DoH, NHLS & SAHPRA 2018/19 Annual Reports; with Minister & Deputy Minister

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Health

15 October 2019
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Annual Reports 2018/2019  

The Committee was convened for presentations from the National Health Laboratory Services (NHLS), the South African Health Products Regulatory Authority (SAHPRA) and the national Department of Health (NDoH) on their annual performance reports and financial information for 2018/19.

The NHLS said that overall it had achieved 100% against most programme targets. However, it had not met its targets for employment equity, performance agreements and training, and diseases under surveillance. Members asked about the Auditor-General’s (AG’s) ability to identify the irregular expenditure at the entity. The potential of information technology (IT) to pioneer a new business strategy for the NHLS was highlighted. They asked about the backlog in improving laboratories, the regression in supply chain management, the suspension of its top executives, strategies to retain trained registrars, and its methods of collecting outstanding debts.

SAHPRA gave details of the challenges it had faced in transitioning from the former Medicines Control Council (MCC). These included inheriting a dysfunctional entity which had been an under-staffed and under-resourced, severe labour disruptions, inappropriate accommodation facilities, a huge backlog of approval applications, and a perceived lack of support from the Department. Members nevertheless expressed concern over the entity’s extremely poor performance. They asked about the licensing of growing cannabis for medicinal purposes, the lack financial and human resource capacity, and its irregular expenditure. They encouraged SAHPRA to engage with small commercial farmers on the cannabis licensing issue.

With both the Minister and his deputy present, the Department of Health presented its performance and financial reports. The Minister gave an extensive overview, covering such issues as progress with the National Health Insurance ((NHI) scheme, the Department’s focus on primary health care, the training of nurses and the impact of the Cuban doctor training programme. During the discussion, Members raised questions about possible undue political influence on the NHI bill; intimidating attitudes from health workers at HIV testing sites; mental health and its correlation with crime; the cost of chartered flights for Cuban-trained doctors; the use of technology to promote E-health and the Health Patient Register System (HPRS); safety guidelines for emergency health service (EMS) workers; the health market inquiry; and the security of drug availability.

Meeting report

National Health Laboratory Services (NHLS): 2018/19 Annual Report

Prof Eric Buch, Board Chairperson, NHLS, said the entity’s mandate was to provide a cost-effective and efficient health service. It reached out to most distant and rural areas to the country and provided service in an equitable way. It also had to provide support to research organisations. There were three statutory functions which involved diagnostics, research and training.

Institutes of the NHLS were the National Institute for Communicable Diseases (NICD), the National Institute for Occupational Health (NIOH), the South African Vaccine Producers (SAVP), and Diagnostic Media Products (DMP)

An overview of the NHLS performance was given, after which the number of tests conducted by the NHLS were compared to those carried out in the private pathology market. The Committee learnt that close to double the number of tests were done in the private sector, which indicated the responsibility of the NHLS, as a Section 3A entity, to act in the national interest.

Among the key issues dealt with by the board were the finalisation of disciplinary proceedings against the chief executive officer (CEO) and chief financial officer (CFO), and the appointment of replacing them and the chief information officer (CIO), who had resigned. There would be a focus on ensuring stability in the finance, management and governance areas.

Prof Buch said the NHLS appreciated the efforts this Committee had made to urge provinces to pay for its services. This would benefit the financial sustainability of the entity. Although there were challenges with organised labour, the unions were generally happy with the board’s firm stance on rooting out corruption. The South African National Accreditation System (SANAS) accreditation had been a key focus, and the NHLS had an independent external body to ensure quality. The financial and information technology (IT) sections had been improved. He emphasised the importance of IT in the organisation, because members in rural areas needed to be able to access and research medical information.

Dr KarmanI Chetty, Acting CEO, summarised the NHLS’s key achievements, and said that overall it had achieved 100% against most programme targets. However, it had not met its targets for employment equity, performance agreements and training, and diseases under surveillance.

The entity had 7 532 employees at the end of the financial year. Costs of employment amounted to R3.6 billion, which accounted for 46.96%/ of its expenditure. The average personnel cost per employee was R478 000. There was a very strict employment equity (EE) plan, but the limited pool from which to choose senior management positions and some professionals had been a challenge.

Mr Michael Sass, Acting CFO, said the NHLS’s bank balance was healthy and sustainable, but it still had to be very frugal. Even a 1% change in the volume of testing would make a huge difference because of the high costs involved..

Dr Chetty said the qualified audit outcome in 2018 had been due to the currently suspended CEO and CFO unable to quantify irregular expenditure. The entity now had to go through every contract in its catalogue systematically to determine whether it was regular or irregular. It had been buying equipment and paying for it without going out to tender.

Prof Buch said the acting CEO and CFO who had been suspended had continuously been feeding the auditor a great picture. The board had had to intervene and had discovered that R1 in every R3 was spent in irregular expenditure due to purchases without tenders, without due procurement process, and so on. He asked the Committee to investigate how the auditor could miss that. The entity was now clearing up the issues from the past and was instituting new processes to close these gaps.

Mr Sass said that most of these irregular expenditure had provided the actual value, and the fault was more to do with the administrative procedure not being followed. Laboratory equipment cartridges, for instance, could only be used as lab equipment, and thus could not be used in the normal market.

Dr Chetty briefed the Committee on the entity’s challenges, stressing its inability to attract pathologists due to its competition with the private sector. It was looking for a way to resolve the difficulty. Although personnel costs had been rising, the NHLS was trying to keep them down.

Discussion

Mr T Munyai (ANC) commended the NHLS’s ability to identify its challenges and irregular expenditures. He expressed concern over the Auditor-General’s (AG’s) ability to identify those challenges, and questioned how many other organisations had similar issues that the AG was not able to identify. He suggested the Committee to use NHLS as a case study to interrogate the AG. On the IT issue, he emphasised the importance of the availability of the spectrum for e-health and e-governance, as this was where the future was heading. The NHLS could be the pioneer in the sector with an E-system as a business strategy to maximise profits, as well as performing administrative work such as identifying irregular expenditure.

Dr P Dyantyi (ANC) wanted to know why five targets had not been achieved. She asked if the NHLS had tried to identify and prevent the repetitive and unnecessary tests that were happening at the Nelson Mandela Academic Laboratory.

Ms M Hlengwa (IFP) expressed her concern over the backlog to improve labs, and asked what plan had been made to address this matter.

Ms S Gwarube (DA) referred to the challenges with recovering funds in KwaZulu-Natal (KZN) and Gauteng. Besides motivating the provincial treasuries, what other avenues were available for the NHLS to urge provinces to make payments? She asked about the regression in supplier chain management (SCM) indicated in the AG’s audit outcomes. She understood that there was a challenge with the internal audit, and it was not necessarily the fault of the AG. However, what steps had been taken to ensure better internal audits in future?

Ms E Wilson (DA) said that she was the only Member that had served on this Committee in the 5th parliament, and recognised the challenges the NHLS was facing. She commended their quick actions to deal with them. She enquired about the progress of the cases against CEO and CFO because of the effect on the reputation and integrity of the NHLS.

Ms H Ismail (DA) asked how often the district-level laboratories were reviewed, and how soon the court case would be resolved. 

The Chairperson asked what steps the NHLS had taken to address transformation. What was meant by “SANAS-accredited.” What were the benefits of this accreditation? He questioned whether Mr  Sass had been involved with the CEO in misleading the board in corruption. He asked how the NHLS had been impacted due to the decrease in donor funding in the country. He needed clarity on the health-patient register system linked to the laboratory system.  He asked if NHLS could accredit people, and what its mandated responsibility was for the training of registrars. In Durban, there were 60 oncologists, and only seven were willing to work in government service. Was there a process by which the NHLS could retain them, and not keeping losing them to the private sector? Irregular expenditure and SCM misdemeanours should not happen. Had the NHLS considered to collaborating with the Department of Health (DoH) and other entities to root out such issues, because if they were rooted out, things at the NHLS would improve tremendously.

