Department of Health & Office of Health Standards Compliance on their 2015/16 Annual Report, with Minister present

Meeting report

The Chairperson noted that the Committee is pleased that the Office of Health Standards Compliance (OHSC) finally has its own infrastructure. 

Office of Health Standards Compliance (OHSC) on its 2015/16 Annual Report
Prof Lizo Mazwai, OHSC board chairperson, thanked the Chairperson and requested the Acting CEO proceed with the presentation.

Mr Bafana Msibi, Acting OHSC CEO, presented the entity’s performance information by programme, the annual financial report and the human resources statistics. The Office of the CEO programme has six strategic objectives. The first strategic objective was the system for certification of compliant establishment which was to be set up and functional and this objective was not achieved in 2015/16. Though the target was not achieved there was work done in the Office where they designed the Threshold for Compliance proposal which was presented to the board and now the Office is still waiting for the promulgation of the regulations so that it can be adopted as a formal certification process. The second performance indicator was systems and procedures for timely enforcement action which was to be set up and functional. The Office was not able to reach the target, however work has been done at the Office where an enforcement policy was developed which was presented to the board and the Office is waiting for the promulgation of the regulations so that it can be approved. The third objective which the Office was unable to achieve is the system and procedures for communication and monitoring of Ombud recommendations. By the end of 2015/16 there was no ombudsman within the Office, however the ombudsman has now been appointed and started in June 2016.

The Office was able to achieve a few performance indicators. The first indicator dealt with a number of media communications, campaigns and events to increase the awareness of the Office amongst the public, the providers and stakeholders. The Office exceeded the target and conducted eight media and communication events in most areas of the country. The second achievement was the number of Memorandum of Agreements (MoA) which regulates the Office to protect and promote quality and safety. The Office exceeded its target and has signed two MoAs which allow it to collaborate with other regulators and other stakeholders. The last achievement within the Office of the CEO programme is the number of reports on inspections conducted, recommendations and compliance status. As part of the achievements the public is now more aware of the existence of the Office and its mandate to promote the quality and safety of health care users because of the media coverage on the role and powers of OHSC.

There is some work that is in progress at the Office which involves:
• Systems to certify compliant health establishments (HE’s) which has been finalised and the Office is now awaiting the promulgation of the regulation, but within the Office the system has been finalised.
• The Boards Certification and Enforcement Committee agreed to the Compliance thresholds on the IT system that require timeous reporting for decisions on certification of compliant health establishments (HE’s).
• A draft enforcement policy was developed during the first quarter of 2016/17 and presented to the board. OHSC is awaiting the promulgation of the regulations in order to finally approve the enforcement policy.
• The system to determine compliance will be installed once the IT system required for certification has been acquired.
•  A system functionality proposal that supports timeous decisions about certification was presented to the board for approval and the Office is now waiting for the promulgation of the regulations.
• The monitoring of Ombuds recommendations has commenced shortly after the Ombuds was appointed.

The Office of the CEO programme experienced a few challenges, one of them being the functionality of systems to certify health establishments and enforce measures against non-compliant health establishments as it depends on the regulations. The Office is currently unable to certify health establishments until the  promulgation of the regulations. The second challenge is similar to the first one where enforcement policies cannot be implemented because the regulations are not promulgated. Lastly the Memorandum of Agreements with relevant institutions will further the mandate and objectives of OHSC, which is a new indicator will be effected in the new financial year. The process has already begun for the new financial year but the Office is still experiencing some challenges with the South African Nursing Council in finalising the MoA. OHSC has referred the matter to Dr Anban Pillay, the Deputy Director General of Health Regulation, for assistance in facilitating the discussions with the Council.

The Corporate Services programme has three strategic performance objectives that the Office had to achieve, the first being the appointment of the 60% funded staff. The Office exceeded its target and appointed 92% and this included the staff transferred from the National Department of Health (NDoH). The Office had a planned target of achieving an unqualified audit report which was achieved although the Auditor General raised some Findings. The third performance indicator was having the IT system in place and functional because the Office started from scratch and this has been partially achieved. Within the Corporate Services programme, OHSC has been able to achieve 88 of the 96 funded posts with positions filled at the end of March 2016. NDoH transferred 41 of its employees to OHSC to provide support for the transfer of its compliance inspection function to OHSC. The Office managed to recruit about 47 employees directly through the OHSC recruitment drive. As a new public entity the Office developed and implemented the necessary policies, procedures and systems to ensure compliance with the requisite regulatory frameworks. During the year under review, the primary focus of the Office was on installing information systems for finance and accounting, procurement, payroll administration and assets and inventory management which the Office achieved. OHSC continued to use the district health information system (DHIS) during the review period and the system helped the Office with inspections and identifying risky health establishments.

Challenges for the Corporate Services programme include inadequate office space for OHSC for the fast expanding organisation because it is currently housed at the Medical Research Council in Pretoria. The space is not enough for the Office given the number of staff members and processes are being followed by the Office to get a space that will permanently be used by OHSC. The scarcity of health professionals with specialised skills led to the re-advertising of some posts but met with no success. The critical need for IT systems to manage complaints and compliance inspection was not met, as the procurement of both was included in OHSC Line-of-Business Solutions (LOBS) tender that was cancelled by the NDoH. However work has begun in the field to ensure that there is a system for complaints management and for compliance inspection.

In the year ahead OHSC will obtain enough office space to cater for a growing organisation and headhunt specialised health professionals where the traditional recruitment methods are unsuccessful.

