Delivery of Health Services: Provincial Departments of Health: KwaZulu-Natal; Limpopo; Northern Cape; Gauteng; Mpumalanga; & Western Cape

Meeting report

Kwa-Zulu Natal Department of Health briefing

Dr Sibongiseni Dhlomo, MEC, KwaZulu-Natal (KZN) Department of Health (DoH), said that the Department had a huge liability arising from medico-legal claims, and had devised a plan to address the claims, which would be shared with the Committee at a later date. He emphasised the need for a pharmaceutical company in the country to reduce the cost of acquiring medicines and equipment overseas. The exchange rate was one of the reasons for the Department’s inability to perform fully in some areas, as the cost of medicines was often more than what had been budgeted for.

The human resources challenge was being addressed by the Cuban doctors’ programme, which was aimed at training South African students to be doctors. The bursaries for the student doctors had to be turned into salaries upon completion of their studies, which inflated the Department’s spending on the compensation of employees. However, the increased number of doctors would mean that there were more doctors to attend to patients even in the most rural areas.

Dr Sfiso Mtshali: Head of Department, KZN DoH, began the presentation by outlining the strategic financial health goals for the 2017/18. The Department had an estimated R39.5 billion in voted funds and conditional grants. A review of percentage growth in payments and estimates showed evidence of diminishing growth in the equitable share allocation, and significant growth funding was mainly from the HIV/AIDS grant. The Department estimated a 10.6% growth in the 2017/18 financial year for conditional grants. Programme 1 (administration) took 2 24% of the budget. Programme 2 (primary health care), which was the core of the work of the Department, took up 48.03%. Programme 4 (regional hospitals) followed at 26.83%, with Programme 5 (tertiary hospitals) at 11.58 %. Budgets over the medium term expenditure framework (MTEF) displayed prioritisation of core service delivery programmes.

There was a progressive decline in compensation of employees’ growth over the MTEF period, and the Department was targeting it to be below 63%. There was a significant reduction in goods and services, at 2.9%. The cost drivers in goods and services were medicine, NHLS, medical supplies and property payments. Medicine expenditure continues to grow mainly due to ARV medicines which were affected by the exchange rate, and National Health Laboratory Services (NHLS) expenditure for HIV/AIDS increase in patients. The Department would not be able to pay all accounts within the prescribed 30-day period due to prioritisation of service providers, and HIV/AIDS was under-funded by R500 million for 2017/18.

The Department had identified areas of expenditure pressure as housing allowances and the NHLS migration flat fee per invoice. Other factors included medical inflation above the consumer price index (CPI), challenges in outsourced items like cleaning and security services, and above budget wage agreements. A once-off 0.4% increase above the wage agreement was not fully funded. The weakening rand, increasing food prices, water, electricity, and cleaning and security contract costs remained a challenge that could not be fully budgeted for. Accruals exceeded available monthly budgets and additional funds would be required to continue acceleration of HIV/AIDs treatment and ensure payments within 30 days. Investment in an electronic inventory, medicine and medical record system remained a priority, but required additional funds.

The Department had undertaken special projects such as Jozini Community Health Centre (CHC), for which Phase 1 provision was made. A budget allocation of R100 million had been set aside for medico-legal claims and R190 million for information technology (IT). Transport equipment was budgeted at R147 million, of which R43 million was set aside for replacement of ambulances, R104 million was set aside mainly for mobile clinic replacements, as well as for outreach team vehicles. R254 million was for health technology services (medical equipment), R66 million for infrastructure-related equipment, R57 million for the National Tertiary Services Grant (NTSG), R32 million for emergency medical services medical equipment, and R180 million for replacement of essential non-medical equipment.

With reprioritisation for 2017/18, the Department had taken into consideration the alignment with the 2016/17 projected outcomes, the sustenance of the current level of services, the strengthening of primary health care services and optimising hospital services.

The Department had to ensure a sufficient budget allocation for non-negotiables, with the main shortfall in funding being for the HIV/AIDS grant. Expenditure had been accrued due to the lack of funds, and inventory management and efficiency would result in reduced pressure. The percentage of beneficiaries accessing free services was increasing over the MTEF period, and growth in revenue was less than growth in expenditure.

The alignment of health information systems in the province was a work in progress. The national DoH (NDOH) did not prescribe a system. The Meditech billing module was used in six hospitals -- Greys, Vryheid, Newcastle, Dundee, Ladysmith and RK Khan – while the Meditech full package was used in Inkosi Albert Luthuli Central Hospital (IALCH), Addington and King Dinizulu. ProClin IT was used at St Aidan’s Hospital and King Edward VIII Hospital. Track IT was used at McCord Hospital, and manual systems at other hospitals and CHCs. There were plans in place to implement the upgraded Meditech with full packages at six existing sites. NDoH had developed a plan to implement a comprehensive information system for the pharmaceutical supply chain in collaboration with National Treasury and the Auditor General of SA (AGSA). Intenda would be the backbone of procurement administration. It would address warehouse management systems, contracting, supplier performance and finance. It would also cover Rx Solutions, SVS, dispensing applications for Central Chronic Medicine Dispensing and Distribution (CCMDD) and the pharmaceutical service management dashboard.

NDoH prescribed the District Health Information System (DHIS) for aggregated patient activity data. It had been used since inception as a stand-alone access-based system, which had since been upgraded to webDHIS, which was an online capture and reporting system, and had been implemented at all hospitals and CHCs in December 2016. webDHIS was part of the e-Health strategy being implemented, which would see implementation of the Health Patient Registration System (HPRS). The system allowed for the registration of all clients in the population who were attending the public health facility. Each client would have their own unique identifier, which was a pre-requisite for an electronic patient record.

NDoH had commissioned the Council for Scientific and Industrial Research (CSIR) to produce a normative standard framework for health information systems used in South Africa that would comply with an approved set of norms and standards. A virtual electronic medical record (VEMR) system and Meditech were used at selected districts, and had to be inter-operable with the provincial systems. Telemedicine facilities had been extended to 37 sites, with a targeted 65 functional sites by 2020. A tender for the supply of video conferencing equipment had been advertised, and a tele-health strategy had been aligned to NDoH strategy. A malaria information system was currently being piloted, and 99 health facilities had currently been trained and piloted on Malaria Connect, with results showing that the system was effective and efficient in terms of reporting time.

Persal was used for human resources management, BAS for financial management, and Vulindlela for report generation of financial and human resource data. A manual system was used in all health facilities for general registry, HR and medical. Only Inkosi Albert Luthuli Central Hospital had an electronic management system. For all medical files, most facilities used the ID number as the unique identifier, and some used a numerical number.

There was a slow rollout of broadband in the province in general. The technology deployed in facilities was not in line with SA Connect, and only two hospitals qualified for SA Connect broadband definition. One CHC had broadband, though all had connectivity, and 151 clinics had data line infrastructure but were not classified as broadband. The current challenge was the exorbitant State Information Technology Agency (SITA) connectivity costs, the limited network infrastructure layout in rural areas and connectivity integration limits. The Department had started a project to consolidate the servers and had a central data centre in Pietermaritzburg, with a redundancy in Durban for disaster recovery purposes. The current infrastructure was outdated, and did not allow for convergence. Migration was inevitable, so that the Department could implement services such as voice over internet protocol. The Department suffered from ICT support deficiency. Insourcing of skilled personnel using Department of Public Service and Administration (DPSA) standards would be better to reduce Service Level Agreement (SLA) costs, and provide improved security and support.

The pressures on the Department’s budget included severe storms which destroyed hospital infrastructure, municipal clinics within communities, whose infrastructure was far from compliant and could not be improved due to budget constraints, lack of access to a reliable supply of water, and less collection of revenue.

