Department of Health Strategic Plan & Annual Performance Plan; with Deputy Minister

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Health

20 May 2020
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Department of Health 2020/21 Annual Performance Plan 
Audio: Department of Health 2020/21 Annual Performance Plan 

Annual Performance Plan (APP) of Government Departments & Entities 20/2021

The Deputy Minister said the Strategic Plan was informed by a compact that signed by stakeholders in July 2019, identifying nine pillars for strengthening the health system. This compact came out of the Presidential Health Summit held in late 2018. They also address interventions identified in government’s Medium-Term Strategic Framework (MTSF) for 2020-2024. The National Health Insurance (NHI) Fund processes were being put in place pending the passing of the Bill. He noted that in general the three-year budget had been adjusted downwards. The COVID-19 pandemic has exposed many a gap in the health system and has equally afforded an opportunity to demonstrate resilience in the midst of this pandemic. The Department will review the APP and adjust its budget to include COVID-19 interventions with guidance from National Treasury and the Department of Planning, Monitoring and Evaluation.

The DoH Chief Operations Officer explained that the Strategic Plan and APP respond to two impact statements in the MTSF—improved life expectancy and universal health coverage. Departmental targets include ensuring a continued increase in life expectancy, with the goal being 70 years by 2023. Additionally, that infant and neonatal mortality rates and HIV and TB are reduced. CEOs and senior managers are to be delegated more decision-making space. The aim was for NHI to be purchasing and distributing access by 2023 and that quality of care would improve. Other targets include to increase the percentage of certified public health facilities and increase the number of primary healthcare facilities that qualify as ideal clinics.

Questions fielded by the Committee included why the targets around primary health care facilities was so low; the clear regression in audit outcomes especially in financial management, information communication technology (ICT) management and compliance management; concerns about the maternal, infant and neonatal mortality; the impact of COVID-19; about the readiness of schools to re-open and if health preparations had been made for schools.

Enquiries were made on how the Department intends to strengthen the National Institute for Communicable Diseases (NICD), which has been incredibly valuable during this pandemic; the timeline for completion of building projects such as the Limpopo Academic Hospital; the decision about the Head Office at the unsafe Civitas Building; and the effectiveness of sexual and reproductive campaigns among women and the youth.

The remaining questions dealt with how the Department was engaging with the provinces, in particular with the flare up of the virus in the Western Cape; what processes were in place to address lack of access to resources like PPE in the emergency medical services; the number of nurses sitting at home due to cancelled contracts. The Department answered most of these questions but undertook to respond further in writing as the meeting ran over time.
 

Meeting report

Opening remarks
Dr S Dhlomo (ANC), Portfolio Committee Chairperson, welcomed the Deputy Minister of Health. The Minister sends his apologies as he was asked by the President to accompany him to the meeting by with faith leaders. The Department of Health delegation would be led by the Deputy Minister.

Deputy Minister, Dr Joe Phaahla, said that the Director General has sent his apologies and may join the meeting later as there had been a number of meetings today. The Deputy Minister had just finished a meeting of the Non-aligned Movement (NAM) on the sidelines of the World Health Assembly; there were a number of activities of the National Command Council, a number of Cabinet meetings and a meeting with religious leaders hosted by the President which kept pushing other meetings later. The DG would be presenting the Health sector recommendations with the Minister of Health.

Ms M Gillion (ANC, Western Cape), Select Committee Chairperson, commended the Minister, Deputy Minister and the Department for the hard work they are doing. Taking into consideration the pandemic, she noted the importance of this joint Portfolio and the Select Committee meeting with the Department. If the Department, Ministry and the Joint Committees work together, they can overcome the structural challenges faced by the country. It is important for the Department to give their overview and to allow all the Members of the Committee to speak, as they take their jobs very seriously to ensure that the healthcare system is accommodating every single person in the country. The NCOP Committee gave its assurance that as representatives in the provinces, they are trying their utmost to follow up on queries. The Members remain cognisant of other health issues communities suffer from in the country in addition to the virus. She thanked the Department for their rapid response when Members ask questions.

Deputy Minister’s introductory remarks
Deputy Minister Phaahla noted the apology of the Minister who was joining the presidential consultation with religious leaders on how we move from lockdown level 4 at the end of May. He noted the Presidential Health Summit held in late 2018 which lead to the signing of a health compact by stakeholders in July 2019. This compact identified nine pillars for strengthening the health system and has guided the development of the Department’s Strategic Plan and APP. The outcomes targeted by the Department, firmly respond to the impact statement of priority number three in that compact, which addresses education, skills and health. The current Strategic Plan and APP also addresses interventions identified in broader government’s Medium-Term Strategic Framework (MTSF) for 2020-2024.

