National Health Budget; Provincial Budgets: KwaZulu-Natal, Gauteng, Northern Cape

Meeting report

HEALTH PORTFOLIO COMMITTEE
4 April 2001
HEALTH BUDGET: BRIEFINGS

Chairperson: Dr S Nkomo

Documents handed out:
Quality in Health Care for South Africa
District Health System Development
Hospital Services
Health and Welfare Negotiations & Industrial Relations
Mental Health and Substance Abuse
Disease Prevention and Control
KwaZulu-Natal Budget Review
Gauteng Budget Review
Northern Cape Budget Review
[documents awaited; email [email protected] for any document of particular interest]

SUMMARY
Department clusters, including the District Health System and Health & Welfare Negotiations & Industrial Relations, continued to brief the Committee. However, owing to time constraints many of them were not allowed to give full briefings and limited discussion took place.

The Committee heard presentations from the Health Departments of KwaZulu-Natal, Gauteng and the Northern Cape. It congratulated KwaZulu-Natal for its success in the fight against the spread of cholera in that province, but was concerned about the levels of tuberculosis and HIV/Aids in KZN, the highest in the country. Suggestions were made for schemes to purify water and raise awareness of the epidemic.

The issue of home-based care arose in discussions with both Gauteng and the Northern Cape. HIV/Aids and its impact on maternal deaths as well as tuberculosis were common concerns raised in all three discussions.

MINUTES
District Health System
Mr Asia stated that the allocated budget for running the District Health System (DHS) directorate (such as expenses for salaries, computer, travel, workshops) is R1.9m. R1.3m had been spent. Mr Muller had indicated that there had been underspending of approximately R500 000. This could be because the District Health Systems budget had included an allocation towards assisting with the municipal demarcation process. However the Demarcation Board had already been allocated an amount for this purpose. The result was that the R500 000 remained unspent. There was no specific allocation to the District Health Systems development as part of the conditional grant was allocated to District Health Systems.

The District Health System (DHS) directorate had been allocated R17.05m for the last three years (from EU funding). Of this amount R6m had been rolled over into this financial year. The R6m had however been committed to various projects which will be spent in April and R1m would be allocated to each metro to assist with Primary Health Care delivery.

The proposed allocation for 2001/2002 is R1.9m. The EU had allocated an amount of R26m to the new Public Health Sector Support Program. This amount would be split evenly over two years and the funder has prescribed the budgeted items.

Mr Asia then read through the document titled 'District Health System Development 2001/2002'. (See Appendix)

Health and Welfare Bargaining Sector Council
Dr Hendricks stated that the Health and Welfare Negotiations and Industrial Relations Cluster reported to both the Ministers of Health and Social Development. They had only started to appoint their full time staff early this year and have therefore been unable to spend the entire amount allocated for this purpose.

Dr Hendricks then proceeded to read the document. (See Appendix)


Quality of Health Care for South Africa
Dr S Khotu said that with the use of the National Health Care Information Systems, it would be possible to register a patient with a minimum of information. This would impact positively on appointment scheduling and would be implemented in 4000 clinics and 400 hospitals.

The aim is to use information on births and deaths to develop the District Health Systems project. It would then be possible to identify every patient and every citizen in South Africa.
Various problems arose with regard to its implementation. Firstly, with the demarcation of municipal boundaries, the data was categorised in terms of the new boundaries. In addition, a 1994 survey indicated that there had been 1.2 billion births in the country to date. Only 20% of these births had been registered. Statistics also show that only 50% of deaths had been registered.

To help solve this problem nurses were then forced to register children when born. This project, which started in the Eastern Cape, then spread to all the provinces. The result is that in 1998 for the first time the number of under-16's registered exceeded that of the over-16's.

Dr Khotu then briefed the committee on the quality of healthcare. (See Appendix).

Discussion
Ms Marshoff (ANC) referred to the integration of systems to improve the quality of care. She said that this was difficult because in some provinces the systems did not communicate. She asked if the Department could ensure that the systems would become compatible.

Mr Khotu said that the Committee had decided earlier on a National standard with regard to the information systems in the Department. He added that not even the Department of Finance or the military have a single system although many departments are striving toward this. It is important to have compatibility standards and it is important that the Committee assisted the Department to ensure that the provinces are abiding by the standards. The Department currently has five systems running and which had been procured in the past four years. This was the best technical solution that the Department had. In many cases the systems did not meet the national standards.