The Compliance Inspectorate programme whose purpose is to manage the inspections of health establishments to assess and encourage compliance with national health system norms and standards as prescribed by the Minister and take measures to ensure such compliance. OHSC managed to achieve most of its strategic objectives. The first one was the percentage of public centre clinics, community health centres (CHCs) and hospitals inspected annually by the Office and the target was exceeded. The second was the percentage of provisional non-compliant health establishments subjected to re-inspection or review within six months and this was achieved. The requirements and procedures for the accreditation of the inspectors were approved by the board in January 2016 and the inspectors will all be accredited. The Office is currently running a programme of training inspectors where a curriculum has been developed and also approved by the board. In this programme OHSC achieved a number of its targets, one being exceeding its inspection and re-inspection targets by 3% and 5% respectively. The implementation of Standard Operating Procedures (SOPs) has supported the well-planned and rigorous inspections.

Challenges within this programme included the non-promulgation of regulations and inadequate resources which made it difficult to exercise enforcement powers and inspect 25% of private health establishments as mandated by the National Health Act. Additional funding is required for resources to meet set targets within the inspectorate. The process of re-inspections increased the number of inspections significantly and impacted on resources which could have been directed towards routine inspections. The tender for a service provider to design the curriculum for inspector training was re-advertised without success.

The OHSC appointed inspectors and senior inspectors to increase the capacity within and the number of inspection teams from five to eight in order to deal with the inclusion of private health establishments under the awaited promulgation regulations.

The Complaints Management (and Ombud) programme serves a purpose to consider, investigate and dispose of complaints about non-compliance with prescribed norms and standards in a procedurally fair, economical and expeditious manner. The Ombud’s functions have been integrated into the strategic objectives as an Ombud is functionally located within the OHSC as per legislation. The planned call centre was not able to be achieved in 2015/16. However, the Office started the procurement process towards the end of the financial year and is now in the final stage to be able to implement the call centre within the next 30 days. One of the targets was the percentage of complaints lodged with OHSC to be resolved within six months. This particular target was not achieved as it targeted to resolve 50% of the complaints but only managed to achieve 45%. The major contributory factor for this was that OHSC received a lot of complaints related to the private sector and when OHSC tried to engage with the private sector they were informed that they do not have regulations and therefore cannot try to force them to cooperate. The system and procedures for investigation of complaints was set up and the target was partially achieved and OHSC is currently awaiting the promulgation of the regulations to finalise the system.

Two of the targets for the Complaints Management (and Ombud) programme were partially achieved and some not achieved. Their underachievement was due mainly to the delays in promulgating the procedural regulations to investigate the healthcare norms and standards as well as establishing a call centre. While some progress occurred within the setting up of the call centre, the appointment of a service provider to install the system will be completed only in the first quarter of the new financial year. The majority of complaints received were about private sector health establishments but OHSC is waiting for the promulgation of procedural regulations which will empower OHSC to investigate and enforce action to remedy non-compliance.

The last programme is the Health Standards Design, Analysis and Support and its purpose is to provide high-level technical, analytical and educational support to the work of OHSC in the development and analyses of norms and standards and support for their dissemination. Its achievements are as follows:
• A key milestone was the revision of regulations based on stakeholder comments.
• State law advisors reviewed the revised regulations, which were submitted to the Minister and are awaiting approval and final promulgation in the Government Gazette.
• The OHSC undertook provincial visits to eight of the nine provinces and carried out risk-based inspections at four health establishments that were identified through early-warning systems (EWS) reports.
• OHSC inspectors also piloted a facility profile tool intended for use by health establishments to submit their annual data. The pilot process helped to refine the tool for seamless transition for when the system is in place and regulations promulgated.

The delay in promulgating the regulations also delayed key processes, such as extending guidance and support to the relevant authorities for health establishments in the private sector. The installation of the IT system for the EWS real-time reporting process will be finalised in the new financial year and could not be comprehensively tested. The Greenfield nature of the work done by the Health Standards Design, Analysis and Support programme required staff with scare high-level technical and analytic skills and despite being re-advertised, the key senior management positions remained vacant. The Office was able to fill the positions in this year.

In the forthcoming financial year OHSC will fast-track the development of the EWS and the annual data submissions system to ensure a seamless transition once the regulations are promulgated. The relevant authorities will be identified from health establishment submissions and guidance and support visits will be scheduled to the relevant authorities. The comprehensive framework for the early-warning systems (EWS) will also be tested with sample health establishment data to ensure its readiness for implementation.

The Chief Financial Officer of OHSC, Mr Julius Mapathato, present the finances of OHSC.

The OHSC received an unqualified audit outcome from the Auditor General but there were material findings which were subsequently corrected. These include: property, plant and equipment, service bonus provision, related party transactions, loss of transfer of functions, process for the procurement of office space and the calculation of a performance target. The OHSC realised a surplus of R26.4 million. The reason for the surplus is that recruitment happened throughout the financial year which meant that while the recruitment process was taking place, OHSC accumulated savings on a monthly basis. In addition there were crucial positions such as the CEO and the Ombudsman which remained vacant throughout the financial year. The process for the procurement of the call centre will be finalised in the new financial year and so there were some savings acquired from that. Additional savings were realised in the administrative expenditure such as telephone costs, computer maintenance, audit fees and office lease which were lower than OHSC had anticipated. The Office has since made a request to National Treasury which has approved OHSC retain the surplus to be used for items such as ICT infrastructure and furniture for the new space.

The Chairperson invited Prof Mazwai to comment before opening the floor to the Committee. Prof Mazwai requested he make general comments later in the meeting because the Chairperson mentioned that the Committee would like to be empowered. He acknowledged that the Portfolio Committee has all the power politically but there needs to be some information shared regardless of the power.