Board Chairperson’s response

Prof Buch commented on the governance issues. The NHLS had to be cautious when making allegations against employees for fear of complications and unnecessary litigation. What the AG and the NHLS board had both experienced was the level of difficulty when members of the entity behaved irregularly. Regarding the dismissal of the CEO and CFO, the case affecting them was in the IT area, and the transgressions were blatant.  As per regulations, any procured item that exceeded R10 million in value needed to be approved by the board. He assured the Committee of the board’s determination to root out those transgressions, but pointed out that it had to be done within the confines of laws and regulations. In the case of the CEO’s and CFO’s dismissals, the prolonged disciplinary process had also been caused by both dismissed members taking the matter to Commission for Conciliation, Mediation and Arbitration (CCMA). The NHLS had had to refer the matter to the labour court.

Regarding the CIO’s dereliction duty, this was also in the middle of a CCMA process. The NHLS did not have jurisdiction over members who resigned. The other three members who had been found guilty of misconduct had resigned in the middle of the process. It was up to Special Investigating Unit (SIU) to decide whether they would face charges.

On ensuring payments from provinces, the former Health Minister, Dr Aaron Motsoaledi, and the Director-General (DG) had engaged extensively with the provincial treasuries for payments. The NHLS was negotiating with the provincial treasuries itself. It had resulted in the reimbursement of R1.1 billion from Gauteng. Provinces recognised the national asset status of the NHLS and encouraged their provincial treasuries to make expeditious payments. He expressed his confidence that through engaging, advocating and working collaboratively, recouping funds would not be hard.

Prof Buch emphasised the vital role of transparency in the responsible governance of entities. The NHLS did not hide things from the auditors, and the regressions indicated in the report were a cumulative combination of legacy and new issues that it was clearing up.

On the backlog of complaints received regarding forensic lab services, Prof Buch clarified that it was not part of the mandate of the NHLS. There were two types of laboratories in the country. One was clinical laboratories, which support patient care; the second was forensic laboratories, which provide evidences in rape and murder cases in support of the South African Police Service (SAPS). The NHLS would be enthusiastic about possibly taking on this new responsibility in future, and assured Members of its dedication to reducing the turnaround time.

Acting CEO’s response

Dr Chetty explained issues related to the Auditor-General’s findings. Regarding e-health and e-governance, the NHLS possessed a few years’ data, and the laboratory information system was proving effective so far. However, she indicated her entity’s resolution to look at modernisation of the equipment and lab systems. Exciting news could be expected at the next meeting.

To eliminate unnecessary and repetitive laboratory tests, the NHLS had recently instituted a new system called electronic gatekeeping.  The system would pick up if an intern repeated a test twice a day, and block the process. It had the exact number of how many tests had been rejected.

Regarding the forensic chemistry lab and the backlog, Dr Chetty recognised that there had been delays in blood alcohol and toxicology, and the NHLS had had difficulties in reducing the turnaround time. She assured the Committee that a plan to address the issue was well underway.

On the motivation for provinces to pay NHLS, Dr Chetty said that the working relationships between the entity and provincial governments were strong. The NHLS also had an effective billing system. In addition to this, the NHLS Amendment Act also helped to look at alternative reimbursement models to ensure the entity’s financial sustainability.

She agreed with Members that donor funding was a major problem for the NHLS. The Department of Health (DoH) had been working to address the issue. The most significant impact on the NHLS due to the decrease in donor funding, was on the number of people it could employ.

The interface between health information and laboratory system information had been making tremendous progress. The system could pick up a patient’s health information by locating its data on its laboratory system database. The NHLS was in the process of looking at tenders to provide connecting and expanding networks services to clinics.

The entity had brought in the South African Institute of Chartered Accountants (SAICA) to assist them with auditing outcomes. 

Prof Buch commented on registrars’ pass rate, and explained the roles of the four players involved in the training and accreditation of specialists, and highlighted each one’s responsibilities. The four players were the NHLS, the universities, the Health Professionals Council South Africa (HPCSA) and the examinations of the College of Medicine of SA. Among them, the NHLS employs specialist students to provide them with a learning place environment and platform, as well as giving them time to study and research. The universities’ responsibilities were teaching and training. The Health Professions Council of South Africa (HPSCA) sets registration standards and norms, and the College of Medicine was in charge of specialists’ examinations. Regarding the pass rate, the NHLS could only engage with other entities and give advice, but it did not have the power to do anything directly.

Prof Koleka Mlisana, Executive: Academic Affairs, Research and Quality Assurance (AARQA), responded to the accreditation issue. She explained that SANAS was the board that evaluates and certifies the ability of institutions and laboratories to perform for clinical laboratories according to ISO standards. There were different International Organisation for Standardisation (ISO) standards. For instance, ISO 15189 was for diagnostic laboratories, and different ISOs applied for public labs or administrative units. The ultimate goal for NHLS was to have all labs SANAS-accredited. The process began with the NHLS taking steps and employing internal audits before SANAS accreditation. These were all done in preparation. In the beginning there were only a few labs that were accredited, but now almost 90 labs were SANAS-accredited. Those unaccredited laboratories would have to go through her office so that preparations and actions could be done for them to be accredited. For those laboratories that were not accredited by SANAS, they got a yearly internal audit.

The NHLS was trying to push 85% of the laboratories that had not been accredited to achieve 80% of their targets. In the year when the audit had been conducted, the goal had not been reached as only 65% of the unaccredited labs had achieved the 80% goal. She commented that poorly-performing laboratories required extra support in human as well as equipment resources. The current status was that there were 50 of the national central laboratories out of the country’s ten medical schools, and the target set had been 51 out of 53. The 51st laboratory had followed and passed all due processes, and  it was an administrative issue that it had not been accredited yet.

On the training of medical scientists, the target set was to enrol 50, but only 36 had been enrolled. The under-achievement had been because a lot more had been enrolled in the previous year, which had affected this year’s capacity to take on more. The same applied to medical technicians.

Regarding the frequency that laboratories were reviewed, Prof Mlisana said the national office did a yearly audit on those labs that were non-accredited. Regional audits could be more intense, depending on the performance of those labs, because the ultimate aim was to push them to be accredited by SANAS. The parameters used to evaluate involved both management and technical support.

She commented on the training of registrars, and reminded the Committee that the mandate of training resided in universities. The NHLS simply provided a training platform and employed registrars. Trainers were jointly appointed staff at NHLS and universities. The HPCSA informs each university of the number of registrars they are able to train within the pathology discipline.

Prof Mlisana emphasised NHLS’s vital role, in that it was training not only for itself, but also for the country as a whole. Commenting on struggle regarding the registrars’ pass rate, she said that stakeholders were looking into the matter.

Regarding transformation, the NHLS said it was comprised of people and technology. On people, it had been progressing very well, as well as with its modernisation and automation projects. Race and gender was an important aspect of the NHLS’s employment equity plan, which had seen good outcomes. The only challenge that NHLS faced was lagging behind the target of 65% for senior management positions, but it was working towards it. 

Acting CFO’s response

Mr Sass commented on the recovery of debts from provincial governments, and said that provinces always paid because there were agreements in place.

On SCM regression, he would speak to the AG to find a solution and address it. However, he recognised it a huge challenge, and warned the Committee that it might repeat again next year. He also expressed his view that the AG might have indicated a regression in the report because of NHLS’s proactive approach that had actively exposed all the irregularities in the supply chain. 

On the Chairperson’s remark on collusion with the suspended CEO, Mr Sass commented that the suspended CEO had been very knowledgeable on financial matters. Board members were also experts in this regard, so if that had been true, he would have been reported to the board.

Prof Buch interjected and reminded the Committee that Mr Sass had previously been the Accountant General of South Africa.