The Department had a number of completed projects, such as Edendale hospital, Usuthu replacement clinic, Benedictine hospital (with an expected completion date of April 2017), Ekhombe hospital, Addington hospital and Inanda community health centre. There were major projects underway at Jozini hospital, Ngwelezane hospital, Dr Pixley Ka Isaka Seme hospital, the KZN Children’s hospital, and Stanger hospital. Some of the challenges that had affected completion times and budget allocations included poor project procurement and supply chain issues, poor project delivery, and budget inflation due to the extra funding required to complete the projects.

Dr Mtshali concluded by highlighting the ways in which the Department had worked hard over the years to improve infrastructure management in the province, improving water security in facilities, the expansion of laundry services, the maintenance of critical equipment and facilities, as well as asset management.

Emergency Medical Services (EMS)

Emergency medical services and patient transport services included emergency response, special operations, communication, and air ambulance services and planned patient transport. The Department had a hybrid system with oversight from head office and district EMS offices established, with limited administrative support from district health offices. EMS services operated across 11 districts through 75 EMS bases. There were 12 communication centres supporting these services, of which five were computerised, six paper-based, and one provincial operations centre. The fleet was comprised of 501 ambulances, 228 patient transport services, and 165 operational support units. The aeromedical services included two rotor-wing aircraft helicopters and one fixed-wing aircraft. The ambulance ratio was around 0.18 per 10 000 population. Of the staff complement, 2 121 were ambulance operational personnel, 257 were patient transport personnel and 303 were communication centre personnel. EMS staffing norms required a total of 8 457 operational personnel, and 10 571 ambulances were required

Routine maintenance, repairs and staff availability affected utilisation of vehicles. Although patient transport services were covered widely using buses, ambulances were also utilised for non-emergency patients that required a stretcher, as this facility was limited in the current available buses. The operational schedule for ambulances was a total of 290 per shift, broken down into three categories: 212 emergency ambulances, 40 emergency obstetric ambulances and 38 inter-facility transfer ambulances. The key challenges were staff availability, labour disputes, turnaround time for repairs, the ageing fleet, unfriendly terrain which caused accidents, and the condition of regional airstrips. The recommended EMS priorities were to improve access to quality EMS and disaster medical services, transformation of EMS education and training in compliance with policy, effective governance systems to improve overall efficiency, and an effective EMS information system to ensure quality of data to inform planning and decision-making.

Ms Belinda Scott, MEC, KZN Provincial Treasury, requested to speak on the budget constraints of the Department and the medico-legal claims challenges. She wanted to help the Committee understand the challenges the Department was facing from a provincial fiscal point of view. The provincial treasury had been able, up until the 2016/17 financial year, to buffer the departments of health and education to allow core service delivery from its reserves. The reserves had been depleted and in 2017/18, the departments would be facing the challenge alone. This was going to prove difficult, considering what Dr Mtshali had said about the R500million shortfall in funding and the R1billion in accruals. A further R100 million would be taken away from the Department’s budget to fund a project for the national department. There were expert financial people within the Department who were doing their best to keep it running, although it had no money going forward. The exchange rate had a direct impact on the budget, together with NHLS costs. The medico-legal claims were in the region of R10 billion in the entire province, and this spoke to collusion among lawyers to claim money on behalf of poor people, who never got the money in the end. The medico-legal claims in the province needed to be addressed urgently, as the province had the second highest claims after Gauteng province.

Discussion

The Chairperson thanked the Department for the presentation and the MEC for the added comments on fiscal consolidation. She said that provinces should re-visit their strategic plans after budget ceilings had been lowered to see where adjustments could be made, but still to ensure that core service delivery was not affected.

Mr D Khosa (ANC) asked about the management and how often they conducted continuous professional development to address issues of medico-legal claims. Were the unit managers doing their jobs correctly? What was the Department doing about the repeated findings in the Auditor-General’s report, and how did the Department want to be assisted to address them? Had the service providers been informed about the Department’s inability to pay within the 30-day period, and what arrangements were in place to ensure that service providers were able to continue providing services to the Department?

Mr Shaik Emam (NFP) asked about the challenges that were found at clinics and hospitals within the province, and how they were being addressed. What was the impact of the HIV under-funding challenges on the Department’s programmes? Were the rumours about a measles outbreak in Durban true? The Department had been making efforts to absorb temporary workers into the system as per national’s instruction -- what was the progress? The challenges relating to private morgues in the province and criminal activities -- what was the Department doing to address them? What was the Department’s involvement in terms of cost in the training of student doctors in Cuba, and was it in a position to accommodate them upon completing their studies? It appeared that a lot had been done in the province, but what did the Department suggest be done differently to address the health budget challenges in order to improve service delivery?

Dr M Figg (DA) said that when a presentation contained a lot of details, there were always issues that came up. He asked about the accruals in the Department, which were invoices that had been received but had not been paid because of cash flow problems. If these were not paid, it meant that interest was increasing on these payments. To what extent was the Department using the services of the Office of the Chief Procurement Officer? There were delays in projects not being completed on time which could have been avoided, as they resulted in increased spending that was not budgeted for. What was the estimated cost of delays in the three hospitals? The collusion between lawyers had to be addressed as a matter of urgency.

Dr C Madlopha (ANC) asked about the plan to address the issue of medico-legal claims, and wanted to know when the problem that led to an accumulation of claims totalling R10 billion had started. Had research been done to assess whether there was a loophole in health institutions that resulted in the increased number of claims? What were the challenges of responding to the recommendations of the Auditor-General’s report? What processes were in place to ensure the permanent filling of the Chief Financial Officer’s post, as it was a critical post in the province? What was being done about irregular expenditure in the province? Why was the asset register not properly maintained? What was the plan to turn around the challenges highlighted in the presentation? What was the status of the machine that had not been used since 2014 in the TB ward at King Dinizulu hospital, but which was continuously being paid for?

Mr A McLoughlin (DA) said that the aspect of collusion by lawyers and medico-legal claims needed to be addressed adequately. He took it personally when the legal profession was attacked without proof, and lawyers were said to be stealing files. If there was proof that such was taking place, had the relevant authorities been contacted, such as the law societies and police stations? If not, then it meant the Department was using collusion to try and hide the fact that it was failing to perform its duty to avoid the high number of claims. The claims had gone up radically over the financial years, and the presentation described the amount as overspending. This meant that the Department had had a figure in mind, and the claims had been higher than that amount. There was only one reason a court would find in favour of a medico-legal claim, and that was negligence. The staff were incompetent and incapable of performing their duties, and this had resulted in the high medico-legal claims. This was also linked to the lack of consequences for poor performance and the slow response to the Auditor-General’s recommendations. There was an amount of R107 million for unauthorised spending -- had this been budgeted for? What was the collection rate for billing and what was being done to collect outstanding monies?

Ms D Senokoanyane (ANC) said the medico-legal claims were a matter of concern across provinces, and it raised the question as to whether the Department was managing to win the cases. The accruals meant that service providers had to suffer because they were not getting paid. What was the explanation about the NHLS migration rate and how it affected the budget? The province had a high rate of HIV/AIDS, which was affected by the budget constraints. What was the plan to mitigate this?

Ms M Manana (ANC) also asked about the medico-legal claims that were a huge concern. She said that she knew about lawyers being struck off the roll because of the theft of files in hospitals. There were pages which were missing in the files of patients, and the national department must intervene, together with law enforcement agencies, to address this. The Department was not going to pay suppliers within 30 days, which was contrary to what was prescribed.