Ms Marshoff referred to the Minister's suggestion that the members made use of public facilities. She pointed out that this was difficult since public hospitals were unable to bill medical schemes.
Mr Khotu responded that a National Billing system was put in place on 1 April 2001.

Ms Marshoff referred to the problem of racism within health care where services were packaged according to race. She suggested that the Department should interact with the provinces to ensure that this problem was resolved.

Ms Madumisa asked for more information on how the system of telemedicine operates.
Mr Khotu suggested that the Department could hold a demonstration to illustrate to members how the system would work. He said that initially the doctors had utilised the telephone and e-mail to contact specialists for advice.

Dr Mbulawa asked how the Department would monitor the use of the R6m allocated to the various metros.
Mr Asia replied that the Department serves as a custodian for the funds received from the European Union. In terms of spending the money, the Department no longer focused on what the EU felt the money should be used for. Instead they now focused on what the needs of the metro are. A Steering Committee was appointed to monitor and evaluate the spending very strictly.

Dr Mbulawa asked whether the call centre could be compared to the Ombudsman or the toll free number used to enquire about Welfare issues.
Dr Hendricks said that the use of an ombudsman was recommended and that negotiations are taking place on the issue.

Ms Njobe asked how long it would take for the demarcation to be completed.
Mr Asia said that the demarcation process had been completed although re-alignment still needed to be done. This will be done by 30 April 2001.

Ms Njobe asked if the underspending with regard to Primary Health Care had anything to do with a lack of capacity.
Mr Asia responded that the Department assisted with the demarcation process. An allocation had been made in their budget for this purpose but had not been used since the Demarcation Board had already budgeted for it. The underspending had nothing to do with a lack of capacity. All the Department's contracts with consultants deal with capacity issues in terms of which it is stated that they should leave enough capacity behind in order to sustain the projects.

Ms Madumisa enquired as to the application of the Patients' Charter.
Mr Khotu said that the Charter was applied in all their facilities.

Dr Rabinowitz asked if there was any sort of accountability if the Patients' Rights Charter is not adhered to.
Dr Chetty said that the Department has appointed Inspectorates in the different provinces to see that minimum standards were adhered to.

Ms Baloyi asked whether the patients understood their rights in terms of the Charter.
Mr Khotu said that the Department would have to monitor this in order to see if lay people were even aware of it.

Dr Rabinowitz asked if the costs of evaluating various diseases had been considered with regard to telemedicine.
Mr Khotu responded that the bulk of the costs were due to the medical devices used to examine the patients and not the communication devices.

A member asked whether telecentres are likely to be established in the Northern Province.
Mr Khotu responded that the Northern Province already has two, which they are developing on their own.

Ms Mnumzana referred to the overspending on equipment referred to in the presentation on the Health and Welfare Bargaining Sector Council. She asked if the purpose of the overspending was to upgrade equipment or to purchase new equipment.
Dr Hendricks replied that the allocated amount had gone into capacity building and purchasing hardware (on a need basis) and software. In addition the spending had gone into introducing the Vulindlela system which would enable them to monitor the information on any health worker in the country.

Communication
Ms J Collinge briefed the committee on health information, evaluation and research. She stated that there had been an underspending of R2m. In addition, R20m was needed to expand the telemedicine program. The Department had not spent all its money allocated to this program because they had needed additional funds to go out on tender.

Discussion
Dr Jassat (ANC) pointed out that there had been extensive political mobilisation around the issue as to the cause of AIDS. He suggested that the Communications Department could do much to assist in this regard.

Ms Madumise (ANC) asked if the publications of the Department were language-friendly to the majority of South Africans.

Ms Collinge said that there were many challenges as a result of the diversity of the languages in South Africa such as cost implications of distributing materials in all the official languages. The language in which the public education campaigns are conducted, depends on the area they are targeting. The corporate campaigns are however conducted in English. She admitted that this could be problematic if they were dealing with health workers.

Ms Baloyi said that the dissemination of important information on AIDS should be done in simple and understandable language. This should then be given to the Portfolio Committee, as they need the information when they go into their communities. The information on AIDS should be able to be understood by school children as well as their grandparents.

Ms Collinge responded that there were other sections of the Department that performed a communication function as well. Some of these groups handled the media liaison on AIDS and are assisted by the Communications department. Due to the importance of the issue, its messages cannot be reinforced enough and tender consortiums have been employed to do AIDS campaigns

Ms Madumise asked if the Portfolio Committee could have access to the Department's publications.

