Department of Health Strategic Plan and Budget 2011 - 2014

Meeting report

Department of Health Strategic Plan and Budget 2011 – 2014
Ms Malebona Matsoso, Director General, Department of Health, explained that the Minister of Health had signed a Service Delivery Agreement with the President, and this formed the basis for the Negotiated Service Delivery Agreement (NDSA) of the Department of Health (DOH or the Department). She read the vision and mission of the Department, and noted the four outputs of the service delivery agreement, as, firstly, increasing life expectancy, secondly, decreasing maternal and child mortality, thirdly, combating HIV and AIDS and decreasing the burden of disease from tuberculosis (TB), and lastly, strengthening the effectiveness of the health system.

Mr Matsoso noted that these four outputs contributed to the achievement of the Millennium Development Goals (MDG).

She then presented a slide outlining how the Health Sector 10-Point Plan, the NDSA, and the future National Health Insurance (NHI) would all contribute to the vision of the Department. The next slide presented another graphical representation relating to health sector inputs, outputs, outcomes and their impact on increased life expectancy of South Africans (see attached presentation).

Ms Matsoso then moved to the health sector's response and strategic interventions in key areas over the 2011/12 – 2013/14 period. 

Key interventions into reducing new HIV infections area included increasing distribution of 1 billion male and 6 million female condoms annually, increasing the number of medical male circumcisions, and increasing the uptake of preventative measures from 80% to 90% by 2013 to 2014. The goal was to keep those who currently did not have HIV free of the disease.

In the area of improving quality of life of people living with HIV/AIDS, key strategic interventions included increasing the number of new patients initiated on anti-retroviral therapy (ART) to between 625 000 and 675 000 annually, increasing the number of primary health care facilities (PHC), and implementing nutritional intervention for people with HIV/AIDS and TB from 77% to 88%.

In the area of reducing infant, child and youth morbidity and mortality, key strategic interventions included maintaining 95% immunisation of children under 12 months, maintaining 95% measles immunisation coverage, increasing the number of sub-districts implementing school health services from 100 to 232 by 2012/13, implementing programmes in secondary schools to address youth risk behaviour, and increasing the vitamin supplementation coverage in children from 12 to 59 months.

In the area of reducing maternal mortality, key strategic interventions included maintaining ante-natal coverage at 100%, increasing the proportion of deliveries in health facilities, increasing the proportion of designated health facilities providing Choice on Termination of Pregnancy (CTOP) and increasing the percentage of mothers and babies who received post-natal care from 40% to 80%.

In the area of improved access to reproductive health, key strategic interventions included increasing cervical cancer screening, and extension of screening to prostate and breast cancer.

In the area of expanded Prevention of Mother to Child Transmission (PMTCT) coverage to pregnant women, the Department planned to ensure that 100% of pregnant women would be tested for HIV. It aimed to decrease the percentage of babies testing PCR positive, six weeks after birth, from 10% to 6.5%, and to increase the uptake rate for AZT therapy at ante-natal clinics since studies had shown that if mothers had AZT therapy prior to going into labour, this reduced MTC by 1% to 2%.

In the area of reducing the burden of disease of tuberculosis, key strategic interventions included increasing the TB cure rate from 70% to 85% and reducing the TB treatment defaulter rate to 5%. Further percentage targets were then set out for reducing co-infection burdens, increasing the numbers of HIV positive patients screened for TB and those receiving prophylactic therapy.

In the area of reducing the burden of disease from communicable and non-communicable diseases, key strategic interventions included decreasing the incidence of malaria from 0.62 per 1000 population at risk to 0.54 per 1000 population at risk. Chronic care for both communicable and non-communicable cases would be aligned within a single Chronic Care Model, which would be rolled out in three districts in 2011/12. There would be 52 districts implementing the long term care model for diabetes and hypertension by 2013/14.