Ms Nelisiwe Mkhize, Chairperson: Remuneration and Human Resources Committee (RHRC), explained the strengthening of internal processes, the disciplinary process that had been gone through, and said the head of internal audit appointment had been made. Prof Buch also reminded the Committee that positions could not be advertised for recruitment until the outcome from disciplinary hearings was reached, and those processes would be concluded in November.

The Chairperson remarked that both the Acting CEO and Acting CFO had shown their competence in performing their responsibilities. He suggested that overall clear guidelines were needed to guide the work. On provincial governments’ payments, he mentioned an instance where a provincial department could not pay NHLS, and it had gone straight to the DG of the Health Ministry , who had then gone to the Minister to squeeze their conditional grant, so that provinces would realise the repercussions of owing the NHLS money.

The AG commented on the difference between internal and external audits.   

On regression, it had been recorded that there was irregular expenditure R1.6 billion in the last financial year. In order to clear this up, management had brought in SAICA to assist them and discovered that the main issue was the amount spent vs the contract amount, where the spent amount had been greater. Last year, auditor could not get the documents that referred to the matter, which was why the opening balance had increased from R1.6 billion to R4.4 billion. Since the implementation of the automation system, the position looked like it was improving.

South African Health Products Regulatory Authority (SAHPRA): 2018/19 Annual Report

Prof Helen Rees, Chairperson: SAHPRA, outlined the entity’s strategic outcome-oriented goals. These included:

  • To demonstrate publicly responsiveness and accountability as an effective and efficient high-performance organisation;
  • To take timeous regulatory decisions on medicines and medical device applications to ensure compliance to defined standards of quality, safety, efficacy and performance;
  • To re-evaluate and monitor medicines and medical devices;
  • To investigate, monitor, analyse and act upon existing and new adverse events, interactions, information with regard to post-marketing surveillance and vigilance;
  • To ensure regulatory compliance through a process of active inspections and investigations;
  • To evaluate clinical trial protocols in accordance with defined standards;
  • To evaluate the applications for sale of unregistered health products in accordance with defined standards;
  • To establish and strengthen collaborative initiatives with any other regulatory authorities or institutions in order to achieve the objectives of the Medicines Act; and
  • To ensure SAHPRA was capacitated by adequate, competent and motivated human capital.

The SAHPRA Board included Prof Rees and Ms Mandisa Hela, as the new chairperson and vice-chairperson respectively. The remaining 13 members comprised experts from various sectors of health, including global and South African public health, medicines registration and regulation, as well as medical research fields, law, governance, ethics and finance. The members had extensive experience in both public and private management. This depth and diversity of experience and qualifications had been crucial in supporting the entity at its inception. SAHPRA was accountable to the Minister of Health through a 15-member board appointed by the Minister.

The organisation had insufficient technical staff, and was in the process of filling in 109 positions which had been advertised.

With this background, SAHPRA had started to make good progress, but the birth of this new public entity had not been without challenges. At the outset, it should have been regarded as a ‘start-up’ organisation and have been provided with adequate corporate service support and technical staff to deliver on its expanded mandate and inherited problems. Neither of these essential underpinners had been provided to SAHPRA. This transitional period had coincided with industrial action in the national Department of Health’s (NDoH’s) Civitas building where SAHPRA was still housed, and this had limited the support that the NDOH departments could offer SAHPRA.

The SAHPRA staff themselves had been affected by the industrial action, so at the beginning of 2019 the regulator had had to precipitously move out of Civitas and into new premises on the campus of the Council for Scientific and Industrial Research (CSIR), to allow work to resume.  Lack of IT and phone connectivity had further hampered the regulator, and the spread of its activities across five remotely situated buildings within the CSIR campus continued to make its work challenging.  This entire experience put enormous strain on the existing and newly appointed staff at a time when they had been asked to undertake many turnaround processes. Despite these challenges, a team of committed and resilient staff and board members had rolled up their sleeves and led SAHPRA through this difficult period to emerge as a growing organisation, into a good and positive space.

The entity was characterised by its inadequate corporate service support, inadequate technical staff, prolonged labour unrest, and inherited backlogs, with was about 16 000 products sitting in the queue. The entity was witnessing a huge turnaround.

Ms Portia Nkambule, Acting CEO, briefed the Committee on the key achievements of SAHPRA. Those included the relocation to the CSIR in December 2018, and the top priority focus on the backlog of applications. The entity’s objectives in the new financial year were the backlog clearance programme, procurement, forming backlog clearance team, and regular, constructive engagement with industry and other health system stakeholders.

Only 20% of staff had been at work due to protest action. However, the overall percentage was still 58%, which was quite good considering the number of staff at work. She outlined the key performance outputs of SAHPRA.

Mr Molatlhegi Kgauwe, CFO: SAHPRA, briefed the Committee on the entity’s financial performance. He informed Members that SAHPRA had received whistle-blower information that some officials were engaged in misconduct, and the board and management were on top of it and would inform the Committee in due course.

Irregular expenditure for the current financial year was R1 206 785. The reason was related to non-compliance with SCM regulations. This emanated from the lack of capacity within the SCM unit and personnel lacking the required skills. The plan given in response to that was to capacitate the SCM unit and train staff on SCM processes

Discussion

Mr M Sokatsha (ANC) expressed his grave concern on SAHPRA’s poor performance in achieving its targets across all programmes. He questioned the R30 million saving on employees. The funds clearly should have been used in capacitating units in the entity. He criticised SAHPRA for asking for additional funds from Treasury -- why could it not use the R30 million it had saved?

Mr D Jacobs (ANC) recognised the qualified audit and the difficulty in getting qualified personnel, as well as all other challenges. He said these problems inevitably caused its failure to achieve its key performance indicators (KPIs). He appreciated Members reflecting on difficulties and coming up with corrective measures to perform better. He suggested that SAHPRA provide feedback on the progress of resolving those outstanding issues within a certain period of time. He hoped that by then the entity would have achieved some progress. 

Ms N Chirwa (EFF) asked about the licensing issue for medicinal purposes. She wanted to know many Medicines Control Council (MCC) personnel had been absorbed into SAHPRA. What had been the changes in this transition, besides the digitisation of the backlog? What measures had been taken to assist entry-level manufacturers?. What would the SAHPRA agenda look like if SA’s health system were to prioritise prevention in health care? What criteria were used to determine the targets on the agenda of SAHPRA? What measures had been taken to deal with the capacity limitations? She cautioned it not to use labour unrest as a scapegoat for its problems. She asked for an explanation of its ICT difficulties.

Ms Gwarube said the audit outcomes painted a dire picture, with every indicator pointing to something wrong in the entity. She asked SAHPRA to provide a recovery plan to the Committee and a reasonable timeframe given for what goals ought to be achieved, and by when, with a special focus on governance. She expressed growing concern over cannabis licensing. This industry had been, and would be, hijacked by big businesses to the detriment of small communities. She had heard that a big farm in Stellenbosch had already been given a licence. To what extent, then, could SAHPRA engage with small communities, and was it within its mandate?

Ms Hlengwa sought clarity on the safety of medicines. She said that the Department needed to ensure regulation compliance through active inspection and investigative actions towards non-compliant behaviour.

Mr Munyai suggested SAHPRA should debate the cannabis issue at a separate meeting. He described SAHPRA as the worst entity in the DoH portfolio in respect of its auditing outcomes and financial statements. The audit outcomes were a disgrace. It looked like there had been no CFO, or a CFO who was lacking in skills. Consequence management needed to be in place, and that was what its turnaround strategy should start with. He had read a Congress of South African Trade Unions (COSATU) letter alleging that the board appointed among themselves. If this was true, that would be a transgression. He highlighted the importance of proper procedures with the appointment of the CEO. Because the irregular expenditure was so massive, it was crucial to put consequence management in place.

The Chairperson wanted to know if the MCC had ceased to exist and then SAHPRA was born. Had they got the entity to die so all staff had to apply for new positions? Since the performance report was so bad, what had been the consequence management for all those involved? If SAHPRA was a start-up organisation, what had happened to the previous organisation -- what did the country lose? Who was in charge of the company when it was lost?