Ms Collinge pointed out that the department is busy overhauling its website and establishing a database. The Portfolio and Standing Committees and the Legislature should be provided with information on a regular basis in the future.

Dr Mbulawa said that the media often chooses what they wish to tell the public and their reports about what the Department had said, are often inaccurate.

Ms Collinge commented that the Department would start putting out its press releases on its website. The public could then decide whether they wished to believe the press in the light of the information from the Department itself.

The Chair remarked that there are many organisations sending out messages on AIDS. He suggested that there should be a correlation of services such as the Department working together with Lovelife.

Ms Collinge noted that this had been attempted. There are organisations like the Aids Chief Directorate that have worked with government on the Aids issue. The Department has also initiated contact with the UN. Dr Chetty said that the Department had worked with Lovelife as it was important to get the message across as much and as often as possible. It is however important that the messages sent out by the Department should not conflict with those of the other Aids organisations. There had also been great progress in working with NGO's.

The Chair asked whether the Department had managed to move away from the idea that publications by the State are propaganda tools.

Ms Collinge remarked that this idea could be perpetuated if there was even a degree of inconsistency in their publications. In addition the Department had to expand its own publications without it appearing as if they wished to create a monopoly. This expansion could be done by linking with partners such as the Nursing Journal and having their articles published in journals that people trust. In this way they could avoid creating the impression that they wished to control the information. She pointed out that very often it is the identity of the messenger that determines if people accept what is being said as truth or not.

Ms Madumisa remarked on the Minister's statement that the Department had a good relationship with the producers of the program 'Soul City'. She referred to the fact that the program 'Yizo Yizo' was closely linked to the Education Department and stated that this program highlighted the fact that the impact a publication was assumed to have could in fact have the completely opposite response. Although 'Yizo Yizo' used shock treatment to get its message across, if it achieved its objectives, people should accept it.

Dr Chetty added that the Department worked very closely with the producers of 'Soul City', especially on the issue of Aids.

Hospital Services and Emergency Services
Dr Sibeko briefed the committee on Hospital Services (See Appendix) very briefly. However there was not enough time for discussion.

Psychiatric and other Mental Health Services
Prof M Freeman spoke on psychiatric and other mental health services but due to time constraints no discussion took place.

Disease Prevention and Control
Dr J van Heerden briefed the committee on disease prevention and control, but due to time constraints could not complete his presentation. No discussion took place.

KwaZulu-Natal Health Department
Prof R W Green-Thompson, Head of KwaZulu-Natal Health Department, briefed the Committee on the province's budget review for 2001/2002. He highlighted the Department's key strategic objectives, reviewed the budget and expenditures and highlighted strategic service areas, such as hospital services, primary health care, teaching and training, mental health, TB services, emergency and support services. (See Appendix for full document).

The Chair proposed a resolution that a word of congratulations from the Portfolio Committee should be expressed and recorded. The resolution was unopposed and accepted.

Discussion
Dr Cwele (ANC) congratulated the Department on its success in dealing with the cholera epidemic. He asked if there are mechanisms in place to monitor people's access to health care facilities in KZN due to allegations there is a patronage system that favours certain people for treatment. He also asked how the Department plans to deal with maternal deaths through HIV. He finally asked if pilot projects such as Addington Hospital had been finalised to redress the poor quality of some institutions.

Prof Green-Thompson said a Commission had been appointed to deal with the problems at Addington Hospital and that an advocate and a professor of Family Medicine were to give recommendations on how to improve the facility. He said the lesson learned from Addington was that quality must not just be initiated, but effectively maintained.

With reference to the deaths of mothers with HIV/Aids during child-birth, Prof Green-Thompson said that the mothers are immuno-compromised and die during labour through ruptured membranes. He said that preventing the rupturing could cut down on the amount of maternal deaths.

Dr Nkomo (ANC) congratulated the Department for its treatment of the Cholera epidemic. He said a major contributing factor in spreading the disease is the custom of hand-washing at funerals. He asked the Department if they had considered introducing special urns so that people could wash their hands without infecting the water. He also enquired about the possibility of training doctors through the SANDF and the possibility of prospective doctors receiving scholarships to train with the SANDF.

Prof Green-Thompson said the SANDF would be encouraged to help with training doctors.