Discussion
Mr T Khoza (ANC) thanked OHSC and mentioned that he was confused as to whether the Ombud has been appointed. What are the strategies for the recruitment of health professionals since the re-advertising was not a success. It seems as if OHSC has a serious challenge for its performance if it struggles to fill the vacant senior management positions. He asked for a timeframe of when the call centre will finally be established.

Mr S Jafta (AIC) commented that his main concern has always been the inequality that seems to persist which disadvantages society together with the institutions. People living in rural areas are the ones who get disadvantaged the most and that gap still exists where you find that the facilities in rural areas are understaffed and lack resources. How does OHSC see that gap and what do they think can be done to get rid of the gap. Of the many health facilities inspected, what were the main improvements found in these facilities on reinspection?

Mr H Volmink (DA) addressed the regulations which he referred to as the elephant in the room. He asked what the developments have been so far because the draft regulations were submitted about ten months ago and it is not fair to blame OHSC for the delays because it has done its job of submitting the draft. He congratulated OHSC on its audit outcome but OHSC as well as the Committee does need to pay attention to the findings of the Auditor-General. He asked about the process of correcting the challenges with the Memorandum of Agreements, especially with the South African Nursing Council. A question on office space was raised where clarity on the budget allocated for the new office space was sought. It is sad that the Ombud was not present at the meeting because the Ombud plays an important role and it would have been good to get an update on the investigations and receiving a timeline. It would have been good to hear an update of the investigations on the 36 patients who died in Gauteng as well as developments in the investigation of the patients at Bongani Hospital in the Free State.

Ms C Ndaba (ANC) commended OHSC for receiving an unqualified audit opinion from the Auditor General. A clear indication of the number of complaints instead of percentages would be appreciated by the Committee and she asked OHSC to give an example of some of the complaints raised because it is not clear what kind of complaints they receive. It seems as if the establishment of the call centre will happen in the next financial year and giving a 30 day promise is not practical because it does not look like it is going to happen and OHSC needs to be realistic. OHSC needs to act fast now that it has filled most of its vacancies and is confident with its inspectors' capabilities so that they can solve the non-compliance in the health establishments of the country before the country’s health system collapses. It is unacceptable that OHSC reports that they were unable to address the complaints raised by people using the private sector because of the regulations. She suggested that OHSC moves fast on the regulations because she does not understand why the approval of the regulations is delayed. The Committee members expect OHSC to comply and to meet its targets when it sets them because OHSC cannot be a compliance office then fail to comply itself. That would mean that OHSC does not follow its own mandate and it is important that OHSC leads by example. OHSC needs to provide the Committee with a timeframe of when it intends to conclude the appointment of the CEO.

Dr P Maesela (ANC) mentioned that the inadequate space should be resolved because it would be a case of letting money going down the drain if the office keeps renting in the long run. In terms of progress made with inspectors, what is the exact number of inspectors that the office intends to train, how many inspectors have been trained so far and when is the training process going to be completed. Another question was how many health facilities have been inspected in 2015/16 and if there are any could a report be provided so that the Committee can discern a pattern of repeat offences and also the Committee could have the report in mind when it is conducting oversight. The Committee almost evacuated Bongani Hospital and fortunately some evacuations were made before the Committee arrived. He went on to mention that the hospital was in no condition to house patients and the smell itself could have killed the patients. Does OHSC intervene between health care facility users and private medical schemes because this has become a multifaceted problem which needs to be tackled from different perspectives and by different role-players.

The Chairperson asked about the province that was not visited by OHSC and the reasons for the failure to visit. How many districts was OHSC able to visit within the eight provinces it visited. The Committee needs to have an understanding of what has been done by OHSC and which districts it has visited to avoid the idea that there is a disjuncture between the Portfolio Committee and OHSC. She also asked what kind of complaints were raised by communities. Why does the company still have an acting CEO instead of a permanent CEO. She agreed that the report given by OHSC is too technical and does not provide exact details of the complaints raised.

Prof Mazwai requested to be the first person to reply and set the tone. The Office has discovered that there are certain constraints about its mandate in very diverse countrywide environment which tends to restrict them in inspections, certifications and dealing with complaints. OHSC has come to a somewhat complex environment making it difficult to execute its mandate. The delay in the approval of the regulations is extremely frustrating because OHSC is to some extent unable to perform its work. OHSC proposed two sets of regulations, one being the norms and standards regulations and the other being procedural regulations. The problem OHSC experiences is around the norms and standards regulations. The request for public comment was first put out in February 2015 and in May 2015 the comments were received and it took OHSC six months to have everything ready to present to the Minister. When no progress was apparent, OHSC began to ask the Department of Health about the delay and the response was that the National Health Council was not happy about the norms and standards and OHSC was not given specifics on what it was not happy about. The OHSC board arranged a special meeting with the NHC Tech where the board was informed of what exactly the council is not happy about. As a result the Director General stated that she wants to have the matter resolved because there is a disagreement between OHSC board and the NHC about how the regulations should be structured. The Director General invited an external WHO team to help resolve the matter. The WHO team is in the country and has met with Department of Health and some of the board members where they tried to resolve the existing differences about the norms and standards regulations. He believes some progress has been made and there is now a task team which consists of OHSC board members, NDoH and the WHO team to try and sort out the differences. The Minister is not unhappy with the procedural regulations, but is with the impact of the norms and standards regulations.

He explained that the Ombud is appointed by the Minister and when OHSC was recruiting, the Minister was looking for a person who would have the gravitas, power and understanding of the system. The Ombud is still finding his feet in OHSC and following the tragic death of the 37 people in the Gauteng mental institution, the Ombud has been appointed to lead the investigation and has reported to the OHSC board chair that he has set up a team that will advise him.

