem pointed out that the low health expenditure by provinces had been the trend for the last 3 financial years. He asked why there was this trend.

The Chairperson asked when the primary care health packages would be finalized and at what stage were the consultations.

Ms Matsau explained that the anti-retroviral (ARV) guidelines were only now being developed and therefore cannot release the document at this stage. The HIV/AIDS survey is an annual survey, and has been submitted already, but a copy will be sent to Dr Nel.

Ms Matsau agreed that many complaints of mismanagement of psychiatric patients had been received, and this will form part of the report. The problems were mainly due to negligence.

Packages of care in 1996 had begun ambitiously, and the DOH had thought that they would be finished within a year, but experience has shown that 3 years is necessary. Because of the consideration of resources, the package cannot be prescribed unless the resources are available. New issues always come up. Therefore a definite time could not be given. December is the deadline for debate with the different stakeholders. The DOH has asked for international help as they have not found anyone with the appropriate expertise in South Africa.

Mr Muller answered Mr Willem, and said that it was true that this trend had been around for the last few years. The National DOH prescribes that each province spends 85% of its budget on education, wealth and health. To assist the provinces, they have strengthened the national health economics unit to assist the provinces in ensuring that their budget submissions are well prepared. This has been discussed extensively with the Treasury and there is cognizance that some provinces are not spending enough of their budget on health.

Dr Chetty pointed out that the standards of blood supply have been improved through unification, as fragmentation increases costs. Blood transfusions have been monitored stringently, and over the past 6 months there have been no blood transfusion cases of transmitted disease.

Dr Chetty also pointed out that a pro forma business plan has been circulated to the provinces for any additional budget requests.

The Chairperson asked why there was no spending on poverty alleviation, is it a problem with financial management?

Mr Tlhagale (UCDP) asked about the quality of health care, he pointed out that in some cases clinics do not have medicines, hospitals are having medicines stolen, clinics are closed at night. Mr Tlhagale asked how he could understand that these services had indeed been improved.

Mr B J Mkhaliphi (ANC) asked how much money is spent on public awareness. Mr Mkhaliphi agreed with Ms Matsau that ignorance and denial remain in the communities.

Ms Ntlabathi (ANC) requested the document on medical legal services and asked if nurses would be trained in legal matters. She stated that she was grateful that gender issues would be addressed.

Ms Ntlabathi (ANC) also raised the point of international health issues, and suggested that some provinces should be involved in the formulating of policy around international health, as infectious diseases coming over their borders more directly affected them.

The Chairperson enquired about Termination of Pregnancies (TOPs) and asked why women would still use a back street abortionist. She had heard that in Gauteng apparently a health care centre had put aside a room for TOPs, but that it was just a room, no equipment and no services were available. She asked if all state institutions were adequately equipped? Otherwise the objectives of legislation were being defeated.

Ms S Ntlabathi (ANC) enquired about terminations of pregnancy, and asked if the DOH were aware of young women using TOP's as contraception.

Ms Matsau answered the point about poverty alleviation, that the DOH had engaged the auditing firm of KPMG to look at school feeding programmes in the context of the strategic framework. KPMG had looked at each province in detail, and had provided a good overall picture. They had found that:
1.There is not enough capacity in provinces, that staff are young and have no knowledge of how to run these programmes successfully;
2.There is no knowledge of business plans, so the province could not access further funding. Business plans had since been provided by the DOH, but once they had accessed the money there were no efficient monitoring of the funds. There had been corruption and mismanagement.
3. Staff were expected to take on extra tasks, as well as completing their usual work. Therefore provinces have been battling, there has been a low uptake of funds, and the programmes are open to abuse and fraud.

In terms of quality of health, the DOH has been looking at keeping clinics open at night, but the lack of security meant that their personnel were attacked.

Concerning the theft of medicines: the DOH has developed capsules that can be used with most medication, and which is able to be printed upon. The DOH plan to print "Department of Health, not for sale" on the capsule. The DOH is also looking at civil society, as some people are very willing to buy stolen medicine, so the DOH will try to reduce the market for stolen medicine by alerting the public to the dangers of buying untested medicines. The DOH want the justice system to mete out stiffer penalties for stolen medicines.

Ms Matsau pointed out that public awareness is the highest funded area of the budget. She stated that the Gender Policy Document will be made available for discussion. An intergovernmental liaison is already in place to discuss communicable diseases.

Ms Matsau said that she was not aware of the particular place in Gauteng that the Chairperson referred to, but would investigate this claim. She was unaware that pregnancy termination was being used as a contraceptive, but would investigate this claim also.

Dr Chetty said that the issue of providing legal training for nurses would be looked at, as well as improving the skills of people in state mortuaries.

Ms Gouws (DP) asked about the problem of rollover, why had the money not been spent.

The Chairperson asked about HIV/AIDS condom distribution. If the government has distributed 5 million condoms in one year, is this all that we can afford? Or is it an actual figure?

Mr Muller replied that they had not yet reached a position where the condom market is saturated, but the department is stepping up purchases and distribution.

Ms Matsau has noticed a better uptake of condoms but not enough access in some areas. Funds for condoms have grown from R93 million to R450 million.

Mr Muller has pointed out that the DG has set the task to find money and distribute more condoms.

Dr Chetty stated that condom distribution needs to be unpacked, as both males and females have a need for condoms.

The Chairperson pointed out that the condom vending machines in the toilets of the building of the DOH needs refilling.

The Chairperson asked for any other questions and answers to be put in writing as the budget debate takes place on June 12.

The meeting was adjourned.