Life-expectancy is currently at 64.7 years of age and is continuing in an upward trajectory and is the highest it has ever been. This exceeds the target of 64.2 years set in the previous MTSF, set five years ago. In the next 5 years, the Department aims to achieve a life expectancy of 70 years by 2030. It also hopes to progressively achieve universal health coverage and financial risk protection for all citizens seeking healthcare through the application of the principles of social solidarity, cross-subsidisation and equity. These targets are in line with the United Nation Development Goals, which the country subscribes to. Their vision as described in the National Development Plan (NDP) also envisions the life expectancy goal of 70 years of age by 2030. A stronger health system and improved quality of care will be fundamental to improving service delivery and ensuring the well-being of South Africans. In total 12 of the 18 outcomes in the Strategic Plan prioritise strengthening the health system and improving the quality of care. The remaining outcomes are aimed at reducing the burden of disease faced as a country.

The National Health Insurance (NHI) Bill aims to introduce structural health system reforms to ensure that the national health system is a united system under the NHI, rather than the fragmented one that exists today. It aims to create a unitary public system, based on the principles of equity and quality.

The current financial allocation for the Department of Health is R55.5 billion, of which R1.2 billion is devoted funds, R2.7 billion is earmarked funds, R49.2 billion is for direct grants and R2.3 billion on indirect conditional grants. The budget baseline reductions intended to lower the national aggregate expenditure ceiling have resulted in decreases. Overall, the earlier Medium-Term Budget Framework has been revised downwards. The Department has not been saved from downward budgetary revisions. Indirect grants contain two subcomponents for 2020/21 under non-personnel services; firstly, ensuring a quality improvement plan is put in place and secondly, to fund internships and community service programmes across the health professions. Direct grants were merged as part of the reforms implemented to ensure reduction in the number of grants and to ensure the integration of the grants with the Human Papillomavirus (HPV) grant merged with the HIV grant and the Professionals Training grant merged with the Human Resource Capacitation grant.

The COVID-19 pandemic has exposed many gaps in our health system and has equally afforded us an opportunity to demonstrate resilience in the midst of this pandemic. The Department is expected to review and adjust its budgets and plans to include COVID-19 interventions with guidance from National Treasury and the Department of Planning, Monitoring and Evaluation (DPME). The Deputy Minister assured the Committee that the Department, as led by the Ministry and senior management will provide stewardship and leadership to the national health system as a whole, in collaboration with the provincial Members of the Executive and senior management in the provinces to reform the health system over the next five years and ensure that it continues to improve on health outcomes for the good of the population.

Department of Health Strategic Plan 2020-2024 & Annual Performance Plan 2020/21
Dr Gail Andrews, DoH Chief Operations Officer, said that the Deputy Minister’s introductory remarks have given the context for their Strategic Plan and APP, which was tabled in Parliament on 10 March 2020.

The plans were founded on government’s 2030 vision outlined in the National Development Plan (NDP) and in line with the Sustainable Development Goals. It derives its mandate from the MTSF 2019-2024 which responds to the priorities identified by the Sixth Administration Cabinet. It recognises the policy directives of the NHI Bill currently in Parliament. Whilst the Strategic Plan was being drafted, Parliament was having public consultations on the Bill in the provinces. The Department looked at a number of seminal documents to inform their analysis and how they should respond. These included: the Presidential Health Summit compact; Lancet Quality Commission recommendations; Health Markey Inquiry recommendations; and the South African Demographic and Health survey.

The Department has rationalized the number of indicators to be monitored in the APP 2020/21 through the National Indicator Data Set (NIDS) in line with the revised 2020-2024 strategic objectives, as there is a growing need to reduce the data collection burden on facilities in the health sector.

Heath Status Indicator: Life expectancy
Since 2009, there has been a great improvement from a life expectancy of 62.9 years in 2014 to the current expectance of 64.8 years since 2018. It has also achieved its targets for male and female life expectancy.

Heath Status Indicator: Neo-natal and infant mortality
These rates have been a challenge and the targets for 2019 have not been met.

Dr Andrews noted the inter-relationship between the Presidential Health Compact, the NDP and the Department’s NHI goals, which are to culminate in long and healthy lives for all South Africans. The targets for this 5 year term were defined with the view that they only have two terms to achieve their 2030 targets. The Department’s four goals are: improving life expectancy and achieving universal health coverage and improving quality of provision of care and building health infrastructure for effective service delivery.

Strategic plan for 2020-25
The plan responds to the two impact statements in the MTSF— improved life expectancy and universal health coverage. The Department’s key targets hoped to be achieved within the five-year time frame:
Improving maternal, child and infant and reducing infant and neonatal mortalities. Prompt treatment of HIV and other sexually transmitted diseases with the goal of reaching the 95:95:95 targets by 2024.

These targets relate to reducing incidence among the youth making progress towards ending TB and addressing the problem of premature mortality from non-communicable diseases. DoH also aims towards implementing a more equitable budgeting system , resulting in a more equitable share model for financing, the review of conditional grants in order to combine grants and reduce fragmentation.