Mr N Gcwabaza (ANC) commented on the additional funding required to sustain services. What was the figure that was required? What were the cost escalations of delayed projects and the plan to address these in the 2017/18 financial year? Structures needed to put their heads together to address the alleged collusion by lawyers. Funding needed to be structured to assist provinces who had inherited the former homeland infrastructure, which was dilapidated and affected service delivery in rural provinces. He suggested that a team be put together to highlight problem areas that needed to be addressed to ensure service delivery challenges in the health sector were addressed.

Ms S Shope-Sithole (ANC) said it was necessary to assess the presentation of the province, taking into consideration the history and geographical terrain of the province. A budget may be made for medicine purchases, but the exchange rate would always affect the final budget. She said the collusion by lawyers must be dealt with urgently, because every province complained about medico-legal claims. The National DOH must deal with the matter decisively. The Department must deal with all the recommendations from the Auditor-General and get a clean audit.

Dr P Maesela (ANC) said that the motto of the Department gave hope that it took into consideration the most important issues in health matters. The bursaries of doctors were turned into salaries upon completion and that was appreciated, because practitioners were needed to offer service delivery. The medico-legal problem was a national concern, so how was the Department planning to combat the underlying causes that lead to these claims. Why did the Department have a machine that was not being used? This meant the Department was lacking in internal control mechanisms.

Mr S Jafta (AIC) said that the province should provide details of how many patients were on the anti-retroviral (ARV) programme, as the province was the most affected in terms of HIV infections. Was the province having challenges with the retention of staff due to the migration of nurses to the Western Cape?

Dr W James (DA) said that from the numbers presented in the presentation, it meant the Department was bankrupt and that was more than a crisis, considering the services the Department provided.

Ms M Dunjwa (ANC) said that she was worried about outsourcing in the Department, and it had not outlined a plan to address this. The presentation was silent on the impact of immigrants on the budget, although the province was on the border. The population was increasing due to the increased number of immigrants in the country. Research should be conducted to determine its impact on health sector services delivery. What was the role of the private sector in the province? Medico-legal claims were not a new thing, because there was once a scam in country that included the stealing of files, which appeared to be still continuing. Negligence was a factor, but sometimes some of these things happened because there was nothing that could be done. It could be because systems were not well-coordinated, files were not being kept safely, or communities were being coerced into laying claims against the Department. She hoped that the Department would address the recommendations in the Auditor-General’s report for the 2015/16 financial year.

Co-Chairperson Phosa asked about infrastructure development and whether the Department had an infrastructure unit with personnel that was capacitated. The Department should provide an infrastructure plan that was costed. There was a problem with contract management which resulted in half-built structures, which affected the budget. How many ambulances were needed in the province, and how many would the budget be able to buy? There were serious complaints about the attitude of nurses in hospitals. What was the Department doing about that? What was its plan for a waste management strategy? She asked the Department to elaborate on the district health programme, as there were rumours that district offices were being used as post offices. What was the district level plan to incorporate National Health Insurance (NHI) at the district level? With the rise of cancer problems in the country, what was being done to introduce oncology wards in the hospitals and to train oncologists?

Department’s response

The MEC responded by saying that there was a programme called Central Chronic Medicine Dispensing and Distribution (CCMDD) that traced patients who were on months eight, nine and ten of chronic medication for hypertension, diabetes, arthritis and so forth. They were given medication through MediPost to prevent them from coming to the clinics and hospitals on a daily basis. More than half of the beneficiaries of this process were from KZN, and patients were able to collect for family members who were unable to collect medicines for themselves. Many of the questions raised by Members related to the issue of medico-legal claims, and he clarified that negligence was a component of the claims, but not the single reason for their existence. The national department had lagged behind on this, because the Minister had been made aware of the touting by lawyers on national radio stations, which had not been addressed. Claims would continue to exist until files were saved electronically, because the manual system was a problem when doctors’ handwriting was not legible or they too could not remember what had been written in the file. The claims were mainly for future medical costs by claimants.

The Department could have done better to deal with the recommendations in the Auditor-General’s report. It was a problem of inability to be transparent regarding the challenges where it had to implement the recommendations. Irregular expenditure was sometimes beyond the Department’s control because sometimes there were objections to the tender process. This meant that the services would need to be paid on a monthly basis until the appeals process had been completed.

The number of patients on ARVs in the province was approximately 3.6million. There was a nurse’s programme in the province that had assisted in getting patients on to ARV treatment. The outsourcing of services in the province was still a work in progress, and the final outcome would be determined by the national DOH after a clear directive was given and budget constraints had been addressed. It was the aim of the Department to implement a strategy that would see the gradual absorption of employees, and not renew contracts at the end of the financial year. The appointment of the Chief Financial Officer position would be finalised within two months.

There were facilities which had been inherited from the former KwaZulu government which did not meet the standards of health facilities. This had meant that the Department had had to prioritise revamping these facilities, which had also resulted in better service delivery. There were hospitals which were previously whites-only facilities which were not in a good condition because they had not been revamped.

Ms Scott responded on the accrual issue by saying that it was comprised of two things -- unpaid invoices and carry-over costs. The Department was under severe strain financially, and the bulk of the budget went to primary health care and the compensation of employees. The medico-legal claims were mainly in the area of gynaecology and obstetrics, which had also affected the private sector. This had resulted in specialists taking out exorbitant amounts for insurance, and an increased reluctance among doctors to deliver babies or specialise in obstetrics and gynaecology.

Dr Mtshali responded to the training of staff by saying that the health practitioners underwent Continuing Professional Development (CPD) training. Most of the claims were on CPDs from 10-15 years ago, and sometimes even 21 years ago. The district offices were being audited to check their function, as most of the irregular expenditure was from district offices. There was a plan to capacitate district offices to avoid this, also in terms of NHI funding. The TB unit and machinery was being utilised and the challenges had been addressed. There had not been a costing plan for infrastructure for the entire province, as it had been done only per facility as the commissioning of a project was in the pipeline. The delays in infrastructure were dealt with through penalties, which sometimes went up to R100 000 per day.

Limpopo Department of Health

Dr Phophi Ramathuba, MEC, Limpopo Department of Health, thanked the Chairperson for the opportunity to present, and handed over to Mr Justice Mudau, Chief Financial Officer, to take over the presentation.

Mr Mudau said that the alignment between budget processes highlighted the challenges which needed to be addressed. The equitable share per province showed the province had a 4% shortfall in equitable share, which meant that the province was under-funded by approximately R1.3billion. The relationship between the Department and the provincial treasury allowed for an alignment with budget processes to ensure service delivery. There were unfunded mandates, such as primary health care re-engineering, which required all clinics to reach ideal status. The Department was unable to ensure all clinics were at ideal clinic status, due to the lack of funding availability.

There had been policy changes in terms of international health standards introduced in the middle of the financial year, and medico-legal claims which had not been sufficiently budgeted for. The Department’s spending trend was at more than 83%, due to overheating in programmes 1 to 3 during the financial year. The Department had R594 million in over-expenditure as at January 2017. Compensation of employees was fully funded, and the Department anticipated overspending on goods and services, medico-legal claims and the Cuban doctors’ programme.

The medico-legal claims increased by an average of R30million each financial year and were not sufficiently budgeted for. The Department had developed a plan to deal with this on a short and long term basis. The trend of accruals from when the Department was under administration had gone down over the financial years, due to investigation of accounts. The amount had increased in 2015/16, when movement had begun after the Department had been removed from administration. The Department would hold a benchmark exercise with the national department to evaluate the credibility of budget allocations.

The alignment of provincial information communications technology (ICT) for effective coordination in the health sector had been developed. Duplication of patient files was being dealt, with which helped restrict people from collecting the same medication more than once. A project to upgrade the ICT infrastructure was scheduled for the new financial year. All support functions in the Department had been dissolved up to district level. Very few matters were dealt with at head office, to ensure quicker response to the workload and the payment of invoices. The compensation of employees’ allocation showed cost of living adjustments which translated into R724million. The Occupation Specific Dispensation (OSD) required around R35 million of the budget.