SAHPRA’s response

Prof Rees said the feedback from some Members had been tough. She asked the Committee to bear in mind that SAHPRA had inherited a dysfunctional entity which had been an under-staffed and under-resourced entity. When it was first taken over, there had been 60 000 dossiers that had not been looked at properly since 1992. 62% of those dossiers were five years old or older.

The reason the MCC had been removed was because it was regarded by the world as best practice to allow the entity to become independent in order to avoid the pressure from being under the Department of Health, and able to provide the Minister with the best advice.

She also raised the issue of the entity’s struggle to get support from the DoH. What had been extraordinary was the hard work of the Acting CEO and the directors. No one had been there to actively support them in turning around the entity. For the appointment of CEO, they had had to advertise the position themselves without the anticipated DoH’s endorsement. Their own advertisement had not achieved a positive outcome, and no candidate was found to be suitable. It had finally resolved with the assistance of the previous Minister. Two months into the inception of the entity, 80% of staff members had stopped working, and the way the entity continued was entirely by relying on senior management and a few colleagues who had worked day and night, including Christmas. During the protest, industries could not deliver their applications to SAHPRA because they had to move core services to a non-governmental organisation (NGO) office, and some people got threats for doing that. There was also backlog project from a donor project for which there was no budget. A lot of the cases had to be investigated and uncovered recently, with no connectivity and telephone.

Prof Rees said that the staff employed had been transferred from the MCC, and this was finalised only in November.

In defence of the CFO, she said that the CFO had been with SAHPRA for only four months. Again it showed the entity’s difficulty in appointing people without HR support. She really appreciated the good team that she had now. She remarked that if she had had to present in March this year, she would have told the Committee the situation could not be worse. Considering the legacy context, the few achievements were impressive and significant.

The processes for dealing with the backlog of applications had been re-engineered, which would cut the turnaround time down. They aimed to have 16 000 applications handled in two years. The entity had already got rid of 30% of the backlog, and was not going to allow a backlog to develop in future. had had meetings with industry leaders for the past six months, and they had at that time been on the edge of taking SAHPRA to court. Now they were not, because they could see the changes going on.

Referring to the staff, she said she had never known a staff contingent or a board to work so hard to give strategic support, and to transition this entity into a world class regulator. She asked the Committee to allow them come back within a short period of time to show them its turnaround progress. It would see a turned around organisation and improved morale.

The Chairperson reminded the Committee of SAHPRA’s legacy of inheriting a backlog, and said they needed to give them a chance to improve.

Ms Mandisa Hela, Vice-Chairperson: SAHPRA, referred to the rationale behind the transition from the MCC to SAHPRA. The MCC used to have a committee of 24 members, which included experts from academia and researchers. All of them had primary duties elsewhere and their work at the MCC was done part time. It was not uncommon, when a professor had to be approached, to be told that the professor was travelling or on sabbaticals. She also pointed out that most of their employees had generally been mature, including many retirees. Due to its lack of a financial compensation package, young people were usually not attracted to the work. Whenever there was a squeeze on the fiscus, the MCC was the first one to take the chop.  Considering the productive work it was performing, it was wrong to impose a moratorium, which was why the decision was reached that MCC had to be separated from the DoH to have more independence.

The Chairperson understood Members registering of their frustration, as he personally was also dissatisfied with the reports. He reminded the Committee that the team was trying to turn around the organisation, and suggested SAHPRA should come back to show Members its progress in due course.

Prof Rees referred to the commercialisation and licensing of cannabis, and said SAHPRA had a limited role in the matter of engaging with small-scale community farmers. The current permits were for growing cannabis for medicinal research, not for manufacturing. Cannabis was a global issue involving not only agriculture, but police, the judiciary and education. Discussion with the Minister was a political issue. Questions needed to be asked on how one viewed cannabis in SA, and this required a broader national dialogue. Also, to give a permit for a medicine registered in another country, SAHPRA had to be able to give permit when motivated. Of the 90 applications, only five had been favourable. There was very strong engagement between SAHPRA and the people involved, and the requirements were very strict.

Department of Health: 2018/19 Annual Report

Minister’s Overview

Dr Zweli Mkhize, Minister of Health, said his Department had tabled the National Health Insurance (NHI) bill, and had done a lot of preparatory work for its introduction. However, it was still too early for details of the implementation plan to be given at this stage. A unit comprising existing staff in the Department and outsourced additional capacity would be doing the work to create the structure for NHI.

The Department had put in place a quality care improvement plan across all the provinces, and a budget had subsequently been drafted. The Office of Health Standards Compliance (OHSC) was being used to provide guidelines to benchmark and assess the quality of care. He emphasised that quality of care was a non-negotiable issue for the DoH.

The re-engineering of primary health care had been raised in the budget speech, and the Department had begun the process of incorporating private healthcare practitioners. He believed that the outcome would be to ensure quality primary health care, as well as the strengthening of relationships so that referral patterns could be stabilised.

The Department had set specific targets for human resources. It was in the process of reprioritising programmes in order to make savings. Currently, R800 million had been raised in collaboration with National Treasury. These funds were critical for filling the vacancies to correct the shortage of staff due to the freezing of posts.

The DoH was ensuring that interns were placed in positions. This included Cuban-trained students and those doing community service. The National Health Council had to submit a review on a quarterly basis.

Attention had been given to the training of nursing students. The Minister described the process as going appropriately. Nursing training programmes in hospitals had been introduced.

The Department was committed to strengthening health management and leadership. It was creating an understanding of what the NHI was about so that the officials couldNHI engage with people at the community-level. One of the initiatives was for leaders to learn from experience in other countries. So far, the first such team, which included Members of Executive Councils (MECs) and heads of departments, had just returned from countries like the United Kingdom, Turkey, Thailand, France, and Japan. There was also another team that was dedicated to look just at HR issues. A review of the matter had already been submitted. There was also a team which had looked at management delegation, so that management structures would be streamlined in future.

 

The DoH was working with National Treasury to accelerate the delivery of infrastructure within a period of five to seven years. The suggestion from Treasury was to focus on replacement, refurbishment and renewal, which was also key to the NHI.

On the security of supply of medicines, the Minister emphasised the need to ring-fence the budget for medication so that this area was protected.

The Department had focused on key programmes such as those dealing with HIV and TB. It currently aimed to add two million recipients for anti-retroviral (ARV) treatment to increase its cover to six million people. It had reactivated the TB caucus in this House so that the issue could be handled at the highest level of leadership. There was also a need to exchange views and communicate with TB programmes outside the country, such as the Global Caucus on TB.

On maternal and infant child mortality, there had been continuous deaths in this area, and this was where the Department got the largest number of lawsuits related to difficulties during births. However, it had made significant improvements, considering there had been a 40% decrease in incidents. What the Department needed to do was to make sure it continued this trend.

The Department had already compiled a health patient registration system for 73% of the population and was moving towards getting the total population recorded. It was also digitising health patients’ records to reduce their waiting time. Some hospitals had already installed such programmes and some provinces had implemented E-pharmacies and drug-dispensing ATMs successfully.

The Minister emphasised the importance of IT in diagnostics, and said that it had been employed quite often to cover duties unable to be performed due to the shortage of staff. The outcome would be shared with the Committee in due course.

The Department planned to integrate mental health as well as other chronic non-communicable diseases into primary health care, with the main focus on detection and prevention.