DoH hopes to solve delegation challenges to give CEOs and senior managers more decision-making space. It also hopes to solve procurement challenges by putting in place a transversal contract before 2025 for core supplies and low-value equipment to reduce buy-outs and derive economies of scale. It also aims to do away with stock outs on medicines in 100% of facilities and achieve the target of 100% of primary health care facilities with cost accounting centres. It would like to ensure that they move from an unqualified audit to a clean audit by 2024/25 and improve the audit outcomes of all provinces. It would like to address the problem of contingent liabilities and reduce medico-legal cases to under 50% by 2022 and reduce overall claims on their register to 80% by 2025.

It aims to ensure that the package of services provided by the NHI Fund is distributed to the population based on equity and cost effectiveness. DoH’s goal is that the NHI Fund will be purchasing by 2022/23.

Other targets include improving that quality of care, increasing the percentage of certified public health facilities, increasing the number of primary healthcare facilities that qualify as ideal clinics, improving the percentage of traditional health care workers offering high quality services. It would like to reduce the percentage of people requiring preventative chemotherapy for schistosomiasis to 50% by 2025. An improvement in compliance of health services with health regulations at all 44 ports of entry as well as ensuring provincial compliance with Emergency Medical Services regulations in all 9 provinces by 2025.

Human resources and nursing colleges
DoH aims to ensure that staff are equitably distributed and that all human resources in the sector have the right skills and attitude. It aims for all nursing colleges able to provide quality basic and specialist nursing programmes by 2025. It aims to implement the Human Resource for Health Plan within this time frame.

Community participation
This aims to address the responsiveness of the health system to ensure it is meeting the needs of communities by their participation. The goal is that 85%of patients are satisfied with the care they achieve in the public sector as indicated by experience surveys.

Improving infrastructure in the public health sector
By 2024/25, it hopes to have refurbished, repaired and be maintaining 80% of public health facilities.

Information systems
It hopes to be responsive to local needs and enhance use of data to improve quality of care. Information should be used to strengthen learning and decision-making, thereby strengthening the health system. To this end, DoH hopes to implement the use of performance dashboards across its branches so it can respond readily to local needs and to enhance the use of data across the country as data use drives data quality.

Annual Performance Plan
Dr Andrews stated that currently the budget programme is not aligned with DoH’s organogram. However, these will be brought into alignment once the new Director General starts.

Programme 1: Administration
The key outcome is to improve DoH’s budgeting process and reduce fragmentation. The key target of the coming year is to ensure a needs-based approach to the distribution of budget and to ensure that conditional grants are reviewed. Also ensure desired resource outcomes are available to managers at the frontline.

Programme 2: National Health Insurance
This programme aims to improve access to quality health services with the aim of achieving universal health coverage and health. It aims to provide a comprehensive response to the Portfolio and Select Committees on the NHI Bill as the Bill is currently with Parliament.

Within 2020/21, DoH hopes to see 46 million people registered on the Health Patients Registration System. It hopes to implement a national accreditation framework for primary healthcare facilities and general practitioners and a service benefit framework primary healthcare. It wants to ensure that the master health facility list published on an electronic platform has an improvement in the total number of facilities reporting stock at the surveillance centre.

Programme 3 Communicable and non-communicable diseases
This programme aims to reduce the incidence of communicable and non-communicable diseases as well as addressing the challenges to maternal and child health, specifically reducing maternal and child mortality. DoH aims to have campaigns by radio to promote all aspects of child health and nutrition. It aims to develop a monitoring and reporting system to monitor implementation of early childhood development programmes.

It aims at reducing HIV incidence amongst the youth by increasing the number of primary healthcare facilities that have youth zones to 800 by the end of 2020.

Programme 4 Primary Healthcare
This focuses on developing legislation, policies and systems to promote a well-functioning district health system, including Emergency and Environmental Health Services. Key targets aim to have hospitals implementing the quality improvement programme, the policy on traditional medicine developed and more facilities qualifying as ideal clinics.

Programme 5: Hospital systems
This aims to address national tertiary service infrastructure through the grant and the planning of infrastructure as well as improving the quality of hospitals. The first target is 54 primary healthcare facilities constructed or revitalised and 24 hospitals refurbished or revitalised and 150 public healthcare facilities repaired, maintained or refurbished by the end of the year.

Programme 6: Health System Governance and Human Resources
This deals with health systems monitoring evaluation and research as well as the whole portfolio of human resources for health. Key targets include nine colleges to be accredited to offer basic nursing and midwifery programmes. Clinical governance systems and provinces need to be assessed in their development of clinical governance implementation plans. DoH intends to develop Human Resources for Health capacity through policy development, planning and monitoring. It wants implement a guideline on the use of the patient health registration system (HPRS) to ensure that all public health facilities has a Health Patient Registration Number (HPRN) for every patient.

DoH wants to revise the interoperability norms and standards for digital health and ensure that a revised version is published and develop two priority cases for use this coming year. It aims to develop performance dashboards to encourage reflection in decision making at all tiers of government in the health system. It will implement national health research priorities which will be identified as soon as the National Health Research Committee is established. The Minister has already appointed the members and the first meeting will be held soon.

The target for blood and alcohol tests is to have 90% of tests completed within a normative 90-day period. ‘

Lab tests currently fall under forensic pathology and they will be moving over to the National Health Laboratory Service, as this process has been under way for the last two years.