Infrastructure expenditure showed R597million, and the Department was confident that it would break even at the end of the financial year. There was ageing and dilapidated infrastructure in the province, which was not fit for purpose. The limited capital and maintenance budget was not aligned to the needs, and a resuscitation committee was being put together to address these concerns.

Discussion

Mr Khosa asked questions about the Auditor-General’s report on shortages of staff and what plans were in place to address these challenges. How did the Department plan to address the repeated findings by the Auditor-General?

Dr Maesela asked about the TB cure rate in the province, which was above the national target. What was the Department doing so that other provinces could learn from them? The record of maintenance was appalling -- what was going to be done to catch up with maintenance of infrastructure?

Mr Jafta asked about the contractors in the Department who did not do quality work, and the facilities being under-utilised. What measures were in place to address this?

Ms Shope-Sithole thanked the MEC for attending the meeting, especially with the challenges the province was facing at present. The province had been trying to get up to speed after being in administration. She recommended that the Department address the challenges raised by the Auditor-General’s report.

Mr McLoughlin asked about revenue collection and what systems were in place to collect bad debts.

Ms Phosa commented on the over-expenditure by the Department, and said that it was wrong to undermine the Public Finance Management Act (PFMA). The Department must stick within the budget allocation and not be fixated on the programmes it had. It must go back to the strategic plan and if need be, postpone other programmes that were not key to the next financial year, so that medication was provided and cleaners were hired, so that hospitals were clean.

Dr Figg asked what the Department was doing regarding its health care workers.

Department’s response

The MEC responded by saying that the way health was being funded was a challenge, but that was not an excuse for not abiding with the law. The Department faced challenges with the compensation of employees which restricted the employment of cleaners, groundsmen and food services. The Department was engaging with the national department to say that programmes that ran for a particular period should not employ personnel on a permanent basis, because once the programme had run its course, the provincial Department sat with employees that it had to compensate, but who were not budgeted for. Each specialist was paid at the OSD level, which ran into approximately R1.8 million per specialist. The employees could not be removed from the payroll because of labour disputes. It was possible to spend within the budget if the compensation of employees was rationalised and personnel were taken on when they were needed according to their skills and qualifications.

The TB cure rate was as a result of collaboration between the HIV/AIDS unit and TB unit with the South African National Aids Council. There were dialogues within communities and TB patients to educate the communities that TB was curable. Traditional healers and traditional leaders in mining communities promoted the TB screening of miners to ensure early detection and cure of TB. There were faith-based institutions which supported fighting diseases, and the Department had won a case against a pastor who had used Doom on his congregants. The Auditor-General’s recommendations were being dealt with by the audit committee to address each recommendation, and the comments were being taken seriously. Communities did indeed require basic services such as a clean hospital, a nurse and doctor to examine them, and a basic meal.

Northern Cape Department of Health

Ms Thembi Mazibuko, Acting HOD, said that the Northern Cape Department of Health received R4.4 billion of the national health allocation. Extreme distances between communities and poor road quality make the cost of emergency medical services exceptionally high. There was a strong national push to prioritise direct patient care, such as non-negotiables and clinical governance. The funding came from corporate support functions, as there was no additional budget, and this put tension on issues of corporate governance, which was the main focus of the Auditor-General’s report.

The Department made use of a patient administration and billing system known as Nootroclin, and was procuring a new system through SITA. The effectiveness of the system was affected by connectivity in facilities. The provincial medical depot was installing Intenda WMS to manage the flow of medication between suppliers and facilities. The system was to be installed in all provinces to ensure uniformity, and would function from 1 June 2017. Clinics would have Rx Solution installed and would be aligned to Intenda. Clinics were currently using the stock visibility system to monitor and improve medicine availability at facilities.

The province had migrated from DHIS to webDHIS, and some facilities captured their data monthly while others used stand-alone computers. ETR.net was a live system that ensured the TB register was updated daily. The cost analysis for installation and upgrade of network infrastructure at all facilities was R38 million for a local area network, and R3 million for a wide area network. Only R6 million could be reprioritised from the health facilities’ revitalisation grant. R13 million per annum was required over a period of three years.

All human resources functions rested with the executive authority, and chief directors and directors were responsible for all cost centre budgets. Key functions were centralised in the short term to strengthen internal controls. Standard operating procedures were being developed and budget bilateral processes were underway in all cost centres. The cost of health care services in the province was exceptionally high due to an inability to attract clinical professions. Housing allowances were provided as a retention strategy to doctors at R12 000 per month. Clinical staff was claiming exorbitant amounts for overtime, due to staff availability. The Department had three infrastructure sub-programmes that aligned with national priorities. These were the maintenance of health facilities, health facility upgrades and refurbishments, and the building of new health facilities. The Department was faced with challenges of slow delivery of projects by appointed contractors, and insufficient capacity in infrastructure units.

Discussion

Dr Maesela commented on the housing allowance of R12000 per month, and asked whether the Department had communicated with the Department of Public Works to build houses which the doctors could lease from the Department. What was the reason for slow delivery by contractors? Was the connectivity for the Health Department only, or for the entire province?

Mr Shaik Emam asked about the Department’s HIV programme and the alleged corruption taking place in the department. What was the progress with the mental hospital?

Mr McLoughlin asked what the collection rate was and what billing systems were in place to ensure the proper collection of revenue. Was it possible to centralise primary health care services by having a hospital where all patients were taken, to curb late responses by ambulance services? The province was exceptional in that medico-legal claims had gone down -- what had been done to reduce them?

Dr James asked about flying ambulances in the province, considering how big the province was in terms of geographical area.

Mr Khosa asked about the contradiction to the Auditor-General’s report, which says that the Department did not have sufficient funds for the refurbishment of facilities when the presentation said that the Department had been focusing mainly on maintenance instead of the building of new facilities. He further asked about the permanent filling of positions, as most of the team were in an acting capacity.

Ms Shope-Sithole asked about poor delivery by contractors and the hospital in Kimberly, which was now costing five times the original price.

Ms Senokoanyane asked about the possibility of providing accommodation through Public Works, and the comparison with other provinces on the equitable share percentage of funds.

Ms L James (DA) asked about the upgrading of clinics to address the HIV, alcohol and drug abuse needs in the province.

Dr Figg (DA) asked about the capacitation of employees to deal with core functions after they had been employed, when they should have possessed the skills before being appointed into the positions.

Ms Dunjwa wanted to know where Prieska was located in the province, and whether it was where a state-of-the art hospital was located.

Ms Phosa asked how the Department was strengthening its district offices and the processes in place to prepare for NHI in the province.

Department’s response

The MEC responded by saying that the issue of houses was being dealt with through discussions with Public Works to look into the possibility of having a complex within facilities which would reduce the cost of housing allowances for doctors. It would be cheaper in the long term for the province. The corruption matters had been dealt with through the suspension of senior managers who were alleged to have taken part in fraudulent activities. Some of the managers had been dismissed after they were found guilty on their charges, and some disciplinary processes were still being finalised.

People were trained because new systems were introduced over time which would require the existing personnel to be capacitated in order to perform their duties effectively. The newly appointed CFO was working hard to capacitate supply chain directors to avoid corruption and intimidation. The benefits of having one hospital would have been possible if the province was as small as Gauteng. This was why a decision had been taken to strengthen the periphery, to avoid the unnecessary referral of patients to tertiary hospitals. The refurbishment of facilities was being done at a pace which took into consideration the staff capacity in these facilities.