He expressed his concern over the comments made by the Financial and Fiscal Commission (FFC), and planned to have a meeting to discuss this with them. It had been inappropriate for the FFC to approach the Committee without first consulting the leadership of the health ministry. Among the issues the FFC had addressed, it had made a pronouncement about the limited time for the implementation of the NHI by 2026. This should have been discussed with the Department first -- it was disturbing that the FFC had not included DoH in the discussion

The FFC had also raised the issue of the inter-governmental fiscal framework. The Minister said the process would be for funds to follow function -- this was how the Department was going to allocate responsibilities, and once they were assigned to specific authorities, then the funding would be dealt with. The concern was that the legislation that gave power to the Minister, created the feeling that the funds would be operated at the national level. The Minister pointed out that there were two pieces of national legislation around that matter -- one was on delegating power to the provinces, and the other was on provinces allocating funding. At the last National Health Council, a proposal had been tabled about powers and delegation. Once consensus was achieved, then Treasury would be able to resolve the challenges. However, this could not be used as a pre-condition to prevent the NHI from happening. The Minister believed the FFC needed to be more informed on the matters that they had raised.

The Minister explained that the health market inquiry emanated from the DoH’s efforts back in 2004 to regulate certain aspects of the health sector, such as the challenge around issuing of certificates and pricing. It had always been the Department’s view that government should act as a regulator in relation to the private sector. He believed that certain interventions from the government to address the challenges in private sector were in the best of interests of both the sector and patients. There was a sentiment felt by some parties that there was nothing wrong with the private sector, and the DoH should just focus on the public sector, such as some of the issues raised by the FFC. However, after the Department had gone through an objective process to evaluate the private sector, challenging issues had been exposed and uncovered. Among them were the monopolistic behaviour towards new players in the sector, the preponderance of private health beds in areas which was not guided by patients’ needs but rather by financial considerations, and the over-utilisation of private health services leaving patients unprotected. These issues needed the DoH’s attention and an effort to close the gap.

The Minister said that patients complained about the lack of an oversight body for the performance of health products so that they could see the value for money. He had taken note of the weakened position of health product consumers in the market. With private medical aids, companies offer hundreds of options, but consumers only bought out of instinct, without having the ability to compare. His team would in future inform the Committee which of the services offered had been covered by NHI, which services were needed to strengthen the private sector, and which areas needed policy development.

Annual Report briefing

Ms Malebona Matsoso, Director-General: DoH, said the AG had actually commended the Department on its internal controls in its report. She was not aware of what the AG had said to the Committee, but she could share her record of the report with the Committee.

Briefing the Committee on the annual report, she outlined key aspects of the National Development Plan (NDP) 2030 and the medium-term strategic framework for 2014 to 2019.

The Department had received an unqualified audit outcome. The NHI Bill had been presented to Cabinet in January 2019, and approved for further processing. President Ramaphosa had received a Universal Health Care (UHC) award on 23 September in recognition of his leadership of the NHI towards UHC 2019.

The new national eHealth/digital strategy for South Africa (2019 - 2024) had been developed and approved in 2018/19, and the eHealth strategy had been published and disseminated in the 2019/20 financial year. The process of involvement had included strategy review workshops and consultative meetings. The DoH, in partnership with the Council for Scientific and Industrial Research (CSIR) had developed the Health Patient Registration System (HPRS) with the goal of providing a single authoritative national source of patient demographic information, and of standardising patient registration across all health facilities in the country. The HPRS uses the South African identification document (ID), and all other legal IDs such as passports as the unique identity verifier of the patient. A national patient registry had been created by the HPRS, and it would be the source of the NHI beneficiary registry. As at 31 March 2019, 2 955 primary health care (PHC) facilities and an additional six hospitals were implementing the HPRS.

Ms Matsoso referred to the Department’s programmes for HIV and AIDS, TB, and maternal, child and women’s health, and informed the Committee:

  • 692 397 new patients had started anti-retroviral therapy (ART) in 2018/19, with a total of  4 629 831 patients on ART remaining in care at the end of the period;
  • 14 874 879 clients were tested for HIV (including antenatal) against the medium term strategic framework (MTSF) target of 10 million tests per year;
  • 1 385 of 187 879 (0.74%) of infants born to HIV positive mothers were found to be HIV positive at 10 weeks through the polymerase chain reaction (PCR) test;
  • There was a 79% TB client treatment success rate, and a TB death rate of 3.9%;
  • There were 20 530 adherence clubs, with 601 605 patients participating.

The implementation of the 90-90-90 Treatment and Retention Acceleration Plan had been strengthened through daily reporting and monitoring of 328 high burden facilities. Health facilities were required on a daily basis to trace patients who missed appointments and were lost to follow-up. Additional data capturers had been appointed in some facilities. Data capturers had also been given daily capturing targets. Health promotion through radio talk shows and the print media covering medical male circumcision (MMC) would be intensified, and winter campaigns on MMC would also be continued during the 2019/20 financial year. The fieldwork for the immunisation coverage survey had commenced in April 2019 and would be completed within the 2019/20 financial year. Officials of the national Department would be deployed to work directly with provinces, districts and health facilities that were under-performing in order to ensure that undiagnosed persons with TB were found and initiated on treatment

On child, adolescent and maternal health, new guidelines had been developed in order to emphasise a rights-based approach to sexual and reproductive health services. The institutional maternal mortality ratio (MMR) continued to decline, reaching the lowest ratio of 102:100 000 deliveries as a result of the implementation of quality improvement plans. A nationwide immunisation coverage survey currently under way would estimate the proportion of children in South Africa at national and district levels who were fully immunised up to 18 months of age. The human papilloma virus (HPV) coverage for eligible girls in 2018/19 was at 83.1% for the first dose, and 61.2% for the second dose.  86.7% of schools with grade four girls had been reached by the HPV vaccination team

Ms Matsoso referred to the performance of the Primary Health Care (PHC) programme. She said the functionality of PHC governance structures had been assessed and intervention plans developed to ensure that the crucial link between communities and health facilities remained intact. The “ideal hospital” framework had been introduced for implementation at hospital level. A cumulative total of 1 920 facilities had qualified as ideal clinics. 22 municipalities and 110 public health facilities had been assessed for compliance with the national environmental health norms and standards. Training on norms and standards had been conducted in three provinces. 12 of the assessed 18 points of entry were compliant with the International Health Regulations (IHR) 2005 requirements.

Regarding the programme covering hospitals, tertiary services and workforce development, there had been 1 928 students in Cuba, of whom 647 arrived back to South Africa in July. In July last year, 713 South African medical students participating in the Nelson Mandela Fidel Castro Programme (NMFC) had returned from Cuba. On 6 July 2019, 87 South African medical doctors who were trained in Cuba had graduated at the Walter Sisulu University in Mthatha, Eastern Cape.

The DoH had introduced the HR capacitation grant in 2018 to supplement resources for the appointment of personnel required to fulfil statutory obligations (medical internships and community service posts), and to support the appointment of personnel into 2 638 prioritised critical posts across the provinces. The intersectoral coordination and strategic partnerships (ICSP) online system had been developed and implemented to manage medical internships and the pipeline for 18 categories of health professionals entering the work environment after completing their qualifications. A new human resources for health (HRH) strategy was being developed. It would provide guidance on the number of health workers required for effective service delivery in both the public and private sectors, as well as strategies for dealing with key HRH challenges.

All nursing programmes were aligned with the Higher Education Qualification Sub-Framework (HEQSF). All colleges had prioritised a three-year Diploma in General Nursing, and these had been approved by accrediting bodies for implementation in 2020. All provinces had also developed and costed three-year infrastructure improvements.

Mr Ian van der Merwe, CFO: National DoH, briefed the Committee of the Department’s financial performance, including a detailed breakdown of all expenditure on each of its six programmes.

R40.9 billion had been allocated in conditional grant, representing 97.9% of the adjusted budget of R41.7 billion, compared to the R38.9 billion spent during the same period last year. The Health Professions Training and Development Grant (HPTDG), the National Tertiary Services Grant (NTSG) and HIV/AIDS grants were spending within the acceptable norm, but the Health Facility Revitalisation Grant (HFRG) and the Human Papilloma Virus (HPV) were spending below the acceptable norm.