Financial Management
Chief Financial Officer, Mr Ian van der Merwe, noted there had been an eight percent increase in the total budget from R51 billion to R55 billion.

Grants
Grants are the biggest budgetary item. The NHI Programme experienced a shift when the Health Practitioners Contracting grant (indirect grant) moved to the NHI direct grant. This was moved Programme 6 along with the Human Resources Capacitation grant. Slides 59 and 60 speak to this. The NHI indirect personnel grant and a non-personnel services grant still resides in Programme 2.

Programme 3 had a 9% increase in budget, mainly because the Human Papillomavirus (HPV) grant is being combined with the HIV grant and the isolation of Community Outreach Services grant.

Programme 5 experienced an increase in budget for hospital systems.

Programme 6 increased a 24% increase mainly because of the moves from Programme 2 to Programme 6.

Economic Classifications
The biggest portion of their budget goes to transfers to the provinces.

Indirect grant summary
There as an increase of 5% for the Health Facility Revitalisation grant. The non-personnel service grant has been reduced by 2%. There is an additional component of R25 million for quality improvement grant. He noted that within the non-personnel service grant, there are additional grants for internship and community service programmes. In total, a reduction of 2% for indirect grants, although the infrastructure component had a 5% increase.

Direct grants
There was an overall increase of 7%. This increase is above inflation but mostly increased in the HIV component and the community outreach component. There was no particular increase on the NHI. The remaining slides were breakdowns of all the components of the direct grants.

Discussion
Dr P Dyantyi (ANC) asked for the impact of COVID-19 on DoH programmes. She asked what lessons they have learnt. She was concerned about the reconfiguration of the child and youth school health programme with HIV. What impact will COVID-19 have on the reconfiguration. She noted the role that the NICD has played in the pandemic and asked how the institution will be strengthened.

Ms S Gwarube (DA) said that if organisations do not adapt to the current environment, they will not survive and this cannot be truer for the Department of Health which is the lead department in this pandemic. The Committee is considering a plan which does not consider what has happened in recently. She asked what processes are being put in place to reconfigure these plans. As some of these programmes are probably going to be obsolete, she asked how will this be incorporated in the Strategic Plan and APP as the pandemic will change how business is done and how healthcare is delivered. She asked whether programmes like the NICD will become more prominent and asked how this will be incorporated in the plans.

Last week the Committee was briefed by the Auditor General on the DoH financials. The Committee saw a very clear regression in DoH financial management, ICT management and compliance management. They have never seen a regression quite like this and she asked why this is the case. She asked if ICT will be incorporated into the quality of care and how will this be done if the ICT is an issue flagged by the AG. If universal healthcare is going to be achieved, why are only 100% of primary healthcare facilities to be certified by the end of five years and only 60% of hospitals to be compliant with the Office of Health Standards Compliance (OHSC) in five years’ time. She is not sure why these standards are so low and asked why the target of 100% of primary health care facilities was set for five years’ time when universal healthcare cannot be achieved if facilities are not of standard. With the reduction in real terms of the DoH budget, how does DoH intend to achieve equitable access to the NHI when there has been a reduction in the budgetary allocations to the provinces for NHI.

Mr P Van Staden (FF+) asked how the treatment of HIV and TB is being dealt with in the current conditions. He asked how the R20 billion COVID019 relief package is being spent. Are DoH and public hospitals now ready if the numbers of COVID-19 infections peak right now? What will be the impact of COVID-19 on their Strategic Plan and APP? On the target of 80% of public hospitals being refurbished and repaired, he asked if there is a timeline for this action. The AG audit report found the same material findings in this financial year as in the previous year on medical equipment.

Ms A Maleka (ANC, Mpumalanga) asked how the COVID-19 affects the NHI plans, if at all, and what the implication of the reduced HPV funding will be.

Mr M Bara (DA, Gauteng) agreed that the Committee had not heard much which speaks to COVID-19. He expressed concern about timing for the targets for an unqualified audit. He noted that litigation takes up a large amount of the budget and asked how it intended to reduce this with pending budget cuts. What has DoH learnt which will assist it in strengthening NHI or will ensure that it is able to adapt when faced with a pandemic like COVID-19?

Ms D Christians (DA, Northern Cape) asked how DoH aims to strengthen sexual health, particularly among women. She asked why HPV funding been decreased and how DoH intends to create more awareness in women about reproductive health. With mental health being a critical issue in South Africa, she asked what the allocation is for implementing a mental health policy framework. Health facilities, such as the one in the Northern Cape, have taken over a decade to build. She asked how DoH will ensure that facilities like it will be fully capacitated in the future. She asked what are the causes for neo-natal and infant deaths and what DoH is doing to deal with this appropriately. She noted that with the re-opening of schools, if clinics are provided for should a child or teacher become ill or if there is a COVID-19 spike within a particular district. She asked if schools have been provided the necessary healthcare guidelines and information to deal with those circumstances. If there is such information, she asked that it be made available to the Committee and to the provinces. Are hospitals geared to serve learners who may become ill. She asked if funds have been re-directed specifically for this. She asked if there was any truth in reports that those receiving HIV and TB medication have not been collecting their medication during this period. She asked what is being done to salvage the situation and what impact this will have on DoH 2020/21 APP.