OHSC has had one Memorandum of Agreement with the Department of Health to specifically deal with the transitional issues such as the staff, furniture and all other activities including procurement. In the first year of OHSC’s existence, it used the Department of Health’s systems and that had problems of its own, one of them being the staff from NDoH refusing to join OHSC.

During the first year of OHSC’s existence, the board agreed that it will hire an interim CEO and afterwards advertise the post. The Office thought that they had identified the right person and the Minister did not concur with the recommendation and so OHSC had to go back to the drawing board. The Office advertised the post once again but was not able to find a suitable candidate until the Office advertised the post for the third time and found a suitable candidate who the Minister was not happy with for his own reasons leading to no concurrence. There is great difficulty in South Africa in finding people of the calibre that OHSC needs and the Minister requires OHSC to have.

Prof Mazwai said the Office believes that through inspection it will be able to pick up cases such as inequality in the health facilities and poorly performing institutions in rural areas. There are instances where people are afraid to complain because they have been so used to suffering. If they come and stay at the clinic for a full day they are grateful for having being served instead of complaining about having been there the whole day. He explained that OHSC was compelled to use the template that they have used for the report and he is aware that there needs to be a lot more detail about the complaints.

The Chairperson suggested that the Committee discusses some of the issues raised by OHSC with the Department of Health in the afternoon session.

Prof Martin Koscos, OHSC board member, addressed the matter of the deadline to get the call centre up and running and assured them that the call centre will be open in 30 days because OHSC has now signed contracts with a service provider and will soon give the Committee the number to call in order to launch a complaint.

Ms Thembeka Gwagwa, OHSC board member who serves in the HR committee, agreed with the idea that they need to empower each other because the board members are also anxious of the collapse of the country’s health system. Trying to keep the health system of the country in good condition is not in the hands of OHSC only but in the hands of all bodies rather than competing with each other. She agreed that the template of the report is not good however the template was imposed on them and they were informed that if it do not use the template they will receive a qualified audit opinion. The issue of dealing with the inequality is not the job of OHSC because the problem with the phenomenon is that it is not just money that is a factor. People do not want to go and work in rural areas because of the poor quality of accommodation and schools in the areas and these are issues that OHSC cannot deal with.

Prof Ethelwynn Stellenberg, OHSC board member, said that it was really excited when the regulations were submitted to the Department of Health. Employers have a responsibility to empower their staff with reference to any regulation or policy pertaining to health establishments and no member should claim to not know what is going on if they work in the health sector. It is a failure from the Department that any regulation old or new is made unaware to employees in the health sector. It is important that employers empower their staff on what is expected of them and what new developments have come up in the field. The Office was not aware that they had to provide the statistics in the presentation because they did not think that they would discuss them. The Office was under the impression that it will produce a full report of the inspections and the early warning system in the next meeting with the Committee.

The Chairperson replied that it can never be the responsibility of the Department of Health to ensure that workers are aware of regulations and new Acts, that responsibility rests on the employee. She warned Prof Stellenberg not to portion blame to the Department of Health because leaders in the department have their own responsibilities.

Prof Mazwai then handed over to the Acting CEO so that he can address some of the questions raised.

Mr Msibi said the province that was not visited by OHSC is North West and this is because there was no response from the province when OHSC tried to communicate with it to set up a visit despite several follow ups. In 2015/16, OHSC inspected four central hospitals, nine community health centres, 566 primary health care clinics, 27 district hospitals,12 provincial and tertiary hospitals and 9 regional hospitals making a total of 627 inspections. Out of the 627, it revisited 132 facilities and these were facilities that it considered to be high risk and so re-inspected. The Office will return to the Committee and provide a detailed report on the inspections. The majority of complaints related to attitude of staff members and long waiting periods.

Ms Ndaba commended OHSC on its dedication and it is clear that OHSC is passionate about serving people and she is confident that it will transform the health system of the country.

Prof Mazwai expressed appreciation for the manner in which the Committee has treated OHSC and the advice as well as compliments given to it.

Afternoon session
Department of Health (NDoH) on its 2015/16 Annual Report
The Chairperson welcomed the Minister of Health and mentioned that the Committee will be visiting all entities under the Department of Health and will also visit the department when they conduct their constitutional duty of oversight as the Committee. The Chairperson mentioned that the Committee has received quite interesting presentations this week and invited the Minister to address some of the issues that were quite prevalent such as the OHSC regulations, the appointment of the Ombuds, the Registrar and issue of space for the OHSC office.

Minister of Health Aaron Motsoaledi asked if he could address the business of the entities before the presentation on the Annual Report. The Minister asked Dr Humphrey Zokufa, the representative from the Board of Healthcare Funders to recuse himself since he is involved in one of the questions raised. The question on the appointment of the new registrar is an issue of conflict of interest. He mentioned that he is not sure of where the conflict of interest is exactly. On the relationship between the Ombuds and OHSC board regarding accountability, the Ombud is a Chapter 9 institution who is to be given as much autonomy as possible. The Ombuds person is resident in OHSC and reports to the CEO regarding administration, the budget and regulations. However the Ombud is an independent person and people can send complaints directly to him and not first go through the OHSC. The Office can also go to the Ombud to report on findings from its inspections and seek guidance and ruling from the Ombuds. The Minister mentioned that he met with OHSC and it did not raise this matter but will meet with it again to get clarity on what the issue is exactly. The CEO matter is a matter of exercising caution because the Minister has mentioned to the Committee a number of times that one of the leading problems in health care is that Human Resources are appointing unsuitable candidates for positions and he assured the Committee that that will no longer happen. It is extremely difficult to find someone suitable for CEO positions in the country. With the last candidate, the Minister mentioned that the candidate was previously interviewed for a lower ranked position in the Department and did not get hired and so the Minister saw no reason why they should appoint someone who could not secure a low job position as the CEO of OHSC.