Appendix 1:
DEPARTMENT OF HEALTH
DIRECTOR-GENERAL
Dr A Ntsaluba

DEPUTY DIRECTOR GENERAL
BRANCH: POLICY AND PLANNING
Vacant

DEPUTY DIRECTOR GENERAL
BRANCH: REGULATION SERVICES AND PROGRAMMES
Dr JHO Pretorius

CHIEF DIRECTORATE: National Health Systems
Mr VR Mabope
Formulation of National Health System Development Strategy
Allocation of Health Care Resources

CHIEF DIRECTORATE: Facility Planning and Hospital Management
Dr T Wilson

CHIEF DIRECTORATE: Health Resource Planning
Prof R Gumbi
Collection of Health Human Resource Information
Collection of Health Care Facilities Information

CHIEF DIRECTORATE: Health Information Evaluation and Research/Operational and Technical Policy
Ms N Matsau
Development and Maintenance of a National Health Information System
Library Service
Ordering of Literature
Establishment of a Minimum Dataset
Maintenance and Updating of the ReHMIS System
National Health Research
Determine National Research Requirements
Obtain Research Information

CHIEF DIRECTORATE: Registration, Regulation and Procurement
Mr B Pharasi
Registration of New Medicines
Issuing of Licenses for the Sale of Health Technology Equipment
Issuing of Licenses for the use of Health Technology Equipment
Ratification of Health Technology Equipment (Equipment Inspections)
Financial Supervision of Medical Schemes
Essential Drug List (EDL)
Monitoring of Supplier Performance

CHIEF DIRECTORATE: Disease Prevention and Control
Dr JM Van Heerden
Testing of Foodstuffs
Toxicology Analysis
Vaccine Production and Distribution Process
Procurement for Vaccine Related Production
Production of Vaccines
Distribution and Sale of Vaccines

CHIEF DIRECTORATE: Environmental and Occupational Health
Mr Sekobe
Support services for occupational health including:
occupational hygiene;
occupational toxicologywith laboratory analyses; and
technical advisory services
Compensation of curent, former and deceased miners

CHIEF DIRECTORATE: National Health Programmes
Dr GJ Mtshali
Management of a Campaign
Plan a Campaign
Funding a Campaign
Promotion of a Campaign
Monitoring of the TB Programme
Nutrition Surveillance

CHIEF DIRECTORATE: Departmental Support Services
[Vacant]
Recruitment of Personnel
Formulation of the Training Policy
Co-ordinate Management Meetings
Complaint Reporting

CHIEF DIRECTORATE: Financial Management
Mr G Muller
Payment of Accounts
Submission of Subsistence and Travel Claims
Requisition Process
Request item
Petty cash
Quotations
State contracts
Tender

Appendix 2
Our vision is a caring and humane society in which all South Africans have access to affordable, good quality health care.
Our mission is to consolidate and build on achievements of the past five years in improving access to health care for all and reducing inequity, and to focus on working in partnership with other stakeholders to improve quality of care of all levels of the health system, especially preventative and promotive health, and to improve the overall efficiency of the health care delivery system.

TEN POINT PLAN FOR 1999-2004
- Decreasing morbidity and mortality rates through strategic interventions
- Revitalisation of hospital services
- Improving human resource development and management
- Improving communication and consultation
- Reorganisation of certain support services
- Strengthening cooperation with our partners
- Legislative Reform
- Improving quality of care
- Improving resource mobilisation and the management of resources without neglecting the attainment of equity in resource allocation
- Speeding up the delivery of an essential package of services through the district health system

Decreasing morbidity and mortality rates through strategic interventions
· Promote integration of government interventions
· Expanded program for immunisation
· National Program of action
· Interventions targeting children and adolescents
· HIV/AIDS campaign
· TB program
· Malaria strategy
· Steps to reduce maternal mortality
· Strategies to address mental health and substance abuse
· Objectives to reduce chronic diseases
· Integrated Nutrition Program
· Curb violence against women
· Strengthening emergency medical services

Improving quality of care
· Strengthening Bathu Pele
· National Policy on Quality
· National Patients Rights Charter
· Complaints Mechanisms
· Clinical Management Guidelines
· Peer Review and Clinical Audits
· Mechanisms to ascertain views and expectations of users
· Program to enhance users' awareness of rights and obligations

Speeding up the delivery of an essential package of services through the district health system
· Accelerating delivery of primary health care services
Work in partnership with other sectors
Essential equipment package
EDL
Appropriately trained personnel
Community Outreach Programs
Tele-education and tele-medicine
Statement of agreement between providers and users
· Health district development

Revitalisation of hospital services
· Revitalise public hospitals
· Implementation of a national planning framework
· Comprehensive Strategic Plan for hospital development
· Hospital decentralisation
Professional managers
Incentives
- New uniform patient fee billing system
Effective Hospital Management Boards

Improving human resource development and management
· Human resource plan
· Training of PHCN and community health workers
· Transformation of training institutions
· Specialist training
· Community service
· Change in work practices
· Functional human resource information system
· Recruitment and retention of staff
· New human resource management strategy

Reorganisation of certain support services
· National Health Laboratory Services(NHLS)
· Effective Health information system
· Medico-legal services
· National Blood transfusion services
· Reorganisation of the office of Registrar of Medical Schemes

Legislative Reform
· Continue with legislative reform program
· Provinces also to pass provincial health bills

Improving communication and consultation within the communities we serve
· Strengthening of communication within the health system and between the health system and stakeholders

Strengthening cooperation with our partners internationally
- Performance targets
· Facilitate and coordinate South Africa's participation in SADC
· Expand bilateral and multilateral relations
· Facilitate and coordinate participation in international organisations
· Facilitate and coordinate donor activities
· Possible readmittance to the Commonwealth
-Priority areas for 2001/2002
· SADC
· Africa
· South-south cooperation
· Multilateral forums
· North south