Ms N Ndongeni (ANC, Eastern Cape) asked how DoH is measuring the effectiveness of their HIV and TB prevention campaigns. What cross-sectoral TB initiatives, if any, are in place with the Department of Minerals and Energy and Correctional Services? She asked for DoH brief the Committee on the integration of community healthcare workers. Finally, she asked if DoH can report on the implementation of the National Mental Health Policy Framework and Strategic Plan 2013-2020 in all provinces.

Ms M Sukers (ACDP) asked about DoH capacity for strengthening health services. In the Western Cape, she reported the challenge of the reduced capacity of nursing care, especially at hospitals and the impact this has on the quality of care patients are receiving. She had received many complaints as there were reports that over 2000 nurses are sitting at home as their contracts were cancelled. She asked DoH to account for this. She noted that testing services are reported to be under strain in the Western Cape in particular and that there are reports that nurses are fearful, anxious and under a lot of strain as the virus continues to spread. Paramedics have reported a lack of personal protective equipment (PPE) available to them. She asked what DoH is doing to ensure that psychosocial support is being granted to them. Although they appreciate DoH’s ambitious plans, the Committee needs to know what DoH intends to do to deal with concerns arising from the COVID-19 pandemic. There are factories operating even though there are more than three people who are positive there. She asked how DoH is working with the Department of Labour to address that.

Ms N Chirwa (EFF) said that she is very underwhelmed by the DoH Strategic Plan and APP presentation as it seems to gloss over the systemic challenges and how it intends to address them. For instance, although the country is entering into flu season in the middle of the COVID-19 pandemic, there has been no report about mass flu and pneumonia vaccinations being distributed. The existence of ideal clinics does not result in primary healthcare being accessed by everyone and benefiting the population. DoH has not given a clear plan as to how it intends to capacitate its entities. For instance, the National Health Laboratory Service (NHLS) boldly claimed that it could conduct 30 000 laboratory tests a day. If this did not manifest, it suggests that entities may not be as capacitated as they are presented as being to the Committee. She asked why entities have not been held accountable for misleading the country as to their capacity and what DoH is doing to ensure their entities are properly capacitated – beyond rhetoric. Risk assessment tests were halted in hospitals because of the pandemic, she asked when it will resume because she thinks that risk assessment is a vital aspect of ensuring that hospitals are functioning properly. Emergency medical services (EMS) transport has not been addressed. She asked for a clear plan how EMS transport will be managed during the pandemic as the Committee knows that transport is a problem in DoH.

The targets for neonatal strategy do not indicate that overcrowding is a major contributor to these deaths as neonatal infants in hospitals share beds. How does DoH plan on interlinking social ills to health when addressing infant mortality.

Ms Chirwa said many people with chronic medication cannot take it because of the lack of access to food. She asked that DoH explain in great detail how it is going to address mental health as there was no grant allocation for mental health concerns. Finally, she asked how DoH intends increasing PPE supply so that it is created domestically as currently only 10% of PPE is produced locally.

Dr K Jacobs (ANC) referenced the recent Auditor General presentation to the Committee. Urgent intervention is needed in IT management, financial management and compliance management for all the departments of health, and not just the National Department (NDoH), then eight of the key focus areas need addressing. He asked how DoH intends on addressing these challenges. He assumed that transfers budgeted for 2020/21 will be adjusted due to COVID-19 but asked for more information about this. Effective and appropriate steps were not taken on irregular and fruitless expenditure as the Committee sees a consistently rising curve when the statistics are placed on a graph in all the departments of health, both national and provincial. The APP notes that resources will be made available for managers and frontline providers to manage with flexibility according to their local needs. He asked how DoH aims to ensure that this does not result in loss of finances. He expressed concerns about the infant and maternal mortality rates in the Strategic Plan and thinks that DoH needs to look seriously at the regression in mortality rates. COVID-19 in the Western Cape is a very serious problem. The province has been reaching out for assistance. Tygerberg Hospital was phoning to express concerns about access to PPE and the provision of transport to nurses. He told the Deputy Minister that the province needs intervention and assistance.

Ms S Luthuli (EFF, KwaZulu-Natal) said that based on the AG’s report, departmental reports are not reliable.

Mr T Munyai (ANC) said that the Western Cape provincial government is irresponsible and reckless. He is waiting on the findings of the Human Rights Commission on the manner in it put homeless people together like sardines in the Strandfontein camp, including people with mental health issues and pregnant women. He would like the government to intervene because sometimes the Western Cape behaves as if they are a federal government somewhere in the Trump administration. He asked the CFO to respond today about the budget allocated to establish the NHI Fund. He asked if provision has been made to address the challenges and dysfunctionality of the Civitas Building. Frontline workers should be congratulated. Unlike Spain, both public and private hospitals must be monitored to ensure they are following regulations and that both public and private beds must be made for public use, including emergency facilities in every province as every province is part of a unitary government.