Spending on the HPTDG was broken down by province, indicating underspending in three provinces. This had been due delays in the assumption of duty by registrars and delays in the delivery of medical equipment in the Eastern Cape, non-delivery of procured medical equipment in the Free State, and slow processes with regard to the procurement and payment of training and medical equipment, unpaid invoices to the value of R1.7 million in Gauteng.

On the NTSG, the Northern Cape, Mpumalanga and the Western Cape were spending within the acceptable norm. All the other provinces were underspending due to: 

  • In the Eastern Cape, Personnel Administration System (Persal) and Basic Accounting System (BAS) interface misallocations between the regional and tertiary/central facilities, and a process of correction was in place;
  •  Delays in the sourcing quotations and the finalisation of tenders regarding tertiary services equipment in Gauteng; and
  •  Delays in the payment of invoices and delivery of machinery and equipment in North West Province.

On the HIV and TB grant, overall spending for had declined this financial year, from 100% in 2017/18 to 98.5%, but this was within the acceptable norm. Overall spending on the health facilities revitalisation grant had improved from 92.9% in 2017/18, to 96.4%. All provinces were spending within the acceptable norm, with the exception of the Free State, Gauteng and North West. Overall spending for the HPV grant had been 89.7% of the budget, with only the Free State, Northern Cape, North West and the Western Cape spending within the acceptable norm. All other provinces were under spending due to the following:

Discussion

Mr P van Staden (FF+) asked the Minister to explain why a message had been circulated among the South African Pharmacy Council to sign a letter of support for the NHI Bill. Would it not constitute undue political influence? Was the Minister aware of the letter, and would he be able to instruct the Council to withdraw this message? It seemed to him that the DoH was forcing organisations to take a stand on the NHI matter. He asked why the Department was not doing the training of nurses, and if the training would still recommence in 2020, and warned about the severe consequence the country would face if it this did not happen.

The said the AG’s report had indicated a number of issues:

  • R1 billion was underspent in this financial year;
  • hospitals did not use equipment optimally;
  • a lack of security and control on access to medicines;
  • a lack of sufficient infrastructure and furniture to ensure safe storage;
  • a lack of implementation of archiving previous records;
  • a lack of a maintenance plan and ongoing maintenance of facilities;
  • insufficient training on IT; and
  • a lack of medicines in hospitals.

He highlighted two incidents. One was the death of a 2-year old girl because she had had to wait for nine hours at a Pretoria hospital. The other was a personal friend who had been waiting 17 hours to be admitted into a hospital who had almost died. He said what was going on in public hospitals needed an explanation, and asked whether strategies and plans could be tabled at the next presentation.

Mr Munyai enquired about the motive behind the FFC’s recommendations, and said its engagement with officials should be regulated. It seemed to him that the Commission was trying to influence National Treasury to oppose the NHI Bill. He commended the significant progress the Nelson Mandela Castro Programme had achieved, and asked when the students were coming back from Cuba. He suggested the placement of those students should be formalised and maybe a policy was needed in that regard. He enquired whether it necessary to consider a formalised process to help promote local content in the supply of medicines. On E-pharmacies and drug-dispensing ATMs, he believed in technology and applauded the Department’s approach in advancing technology in the health sector. He suggested the DoH should look at the security aspects of E-health. He commented that it was in the nature of big businesses to want to have less regulation. However, he reminded the Committee of the role of a developmental state and emphasised that the state must never be undermined. State interventions were needed to strengthen the capacity of the state.

He expressed his disappointment with the two presentations of the NHLS and SAHPRA, as well as the AG report’s findings. The DOH needed to take bold approaches to rectify the situation. As a principle of good governance, it should be the board that appointed the CEO, and he asked the DoH to look into this. These entities could not continuously have irregular expenditure, which pointed to leadership and management issues. He urged the Department to attend to the poor planning and inability to follow proper procedures, such as the cases in supplier chain management revealed in the two entities’ presentations.

Dr Dyanti said the Committee had been hearing the entities’ presentations for the past few days. The Ombudsman’s office had urged the DoH to speed up the process of separating them from the Office of Health Standards Compliance because they were under-staffed and under-resourced. The under-performance in the mental health area was concerning, and she urged the DoH to accelerate the process considering it had achieved only three of the 50 set targets on building mental health establishments. She said the SAHPRA had blamed the DoH for its lack of support in its presentation, and asked why the Department did not pay attention to their concerns. She suggested it should look at the poor performance in health management, and encouraged it to use some top-performing entities as role models for those that were struggling.

Ms Hlengwa expressed her pride that the students were returning home from Cuba. On nursing training, she sought clarity on whether students who received home-based care training were included in the training of nursing. She recalled an incident in a Zululand district where some nursing staff had come to clinics and demanded supervisors to train them so that they could supervise new trainees on their behalf. She asked if those supervisors had been demoted.

Ms Gwarube commented on the audit outcomes, and asked to what extent the NDOH, besides encouraging provincial departments, held them accountable. As there had been no progress with the audits, what mechanisms were in place to address the situation? She said the mandate of the FFC was not to appraise the Department, but to identify where it was lacking. It was not fair to label them as lobbyists. The Department’s chronic underspending expenditure was corroborated by its own presentation. The FFC’s report had indicated the unstable nature of the NHI grants. One reason was the lack of capacity at district and provincial level to effectively spend those grants, since conditional grants needed to be given at least three years before they could be effectively spent. How did the DoH plan to rectify the issue? It had become clear the impasse between the DOH and Treasury needed to be resolved. She therefore asked the Minister what the relationship had been, and said she needed an accurate timeframe to indicate the funding model that was in discussion with Treasury. She wanted to know the role of the provinces and medical schemes within the model.

On the accreditation done by the Office of Health Standards Compliance (OHSC), she said that less than 1% had been accredited, and enquired whether any work was being done for the accreditation of private facilities.

The health market inquiry report had raised some critical points on over-pricing and anti-competitive behaviour in the health sector. However, she refused to accept the Minister’s point that this inquiry could be a validation that the private sector needed regulating. What did the DoH plan to put in place in light of this report? The incoherence of the private system was because it was not a system – it was just private providers trying to help because the DoH had failed to provide such a service. The Department needed to ensure coherence.

On mental health, she was concerned about the poor performance in some provinces. She asked what action had been taken in light of this information and the Human Rights Commission’s report.

She asked the Ministry to explain why students under the Cuban programme had cost R24 million for flights between SA to Cuba. It worked out at R4 million per flight, with only five to six passengers per chartered flight.

She asked if there was an initiative to develop to national guidelines for the safety of emergency medical service (EMS) workers. This area was currently in a deep crisis.

Ms Wilson said that the underspending of R1 billion in a health crisis characterised by staff and equipment shortages was unacceptable. She asked why the 2018 State of the Nation Address (SONA) commitment on the implementation of health infrastructure was not included in the report. She criticised the Department on its performance against budget targets. Considering the small number of targets set, it was extremely concerning. A Limpopo hospital had been under the spotlight since 2017, and she asked the Department to explain its status, as targets had come down but budgets had gone up.

She asked about consequence management for fruitless and wasteful expenditure. Currently there was no evidence from the Department to show any form of intervention. On HIV AIDS testing, the achievements in the report indicated that 14.9 million had been tested against a 14 million target. However, her constituents told her that every time they went to a clinic, they were being tested for HIV and AIDs, and they described the experience as intimidating. She had also raised the issue to the national AIDS council of 47 clinics in Limpopo and Mpumalanga that had been using materials that had expired three years ago to treat patients, as well as patients’ confidential information being released without their knowledge. In her view, this was a violation of human rights, and she expressed her doubts over the deliberately inflated figures.

On the lack of mental health establishments, the recent report indicated that only one in ten people living with mental health conditions were being given the care they needed. Money was being spent only on serious mental conditions. There were no proactive measures to deal with the current suicide rate. Most state hospitals were not complying with Act.