In the area of re-engineering of primary health care, key strategic interventions included implementing community based services in each district by establishing 54 Family Health Teams in 2011/12, which would increase, by 2013/14, to 250. The Department also planned to improve health outcomes by ensuring that 52 District Health Plans were used for planning, budgeting monitoring and reporting through the provision of direct support to District Management Teams.

In the area of accelerating the delivery of health infrastructure, key strategic interventions included the implementation of a national infrastructure plan, developing health infrastructure norms and standards for all levels of care, finalising the health care technology strategy, and finalising the essential equipment lists for primary health care in 2011/12, and for secondary and tertiary health care in 2012/13. The Department would also provide funding through the hospital revitalisation grant, which would be applied to 41 hospitals under construction and 25 hospitals in the planning phase.

In the area of improved health workforce planning, management and development, key strategic interventions would include developing a strategy for rural health workforce, developing norms and standards for the health workforce in primary and secondary health care, and integration of community health workers into the formal health system. 

Work in preparation for the implementation of the NHI would continue.  During the 2011 financial year, the Department would finalise the NHI policy and legislative framework, establish NHI pilot sites, and develop the funding model. 

Ms Matsoso summarised that in order to improve in the quality of health services overall, the Department planned to finalise the policies relating to legislation governing the establishment and functioning of the Office of Health Standards Compliance. This Office would be a national certification body, and would be established by March 2012.  20%, or 800 of the 4 333 public health facilities would be assessed for compliance with the six priorities of the core standards, rising to 40% in 2012 and 70% in 2013.

Ms Tiny Rennie, Acting Chief Financial Officer, Department of Health, presented the budget. She noted that in the Medium Term Framework (MTEF), the Department had requested additional funding for both National and provincial Departments, of R19.9 billion. However, Cabinet and the National Treasury (NT) had approved an amount of R18.1 billion, of which R3.4 billion was allocated to the national and R14.6 billion to provincial departments.

Ms Rennie noted that the Department's expenditure had grown at an average annual rate of 19.4%, and would grow at a further 9.2% over the MTEF. This increase was largely driven by transfers to the provinces for conditional grants.  In 2012/2013, the Forensic Pathology Service grant would be phased out, and the funding formerly allocated for this would be included in the provincial equitable share (PES) allocations.

Ms Rennie set out the baseline funding allocations over the MTEF, and then directed Members’ attention to the Annual Performance Plan booklet (made available to Members only), which gave a detailed breakdown of these allocations, also presenting slides on the breakdown by area of focus and fiscal year. She also provided a breakdown of the programme allocations, the conditional grant allocations for the following three fiscal years, and emphasised that over 96% of the Department's budget was for conditional grants. (See attached presentation for full details). She then provided definitions of Schedule 4 grants and Schedule 5 grants respectively, pointing out that the grant schedules determined whether grants could be withheld for non-performance or compliance, and the interventions that would have to be put in place if funds were withheld.

The final two slides outlined additional priority earmarked funds that were allocated directly to Provinces.

Ms Matsoso interjected that the Occupational Specific Dispensation (OSD) top-up for doctors and therapeutic professions noted in these slides was problematic. OSD was allocated based on the provincial equitable share model, rather than on the actual number of persons employed in each province. 

Ms Rennie added that some of this earmarked funding for other areas was also based on specific bids by specific provinces, but the National Treasury again allocated all funds on the equitable share model. This issue had been raised with the National Treasury, but there had been no resolution on it as yet.

Discussion
The Chairperson asked if the Department should not have a regulatory body to oversee health technology devices.

Ms Matsoso responded to questions on the lack of a separate regulatory system for medical devices. She noted that provisions for these devices fell under the Medicines and Related Substances Control Act of 1965, although they were never enacted.

Ms Matsoso noted that the structure of the Health Technology budget highlighted the Service Delivery Agreement. Health technology could not be achieved in isolation, because it also required improvements in human resources.  There was still a review to determine the appropriate structure at the Chief Director and Director level. Some health systems were already developed and available for rollout, using public funds, which were ready to be rolled out. There was no need to spend more, when the Department could use what was already available.  The Department evaluated all of the systems in the public sector and they wanted to extend the rollout of certain initiatives from the Western Cape to other regions. 

