Health Budget: briefing by National Department

Meeting report

HEALTH PORTFOLIO COMMITTEE
3 April 2001
HEALTH BUDGET: HEARINGS

Chairperson: Dr S Nkomo

Documents handed out:
Estimates of Expenditure and Programme Objectives 2001: Vote 15 (.pdf file)
National Department of Health - Structure (see Appendix 1)
Ten Point Plan for 1999-2004 (see Appendix 2)
Basic Health Indicators
Maternal, Child's and Women's Health
HIV/AIDS and STDs
Pulmonary Tuberculosis
TB fact sheet - 2001
Pharmaceutical Services presentation
Teaching, Training and Personnel presentation

SUMMARY
The acting Director General introduced the various clusters forming part of the Department of Health. The following clusters spoke on their challenges and achievements: Maternal, Child and Women's Health;
HIV/AIDS impact; TB services; Pharmaceutical Services; Teaching, Training And Personnel
They also briefed the Committee on their budget and, more specifically, on issues such as their reasons for underspending and on conditional grants given to the provinces.

MINUTES
Organisational Structure of the Department
Dr K Chetty, Deputy Director General, standing in for the Director General, outlined the Department's structure (see Appendix 1).

Overview
She stated that the Department's vision is outlined in their Strategic Framework Document. She then read through the document outlining the Department's vision, mission and Ten Point Plan. (See Appendix 2.)

Basic Health Indicators
A survey was done comparing the Infant and Maternal Mortality rates as well as the life expectancy of males and females in the different race groups. It was found that the African infant mortality rate was 54.7% while the mortality rate of white infants is 7.3%. The maternal mortality rate of Africans is 58% while that of whites is 8%. The life expectancy of the average African male is 60 years of age while that of a white male is 69. The life expectancy of the average African female is 67 while that of the white female is 79 years of age. These figures indicate a huge disparity between the two population groups.

The figures also indicate a huge disparity between the different provinces and it becomes evident that life expectancy of infants is related to poverty levels. The Eastern Cape, KwaZulu-Natal and Mpumalanga show that a very high mortality rate with Eastern Cape figures indicating a mortality rate of more than 60 deaths per 1000 births. The Western Cape and Gauteng show a relatively low infant rate and this is evident from the fact that the Western Cape has less than 10 deaths per 1000 births.

The Department has made provisional projections in terms of the following categories for the period 1996 to 2005: Infant mortality rate, the mortality rate of children under the age of five, the adult mortality rate and the life expectancy at birth. The mortality rates have increased in the case of the infants and children under the age of five while the average life expectancy has dropped. The decreased life expectancy at birth can be attributed to HIV/AIDS among this group. It is important to note that the figures are merely projections and do not take into account interventions that may take place.

Studies showed that there was a correlation between the education level of the mother and the mortality rate of children of various ages. According to statistics the post-neonatal, infant, child and under- 5 mortality rates decreased as the education levels of the mother increased. This does not apply to neonatal mortality rates where the situation is reversed. The higher neonatal mortality rate of children born to mothers with higher education levels can be attributed to the lifestyle of these mothers and the age at which these women choose to have their children.

The figures on the malaria cases and deaths cover the period between 1971 and 1999. There was a sharp increase in reported cases and deaths in 1992. This can be attributed to the seasonal rainfalls and the impact of malaria resistance. In response to malaria resistance, the Department is looking at other treatment modalities and drugs.

The instances of TB notification show a sharp rise in tuberculosis since 1991. This can be attributed to its inter relationship with the HIV/AIDS epidemic.

The treatment of measles has been the Department's main success story. Although there have been peaks during the period between 1980 and 1998, there has been a sharp decrease in the number of measles cases. This is due to measles campaigns and immunisation. Dr Chetty stated that measles had been a killer disease in the malnourished poverty stricken communities in the past. Figures also indicate sharp decreases in leprosy, diphtheria and meningo meningitis cases.
There has also been a sharp decrease in tetanus due to the immunisation programmes. The decrease in congental syphilis can be attributed to the treatment available for the disease. There has been a decrease in the cases of viral hepatitis as well.

In 1982 there had been a cholera epidemic and figures increased dramatically. Over the following few years there was a decrease in the number of cholera cases. Figures again soared as a result of the current epidemic. The figures were very high during February and March this year after which they started to decrease. Although there is currently a slight increase in figures the overall trend indicates a decrease in the number of cholera cases.