Ms Ndaba welcomed the response from the Minister and mentioned that the reason for not appointing the CEO for OHSC office is understood because OHSC cannot appoint someone who is not fully suitable for the position. It is extremely critical for the regulations to be finalised so that OHSC is able to perform its mandate without any restrictions.

The Minister apologised about the regulations because there was a miscommunication within the Department which was discovered in the week of 9 October 2016. There are two sets of regulations which should be passed and some junior officials were under the impression that the regulations should be kept until all grey areas are addressed and that the regulations cannot be published separately. The Minister signed those regulations in August and the Director General was under the impression that everything was on par. It seems as if OHSC is under the impression that the Office the HODs of provinces want to water down OHSC regulations so that they do not get inspected with tough standards. The Minister assured the Committee that that will not be the case and will never be allowed.

The presentation on the Annual Report then proceeded. The purpose of the presentation was to reflect on achievements and highlight areas were there has been some challenges and what improvement strategies will be put in place to address them. There are six key programmes which link to the Medium Term Strategic Framework 2014-2019.

Administration programme: The key achievement is that the vacancy rate has been reduced from 6.6% in 2014/15 to 3.5% which is below DPSA’s target of 10%. The turnaround time for recruitment was also well within the DPSA benchmark of 6 months. NDoH has for the past five consecutive years obtained an unqualified audit opinion. In terms of the strategic objectives , the target was to have induction wellness programme for health employees for provinces which was achieved. The target to ensure that all senior management of the Department are able to access the domain services outside the department premises at the disaster recovery site has been achieved. The strategic objective to have a National Health Litigation Strategy developed and fully implemented was achieved.

The Department measured itself against a stringent four month target for recruitment; however the DPSA target in public service is six months. NDoH met the 6 months target, though there were challenges in meeting the four month target. NDoH has engaged the institutions responsible for the prerequisite verification of qualifications of selected candidates in order to improve the process. On performance agreements for Senior Management Service (SMS), 95% of Senior Management Service managers signed performance agreements with supervisors within the stipulated three months. Three SMS managers signed the agreement after the three month deadline. In 2017/18, the Department aims to have a target of 100%.

Health Planning and Systems Enablement programme: Achievements included the publishing of the White Paper on the National Health Insurance on 11 December 2015 as part of the public comment process. In addition, the Minister established six National Health Insurance work streams staffed by the Department and external technical staff to support work on the phased implementation on National Health Insurance. These six work streams will develop recommendations on implementation and phasing, focusing on, but not limited to: What financing is feasible; legal and regulatory environment; governance; standards for providers; building capacity; operational requirements; beneficiary indication and enrolment; how providers are organised; determining the provider payment method for the different levels of care.

There were 150 comments on the White Paper by the end of May and the next step is to have the legislation drafted. In terms of sector-wide procurement, a total of 396 567 patients have been enrolled on the Central Chronic Medicine Dispensing Distribution (CCMDD) programme. This programme has greatly reduced the need for patients to wait in long queues in facilities for the collection of chronic medicines and has also reduced the cost of travel and time off work for patients because they can now collect them in sites closer to home like churches, city halls and Clicks. The implementation of Electronic Stock Management System (ESMS) for early detection of medicine stock-out increased from 39 hospitals in 2014/15 to 52 hospitals in 2015/16. ESMS was implemented by 1 869 primary health care facilities. One of the strategic objectives of the programme was to implement the strategy to address Antimicrobial Resistance (AMR) which was achieved because the strategy was developed. The Department has gone a long way to improve the management and control of pharmaceutical services and the targets set for 2015/16 were achieved.

Another key project under Programme Two is the implementation of the Patient-Based Health Information System at primary health care facilities. This system aims to provide patient registry and master patient index using the South African Identity book and other forms of legal identification like passports and residence permits in the case of foreign nationals. The first phase of the project has been completed and is in 657 facilities. In 2014/15 hardware was purchased which was then dispatched to the relevant facilities in a number of districts beyond the NHI districts thus paving the way for operational implementation in addition to 1 400 facilities and therefore the target has been met. NDoH has also in the meantime worked with the Department of Telecommunications and Postal Services so that they become aware of the list of facilities which still do not have access to broadband connectivity which is obviously a challenge. This particular programme has a research project where NDoH is currently doing a South African Demographic and Health Survey which will be providing data to track progress in the health system performance as well as outcomes. What makes the survey even more important is that it forms the base-line for the Sustainable Development Goals. Within this programme there is a National Health Scholars programme (NHSP) which aims to provide Masters and Doctoral scholarships to develop young health researchers in South Africa. Since the launch of NHSP by the Minister there has been a total of 72 students enrolled and now six students have graduated.

There is also a project called the National Health Research Committee which is led by the development of the draft Integrated National Strategy for Health Research 2016-2030 and this plan addresses four key functions of an envisaged health system. These functions include sustainable financing of health research, strengthening human resource capacity, the development of infrastructure to conduct health research at all levels of the national health system, and effective translation of research findings into policy, programmes and practice.