The Chairperson asked if Public-Private Partnerships (PPP) had helped the Provinces.

The Chairperson asked if the Department considered that the allocation for information systems was sufficient to create a uniform system across all provinces. 

The Chairperson noted that the priority within the Department was on Primary Health Care (PHC), with a budget of approximately R700 million, yet the budget for Tertiary Services was approximately R13 billion.  He questioned if the desire was really to promote PHC.

Ms Matsoso commented that the budget did reflect a larger proportion of funding to tertiary care, but this resulted from the way in which the conditional grants were designed. Specialist services accounted for the majority of the tertiary care grant. Specialists would then go on to train registrars. Investment was needed in tertiary care services and specialist assistance was needed to improve the colleges that were training doctors and nurses to fill the PHC positions.

The Chairperson asked if the Department was putting money into OSD to solve a known problem, or whether it was merely putting money in for the sake of keeping it going.

Ms T Kenye (ANC) asked how OSD would be worked out for the various nursing categories. 

Ms Matsoso agreed that OSD was not implemented properly. However, because it formed part of an agreement with unions, this must be respected. It did need to be reviewed. She reiterated that OSD funding was provided by National Treasury, based on the PES formula. Unfortunately, doctors were not distributed evenly throughout the provinces, so the funding was skewed, as some provinces received more than they required and others were not receiving enough. OSD for nurses initially involved overpayments, which the unions held could not be recovered.  There were also some nurses excluded from OSD, including midwives and infection control nurses.  The result of the Nursing OSD Review would be received soon by the Department, and this should address many of these issues.

Mr M Waters (DA) noted that page 38 of the Annual Performance Plan Booklet spoke about preparatory work for NHI, but pointed out that every one of the bullet points, excluding point 4, should in any event be happening in a functional health system.

Ms Matsoso agreed with Mr Waters that many of the items noted on page 38 of the Department's Annual Performance Plan should have been done already.  However, the Department was planning the system to respond to the principle of universal coverage.  She noted that there were quality problems in the public sector that would only be fixed with support, and without doing so the Department could not move forward. The Department needed to protect people from the catastrophic problems of paying out of pocket, so it had adopted the approach of increasing universal coverage and determining the package of services that should be provided.  This would drive the costing model, which in turn would determine what services could be provided. NHI would improve access and coverage and ensure that people could get a basic package of services.  The standards of both the public and private sector would be acceptable to everyone. 

Mr Waters queried if the R10 million per year for forensic chemistry laboratories was enough, and, if it was, when the backlogs would be cleared.

Ms Matsoso commented that the forensic laboratory allocations were over and above what was needed purely for operations, as it was designed to improve services. She noted that the forensic chemistry labs should fall under the National Health Laboratory Service, but this provision in the National Health Act had not yet come into force.   

Mr Waters asked what funding was being allocated towards the Directorate of Radiation Control. 

Ms Matsoso noted that the South African Health Products Regulatory Committee should be overseeing the radiation control technicians and the Department was currently in negotiations with the unions about moving the staff to the new structure.

Mr Waters felt that providing 1 billion male condoms against 6 million female condoms was disempowering towards women. He asked why this disparity existed.

Mr G Lekgetho (ANC) agreed that the discrepancy in male and female condom distribution was a problem.

Ms T Kenye (ANC) also stressed that the gap in condom distribution was worrying, given the patriarchal society of most areas in the country. 

Dr A Luthuli (ANC) also added her voice to the issue of imbalance in distribution of condoms.

Mr Waters wondered why the Department was not seeking immunisation targets for children less than 1 year of age and immunisations for measles for 100% of the population. He also asked why there was only 56% coverage for cervical and breast cancer. 

Ms Matsoso agreed with the comments on the imbalance in condom distribution.  She noted that there was a need to promote usage and improve access.  She also agreed that immunisation targets should be 100% in all cases.  She stated that there was a need to further study the incidence of cervical cancer, including implications with HIV/AIDS.  There was also a desire by the Department to further investigate the use of the HPV vaccine in reducing the incidence of cervical cancer. 