The prevalence of HIV/AIDS indicates that the figures differ greatly from province to province. This is evident in the fact that 5% of the Western Cape population are HIV positive, while approximately 32% of the population of KZN are HIV positive.

Budget and Expenditure Review including the MTEF
Mr Muller reiterated the point made by Dr Chetty that the anticipated expenditure refers to projected figures that are subject to change. To calculate the anticipated expenditure for Administration (Programme one), the following are among the items that must be taken into account: R64m were allocated to overhead costs after which another R4.46m was obtained from EU funding. There has been a saving with regard to fixed capital.

With regard to Strategic Health Programmes, R58m has been made available for the HipVac. If there is a roll over the money will be allocated to HIV/AIDS. There has been a saving of R4m with regard to the International Health Liaison. This figure will be decreased due to the Non Aligned Movement Conference once invoices are presented to the Department.

The figures on disease prevention and control reflect an underspending of R3.9m. This figure will be decreased. With regard to Non-personal health there has been an underspending of R4.5m. Two tenders have been committed to this project which will decrease the roll over. It is difficult to judge the underspending with regard to poverty alleviation with accuracy. This is because there is a long process involved in getting the money to provinces and this gives rise to a great amount of paperwork. The financial data therefore flows slowly, but it appears from the latest figures that there has been an underspending of R20m.

The bulk of the funds from conditional grants are allocated as hospital grants. There has been a high roll over figure for Umtata and certain other hospitals. This is because of the change in which provinces claim payment from the National Department. Previously, the province would make payment and then claim the amount from the National Department by submitting invoices from the transactions. This year business plans were prepared by the provinces and then submitted to the National Department. The national Department then transferred all the money requested by the provinces and this was budgeted for. As a result there was no roll over in the books of the National Department. There is however a high roll over figure for certain provincial hospitals despite the fact that the Department has put in place a monitoring system when it handed over the money.

Discussion
Dr E Jassat (ANC) asked whether the Department had the capacity to meet its objectives as set out in the Strategic Framework Document.
Dr Chetty suggested that this would be answered in the individual presentations by the different directorates.

Dr Mbulawa (ANC) referred to the Patients' Rights Charter and the complaint mechanisms that have been introduced in the provinces. She asked if the department had gotten the community involved.
Dr Chetty said that this question would be answered in the presentation dealing with quality of care.

Ms Mnumzana asked how the budget process restricted the pursuit of equity.
Dr Chetty said that when funds are allocated to provinces the funds have to be divided in such a way so as to compensate for the extent to which a province has been disadvantaged in the past. Mr Muller said that allocations are done according to certain formulae and according to guidelines determined by the Departments of Health, Social Development and Education. He said that firstly, it is based on the disparity between the richer and poorer provinces. Secondly, it is determined by where the central hospital facilities are located.

Ms Baloyi (ANC) referred to the Department's vision. She asked the Department to elaborate on the way in which the norms and standards impact on gender.
Dr Chetty said that this would be discussed in the presentation dealing with quality of care.

Ms Baloyi asked how the Public Finance Management Act is being applied in the Department.
Mr Muller said that the Department had submitted an implementation plan and that it was progressing very well in terms of its implementation. He said that the financial management of the Department had been sound to start with and that the Department was therefore building from a fairly solid base. There were no real problems in terms of implementing the Act as many of the requirements set out in the PFMA had already been in practice in the Department for a while.

Ms Baloyi expressed concern at the levels of underspending experienced this year if compared to the last year's figures.
Mr Muller said that there was R100billion less in rollovers than last year.

Ms Mnumzana (ANC) asked how provinces were monitored to ensure that amounts, which were intended to be used for the nutrition program, were used for that purpose.
Ms Mnumazana asked what happens if provinces fail to submit a business plan. She asked if they are allocated an amount in any case or if the amount is rolled over.
Ms Marshoff (ANC) asked how the Department keeps track of the way in which money is spent in the provinces. She was concerned that the Department transfers the amount requested to the provinces, yet the provinces experience a roll over.
Dr Mbulawa asked the Department to elaborate on the way in which conditional grants are paid over to the provinces and the way in which the process has changed during the past year.