HIV and AIDS, Tuberculosis, Maternal, Child and Women’s Health programme: This is a key strategic programme dealing with the main key indicators that show how the country is moving not only in terms of health but overall social and economic development which is integrally linked to performance on indicators related to maternal and child health. The life expectancy of South Africans has been steadily and consistently improving which is an achievement, the increase has been from an estimate of 61.0 years in 2013 to 62.4 years in 2016. Under-five mortality declined from 41 per 1000 live births in 2013 to 39 deaths per 1000 live births in 2014. Infant mortality rate has declined from 29 deaths per 1000 live births in 2013 to 28 deaths per 1000 live births in 2014. The only rate which did not show a decrease is neonatal mortality which remained stable at 11 deaths per 1000 live births between 2013 and 2014 and NDoH has found that they are recently failing to meet their target with tackling neonatal deaths and they are putting something in place to address this. The maternal mortality ratio has decreased from an estimate of 166 deaths per 100 000 live births in 2012 to 155 deaths per 100 000 live births in 2013. The targets to reduce mortality rates have been achieved. The only target which was not met was the neonatal death rate and the findings are that the main causes of the deaths are asphyxia, infections and prematurity.

The Department is proud to announce that since the introduction of the HIV Counseling and Testing (HCT) campaign in 2010, over 44 million people have been tested. For 2015/16, 11 898 308 people between the ages of 15 and 49 years were tested for HIV. The departments also distributed 839 870 752 male condoms and 27 005 805 female condoms against annual targets of 700 000 000 male and 16 500 000 female condoms respectively and have exceeded their target. There are still some challenges with clients remaining on Antiretroviral therapy but the department is not doing too badly on their target and programme data also shows that there are fewer infants infected with HIV. The child under five years diarrhoea case fatality rate was 2.2% compared to the annual target of 3.20%. The target for children under five years pneumonia case fatality was also achieved where the rate was reported to be 2.3% against the annual target of 3%. 93% antenatal clients were initiated on antiretroviral therapy against the annual target of 88%.

Primary Health Care Services (PHC) programme: This has had some key achievements. The ‘Ideal Clinic’ initiative was established in July 2013 as a way of systematically reducing the deficiencies in primary health care facilities in the public sector. As of the end of March 2016, there was a cumulative total of 322 facilities qualifying as ideal clinics. The Municipal Ward-based Primary Health Care Outreach Team (WBPHCOT) programme has been expanded during 2015/16 and as of the end of March 2016, there were 2 590 functional WBPHCOTs, which is an increase of 842 teams from a baseline of 1 748 in 2014/15. The Department also had Port Health Services successfully transferred as of 1 April 2015 from the Provincial Departments of Health to the National Department of Health in line with provisions of the National Health Amendment Act, 2013.

The National Hand Hygiene Behavior Change Strategy was developed and finalised. The rollout of national hand washing campaign was kick-started in Reimollotswe Primary School in collaboration with Departments of Basic Education and of Water and Sanitation. In 2015/16, attention was also paid to promoting healthy eating in the workplace and in Early Development Centres. Regulations put in place on health care waste management in health establishments which were approved by the Minister on 13 May 2015 but have not yet been gazetted. The regulations cover various aspects of health care waste and are applicable to both private and public health establishments but exclude radioactive, electronic and animal waste. The Department is proud to announce that South Africa was presented with the African Leaders Malaria Alliance award for achieving the malaria goal of the Millennium Development Goals at the African Leaders Malaria Alliance meeting for heads of state of the African Union in January 2016.

Another key achievement was looking at reducing risk factors and improving management for non-communicable diseases which are a becoming a big problem and NDoH has exceeded its target against this strategic objective, in particular with people screened for high-blood pressure and blood glucose. Salt is a big problem and NDoH has fallen short in monitoring salt content even though they have purchased materials so that lab tests on salts can be performed. Unfortunately there was a problem with the shipping of the chemicals which led to failure in reaching the target. With disability services, NDoH had a target framework for the implementation of rehab services for the country but a change of approach was necessitated and the consensus was that there needs to be more monitoring of the readiness of provinces to implement the framework and whether there are resources in place to do so.

Hospitals, Tertiary Services and Workforce Development programme: In this programme the Department has had 1 000 facilities benchmarked against primary health care staffing normative guides. A coaching, mentoring and training programme for health managers has been developed and is now being implemented. Good progress has been made in various health facilities regarding infrastructure projects where 177 facilities were maintained, repaired and or refurbished; and 81 facilities upgraded and the target was achieved. The Department has also achieved its target of having clinics and community health centres constructed and revitalised against the 2015/16 target of 35, the achieved target was 49. 16 140 food tests were performed against the 2015/16 target of 4000 tests. There were some challenges with the number of gazetted tertiary hospitals providing the full package of tertiary services. The target was to have four additional tertiary service hospitals but it managed to achieve none, largely because these hospitals do not have specialists to provide full services.

Health Regulation and Compliance Management programme: It has achieved a number of targets and the department has been working hard under the programme. The Department met its target to establish the South African Health Product and Regulatory Authority (SAHPRA) as a public entity. Also the target to establish the Institute for Regulatory Science providing training was achieved. One of the key strategic objectives was looking at occupational health and compensation services through the development of one-stop service centres and NDoH has managed to get local organising committees established in two districts to support the process of setting up one-stop service centres. The objective is still in progress and has not yet been achieved. The Institute for Regulatory Science will be implemented as part of SAHPRA.

Financial report: NDoH CFO, Dr Ian van der Merwe, noted the Department achieved a 99.4% total expenditure and most of the programmes were within the 2.5% norm that is normally set for expenditure. In terms of economic classification, the Department spent all the funds on compensation, 85% on goods and services, all funds were transferred to provinces as well as all the funds to NGOs and where the funds have not been transferred to NGOs it is because of the organisations failure to submit their financial statements that could satisfy the service level agreement. It is the first time that NDoH has had an expenditure of 99.4% regarding capital as it was normally lagging slightly behind.