Gauteng Provincial Department of Health briefing
Dr Gwen Ramokgopa, MEC for Health, Gauteng, stated that budget is allocated in terms of priorities aligned to national priorities. The primary health care is allocated a total of R6 billion in 2017/18, which increases to R6.7 billion in 2019/20 to enhance service delivery outcomes for community health clinics and centres as well as other community-based services. In the quest to intensify fight against HIV/AIDS and Tuberculosis (TB), the province would continue to implement the Anti-Retroviral (ARV) programme with the increased awareness programme of the test and treat, TB screening and treatment and would continue increase of male circumcisions and condom distribution. The budget allocated towards these priorities amounts to R3.7 billion in 2017/18, R4.2 billion in 2018/19 and R4.6 billion in the 2019/20 financial year. The total budget made available for investment in infrastructure amounts to R1.6 billion in 2017/18, R865 million in 2018/19 and R3.3 billion over the MTEF.

When finalising the budget, national processes have been undertaken to ensure that there is alignment of priorities and funding across the sector, e.g. 10 x 10, National Health Council, Budget Bilaterals, etc. The National Health Standardised Non-Negotiables will ensure key priorities are funded and aligned to national priorities.

With regard to instructions from National Treasury on cost containment measures, the Department has implemented and reported with effect from 30 November 2016 and requested Treasury to schedule a training workshop. A new template has been introduced by Treasury from 1 April 2016 and reporting on in-year monitoring, non-negotiable, and conditional grants expenditure and variance is submitted on the 15th monthly.

For goods and services, additional funding of R1.8 billion over the 2017 MTEF has been made available mainly to alleviate excess spending pressures on items: medicine, medical supplies, consumable supplies and fuel, oil and gas within central hospitals. Regarding compensation of employees, funding has been made available to comply with the 2015 PSCBC Resolution No 4 to Health Professionals qualifying for Danger Allowance. Further allocation was made to recruit nurses to alleviate spending and reduce reliance on nursing agencies. R642 million over the 2017 MTEF was also made available to improve conditions of services for health professionals in service delivery programmes.

The overall 2017 MTEF budget nominal growth is 6.5%. The Nelson Mandela Children’s hospital is funded through the National Tertiary Services grant and receives R150m, R200m and R291 million over the 2017 MTEF.

The Department has 5 health districts, 34 hospitals with appointed District Managers and CEOs respectively. New delegations in HR, Finance, Clinical, Infrastructure and Quality Management would be devolved to district and institutional managers from early April 2017 for authority and accountability. Delegations above Heads  - tenders above R500 000 - would remain at head office. The Department has aligned HR delegations with the Public Service Regulations of 2016 and are under consideration by the executive for approval. The delegations would be done within the framework of relevant Acts and Regulations i.e. Public Finance Management Act (PFMA), Public Service Act, Procurement Regulations. The head office has initiated a process of personnel rationalisation in order to strengthen institutions and district offices where direct patient care takes place.

In relation to alignment with National E-Health Strategic Priorities, the Department has invested in ICT infrastructure, connectivity and moving towards open source solutions to reduce the prohibitive costs of licensing. It has further improved stakeholder satisfaction rate through enhanced ICT corporate governance and compliance. It has also made provision of adequate Health Information Systems (HIS) for management of patients and revenue collection in preparation for National Health Insurance (NHI) implementation, and to enhance ICT security through ICT security plans to ensure protection of departmental information systems, manage ICT risk, minimisation of litigation and ensuring adherence with regulatory and legislative frameworks. On standards and interoperability, it provides integration, interfacing and verification of all GDOH ICT systems to achieve a single view of patient record through compliance to change processes.

In addition, the Department is trying to decrease health cost and increase availability and quality of care by developing and implementing eHealth and mHealth and solutions to optimise efficiency and improve quality of care of patients. It has laid a solid infrastructure, connectivity, registration of patients, and projects are geared to building a full electronic record that is inter-operable with the national electronic health record. It also tried to increase the broadband network access in the Department so that 100% of PHC facilities and hospitals have broadband network access and 100% of total staff will have email access by 2019/20.

In terms of alignment in health information system and infrastructure projects, the province uses MEDICOM system and the PAAB system for patient registration and billing. UPFS tariffs are loaded into the systems. It utilises the DHIS to track and record patient load and activities, and uses MEDSAS system for ordering and dispatching of medicines between all health facilities and provincial medical depot. All business cases and clinical briefs for new facilities are submitted for review by the National Department of Health Peer Review Committee. All Annual Implementation Plans (AIP) are submitted to NDOH. Quarterly Review Meetings have been held for both Health Facilities Revitalisation Grant (HFRG) and In-kind Grant funded projects. 95% of the 2016/17 Infrastructure Budget has been spent, to date.

Some of the following were identified as challenges impacting on alignment and provision of effective health care:

• Under-funding of the health sector: this leads to increase in accruals
• Rapid migration
• Payment of medico-legal claims
• Increases in the number of patients from other provinces: this leads to increases in payment of medicines, NHLS Test, blood, etc.  Once the neighbouring provinces experience cash flow challenges patients are referred to Gauteng hospitals. These patients were not budgeted for and this leads to over commitment.
• Increases in the number of foreign patients
• Medical inflation

(Tables and graphs were shown to illustrate budget allocation aligned to policy priorities, budget allocation per project status, and 2017/19 – 2020 MTEF allocation)

Mpumalanga Department of Health presentation

Mr Sipho Motau, Acting Deputy Director-General: Mpumalanga Health Department, stated that because this Department did experience budget process challenges, it had developed an integrated APP, DHER and MTEF budget processes and asked National Treasury to assist in the development of budget processes for Provincial Treasuries. They proposed that grants frameworks be finalised prior to submission of the MTEF budgets. The budget process must include final budget allocation benchmark exercise.

With regard to alignment in health information systems, the coordination is done through the National Health Information Systems of South Africa (NHISSA) established by National Department of Health. The NHISSA determines normative standards for all information systems implemented by all provinces to ensure interoperability. All provinces are represented in the committee, for easier coordination of National Health Information System. Meetings are held quarterly. However, this forum does not adequately address IT issues as it focuses more on information management issues rather than ICT. The establishment of a Health Chief Information Officer (CIO) Forum is recommended for coordination of ICT issues and it should report to the Director-General.

There is no standardised system for patient administration, revenue and billing across all provinces. This results in costly repeat tests due to unavailability of patient history when patients cross borders. The Mpumalanga Department of Health uses a Patient Electronic Information System (PEIS) for both patient administration and revenue and billing. It is recommended that government enhances PEIS to become a National Health Information System for patient administration, revenue, billing and clinical purposes.

In relation to pharmaceutical systems, the Department is using the RX solution which is supported by the National Department (in 12 Hospitals). The Stock Visibility System (SVS) has been implemented to all Primary Health Care facilities to monitor drug availability. There is no standardised system for managing the medical inventory at the Medical Depots.  A comprehensive integrated solution is recommended for inventory management from suppliers, depot, hospitals to clinics including dispensing to patients.

In terms of network infrastructure, there is no co-ordination of Network Infrastructure from the National Department of Health. The establishment of Health Chief Information Officers (CIO) forum is recommended to focus on Development of Health ICT master plan to guide coordinated ICT infrastructure. There is co-ordination in deploying systems like HPRS and e-tick. These are done under the NHI programme. The Department is rolling out Health Patient Registration System (HPRS), web-DHIS and e-tick to clinics. 281/286 (98%) facilities are implementing HPRS which are 74/76 (99%) at Gert Sibande, 121/121 (100%) at Ehlanzeni and 84/89 (94%) at Nkangala. The Gert Sibande district is implementing e-Tick, while other two districts are planned for roll-out in 2017/18.