Mr Muller replied that the business plan must have a section dealing with provinces' cash flow to projects. Smaller grants are granted quarterly. Provinces must report to the National Department on a monthly basis. The Department then reports to the Treasuries. It is easy to keep track of the larger conditional grants, but the smaller projects are much more difficult. With regard to the two methods of payment to the provinces, he said noted that the invoice system was problematic as it led to the provinces experiencing cash flow shortages. The Department then suggested that the invoices be certified before provinces would be reimbursed.

Dr Chetty added that the individual Directorates could cover many of the concerns that had not been dealt with completely.

Strategic Service Areas:
Maternal, Child and Women's Health
Dr Mhlanga read the document relating to this topic. He highlighted the following issues:
· With regard to the fortification of foods with micronutrients, there has to be agreement as to what kinds of food need to be fortified. The CSIR are performing tests to determine the stability of the nutrients when cooked and examining the taste of the product.
· Genetic conditions- there is a focus on preventable genetic conditions such as Down's Syndrome and folic acid deficiency. Genetic nurses are also being trained.
· Sustainable feeding programmes- this focuses on feeding primary school children and providing households with adequate food.
· Maternal deaths- in some provinces, resources are the problem.
· Termination of Pregnancy- Heads of institutions have to support the program to ensure its success. The problem is that this depends on the personal convictions of that particular person.
· Health worker skills audit- e.g. there is an advanced training program for midwives. This is vital as they can often determine if a woman lives or dies. They are trained to identify the problem so as to transfer the patient timeously.
· Commercial sex work- this group is often sidelined and their health problems ignored. Health workers are trained to be adept to dealing with the specific needs of this group.
· Violence against women- forensic nurses are being trained to deal with this issue.
Dr Mhlanga said that the focus is no longer just on caring for the health of the child, but on the health of the mother as well. A pregnant mother with HIV faces certain death due to infection if a Caesarian Section is performed on her. Thus, an ethical dilemma arises if her baby should be in distress and it becomes necessary to choose between the life of the mother and that of the child.
The Minister said that the role of the members was vital in dealing with the problem of capacity at a provincial and local government level. She said poverty alleviation has to be defined with respect to health. In KZN the department decided to deal with the cholera epidemic by building toilets with funds allocated to poverty alleviation. She suggested that the same thing could be done in dealing with AIDS issues. She said that the immunisation rate only increases when there are campaigns. She suggested that the members get involved to ensure that it is sustainable.

HIV/AIDS impact
Dr Simelela pointed out that the epidemic has stabilised over the past three years. She hoped that this would remain and that result in a downward spiral. There have been increases in a number of provinces, especially in KZN. The rise in Gauteng can be attributed to the fact that the population here is unstable and there are many young people in the province. The Free State is becoming more stable. In addition, a stabilising is evident in the under 20 age group. There is an increase in the 25 to 29 age group. Dr Simelela read out the document on HIV/AIDS and STDs.

TB services
Dr Matji read out the document TB fact sheet - 2001, highlighting the following issues:
The increase in the cases of TB can be attributed to its link with HIV/AIDS. The case findings for 1999 show that the reporting rate is 83.5%. The rate varies from province to province. KZN has a very low reporting rate. The disease has reached epidemic proportions because of its low cure rates, high interruption rates and the fact that 40% of TB cases are HIV positive.

The elements of the DOTS program are a proper diagnosis of the disease, a short course of chemotherapy using standardised regimens. DOTS treatments last at least six months. There are also recording and reporting systems in place to monitor progress.
There are Demonstration and Training Districts where training takes place. Training includes talks on DOTS and a monitoring system. There is also a focus on supporting patients who are at home as many of them are unable to stay in hospital for the duration of their treatment.

The Department has also started working with traditional healers and results have been positive. The emphasis has been on getting the traditional healers to refer the patient to a facility. They are also training NGO's and community based organisations to deal with disease.

The Department has identified hospitals where multi drug resistant TB is managed. The aim is to prevent the disease from ever reaching this stage. There are enough laboratories in South Africa but they are located largely in the urban areas. It is important to improve communication and speed up results from the rural areas. Another area of focus is protecting the health workers from developing TB. There have also been projects that focus on the protection of prisoners and mine workers living in hostels.

Discussion
Ms Baloyi (ANC) inquired into the number of maternal deaths and whether there was a register and follow up done as to the causes of death.