Ms Ismail asked about the NHI pilot project being unsuccessful. Had the Department made reflections on the causes of its failure? She referred to the affect of the specialists’ exam pass rate on primary healthcare, and said she had heard that only Stellenbosch University was approved to accept students for specialist training. She asked for time frame during which short staff and under-resourced issues at state hospitals could be addressed. What was the department going to do about the late payment of suppliers? Why had there been a decline in targets achieved compared to previous financial years? What was the department doing for to ensure non-compliant health facilities were going to comply? The Department needed to explain the situation regarding the training of nurses.

Ms M Sukers (ACDP) had personally experienced the debacle of the HIV testing which Ms Wilson had raised. She had gone for an injury treatment and then health workers had taken her for HIV testing. If the recipient was not fluent in English or Afrikaans, the health workers would take on an aggressive tone to intimidate patients. It was shocking that patients should be treated in such a way. She lamented the lack of consequence management on irregular expenditure. In the constituency where she lives, there was a Facebook page to express the emotional frustration suffered at hospitals. She requested the Department to make a plan to deal with irregular expenditure, and emphasised the importance of accountability and service delivery quality. She suggested nursing training to include the procedure in the past, where students were taken into health facilities to be trained. She asked about the challenges surrounding the amendment to the Traditional Health Practitioners Act, and asked the Ministry to provide more details on the NHI bill so that Members could inform their communities.

Mr Jacobs asked what mechanisms had been applied to avoid duplications when capturing medical records on to the database. He commented on the primary health care system, saying the achievements of 2018/19 did not tell Committee quantitively the numbers, for instance, on malaria elimination etc. He asked whether the mental health issue should be prioritised. He knew the importance of nursing from his own experience of having worked at a hospital. Currently, only Stellenbosch University had been accredited to do nursing training. The other universities had expressed no interest in doing that. With the old nursing colleges being closed by Minister of Higher Education, he asked whether it meant no nurses would be trained at hospitals next year. He asked CFO to give more in details on the funds spent on goods and services and capital expenditure, as Members did not have a finance background.

Mr Sokatsha said both SAHPRA and the Ombuds Office had complained of a shortage of staff. In the case of SAHPRA, they had said its poor performance was due to the shortage of staff. He asked the Department’s opinion. The NHLS had raised a number of issues about the provinces that owed them money. What was the Department doing to ensure the debts were collected? What was its plan to resolve the shortage of EMS staff? The standard of ambulances had been raised, and it had been reported that some ambulances had over covered over 400 000 km, although the regulations said they must not exceed 120 000 km.  

Ms Chirwa asked about the progress in financing infrastructure. She expressed her concern that the integrity of the private sector would be exposed when the Department rolled out the NHI scheme. There was a lack of structure to oversee doctors in the private sector because of its profit-making nature. Could the Department fulfil its initiative to put two million more people on ARV medicines? She asked about the roll out of the major cancer campaign for 2018/19, since there had been no sign of it.

She commented on SAHPRA’s deplorable status and asked the Department to intervene to change the situation. The board was accountable to the Minister. For her, it was just that MCC had changed its name and digitised, and everything else was the same.

She enquired about the reason behind steep decline of the Department’s overall performance from 73% to 23%. She cautioned it against outsourcing security and cleaners because of the lack of accountability and responsibility those outsourced workers had towards the work place, and this compromised the work standards of the Department.  She complained about members of her EFF party being get turned away by hospitals when they tried to perform their oversight function. Regarding ideal clinics, the targets set to improve levels of primary healthcare were not enough. If the ideal clinic did not have enough interaction with the community, then the level of primary health care would not be improved. She asked what the regulations of compliance were to deliver quality emergency medical services. She asked about the backlog of alcohol and drug blood tests.

The Chairperson indicated that too many questions had been asked, and cautioned Members against using terms to generalise that South Africans did not understand the NHI. The AG had said there had been a stagnation in efforts to achieve clean audit outcomes. He asked what the rationale was to help patients register in clinics. He enquired about the lack of an information system in the NHLS’s report. What was the impact of the decrease in donor funding to the sector? He said he would follow up on the processing of the National Public Health Institutes of South Africa (NAPHISA) bill with the House Chairperson. He agreed that the health anti-corruption forum would provide give some success in reducing irregular expenditure. He had been invited by the President for the anti-corruption launch in Pretoria. He commented that the timing of the forum was opportune, as the NHI came with possible corruption.

Department of Health’s response

Minister’s response

Dr Mkhize said the health sector anti-corruption forum was a result of the Presidential social compact health summit, which had raised the concern over corruption. The outcome had been the establishment of a unit which was tasked to root out corruption in both the public and private health sector. This measure had been put in place to prevent the NHI fund from being looted once it was implemented. It was agreed that the DoH would be working with the National Prosecuting Authority (NPA), the Special Investigating Unit (SIU) and various other departments that were involved in crime prevention. Furthermore, the agreement was that the forum should meet regularly and include civil society as well. The idea was to table all ongoing all issues and processes of investigation, and work had been done on the extortion law suits. Arrests had been made in the Eastern Cape, and no more than four legal firms were involved in those law suits across the country. Some of them were fake claims as a result of collusion. He guaranteed that this process would continue. The advantage of having such a forum was that it created a platform where issues could be raised directly. He saw it as a worthwhile effort as it would increase accountability and follow up, and ensure that every case was accounted for. The National Council had agreed to compile a register of all these involved in cases and submit it to the anti-corruption forum. These measures were all steps taken to show sceptics of the NHI that there was a concrete plan to address corruption.

The Ombuds Office had raised two issues. One related to its structure, indicating that it could not improve its performance if the office was placed under Office of Health Compliance Standards (OHCS). The second issue was the lack of resources to complete the workload. The Department was looking at options to improve on those two issues.

Regarding the Medicines Control Council (MCC) and SAHPRA, the Minister clarified that the MCC was previously focusing on regulating medicines, and the expanded mandate had required the MCC to change its name. The expanded mandate included dealing with requests on licensing as well as ensuring good quality and manufacturing. The Department took SAHPRA very seriously and was aware of the weaknesses and backlogs. The main issue at stake was resource constraints -- the responsibilities it was expected to perform were more than what was available in the budget. However, the Department was looking at alternative solutions to facilitate the operation of SAHPRA . He expressed his confidence in SAHPRA’s team and updated the Committee that it had just concluded the appointment of a CEO. The rest of structure would be appointed very soon.

On the issues related to the FFC, the Minister said that there had never been a moment that the Department did not take FFC seriously. There had always been engagements and discussions between them around White Paper processes, and they had been engaged on the NHI. He did not think it fair that the Department had been alluded to by a Member as neglecting the FFC’s views. The real concern that he expressed was the categorical statements that had been made by the FFC without engaging the senior leadership of the Department. Some of the issues raised by the FFC were process issues. These challenges required the Department to deal with them on a step-by-step basis. More patience needed for 2026 on the NHI issue.

Dr Mkhize referred to the health market enquiry, and pointed out that it was easy for Members to throw accusations, such as dereliction of duty. He reminded them to look at the history of the Department’s interventions in the private health sector. Pricing regulations had begun since 2007, and they had not been approved by the National Health Council. The price negotiating structure had been set up, but the private sector had rejected it and subsequently took the government to court. The government had been interdicted in court. Some of the issues around which the government intended to intervene were like the certificate on the number of beds needed for patients. Criticisms had been directed at the government for being indecisive on the matter, but the fact was that government had been stopped by a court order instigated by the private sector. The pattern was that the DoH had been pushing to intervene in those gaps in the private sector, and these issues had remained unresolved because each time their efforts had been foiled by the private sector’s resistance. Even the FFC had asked the DoH to go ahead with all recommendations. The DoH had been used as a scapegoat, and a false impression had been created that the DoH was fighting the private sector. He had had some discussions with judges who felt the DoH had enough material to go back to implementing the regulations.