Concerning the devolution of critical functions to designated level for service delivery, the Department has three district offices. The delegated procurement authority goes up to R500 000. The district offices have Financial Management Units which consist of budgeting and reporting, expenditure, supply chain management to support hospitals and clinics, and a District Finance Committee has been appointed. The Department has 33 hospitals. The delegated procurement authority goes up to R500 000. A Cost Centre Management has been appointed for responsibility managers, and Financial Management Unit which consists of budgeting and reporting, expenditure, supply chain management has been set up. The Hospital Finance Committees (HFCs) have been appointed.

The Department has in total19 945 officials employed on the approved organisational structure. 62% of the total Departmental budget is spent on Compensation of Employees, and 88% of that is spent on Health Professionals and Health Support Personnel. The following measures are in place to ensure that there is effective management of personnel expenditure:

• The Department has an approved organogram and is currently in the process of reviewing it
•  Payroll Management system has been introduced to ensure that signed pay sheets are returned to Salaries for verification purposes on a monthly basis
•  Staff verification exercise was conducted in conjunction with Treasury
• The Department is currently reviewing the organogram and aligning it to service delivery imperatives and for the clinics to the WISN model
• Transference of staff from over-provisioned facilities to under-provisioned facilities
• Monthly cost per head analysis is done

Pertaining to the Ideal Clinic Infrastructure support, 56 backup generators have been installed in Primary Health Care facilities in the province and there has been a rollout of air-conditioners in the pharmacy and thermal controlled areas in these facilities. A gradual rollout of maintenance in district maintenance hubs by internal artisans, MRTT student artisans and cooperatives is taking place. There is frequent servicing of underground infrastructure such as septic tanks and pipes by contracted service providers, and the construction of guardhouses, waste storage areas, septic tanks, provision of jojo tanks and drilling of boreholes in various facilities has taken place.

Common problems that have affected infrastructure rollout include:

• Slow contractor performance
• Re-works emanating from poor quality of work
• Social protests resulting to disruption of work
• Changes on scope of work
• Delays in approval and connection of services such as electricity and water

The following interventions were done:

• Poor performing contractors’ appointments were terminated
• Penalties were applied on projects running behind schedule
• Extension of time approved where necessary
• Re-working of poor works at contractors’ own cost
• Coordination of meetings at senior level for monitoring and evaluation

Mr Motau also reported that the Sector Wide Approach operates at the level of an entire health sector, ensuring a strong focus on bringing together governments, donors and other stakeholders within any sector. The approach should involve, amongst other things:

• Government leadership
• Developing a single sector policy (ideally a policy that addresses private and public sector issues) and a common realistic expenditure programme (budget framework). This would ensure successful implementation of NHI
• A formalised process for donor co-ordination at National, Provincial and District levels with clearly defined donor procedures for reporting, budgeting, financial management and procurement
• Improving efforts to increase the use of local systems for programme design and implementation, financial management, monitoring and evaluation
• Skills transfer by development partners.

(Tables and graphs were shown to illustrate infrastructure budget expenditure, allocations per funding source and facility type, and allocations for 2017/18)

Western Cape Department of Health presentation

Dr Beth Engelbrecht, Head of Department, Western Cape Health Department, stated there is a measure of discontinuity between the interests of the National and Provincial Departments with respect to budget planning. The emphasis at National level is on conditional and earmarked funding, such as AIDS and TB, while the concern at provincial level is to ensure adequate funding for basic services. This leads to the undesirable situation that additional conditional and earmarked funds are allocated to provinces, while the budgets for the bulk of the services decline in real terms. The National Department of Health does not consult the provinces sufficiently when compiling the budget bid.

The Department’s budget has been shrinking slightly in the current and next financial years, while patient numbers continue to increase by between 1% and 2% per annum. The Department’s budget in years 2 and 3 of MTEF reduces sharply in real terms. The same probably applies to all provinces.

In terms of irregular and unauthorised expenditure, the Department has received an unqualified audit report for more than a decade and a clean audit report for the latest audited financial year (2015/16). The Department’s expenditure deviation from budget is very small. The Department in recent years over-collected substantially on its revenue budget. The Western Cape Treasury, generally, returns to the Department any amounts unspent and/or over-collected.

The Department then spoke to conditional grants. Regarding conditional grants, the Department produces a third of the doctors and 77% of the dentists in this country, but the allocation of the National Department to this province for Tertiary Services and Training and Development has reduced substantially in recent years. The allocation is being shifted to other provinces, but those provinces do not have the capacity to increase the number of new doctors and dentists. Since the Western Cape has to reduce training capacity, due to the reduced budgets, the risk is that the production of doctors and dentists in the country as a whole would be reduced. Growth in the AIDS Conditional Grant is lower than the growth in the number of patients in treatment, while medicine costs increased steeply during 2016.

The Departments recovers in excess of R500 million per annum from patient fees. Patient billing is done directly into the program “Clinicom” which is running in the vast majority of Western Cape hospitals. Once a patient has been discharged from the ward or from outpatients/casualty, their diagnosis is coded (ICD10) and they are billed according to their “H status” – H0 are free; H3 receive the highest bills. Clinicom interfaces with Sinjani (WCGH) and DHIS (NDOH) on clinical data, and with BAS in relation to financial data.

In relation to the initiatives the Western Cape Health Department and National Department of Health (NDOH) are working on, NDOH has requested development of interface between the Clinicom Patient Master Index (PMI) used in the Western Cape and the Health Patient Registration System (HPRS). This would ensure that PMI details are shared across both Clinicom and HPRS. This demonstrates that the Western Cape Government Health (WCGH) has alignment to the HNSF. All core systems linkable via HIS number, which is shared – i.e. the only province with a functional unique patient identifier for each patient, allowing the patient care record to be viewed irrespective of the treatment centre. WCG Health ensures that SINJANI is aligned with the National database DHIS, by updating and enhancing the system to align with DHIS - facility lists and codes, data collection tools. Currently WCG Health is using the WebDHIS (DHIS 2) for NCS and HPV. WCG Health has as its strategy to migrate all data collection and collation to WebDHIS in the next two to three  years. Most of the software applications are IHE compliant which is in line with the HNSF.

WCG Health has excellent ICT building blocks, currently maturing, to support new paradigm of using individual level patient data to support clinical care, routine reporting, and health intelligence. Nearly all primary care clinics use either the PHCIS or PreHMIS platform. Electronic dispensing covers 83% of all issues, and is expanding rapidly. All laboratory data are available electronically. Business Intelligence demonstrated the viability & utility of an individual-patient-level health data repository, which will create true intelligence and system independence.

The Department regards IT as a key enabler of service delivery with huge potential for efficiencies and service delivery improvement. The IT vision has been completed and endorsed by Top Mx and would be tabled at provincial cabinet in April. A roadmap for implementation is being finalised. The PT and Depthas allocated additional R60m for IT priorities.

The WCGH and its partners increasingly use electronic information management systems for pharmacy stock ordering, stock visibility, prevention of stock outs and control - JAC is in 100 pharmacies. The CDU (Chronic Dispensing Unit) is electronic – similar to the national CCMD project. MEDSAS is a national procurement system which WCGH uses in the Cape Medical Depot (CMD), which interfaces with JAC through “WINRDM” and helps with stock order generation. The Department would be exploring an e-prescribing system in 2017/18. The system interfaces with other relevant systems through the Provincial Health Data Centre, e.g.  Sinjani for immunisation campaigns, and  Clinicom for bed management.