Dr Mbulawa (ANC) inquired as to whether there was a programme in place to co-ordinate community involvement in terms of Community Based Organisations (CBOs) not being absorbed by Non-Governmental Organisations (NGOs). In addition an inquiry was made as to the regulation of quality standards within CBOs. Dr Mbulawa made a call for greater education around the issue of male sterilisation. She also asked what MPs should do when they discover a problem and how they would be able to assist the Department of Health.

Dr K Chetty (acting Director General of Health) stated that a set of guidelines looking at more effective communication could be distributed immediately to MPs.

Dr Rabinowitz (IFP) asked what she should do when phoned by the media for comment on documents, which the DOH had released, but which they had not yet heard of and whether the DOH could keep MPs informed of new publications.

Dr Chetty stated that she could look at sending information to the MPs but that it could be quite a lot and that the DOH website that was under construction was probably a better solution.

Ms Marshoff (ANC) inquired as to the under-spending on condoms and whether the surplus could not be shifted over to another programme. She also stated that business plans were a continual issue and that there should be a standard plan that could be adjusted to a new situation to help solve the problem in the short term.

Ms Gxowa (ANC) raised the problem of legislation being formulated and not filtering down to the people. She stated that people could not fight for rights that they do not know about. Ms Gxowa applauded the way in which the Termination of Pregnancy Act was presented as it was easy to understand at all stages and she called for this to be the approach adopted for future legislation.

Dr Rabinowitz (IFP) asked whether a school-visiting programme existed and whether contraceptives were available at all clinics. She also asked if the department was offered a million free AIDS testing kits and if they were refused what was the reason for doing so. Dr Rabinowitz asked whether it would not be more effective to test patients for infectious diseases as a whole including tuberculosis (TB) and HIV and in that way avoid stigmatising those having the tests performed. She went on to inquire about how often pap smears could be performed and whether the DOH has assessed how the country could benefit or be exploited by the genome programme.

Dr N Simelela (DOH) stated that the Government - Pfizer partnership required patent registration so that the drugs were not sold on the private market. She went on to relate under-spending to the lack of capacity building in the Provinces with inadequate business plans being produced. She noted that the problem in the Provinces could not be sorted out overnight. Dr Simelela explained that the NGOs that acted as a mentor to CBOs had their funding increased and this was not to swallow up the CBOs. She said that AIDS kits had to be uncomplicated, easy to use and not have to be refrigerated for use in the rural areas and that the free kits had to be refrigerated. However she had provided the donor with a list of NGOs that would be able to use the kits but as yet nothing has been heard from the donor.

Dr K Chetty stated that there was no doubt as to the commitment on behalf of the DOH to stop the AIDS epidemic but that constraints existed at a Provincial level where challenges had to be identified so as to prioritise what the possible solutions could be. Dr K Chetty stated that she would like to stress that the constraints were not overpowering and could be overcome.

The Chairperson, Dr Nkomo (ANC), asked that the members confine the discussion to budget issues and that policy issues and constraints could be discussed at a later date.

Dr R Matji (DOH) stated that there had been cases of TB patients going to private practioners for free medication but were being charged and as a result this process had to be stopped and patients registered. She stated further that diagnosis was a problem and that x-rays could not help to tell whether the TB was active or not and that examination under a microscope was the most effective method. Dr Matji explained that when patients started treatment and did not finish it more powerful strains of TB were able to develop.

Dr E Mhlanga (DOH) explained that cervical cancer screening was done at a Provincial level and that everyone who lived to the age of 60 should have at least three pap-smears. He stated that under-spending was a human resource problem and that new policy was not the answer but training people for plans that already existed was a better option. He went on to say that he had gone public in the media that he had undergone a vasectomy to promote awareness. Dr E Mhlanga explained that a schools visiting programme had existed in the past but that it proved to be unsustainable and free contraceptives should be available in all clinics but whether or not this was the case was difficult to determine.

Dr K Chetty stated that if members knew of any shortages that they should inform the DOH.

Dr E Mhlanga explained that the benefits of the genome programme had been shown with some chronic diseases and cancers and that the DOH was looking at trends on an international level. He stated that a conference would be held in South Africa in September this year on human genetics where greater clarification would be gained.