Ms A Gela (ANC) welcomed the presentation and said she was concerned about the strategy developed for Programme 6. She asked why the budget is so low for primary healthcare facilities, especially as primary healthcare is the face of the healthcare sector. She asked how far DoH is in addressing the audit findings. She said DoH IT and filling vacant posts are concerning but congratulated DoH for appointing Dr Sandile Buthelezi as the new DG.

Mr M Sokatsha (ANC) asked what Dr Andrews meant by the DoH programmes are not aligned with the organogram. To him, this could mean a number of things: that it is appointing people randomly; that it is appointing for roles that do not exist on the organogram, or that DoH appoints people on a contractual basis for a long time or lastly, it can mean that the vacancy rate is not accurate. He asked where infrastructure falls, and if the infrastructure grant is still available within DoH. As they are moving forward to NHI implementation, there are a number of matters that need to be revamped, such as the idea of the ideal clinic. He is concerned about how hospitals are addressing symptomatic people as his brother was symptomatic but was sent home without a follow up and only a note saying ‘pending results. ’

Ms M Hlengwa (IFP) asked what progress has been made about the policies for the flexibility on the procurement of resources. She asked if all hospitals have sufficiently qualified administrators, management and staff to ensure proper procurement under the Public Finance Management Act (PFMA). Secondly, she asked how DoH intends to ensure that suitably qualified people fill vacant posts.

Chairperson Gillion asked for a report on the eight mega-infrastructure projects that are costing over R1 billion, including the Limpopo Academic Hospital. She asked how much money is going to maintenance of infrastructure and equipment. She asked what strategies and plans DoH has put in place to prevent or limit future global pandemics from impacting the country. Given the role that the NICD has played in the pandemic, she asked how this institution will be strengthened, if at all. She asked what role South Africa is playing in the region as a whole. On the audit report, she asked what mechanisms are in place to support provincial departments and ensure improved expenditure and better audit outcomes in the provinces. She welcomed the comments made by other Members about the treatment of people in the Western Cape. She asked the Deputy Minister what was discussed with the Western Cape Government when the Minister visited there on two occasions already. People in the Western Cape are frightened. What is happening in the Western Cape is not at all good. She asked for an indication from National DoH of the support being given to the Western Cape government. What plans are being put in place as the pandemic is increasing on a daily basis. Is there intervention to assist frontline staff with access to PPE. She thanked DoH, the Minister and Deputy Minister for their role in fighting the pandemic.

DoH response
Programme 6
Dr Andrews spoke to the Human Resources for Health Strategy, which unfortunately could not be tabled at the last meeting of the Human Health Council (NHC) because there was a focus on COVID-19. DoH hopes to get the strategy through the NHC as soon as possible so that it can be made available to everybody. DoH can, however, make the draft strategy available to members which is not yet approved by the NHC.

Nurses stranded by placement agencies and impact on services
The NDoH worked with the Western Cape as this issue was mainly located there to ensure that nurses return to their own provinces during the inter-provincial travel period. Other nurses were contracted to work for NGOs and other nurses are on DoH database as part of the surge capacity. These nurses will be injected into the system and employed as more cases increase.

Psychosocial support for nurses
There is a team in place to ensure the well-being of healthcare workers. These guidelines can be made available to the Committee. There is a comprehensive care package for healthcare workers, which must include psychosocial support. As cases increase, outside support will be brought in. Organisations such as Old Mutual through the Health Professions Council of South Africa (HPCSA) have made items such as indemnity cover available for nurses.

Information Systems
The quality of information remains a challenge as long as it is being captured from paper as data capturers will make errors. The more data is used, the more the quality of data will improve, therefore DoH is aiming to build a culture of learning in the health system through use of information, including research. As they move towards more automated and digitised systems, DoH expects to see an improvement in the quality of data. The process of building sound information systems will take long; however, they will use insights from COVID-19 to do so.

Infant and neonatal mortality
Dr Yogan Pillay, Deputy Director-General: Communicable and Non-Communicable Diseases, assured the Committee that mortality rates are coming down. Over the last 10 years, infant mortality rates have decreased from 40 per 1000 live births to 25 per 1000 live births. And neo-natal mortality from 14 to 11 per 1000 live births. Maternal mortality has decreased from 333 per 100 000 to 134 per 100 000. These statistics come from the reports put out annually by the Medical Research Council’s burden of disease unit. Causes of neonatal mortality mainly include prematurity, asphyxia and infections, which are largely HIV infections. In general, all these rates are going down and DoH is doing all it can to address known causes.

Benefit of the lockdown
The lockdown has done two things. It has reduced the potential mortality by about two million and pushed out the peak of COVID-19 infection by about six weeks. The lockdown has disrupted access to services, social lives, the economy and education system and access to health services.