The professor agreed with Dr Nkomo on the introduction of urns to help prevent the spread of cholera. He said plans are in place to provide urns with narrow mouths, so that hands and cups are not dipped in the urn, contaminating the water. Ideally, the urns would have taps. Providing such urns would be cheaper than treating Cholera. Another problem with funerals and other mass gatherings is communal eating.

Prof Green-Thompson also talked about water and sanitation. He said that an Environmental Health Officer had just been employed by the Department to assess the availability of fresh water supplies and sanitation as well as a Field Epidemologist from Uganda to help improve outbreak preparedness and outbreak management.
He said that the reality is that over one million people in the province do not have adequate sanitation facilities. At this stage the most reliable and cost effective method is the 'Jik' purification method whereby a teaspoon of bleach is mixed with twenty-five litres of water and left to stand for two hours. He said that boiling water is not a feasible option for most households as they do not have facilities to boil large amounts of water. In the long term he said that the aim is to drill more boreholes and to bulk chlorinate water.

Dr Mbulawa (ANC) asked why Ulundi and Eshowe have the highest statistics for cholera. She asked if people are leaving the public health service due to poor salaries and working conditions. She also asked what the distribution of doctors in the province is in terms of rural and urban distribution and asked if graduates of the University of Natal-Durban stay in KwaZulu-Natal or move to other provinces.

In response to the loss of skilled medical staff in the province, Prof Green-Thompson said it is not possible to stop doctors from moving to other provinces, especially as some provinces do not have medical schools. He said perhaps some research should be undertaken to discover why doctors and nurses leave the province. He stressed the importance of the role that community doctors and Cuban doctors had played in the province. He also said there are plans to introduce training and management certificates and diplomas to provide nursing sisters at clinics with basic management skills.

Ms Baloyi (ANC) also congratulated the Department on its role in fighting the cholera outbreak. She asked what health services they plan to outsource.

Prof Green-Thompson said hotel services would be outsourced. Critical skills would not.

Ms Mnumzama (ANC) said she hopes other provinces will note the successes of KwaZulu-Natal in fighting cholera. She said that the Committee is aware of the scarce resources in the province and that the provincial department is doing its best under these financial constraints. She asked if there were any strategy proposals to keep nurses trained in KwaZulu-Natal in the province.

Dr Rabinowitz (IFP) asked what initiatives the province has taken to bridge the gap between the private and public spheres. She also asked why the province had the worst record in the country regarding TB and HIV/Aids.

Prof Green-Thompson said that the Department is not entirely sure why it has the worst TB and HIV/Aids record. He said the province has been the worst since the beginning. One factor is probably the province's harbours and ports as well as its migrant labourers. He also attributes the prevalence of these diseases to the rampant poverty in the province. A mother who tests HIV negative at a clinic has a nineteen percent chance of returning the following year infected with HIV. The concern of the Department is to keep HIV negative patients HIV negative. More money is being allocated to fight TB in the province. The Department is fully conscious of the problem of infectious diseases in the province.

Mrs Baloyi asked if the Department had done the costing to ascertain whether outsourcing would be cheaper.

Prof Green-Thompson said they are in the process of doing this, but that they believe that it will be cheaper. Mr Conradie, The Department's Financial Manager, said there are hidden costs in public service. To keep these services within government is not as efficient as when they are part of the private sector, providing that the public sector checks the private.

Gauteng Health Department
The Chair introduced the next speakers, Dr Laetitia Rispel, Head of the Gauteng Health Department and Mr Gert Cromhout, The Gauteng Health Department's Director of Finance.

Dr Rispel went through the document "Report to the National Assembly Portfolio Committee" with the Committee. She highlighted the mission and vision of the Department, outlined the Strategic Service Areas and explained the key health problems outlined in the table on p20 of the document.

Discussion
Dr Cwele (ANC) expressed confusion over the statistics in the table on p20. They seemed to him to say there had been a decrease in septic abortions in the one part and in another part it said that septic abortions had increased.

Dr Rispel said there had been a increase in septic abortions but a decrease in maternal deaths. She said the confusion of Dr Cwele was that 'SA' stood for 'South Africa' and not 'septic abortions' in the graph. She said a decrease in septic abortions was partly due to a decrease in terminations of pregnancies.

Dr Cwele asked if the decrease in termination of pregnancy was not a result of problems of access to the hospitals. Dr Rispel replied that the question of access is being looked into by the Department.

Dr Mbulawa (ANC) asked the status of hospital boards in the province.