Pharmaceutical Services
Dr H Zokufa (DOH) stated that the establishment of a new National Food Control System and the facilitation of the establishment of a Codex office were priorities. A gap existed in coming up with norms, standards and systems for drug supply management systems. If these services were outsourced, these standards would have to be complied with. There was a need for responsible prescribing and that access to affordable medicines must be promoted through schemes such as parallel importing and local manufacture. They also aimed to finalise the issue of ownership of pharmacies by non-pharmacists in light of the broader strategy of improving facilities in the previously disadvantaged areas. Other priorities included the effective law enforcement against theft of medicines and the harmonisation of medicines registration in the region.

Discussion
Dr Cwele (ANC) inquired as to how the progress of these programmes was to be measured form year to year and when all these suggestions would be finalised.

Dr Rabinowitz (IFP) asked how it was planned that theft would be combated. She inquired further as to certain strains of maize that were not fit for human consumption and whether every single drug company had been engaged in discussions as to cheaper drugs.

Ms Njobe (ANC) stressed that there had been resistance to the acceptance of the legislation dealing with the ownership and the licensing of pharmacies and whether the situation had changed now.

Dr Zokufa stated that the current budget was not adequate to take the process forward.

Dr Cwele retorted by saying that if you have a surplus then you should not be asking for more funding.

Dr Zokufa replied that money should not be spent just because it is in the budget and that it would just be wasteful to do so. He stated further that extra funding would be required to take the various proposals forward effectively. Dr H Zokufa stated that regulations as to the ownership of pharmacies had already been drafted and have only to be assented to.

Dr Venter (DOH) stated that a Codex office would cost around R155 000 to set up and that they had had trouble receiving the funding and thus they had asked the DG to intervene. He also stated that genetically modified organisms presented a new challenge and that more staff were needed to cope with this issue and that the DG's approval had been received. Dr Venter stated that he had only heard of certain strains of maize not being fit for human consumption in the United States.

Dr Zokufa explained that a workshop on drug theft had taken place earlier this year and that it was agreed to implement the initiatives agreed to there. He elaborated that the DOH was looking at the possibility of labelling drugs 'for state use only' or having tablets/capsules embossed with the state logo to curb theft.

Dr Rabinowitz asked why the DOH had not tried to obtain a bulk discount for drugs by bargaining as a region.

Dr Zokufa stated that the DOH was keen to benefit from the economies of scale that the region could present.

Teaching, Training And Personnel
Prof R Gumbi (DOH) stated that the provisions of equality legislation were being achieved slowly in the sectors of undergraduate study and community service. Community service was now up and running for pharmacists and dentists.

Her portfolio had consumed their entire previous budget and that they had been awarded a further R500 000 this financial year. The portfolio had nearly achieved the recommended 50 percent black senior management and that the figure currently sat at 46 percent. They would provide support for the provinces to realise the principles of Batho Pele and that focus will be placed on the issue of HIV/AIDS, community empowerment and the new issue of cholera.

Prof R Gumbi stated that at present there was an over-production of specialists in South Africa as well as a lack of representivity at this level.

Discussion
Ms Marshoff (ANC) inquired as to the flight of perceived flight of nurses to first world countries.

Dr Cwele (ANC) asked whether there were any incentives in place to retain South African doctors after their community service.

Dr Rabinowitz (IFP) asked whether doctors form all countries were eligible to work in South Africa or just those countries with whom Government had agreements such as Cuba. She also asked whether students were prepped for community service at University.

Mrs Baloyi (ANC) asked what was being done to increase the numbers of black students enrolling for medicine and related fields.

Mr Marshoff (ANC) inquired about the low numbers of dentists currently involved in community service.

Prof R Gumbi explained that all the provinces have a pool of posts available for community service and that Provincial Co-ordinators did this allocation. She conceded that some areas were predominantly white and that gender ratios were not at the desired level but that the situation had improved in 2001. She stated further that in some specialities that there were hardly any black doctors and thus the possibility of a quota system was being looked at. Prof R Gumbi explained that TB was not taught well in the syllabus and that the curricula with respect to this would have to be reviewed.

Dr Cwele (ANC) inquired as to whether there was a scheme for specialists to do community service to which Prof R Gumbi replied that these doctors had already done their community service and felt that they should not have to be punished twice.

Dr K Chetty explained that the migration of medical professionals occurred in many countries and that poor salaries were only one contributing factor to the issue.

Prof R Gumbi stated that a number of dentists had gone overseas and that many had failed contributing to the low number in community service. She stated that the brain drain of nurses would have to be looked at.

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