The Minister said that he would like to clarify a few points before the Committee comments on the presentation. The electronic stock management system has been established in all the clinics in South Africa. The central chronic medicine dispensing system has increased and more and more people in the country are now receiving their medicine at home. If NDoH plans to reduce the neonatal fatalities it requires a number of highly specialised nurses because there is a very high rate of premature baby mortality as well as neonatal mortality. If babies are dying because of asphyxia, NDoH needs highly trained nurses who are going to ventilate the baby. The problem is that once the nurses have been trained they get rotated once they become very good. The Department intends to have specialised nurses remain in positions and not rotate them until the nurse retires but has not yet made up its mind on the matter given that it is also important for nurses to specialise in a number of areas. The success rate around the treatment of Multi-Drug Resistant Tuberculosis is at best 40%. The Department has introduced a new and extremely expensive drug called Bedaquiline and 60% of people who are on the drug globally are in South Africa. The Minister said they believe that the drug will help fight MDR-TB and that is why that have prescribed it to a lot of people regardless of how expensive the drug is.

Discussion
Mr Volmink mentioned that he recently had the privilege of visiting the Nelson Mandela Children’s Hospital in Johannesburg and walking around the hospital was a great experience. After speaking to the CEO of the hospital and the team he was informed that there were certain commitments with regards to the operational expenses at the hospital that had been made by the Minister of Health as well as the Minister of Finance. They have raised the capital through donations so because the hospital is not technically a government hospital but is a hospital which symbolises what the department is part of. He has not seen any indication in the report that shows the commitment made to the hospital in terms of expenditure. He noted the Auditor-General’s finding looking at the Health Sector of R7.7 billion of irregular expenditure which has pained all members in the Committee as this is an astronomical amount. That money could be used to employ thousands of health care workers, or used to pay 32 000 bursaries for three years for students. It is not acceptable to have that amount of money lost on the Committee’s as well as the Department’s collective watch. What can be done to ensure that a case like this does not happen again?

Ms Ndaba congratulated the Department for receiving an unqualified audit outcome opinion. There is a problem with regression in terms of financials for Limpopo and North West provinces. What plans does NDoH have to assist the provinces? It is important that the National Department looks into this. The Department was commended for its Test and Treat programme for HIV because there is good feedback from communities. There should be monitoring of the programme’s progress in all provinces. She agreed with the Minister not to rotate nurses and suggested that even ICU nurses should not be rotated. The Committee noted on an oversight visit to the Free State where there is a hospital where nurses train for ICU specialisation, who after receiving training, leave the country and work abroad. A concern was raised about the NHLS regarding the high failure rate of medical technologist training. It is not that the students do not know what they are doing but the medical examination board for medical technologists has been a problem for quite a while. She asked who appoints the examination board and there is a need to review the board and decide whether to disband the existing board and establish a new one. It is important that new board members are appointed so that there could perhaps be a change in inclusion, giving a black child the opportunity to pass the assessment.

Dr Maesela asked why the lack of skills contributes to child mortality because skills can be acquired, and if that is the case, then the skills should be acquired to solve the mortality issue. The Department has reached its target of distributing male and female condoms but there is still an increase in infections and this shows that there is something that is not being done right. He suggested that Committee and the Department let go of theories that try to explain the increase of infections and have a look at what it is that can be done to combat the spiking of infections because the country cannot keep throwing money on condoms and advertisements when the infection rate is still rising. In terms of children dying of pneumonia, perhaps there are factors that influence mortality such as socio economic factors which need to be looked into and find out what causes children to be vulnerable to pneumonia. He asked if the HPV vaccine is universally available and where it is manufactured.

The Minister asked him to explain is question about the HPV vaccine because the Department has never complained about the shortage of the vaccine.

Dr Maesela clarified he wanting to find out if the vaccine is imported because if vaccines were to be manufactured locally it would be easier and much cheaper to access them. On the unavailability of chemicals to check salt content in food, he sought  clarity whether the source of the chemicals is unable to supply the required quantities or is it another reason.

Mr Khoza commended the Department on the informative presentation and congratulated NDoH on its audit outcomes. He encouraged the Department to move from the comfortable position of an unqualified audit with findings to a clean audit opinion for a change. The Auditor-General highlighted some weaknesses regarding the reliability of data and he asked if NDoH has strategies to improve the weaknesses and if they could list the strategies if they exist. The issue of health professionals leaving the health system is a serious problem. Does NDoH have plans to ensure that the skills of these health professionals are retained?

Ms D Senokoanyane (ANC) asked for clarity on the development of programmes such as the implementation of the HIV testing and treatment strategy because NDoH must have had programmes and strategies that sought to perform the very actions that these programmes are developed to perform. She asked if these strategies were developed from scratch or edited versions of prior action plan strategies.

The Chairperson mentioned that when the Committee visited the pilot ideal clinics to conduct oversight they picked up a few challenges such as shortage of staff members where health workers multi-task. At all the ideal clinics visited by the Committee, only one ideal clinic appeared to be operating smoothly which is the ideal clinic in Soshanguve and it needs to be upgraded into a community health care centre. Sexual transmitted infections can never be the responsibility of the Department of Health, it is everyone’s responsibility including parents. She went on to suggest that the Department of Health could work together with the Department of Basic Education because it is unfair to blame and make the Department of Health account for a contemporary societal issue. She asked about the impact of the ‘Fees Must Fall’ protest and what its impact will be in the years to come. The South African Medical Research Council reported on the decline of cancer of the esophagus and have attributed the decline to the tobacco restrictions which were implemented by Honorable Nkosazana Dlamini Zuma.