The Department then addressed the extensive and duly authorised set of People Management (PM) delegations in place. The MPSA issued a Directive on Public Administration Delegations in 2014 and the Department’s PM delegation registers were amended in line with the Directive. In 2016 the Department submitted its delegation registers to the DPSA and received highly favourable comment on the quality and soundness of its PM delegations. The PM delegations were again revised and amended in line with the Public Service Regulations of 2016 that came into effect on 1 August 2016. The amended delegations were duly signed by the Executive Authority and HoD on 21 January 2017. Minimum levels of delegation are guided by the geographical footprint and thus decentralised service delivery model of the Department, to facilitate service delivery, especially in more remote rural areas.

The lack of control over personnel expenditure is the root cause for under-spending on Non-negotiables in many provinces. This Department has excellent tools for the management of Personnel Expenditure. In the beginning of each year, the head office negotiates with each facility the posts that can be afforded from the budget (The Approved Posts List). All the other posts are deactivated on PERSAL. Through a hierarchical set of regular meetings, called Financial Management Committees, management is held accountable.

Strong regulatory environment creates an onerous administrative responsibility of compliance which has an opportunity cost for service delivery in a highly stressed environment with escalating service demands and limited resources. The APP of 2016/17 had 228 indicators with the majority being national. The expenditure of certain categories of medicines has far outstripped inflation. For example, vaccine costs have increased by 22% and ARVs by 36 % in the last year. This has put further pressure on the budget. The conditional grants in general have not kept up with inflation. This has meant, for example, that the Department continues to allocate a significant percent of its equitable share budget to subsidise central hospitals.

The Department is strongly aligned with national policy and continues to produce amongst the best health outcomes in the country within a financially disciplined environment despite the challenges of escalating burden of disease and reducing budgets. The Department has identified four pillars to sustain its gains and build health system resilience:

• Ensure patient care and service needs determine organisational priorities
• Strengthen governance both within the Department as well as with external partners
• Build a positive organizational culture based on the values of the Department (innovation, caring, competency, accountability, integrity, responsiveness and respect)
• Strengthen distributed leadership across the organisation

Discussion

Gauteng Presentation

Mr Figg remarked that the budget on the Test and Treat programme is increasing at an alarming rate. If people are educated well about HIV, surely, there would be savings on costs. He also wanted to know if each district hospital had a CEO.

Dr Kenoshi, Acting Head of Department: Gauteng Health Department, stated that the Test and Treat Efficiency Programme was introduced mid-last year. It comes with a cost. The Department supports it whole-heartedly. People would be treated when their CD4 count is at a certain level. He also stated all the 34 hospitals had CEOs with only four being in acting posts, where the Department is still in the process of recruitment.

Mr T Khoza (ANC) wanted clarity on why on all the projects of the Department there is always a budget challenge for maintenance, as pointed out by the Auditor-General (AG). He further asked if the Department is taking the AG findings seriously because there are repeat findings.

Dr Kenoshi said the problem lies with the Gauteng Public Works Department, and expressed dissatisfaction with the work of this agent. A Service Level Agreement had been drafted to elevate the service being received from Gauteng Public Works Department. He also indicated there is an agreement that senior managers would be given authority to look after the maintenance of the facilities they manage. This agreement has been discussed with the MEC. The Gauteng Public Works Department has been advised to bring appropriate expertise that could be placed in these various institutions for maintenance. He noted that there was some improvement in the AG findings, although the Department was not yet where it should be.

Dr James remarked that the Department should focus on preventing and reducing diseases because health education is very important. He also wanted to know if non-negotiables are visible in clinics.

The MEC spoke to disease prevention, saying the Department is focusing on decreasing the diseases. The burden of diseases in her province is very high. The Department is reaching its targets. Vaccination is the intervention in place against cancer of the cervix, unwanted pregnancies and diarrhea. She noted that the Province is pleased about the Minister of Finance's introduction of sugar tax in the fight against disease. More needs to be done and the Province hope to introduce a programme that would acknowledge the role of municipalities in the fight against diseases. Non-negotiables were in place and were reviewed monthly. A report would be sent to the Committee.

Mr S Jafta (AIC) asked how the Department is planning to address the on-going dispute between itself and the contracted community health care workers.

Dr Kenoshi explained it is not easy to control these workers, especially their work attendance. There have been problems in payment of stipends due to them. The Department has appointed a company to look into their payments, especially of those who take their work seriously. The dispute is still negotiated with these workers because there is a perception the Department is doing some kind of labour brokering.

The MEC added these workers could be absorbed into the system but the main challenge is related to funding. There is a need to acknowledge that the dispensation of health workers is better than it was in the past.

Dr P Maesela (ANC) commented that the maintenance and revamp of equipment in tertiary and regional hospitals is not satisfactory. For instance, a lot of work needs to be done at Charlotte Maxeke Hospital and the Chris Hani Hospital used to have a unit replacing engineering equipment, which he doubts still exists.

Mr A McLaughlin (DA) asked the Department to expand on the medical legal costs.

Dr Kenoshi elaborated that claims are outrageous. As a result, the Province is developing a number of strategies to deal with the matter differently. Where there have been settlements, it has been discovered the Department could have done better in terms of getting legal advice or go to court. More and more lawyers are claiming on behalf of patients. Lawyers are now focusing on medico-patient claims whereas their previous focus was on road accident claims. Patient records are looked at and there is a consideration on the table that patients be paid their money directly.

The MEC added that lawyers are claiming 25% of the total claim. That money is for the future medical costs the Department is supposed to pay. Lawyers should be paid only for the work actually done.

Ms M Manana (ANC) remarked it is not only Gauteng that is affected by spiraling medico-legal costs, but all the provinces. She asked if there are enough dieticians in hospitals because there are claims that there is a hospital in Gauteng where patients are fed pap and wors only, irrespective of their ailments.

The MEC said if there are facilities that provide food not appropriate for patients' needs, the Department would make an intervention because it tries to employ dieticians.

The Chairperson wanted to establish how district hospitals are going to be strengthened because they “get treated like post offices”. She further wanted to know if the Department has started to organise the patient registration system and the filing of patient documents.

The MEC indicated the focus has not been enough on district health services. It is the core of a successful health system because the more patients are seen at a district hospital, the more the whole health system would be efficient. As a result, funding has been increased on the district health services and implemented the devolution of authority process. On the health patient system and folders' guidelines, she indicated the introduction of e-filing would reduce the problems. More information would be sent to the Committee.

The Co-Chairperson asked for clarity on why there is no policy for the maintenance of infrastructure and monitoring, because contractors are not producing quality work.

The MEC indicated the new SLAs are going to have a system of monitoring and would factor in the role of the CEOs and district hospital managers. It is hoped this would assist in the system of monitoring.

Mpumalanga Presentation

Mr Khoza asked how the Department is planning to deal with the matters, when the A-G findings state that this Department had no budget for maintenance.

The CFO of the Mpumalanga Health Department stated there has been a reduction in health costs. After carefully looking at the budget, the Department agreed the focus should be on health-related costs, and especially on ensuring electricity and water. Reconciliation of the municipality invoices was needed, because hospitals were paying invoices without looking at the meterage, and they were now paying only what was actually due. The CFO further indicated that budget for infrastructure maintenance starts to address allocations of actual funding. The hospitals had existing assets and they need to ensure they are maintained. Programme C and D are for maintenance issues. Programme D looks at the day to day maintenance while Programme C is for capitalised maintenance.

Mr McLaughlin wanted to know why the organogram of the Department is going to be reviewed.

Mr J Nkosi, Chief Director: Human Resources: Mpumalanga Health Department, explained that in terms of the Public Service Regulations the Department had to align the organogram to strategic plans and the allocations made to the health facilities. The Department would do deployment when there is a need.

Dr Madlopha asked for clarity on why there is no consequence management ,as pointed out in the A-G findings, and she wanted the Department to comment on allocations for non-profit institutions.