Dispensing period for chronic medication
The main reasons for patients not accessing chronic medications are thought to be lack of access to public transport during the first few weeks of the lockdown. DoH has ramped up the centralised chronic medication dispensing and distribution (CCMDD) system. It has since seen an increase in the number of patients accessing medication through the CCMDD programme. It has increased the dispensing period and will now dispense for two or three months to decrease the need for people to visit health facilities. DoH has been working with the provinces for the last two weeks to develop catch up plans and strategies to reach out to patients so they come back to DoH facilities. These plans should be finalised within the coming weeks.

Lessons learnt from COVID-19
These lessons will apply to society as a whole and will not be limited to DoH. Social security systems needed to be strengthened. Government has done a number of things to strengthen the social security net for those who have access to grants and those that do not.

NICD
The National Institute for Communicable Diseases has been central to DoH’s response on the epidemiology of the disease. DoH hears from the NICD daily about how many cases there are against how many were tested as well as the provincial spread of the virus. NICD is a treasure which needs to be supported. He is sure that as soon as the National Public Health Institute of South Africa (NAPHISA) Bill is enacted and the NICD is a free-standing organisation, that itself would strengthen the NICD. At the moment, the NICD is linked under the Act that governs the NHLS and the bulk of its resources, outside of research grants, come from the NHLS.

Improving awareness of sexual and reproductive health, especially amongst the youth and women
DoH has done well on this score, however it has faced supply challenges including for various oral contraceptives. The global shutdown of many countries has impacted on the availability of medicines including an antiretroviral called TEE. There has been a global shortage of the HPV vaccine and the government has decided to do a catch up this year and then roll out in the usual way next year. He will be happy to answer in more detail if needed.

Alignment of the APP with the Organogram
DoH is currently in the process of realigning the DoH organogram with the NHI Bill. Other than this, they have a fully approved structure by the Department of Public Service and Administration.

ICT issues
They have addressed a number of audit findings from the 2018/19 and 2019/20 audits. DoH knows that when the AG inspects again for 2020/21, he will find the situation to have improved tremendously.

Medico-legal litigation
Ms Jeanette Hunter, Deputy Director General: Primary Health Care, said that DoH is assisting the provinces with case management systems. This began being rolled out in the previous financial year, which will assist the department to manage, check and monitor the backlog of cases. The department now has a common understanding of contingent liability, which has previously been a problem. There has been a breakthrough where awards will not all be monetary. The courts have now seen that they can give services to the patient within designated hospitals. The courts now see that DoH is able to provide sufficient care. DoH has put measures in place to track and investigate irregularities and collusion between staff members, some lawyers and some patients.

Civitas Building
The Department of Public Works has identified and approved a building for the NDoH head office. After negotiations and assessment of the level of readiness of the building, DoH will be in better position to indicate the projected timeline for moving from the Civitas Building into the new building.

Financial management and infrastructure
Ms Aneliswa Cele, Environmental Health Director, said that the set targets are based on resources available and affordability in this financial year. A team of experts has been put together from finance, health and infrastructure from the Department of Health and from National Treasury to find alternative models of financial management to accelerate the delivery of health infrastructure. Delivery is expected within the next five to seven years.

There has been a process around the Limpopo Hospital and it has been the subject of litigation. A tender has gone out and appointing a service provider should be complete so that work begins in June.

PPE material availability for EMS services
Stock of PPE is being monitored carefully. There is a monitoring plan. Where PPE is reported as not being available, DoH is able to intervene in that area.

Collaborating with the Department of Labour around factory inspections
Facilities are inspected and social distancing measures have been implemented.

Using ICT to improve quality of care
Dr Andrews said that ICT is one of the key features of a strong health system. They are building a system to quickly contact trace contacts to expand DoH’s ability to do contact tracing is an example of the importance of digital technology in improving quality of care and saving lives. It is planning systems to build the capacity of and use if the health workforce. DoH has begun to work with the private sector in dealing with bed capacity and in the use of telemedicine.

Laboratory services
Dr Pillay replied that the testing rate has not been increased because there is a global scramble for test kits including extraction kits amongst suppliers. Additionally, the shutdown of airports has meant that aircraft carriers that carry these heat sensitive tests to South Africa have not been able to fly in. The result has been a shortage of test-kits available to the NHLS and the private sector. The consequence of this constraint is that DoH is now more selective about who they test and have come up with a testing algorithm to this effect which prioritises certain groups including those who have come into contact, those who are symptomatic and those who are in hospitals. It is now trying to ensure that the turnaround time for test results is decreased so that people can get their test results sooner rather than later.

Antibody tests
None of the antibody tests have been validated or registered by the South African Health Products Regulatory Authority (SAHPRA) as yet. Once this has happened, they can be used, but will be used only for surveillance because they do not indicate acute infection. They only indicate that you have antibodies and the hope is that if you have antibodies, that you will be protected from re-infection at a later point in time. The science on this is still a bit weak because it is such a new virus.

Flu Vaccines
As DoH did not anticipate the COVID-19 virus when it placed its order for 1.2 million vaccines last year, it has prioritised the distribution of these to vulnerable groups such as people over the age of 65 and people with immune-compromised conditions. This criterion is being used in both the private and public sector.