Mr Waters stressed that provinces needed better financial management, yet the budget was increasing over the MTEF to keep the provinces from going into the further deficit.  He asked where the Department envisaged that Provincial budgets would be heading in the long term.

Ms Matsoso agreed that in principle the provinces must improve their finances. Stabilisation funding had been provided in the medium term, but she thought that perhaps it should be reduced for future years. 

The Chairperson asked the Department if it was intending to promote male circumcisions by proper medical procedures, rather than traditional practices, in rural areas. The Chairperson noted that addressing the practices of traditional healers would require a lot of work. 

Mr D Kganare (COPE) asked if HIV/AIDS prevention strategies would be focused towards traditional and religious leaders in order to focus on the truth and not misinformation. 

Ms Matsoso agreed that the traditional religious medicine needed to be strengthened to ensure proper oversight. 

Mr Kganare asked if funding directed towards nursing colleges would increase the intake of students. 

Mr Kganare questioned whether the R3 million for the Health Systems Trust was a negotiated amount, or if it was for a specific purpose.

Ms Matsoso noted that the Health Systems Trust (HST) was not a public entity and that it operated almost like an NGO. The work of HST was confined to the role of health reviews and acting as a barometer of performance.  It received funding from the Department, who in turn also ensured that there was no ‘double-dipping' for funds.

Mr Kganare asked if the money directed towards hospital revitalisation would also address the human resources and equipment shortages in hospitals, in addition to the infrastructure.

Ms Matsoso said that the Department's allocation of R9 million for nursing colleges would be for both infrastructure and to address the training of nurses.  It would not only increase the intake of nurses, but also provide for greater opportunities for bedside training.  This funding would also work in conjunction with the funding allocated for training within the tertiary care budget.

Mr G Lekgetho (ANC) asked where the 41 planned hospitals would be built and how long would it take to plan and build these hospitals.

Ms Matsoso stated that the construction of hospitals would include not only include new construction, but also revitalising of existing hospitals.  Much revitalising would occur because a particular facility could not be relocated, so certain aspects would be rebuilt in the same location.

The Chairperson stressed that once the Department gathered statistics in previously un-visited areas, the incidents of TB would probably rise significantly.

Ms Matsoso said that identifying the numbers of people infected was also aimed at determining who had had active TB and who did not and thus determining who should be on treatment and who should be watched.  Outreach programmes would also ensure that TB was not stigmatised like HIV/AIDS

Ms Kenye noted that the single chronic care model would be rolled out in three districts, but enquired when it would be rolled out in the other districts. 

Ms Matsoso noted that the chronic care model was a pilot program at this time, hence the reason that it was only implemented in three districts at this time. 

Dr A Luthuli (ANC) asked if anything would be done to address prostate cancer, similar to the Department's efforts to address cervical and breast cancer.

Ms Matsoso responded that cancer screening was going to be made into a broader programme.  It would also include men's' health. 

Dr Luthuli asked, in relation to TB, if the Department was 'case chasing' or 'contact chasing' and asked for clarity on what it was doing.

Ms E More (DA) asked if there was progress on the programme to monitor TB patients for default and how this programme was being monitored.   

Ms Matsoso noted that contact tracing was the same as active case finding. The Department's goal was to go out and find cases, so that treatment could be provided early. The TB and HIV/AIDS co morbidity was complicated, because those with HIV had a greater chance of contracting TB, and the treatment for those with co morbidity was more complicated and different. 

Dr Luthuli asked the Department to describe the progress of the school health programme.

Ms Matsoso noted that nutrition programmes not only included babies, but would be provided for all ill persons. School health was broken down into three components of pre-school, primary school, and high school.  This was done to ensure that the interventions were correctly differentiated. The high- school health services were completed and these focused on risky behaviour.  Nurses would be allocated by district or sub-district, because there were not enough nurses to allocate one per school.