The CFO explained the Department was getting support from SA Institute of Chartered Accountants, and was trying very hard to improve matters. A team is working around the clock to improve audit outcomes and it is also looking at issues around consequence management. The Department is improving because some of the mistakes emanated from the preparation of financial reports, and software was now in place to help prevent this. On allocations for non-profit institutions, the CFO said the Department would fund home-based care type services. Having had discussions at national level, the Department had to increase the stipends of home-based care workers from R1 000 to R1 500, and indicated there was a non-profit institution that provides chronic mental health care.

Ms S Shope-Sithole (ANC) remarked that the Department should stop complaining about budget challenges. It should look at the report of the A-G and fix all the things pointed out.

Ms D Senokoanyane (ANC) wanted to know what the purpose of the EMS College is.

Mr Nkosi said the College assists the Department in induction programmes on EMS such as accreditation. The training is done within the province for refresher courses.

Mr Shaik Emam commented the audit report is not a true reflection of what is happening on the ground. The Committee has been to Mpumalanga for oversight and wants to see changes and solutions to the challenges. He noted that although doctors had been recruited from Cuba, Mauritius has offered SA 400 doctors and it was agreed that South Africa should be looking to the SADC region first before going to Cuba.

Mr Nkosi said the Department is sending its own medical practitioners to institutions to train as registrars and when they finish their training, they come back to the Department. The SADC suggestion would be taken into consideration. He said the Department had advertised infrastructure related posts and would be filled soon.

Mr Figg wanted to find out why the salaries of the administration personnel were higher than those of the core business staff.

Mr Nkosi explained that Programme 1 deals with administration and senior managers of the Department. That is why the costs are high.

Mr N Gcwabaza (ANC) wanted to know what "other" stands for in the financial statements; some of these titles had allocations attached and others did not.

The CFO said that section with "other" tries to explain the amount of money that is invested in clinics and hospitals in hotspot areas. There was also a reference to nursing colleges.

The Chairperson pointed out that "other" represents what used to be called "miscellaneous" and that was something which used to be abused. She said the Department should stick to agreed budget principles because Members have to measure the outcome.

The Chairperson remarked that the A-G report on infrastructure development had pointed out that the province had not been able to do infrastructure analysis correctly, and this needed identification. She asked what the turn-around strategy of the Department is, saying there is no feasibility study done on planned projects. She further remarked there Rock Ferreira Hospital in Mpumalanga  is said to have an equipment for helping in the birth of premature babies but that equipment has not been fixed since 2015.

Mr Mfana Phakathi, Acting Chief Director: Infrastructure: Mpumalanga Health Department, elaborated that the departments were essentially competing for the same skill sets in the nine provinces. If one provincial offer was better than another, the staff would move. Now people are given contracts of three to five years and they have to mentor younger colleagues and pass on their skills. He agreed with the AG's report, and said that at the moment there was an approved policy on infrastructure maintenance because the Department was now working with the Mpumalanga Public Works Department. He agreed that there was a need to address the lack of a feasibility study, but as far as he knows no project would start without clinical briefs being done. In regard to the “unfixed” equipment, he said that the Department would pay a visit to Rock Ferreira Hospital because it had been under rehabilitation. He also said that hospital has changed its scope. The Department would try to minimise the challenges.

Western Cape Presentation

Ms Shope-Sithole remarked she was warmed to note the spirit of accountability and impressed by the passion the presenters expressed .

Ms Senokoanyane commended the province for the work it has done. She said TB and HIV death rates had decreased, yet there are deficiencies in coordination at national level and the Department is focusing on its normal budget.  She wanted to know if it is possible for the Department to focus on HIV and TB because these  are of national interest. She also asked what the actual status is of the health infrastructure in the province.

Ms Mbombo, on HIV and TB, stated that the HIV grants have to respond to 80 indicators and not all of them are adding value. In terms of the programme they have to report on the indicators. She added that the rate of default from TB patients is at 8, 5% and the Department is putting more efforts on combining primary health care and community health care. In regard to health infrastructure, regional hospitals have been upgraded and one district hospital was completed in 2001. The document with detailed infrastructure development plans would be sent to the Committee.

Mr Shaik Emam remarked that again he did not think the statements on paper reflected the real situation on the ground, which seemed to remain unchanged across the whole country. The  Western Cape could not be compared with what is happening in the rest of the country because the Western Cape is one province that has been receiving funds for infrastructure development for very long time. It is a privileged province.

Mr Gcwabaza commented the presentation is “conservative in details”. There is no breakdown on spending for the 2016/17 year so that Members could follow expenditure patterns, except for Tygerberg and Groote Schuur Hospitals. Other hospitals like Jooste and Mannenberg were not mentioned.

Ms Engelbrecht stated the Department is not the custodian of Jooste Hospital. It belongs to the Department of Public Works. She further indicated the Tygerberg Hospital serves not only the city but the whole country.

Mr McLaughlin wanted to find out how the Department is planning to address its shortage on pharmaceuticals as pointed out in the AG findings. He asked the Department to comment on its lowest number of claims brought against it.

Ms Engelbrecht said a business analyst is expected to start working early April 2017 on an integrated pharmaceutical system. She stated 8.4% of the total budget goes to claims. The Department has got a small unit staffed by two people. There is a medical doctor who understands both legal and medical terms, and has established relationships with the State Attorney. Staff are trained in every component of its work. 75% of the claims are not justified so at the end of the day only 25% of the claims require a full investigation and defence through the court.

Mr Figg wanted to find out how many doctors and dentists the Department had retained ,seeing that it produced a third of the doctors and 66% of dentists.

Ms E Engelbrecht indicated the Department would train doctors and dentists for the country, not for the province, yet the funding was not equal to the numbers trained. The Department had 6 million hours for students on the system.

Mr Khoza enquired if the Department was planning to expand towards the rural areas for the benefit of the people there because it said it was experiencing shortage of land.

Ms Mbombo said the shortage was actually in a combination of both rural and urban areas because the Province ideally needs sites in Cape Town, George and Knysna.

Mr Jafta asked if the Department has any public awareness campaigns on smoking. Numerous smoking zones are found everywhere in Cape Town.

Ms Mbombo stated the Department sticks to the national calendar in order to build a momentum around anti-smoking public awareness.

The Chairperson indicated that her main concern is that the Department is having difficulties in aligning its budget to the strategic goals of the National Department, due to insufficient consultations. The strategic goals of the National Department are aligned to NDP, so that all provincial departments of health should follow those strategic goals. That should not be departed from. She further wanted to know how the Department is going to measure its performance against “others”, if it had a budget for “others”; the Department should be spending the budget on the specific priorities.

Ms Mbombo stated that the question of alignment alluded to by the CFO related to the budget, not the strategic goals of the National Department. The Provincial Department indeed did abide by the visions of the National Health Act. Provinces needed the same things, but they wanted them differently. The focus of the National Department is not on the services the provinces actually wanted to deliver.

Ms Englebrecht confirmed that “others” referred to pathology services and nursing colleges.

The Co-Chairperson wanted to find out if the Department was asking to be given free rein, when it said that it wanted to provide a service but was restricted by regulations. Her biggest worry is that huge amounts of money are spent on the revitalisation of Groote Schuur and Tygerberg Hospitals, although she did understand that they were central hospitals. On the other hand, nothing is known about what is happening in other areas and it appears that facilities getting improvements are those in Cape Town only.

Ms Engelbrecht spoke to regulations and said the Department tried very hard to get clean findings every year. New regulations are added while the budget is decreasing, and regrettably some did not add value. This had led to the need to increase staff. There is a need to negotiate with Treasury to make sure the Department was only being bound by value-adding regulations.

The meeting was adjourned.