Auditor General audit report
The CFO, Mr van der Merwe, replied that the turnaround of investigations and the internal audit need to be monitored to ensure progress. DoH saw some improvements in its internal controls and the audit outcomes of the provinces during the 2017/18 financial year. However, this had gone backwards in 2018/19 with only two provinces having unqualified reports.

Reconfiguration of the budget
This is currently being reviewed and engagement with National Treasury is taking place around additional funds that may be needed for the COVID-19 response.

R20 billion allocation from the relief package
The additional R20 billion allocation has not yet been received. National Treasury is still going the adjustment of the budgets of various departments before the allocation will be made available to DoH.

Provincial financial management
NDoH is able to assist to some extent but most of the responsibility will remain with the provincial CFOs to ensure there is no mismanagement of additional resources.

National Health Insurance budget
An initial earmarked budget of R20 million had been set aside for the establishment of the Fund. R995 million is going to be the main amount of funding towards the NHI.

Personnel and non-personnel grants
Non-personnel grants relate mainly to information systems and the CCMDD. Personnel grants mainly relate to health professionals contracting and other priority services. These is a split between the two sections of the NHI grant.

Assistance of provinces
DoH tries to support the provinces with their budget process by being a part of the provincial medium-term expenditure framework committees and by assisting with the improvement of cash flow among other things.

District management
DoH aims to ensure that there are delegations in place in the districts to ensure that the districts are stable and able to function properly and adhere to regulations.

School health budget
The amount of R29 million is for the current financial year. Although there has been an overall 8% growth, there were some baseline reductions because of shifts in many other budget grants. Grants are in need of general reconfiguration.

Provincial readiness for COVID-19 peak
Dr Andrews replied that DoH has had a number of meetings in the Western Cape and they had deep drives in trying to assist the province as far as possible to ensure that it is ready. It has looked into whether the province has used the epidemiological model to plan for all their resources. DoH has done the same with the other provinces and those meetings have been led by the chairperson of the Incident Management Team. Epi-modelling data has been used to tell DoH when it can expect to peak in all the provinces. Using this model, they have drilled down to a district level to identify the number of beds needed during the surge as well as the number of oxygen points and the number of health workers. DoH has looked at the capacity needed for mortuaries and their fridges, it has costed these and given the numbers to the CFO who has given the figures to National Treasury. Over and above the Cuban brigade of technologists already sent to the Western Cape, they will continue to assist all the provinces. When the surge happens, they have considered capacitating 6th year medical students to capacitate them quickly for community service. Interns and other professionals and other volunteers are poised to assist. DoH is readying to move professionals across the provinces in case there is a need. She requested that they respond further in writing.

Deputy Minister’s comments
Whilst the NHI Bill is in Parliament, an interim amount of R20 million has been set aside to begin putting interim structures in place to prepare the various legs of the NHI before the passing of the Bill. The legislative and regulations still need to be finalised and preparing the infrastructure and capacity of health services is still in process. A number of structures have been put in place. A number of the grants in place already speak to these preliminary steps such as the direct or indirect infrastructure grants or human resources capacitation allocated to the provinces. The Health Patients Registration System currently has over 40 million people registered. All of these measures put in place are preparing for the Bill's implementation.

Deputy Minister Phaahla agreed that a 60% target for hospital readiness may not be enough and may need to be raised. However there are a number of grants contributing towards the interim structures supporting the NHI but which are not necessarily flagged as being NHI-related.

For COVID-19, the Department's approach is a twin-track approach. They are very grateful for the R20 billion allocation to improve the capacity of its response to COVID-19. As a Department, it is increasingly able to roll out PPE, additional beds and other resources to deal with COVID-19. Chronic illnesses like diabetes, TB and HIV remain a challenge in the country and it cannot lose focus on these. For these and other chronic illnesses, the Department has made amendments to the regulations to ensure that scripts are extended for two or three and up to six months.

In the short term, the Department is looking at how it will adjust the current APP and budget - along with the Minister of Finance - for the adjustment budget happening in October. In the medium-to-long term, the country needs to live differently, because COVID-19 will not disappear overnight.

The Deputy Minister expressed concern about the Western Cape and said that a focused intervention is being discussed with the Minister. They will be returning to the Western Cape and the President may come as the problem in the Western Cape is seen as a national problem since it is an early flare-up. It indicates a similar flare-up can happen anywhere in the country and NDoH is working with the provincial government on the issues. It is incumbent on public representatives to ensure the mobilisation of leadership to ensure that behavioural changes in society are facilitated.

The Deputy Minister said that DoH is working with the SADC region, the continent and the World Health Organisation on how to prepare itself as it cannot work on the assumption that this pandemic is going to go away. Additionally, DoH aims to be ready for future epidemics and pandemics.

Chairperson Gillion thanked DoH and the Deputy Minister for its responses to a number of areas of uncertainty and closed the meeting as the meeting had run over time.

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