Dr Luthuli noted that the presentation did not address proper training for hospital managers, and it would be difficult to run effective hospitals without proper management.

Ms More asked what the Department's plan was now that it had the Development Bank of South Africa (DBSA) results on the CEO survey. She also wondered if the Department had any plans in place to adjust the balance between administrative and clinical posts.   

Ms Matsoso noted that it was not right that some Chief Executive Officers were running hospitals at level 8. Some CEOs were not qualified to run a hospital. There had also been an increase in administrative staff as compared to clinical staff, and the moratorium on filling administrative posts continued. She noted that hospital managers must have adequate skills including management skills and knowledge of health.  Managers could not be trained on the job. 

Ms B Ngcobo (ANC) asked the Department for an estimate of the progress towards reaching the Millennium Development goals.

Ms Ngcobo also asked if there was funding to fill the vacant registrar posts, or whether funding would only be solicited once the posts were filled. She noted that the Department's budget was quite large.  She asked what monitoring mechanisms were in place to monitor this budget and whether there were any mechanisms in place to specifically address fraud. 

Ms Ngcobo asked if there were any roll-overs from the previous year and, if so, what were the amounts.

Ms Rennie gave some further figures on the 80% roll-over of funds for the previous year, noting that this related to the revitalisation grant, valued at R350 million.  It was a result of delays in projects that prevented the handover of money.  There were also roll-overs for IT infrastructure, that had now been spent, and R15 million for the audit of the Primary Health Care project, which was currently under way. There was also a roll-over of R1.2 million for World TB Day, where the payments could not be made by the end of the fiscal year.

She also noted that money that bargained for by the National Department of Health for the Provinces was subsequently handed over to the Provinces.  Not all of the money earmarked for Provincial Departments of Health had been paid to those Provincial Departments and some was still being held in Provincial Treasuries for other provincial priorities. To counter this, the Department had put in a system to track all of the Provincial grants on a monthly or quarterly basis.

The Chairperson asked if the salaries were going to be adjusted for registrars, as historically they were paid less than medical officers. 

Ms E More (DA) asked if the Department could address OSD for specialised technicians.

Ms Matsoso noted that OSD for radiographers and specialists, who were excluded in the past, would be added to the bargaining council negotiations.  She would have to confirm the specifics and report back to the Committee. In relation to nurses, she repeated that there had to be a balance between PHC and tertiary care. The debate around nurses now centred on nursing student stipends as opposed to salaries, and, if they were subsequently seen as employees, what would happen if they failed. There was more discussion that needed to happen in this area.  The balance between PHC and tertiary care needed to address these training issues for nurses as well as for other occupations. 

Dr Luthuli wondered if the hospital revitalisation programme was likely to be hampered by a lack of engineers or project managers. 

Ms Matsoso responded that the Department had a very aggressive project management programme.  The Department had signed agreements with the Centre for Scientific and Industrial Research and the Development Bank of Southern Africa. The Department also stipulated that each Province must have its own engineer dedicated to hospital projects. She also noted that clinical technicians would also be involved in the hospital revitalisation projects.

Ms More asked which districts were chosen to pilot the chronic care programme, and how they had been chosen.

Ms Matsoso noted the districts selected for the pilot projects for the chronic care model.  Also, in regards to TB compliance, they were adopting the directly observed therapy (DOT).  They were also investigating efforts to reduce the pill burden and timelines for TB treatment. 

Ms More asked if the Department had a comprehensive women's health programme that would be broader than cancer screening. 

Ms Matsoso spoke about obesity, noting that South Africa was facing diseases of affluence in addition to diseases of poverty.  All health promotions need to address both of these issues.  She stated that members of Parliament needed to take the lead for a healthy lifestyle.

The Chairperson noted his appreciation for a good report and said that the Committee accepted the strategic plan. He asked that the Department must carry out its intended aims, and the Committee would monitor its progress.

He requested that the Department must provide the Committee with reports on TB, and the registrars report, including their anticipated placements.

The meeting was adjourned.