The Minister addressed the question about the Nelson Mandela Hospital and said that it is the first time that the country has an entity of this nature where a hospital was not built by the state but is public. At some stage the hospital was planned to be run as a private hospital which posed a threat because disadvantaged parents would not get an opportunity to take their children to the hospital. The Minister mentioned that he just received a message from the MEC that NEHAWU has burned part of an administration block at the Kimberley Hospital because they want the HOD of the hospital to go. The MEC called him while he was in the meeting and he has immediately shared this with the Committee members. The Premier of Kimberley told the Minister that he would like to improve the administration department and was going to do so by appointing a new Head of Department that will improve the finances. The Minister raised the report given by Carte Blanche on the illegal tender issued in the Free State province where stem cell treatment was conducted to treat arthritis at the cost of R 30 000 per patient. Stem cell treatment is not available in the country and the Department had to stop the operation after it had sent its inspectors to investigate the allegations. In terms of improving the regression in Limpopo and North West, the two provinces used to perform poorly especially Limpopo and it used to receive disclaimer audit opinions. However they managed to move to an unqualified opinion. The Minister said that he is not sure why the regression is happening again after having improved their performance. He mentioned that it could be wheelbarrow mentality where the province is expecting to still receive assistance instead of working on its own.

The Minister mentioned that the Department will look into the matter of rotating nurses and thanked the Committee for the suggestion. Nurses who specialise in ICU and have received training in South Africa are in high demand in Europe and once they have completed the training, the nurses do not stay.

Dr Maesela suggested that it is better to export them than not have the nurses at all.

The Minister said that the National Health Laboratory tests is a very difficult issue because he does not appoint the examinations board but appoints the board of the NHLS and was not even aware of the examinations board. He mentioned that he is only aware of the test that people who have studied abroad have to take when coming to work in South Africa. The test is said to be very difficult to pass at the first try. One of the members of this particular examinations board told the Minister during a radio interview not to interfere with the test as the test is not difficult and so the Minister is now not sure of what direction to take. He mentioned that he will look into it.

The Minister addressed Dr Maesela’s question on lack of nursing skills being part of the causes of neonatal mortalities . The reason for the lack of skills is caused mostly by the rotation of nurses from one field of specialisation to another soon after training for a specific specialisation. He said  the problem of condom distribution is a sensitive one, there has been great success in the launch of flavored condoms called Max by the Department of Health. The marketing of the condoms was not performed as much as it should have been. Learners were played a big role in the introduction of the condoms as the Department held a competition targeted at peer groups which challenged learners to get involved and come up with a name for the new condoms which is Maximum protection and Maximum pleasure. The reason that pneumonia became prevalent in South Africa is because of HIV/AIDS infections. The Department of Health introduced two new vaccines which have helped decrease the number of admissions for pneumonia by 70% and South Africa is the first country on the continent to have the vaccine. The question on the production of vaccines in the country was addressed by the Minister, saying that as far as he knows there is no vaccine that is manufactured in the country. The Minister mentioned that the Department of Health will never get a clean audit outcome because the longest serving HOD in the Western Cape who has recently retired after 19 years of service has never received a clean audit for his department. The Department of Health does not only get audited on monetary expenditure but also on performance and the Department is sometimes asked to provide evidence of actions taken such as proof that people are actually taking the ARVs that have been given to them and it is not possible to provide such evidence.

South Africa has been found to have more professional nursing sisters than there are enrolled nurses who do the real work which the Minister termed as having more commanders than soldiers. The private sector has fewer professional nurses and more enrolled nurses and NDoH aims to have the same setting in the public sector. The Minister mentioned that they intend to challenge the defence that lawyers use when criminal are for example charged with murder and the lawyer claims that the accused is criminally insane. The ruling of such cases usually leads to having the accused admitted for psychiatric evaluation even when it is evident that the accused is guilty of murder and should go to prison. The Minister made an example of Oscar Pistorius where he said that it was clear that he was guilty of murder but was still taken for psychiatric evaluation because of the claims made by the lawyer. These evaluations usually take 30 days where psychiatric wards are used leading to shortage of beds and the Minister wants to challenge this.

The Minister raised a point that the Tobacco Institute of South Africa has a trick of appointing women because it is under the impression that NDoH will be sympathetic, and that will not work on him. The first thing that the tobacco industry usually raises whenever a regulation on tobacco is introduced is the issue of unemployment and the ailing economy. The tobacco industry wants to reverse the laws that have already been passed because there is a high rate of unemployment in the country. However the Minister assured the Committee that they will not stop fighting. There will be four new amendments to the Tobacco Control Act, the first being the abolishing the 25% space where people can smoke in public spaces. Secondly, the distance where people are allowed to smoke in airports will be increased to about 50 meters because there have been complaints. The display of cigarettes and tobacco in stores will be banned because displaying them is a way of advertising. Lastly vending machines that sell cigarettes will be banned because it is illegal to sell tobacco to children under the age of 18 but vending machines do not have an age detector so the machines will be banned entirely. The Department of Health is planning on changing the branding of cigarettes like England and Australia of having all cigarettes in one branding and packaging. The Medical Research council will hold a conference to announce that incidences of chronic respiratory disease and cancer of the esophagus have dropped because of the laws that have been passed.

The Department intends to assist a few provinces with financing such as the Northern Cape, Mpumalanga and Free State.

The Chairperson noted that when the Committee visited Monapo Hospital they were prepared to shut the hospital down because the hospital was in such poor condition but they lacked the powers to do so. The Chairperson mentioned that she is confident that the Committee will produce a good Budget Review and Recommendations Report (BRRR) after the three meetings that they have had in the week.

The meeting was adjourned.