Dr Rispel said the old hospital boards had been abolished in 1997 to make way for more representative boards.

Mrs Baloyi (ANC) said HIV/Aids patients with TB need to be discussed further in the Department and at MinMec. Mrs Baloyi also asked what conditions were like at Steenfontein and what programmes had led to the savings made by the Department.

Dr Rispel said that there has been an extensive review of the TB programme.

With regard to Steenfontein, Dr Rispel said a new CEO had been appointed to strengthen management and that this financial year would see a decentralisation of funds to the hospital for maintenance.

Dr Jasset (ANC) said the Department had been subsidised to the tune of 90% so why were there always crises in the paying of staff.

Dr Rispel said the savings made by the Department were seen as positive rather than negative, as the Department had managed to avoid overexpenditure. She said 0.02% is a small amount, about five million rand. She said that the savings came from administration rather than the health programme.

Ms Marshoff (ANC) asked how the Department had succeeded in restructuring services, particularly the ambulance service. She also asked the Department to expand on the statement on p6 of the document that said conditional grants required a critical appraisal.

With regard to conditional grants, Dr Rispel said they needed critical appraisal as they were the main source of funding for hospitals and that provincial funds only supplemented this.

Dr Mbulawa (ANC) asked what the relationship is between the Department and NGOs.

Dr Rispel said that NGOs and CBOs are being used to assist with home-based care in the province and that the Department funds them to provide this type of care.

Dr Rabinowitz (IFP) asked why the name of casualty wards was being changed to Emergency Care Centres.

Dr Rispel said that the development of Emergency Medical Centres to replace Casualty wards was not just a change in name only but that these would link emergency services to the rest of the hospital.

Mrs Njobe (ANC) asked why the revenue in Gauteng is decreasing compared to KwaZulu-Natal's when Gauteng is more populous. She also asked if the Department felt that the trend of decreasing maternal deaths would continue.

The Chair announced the Committee would have a recess to vote in the National Assembly before the next presentation form the Northern Cape Department of Health.

Northern Cape Health Department
The MEC for the Northern Cape, Ms Peters, addressed the Committee with her colleague, the Head of the Health Department, Dr Hendricks.

Ms Peters said that in 1999 the Department had to try and match what the ANC said in its election manifesto to deepen the quality of services.

In some facilities, there is only one professional nurse. But in the next financial year, thirty percent of facilities should have at least two professional nurses. Another concern is access, as the province is so large. Some ambulances have only one driver who treats patients and then drives the ambulance. Some ambulances have a million kilometres on their clocks. The Department is working very hard to ensure access to healthcare for all the people and that it would be beneficial for the Committee to visit the province. Ms Peters added that the province has succeeded in attaining high levels of awareness over health issues, particularly HIV/Aids, largely through working with faith-based organisations.

Dr Hendricks went through the entire document with the Committee (see Appendix).

Discussion
Mrs Mnumzana (ANC) asked which part of the Orange Free State used Northern Cape facilities.

Dr Mbulawa (ANC) asked if maternal deaths were in part caused by the fact that there is only one person driving ambulances. She asked if Kimberley Hospital is working with NGOs to provide home-based care. She also asked about the functioning of hospital boards in the province.

Dr Hendricks responded. He said that the section of the Free State close to Kimberley uses the Kimberley Hospital due to the level of care that this facility has to offer. He said that the distances in the Northern Cape make the deliverance of maternity services difficult as they are generally urgent. He said that full-time doctors are now being deployed in areas where they were not before. He said the issue of home-based care is perplexing. The Department is implementing a system whereby NGOs are used to help with home-based care. This is complicated as the NGOs will be working with the state. With regard to hospital boards, he said a problem is the question of ownership as the province runs the hospitals but the boards own the buildings.

Ms Marshoff (ANC) asked what impact demarcation had on boundaries between the Northern Cape and the North-West province. She asked if the budget deficit reduction was a result of cutting services or improving efficiency. She also asked if it was true that the Northern Cape was the only province without a gynaecologist.

The reduction of the budget deficit is due to efficiency gains Dr Hendricks said. He added that currently all staff vacancies are being filled at the moment. The province lost its full-time Cuban gynaecologist to Gauteng but the service is being rendered by part-time gynaecologists

Dr Mbulawa asked how the Department proposes to keep trained personnel in the province.

Dr Hendricks said staff are being sent for training and will be under contract to work in the province for the same amount of time that they received training.

The meeting was adjourned.