On nurses’ training, the Minister said the DoH had signed bilateral agreements with the Department of Higher Education and Training (DHET) five weeks ago. At the moment, the DoH had to ensure that all training was in process, and the Minister of Higher Education had to sign a gazette to approve of the training as well. He had also heard about uncertainties, and agreed this matter should be closed once and for all. He gave an assurance that no nursing school would be left behind.

On Pharmacy Council’s circulated message, the Minister asked Mr Van Staden to show him the message. He believed that the message had been a means to ask the Council for its members’ opinions. He had had meetings with the Independent Pharmacy Association, as well as the Pharmacy Society of South Africa, and both had thrown their weight behind the NHI bill. In the latter case, it also needed the DoH’s support, as it was in the middle of a bidding proess to attract the global pharmaceutical industry to come to South Africa. In his experience, the Minister had not experienced one incident where someone did not support the NHI. He wanted to know who got threatened for not supporting the NHI, because he would do all in his power to ensure freedom of speech and political opinions.

On the irregularity on HIV tests, the Minister said his Department would follow up and ask Members to provide the specific locations of the clinics at which they had witnessed and endured the unpleasant experiences. He said the 14 million included in the report was just plain reporting -- it had no connotation with boasting about the Department’s achievements.

Regarding the Ombudsman’s report on criminality and mental health, Dr Mkhize agreed that there was a real connection. A lot of what one saw on mental health cases were consequence of the violent society. To address the issue would require broader participation. The Minister said that one should talk about social cohesion, the reduction of crime, rebuilding community and family. These were issues that would greatly help in the prevention of mental illness.

Deputy Minister’s response

Dr Joe Phaahla, Deputy Minister of Health, said he had been at a Pharmacy Council conference on Saturday, and the attendees had unanimously expressed their support for the NHI.

The absorption of Cuban-trained medical graduates was happening over time. The returned graduates had been fully absorbed into the workforce so far. What he and the Department were working on was to use their exceptional expertise in preventative care in their allocated positions, to promote primary healthcare. These returnees had been given positions primarily in curative departments. The DoH believed that the 700 students sitting for final exams and finishing next month would also be allocated into internship posts. He reminded Members that the DoH presumed an 80% pass rate at exams, which would require an additional of 550 to 600 medical interns to be absorbed into the health system. This number was almost one-third of all new interns the South African medical schools could produce. Its significance would also contribute to providing services and strengthening the NHI bill.

Regarding the R4 million per chartered flight, the DoH had worked out that it was more cost-effective to do group flight bookings for students coming back to be integrated. This had happened for two years now. Its convenience was also because the time frame between their arrival and their admission to South African universities was very tight. He reported that 710 students had been booked on to three flights last year, and 640 fifth year students would be returning under the same arrangements this year.

Department’s response

Ms Malebona Matsoso, Director-General: DoH, referred to questions on the supply of medicines, and said the AG’s report covered medicines and infrastructure. The NDoH had planned a systematic review before the AG audit to ensure that quality was crucial. For instance, one of the AG’s recommendations had been the establishment of a learning centre in each province -- the Department had begun the process of training health workers in each province from November.

The NDOH would be implementing advanced technology over a five-year period. At the moment, it had just started the E-pharmacy initiative, and others still need to get started.

The irregular expenditure had been carried over from previous financial years. The DoH had already taken steps through the Health Compliance Standards Office to deal with its procurement processes in a similar way to asking the Institute of Chartered Accountants (SAICA) to help provinces improve their audit outcomes. For each procurement, there was a certificate of regular expenditure which she could present to the Committee.

The Department had prepared a manual for each entity so that board members were oriented, and were also subjected to training to some level. There had been some delay in the appointment of the CEO. The newly appointed CEO would begin duties in January and she hoped things would start looking great.

How could the Department make heads of provincial departments accountable to her? Ms Matsoso said she always played a supportive role and had it never occurred to her that an HOD had to report to her. In the past, national departments had always had to use grants as leverage -- as a bargaining chip. Although it was not preferable, the Department would consider this as a possible solution. She also commented that a health system could not be sustained on grants, because grants were short lived. The Department’s view was that this would be resolved through the NHI. It had been discussing one single fund with Treasury.

Regarding national safety guidelines, Ms Motsoso said the DoH had invited the National Institute of Occupational Health to meet with the provinces, and a template had been developed. Three reports from North West, the Western Cape and Gauteng had also been produced.

Dr Pillay corrected Members regarding the mental health numbers, saying they should be read cumulatively under the mental health teams at district level. This meant the total number was 17, not three, although this was still lower than the target. The main challenge was the lack of finance at the provincial level to appoint qualified psychiatrists etc. District hospitals did not have the skills or capacity to deal with mental illness. The DoH had been training over 920 practitioners across the country, with the exception of Limpopo. It had also commissioned the University of Cape Town (UCT) medical research council to calculate how much should be spent on this project. It had accounted for 5% of the public health budget in 2016/17, whilst globally it was three dollars per person. The Department had also commissioned the University of KwaZulu-Natal to look at community mental health facilities, and an NGO had collaborated with the provinces to provide mental health treatment.

Regarding HIV testing, it was NGOs that provided these services in an attempt to reach out people who were reluctant to come to state facilities. Reports indicated that there were quality concerns. In the Department’s observation, most facilities were well run in terms of World Health Organisation (WHO) standards. It was in the process of re-training to improve HIV services. Nevertheless, the Department would look at those two clinics which Members had referred to, and investigate.

A cancer awareness campaign was launched in October last year with the aim of being activated in each province. It also aimed to reduce the cost of treatment for breast cancer.

On nursing training, the gazette for post-graduate regulations would be published tomorrow, and would allow designated nursing colleges to issue qualifications. It was untrue that only Stellenbosch University offered nursing courses -- all nursing colleges had been doing the training. At the moment, three universities would be accredited for nursing training, and seven more were still being assessed for accreditation. The Department had been working closely with DHET and SANAC, and as soon as the gazette was published, most concerns would be addressed.

On the shortage of specialists, the Department was planning to release a communication via the media in the next two days. It did know the total number of specialists within the establishment, and was developing a policy to address the issue.

The DoH had nine indirect grants and nine direct grants. It was looking at collapsing three of the grants -- two direct and one indirect. It was in the process of discussing this with National Treasury

On the Cuban flights, the per capita cost per student had come down since the inception of this arrangement.

Regarding stock availability, the first challenge was when suppliers sometimes did not supply as per the agreement due to production problems. Currently anti-psychotics were a problem globally, particularly those sourced in the UK. The second challenge occurred at the local level, when the province did not pay on time, and the supplier would withhold stock until the account was cleared. The third reason was related to stock management -- whether the manager alerted everyone in the system when a medicine was not available. If the person responsible did not do that, then there would be no stock.

The Department’s shift of focus to primary healthcare was based on the large percentage of the population which relied on primary healthcare. It had introduced a number of intervention systems to implement HPRS. In the past, 35% of hospital patient information was provided by external systems which were incoherent. The HPRS creates a master patient index which links data to this index. The Department had started with the national laboratory health system, and all patients’ information would be on it

On archiving, there was a lack of space for archiving. There was a policy, but there was no solution yet. The Department had tested filing patients at the Kimberley Hospital, and it had taken five months for it to work daily, and could not resolve the challenge of going through all the folders. Electronic records would reduce the space required in future.

The Chairperson asked the DG to come back with mental illness and oncology packages to report to the Committee.

The DG noted that the National Health Council had done a cost evaluation on the outsourcing of security guards, and would present to the Committee in due course.

There were three aspects related to the “Ideal Clinic” programme -- health system performance, outputs and outcomes. Currently, the Department had not triangulated them, so for now most reports received were health system strategies from AG reports. The “Ideal Clinic” captures the health system performance and was more than a tick box – it was more about triangulation. Assessment was a rigorous process, and the data came from patients’ experience of care.

On emergency medical services, the Department would come back and report on it. It was currently making recommendations.

The Chairperson said health market inquiry report should also be provided.

The meeting was adjourned.

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