Hasa.co.za



Meeting reportHEALTH PORTFOLIO COMMITTEE16 March 1998WHITE PAPER ON TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA:HEARINGSDocuments available:Chamber of Mines submissionConcerned Medical Schemes Group & RAMS membersThe White Paper on Transformation of the Health System in South AfricaList of organisations who presented submissions on the White Paper on Transformation of the Health System in South Africa:Actuarial Society of SA Health CareAssociation of Retired Persons & PensionersCOSATUDemocratic Nursing Organisation of South AfricaFreedom of Commercial Speech TrustLife Offices Association of South AfricaMedical Association of South AfricaMedical Research Council: UDWNACOSA (Western Cape)NPPHC NetworkPharmaceutical Manufacturers' Association of South AfricaPrior InstituteOld Mutual Health CareRepresentative Association of Medical SchemesWomen and Human Rights ProjectGender Advocacy ProgrammeSummary:This meeting was the first in a series of five meetings arranged for 16-20 March to garner public comment on the White Paper on Transformation of the National Health System. During the four hour meeting, presentations were made by three parties: the Department of Health, the Chamber of Mines of South Africa, and the Concerned Medical Schemes Group. Each presentation was followed by questions from the MPs directed to the presenters.The presentation by the Department of Health discussed the history of health sector reform in South Africa since the late 1980s and highlighted key points and overarching themes of the White Paper. The presentations by the Chamber of Mines and the Concerned Medical Schemes Group expressed overall support for the vision articulated in the White Paper of a more equitable and effective health system, but expressed concern about specific provisions of the Paper which may affect the private sector.Most of the 16 MPs present were actively involved in the discussions that followed each presentation.The minutes below briefly summarize each presentation and record the questions asked by the MPs and the responses offered by the presenters.MinutesThe meeting was opened at 9:30 a.m. by Dr. S.A. Nkomo. Dr. Nkomo welcomed all individuals present and stated that all present were in agreement on the importance of transforming the health system in South Africa.Presentation 1: Department of HealthThe Department of Health presented an overview of the history and content of the White Paper on Transformation of the Heath System in South Africa. None of the many provisions and proposals in the White Paper are new. All the provisions and proposals have been advanced by one or more groups in the past decade in the course of a national search for a common vision to transform South Africa’s health system. In the White Paper, the government has attempted to undertake a holistic rethink of the South African health sector in order to correct the numerous and serious structural defects of the sector.The current government began the process of formulating national health policy by appointing twelve technical committees to review different elements of the health care system. The recommendations of these committees informed and influenced the development of the first draft of the White Paper. [Note: no Green Paper was developed.] After publishing the first draft of the White Paper, the Department of Health received approximately fifty substantive responses from private sector and civil society organizations. These responses were reviewed and incorporated into the second draft of the White Paper. About eighty substantive responses were submitted to the government after this draft was released. These submissions were considered in drafting the final version of the White Paper, published in April 1997. The hearings this week have been called to garner input on this final version. The presentation continued with an overview of key points and overarching themes in the White Paper.Questions and DiscussionMr. M. Ellis of the DP asked how the submissions received at these hearings would be used. Would the White Paper be rewritten to incorporate the views expressed? Mr. Ellis commented that these hearings should have been held before the consideration of the three health bills passed last year. He expressed the hope that the results of these proceedings would impact substantially on the debate on the health bills to be considered in the 1998 session of Parliament.Dr. Nkomo answered that the White Paper has been finalized and will not be altered to reflect views expressed in these hearings. He said that these hearing should not be considered an idle exercise, however. Rather, the hearings afford interested parties an opportunity to offer comments that can guide the forthcoming translation of the principles and implementation strategies articulated in the White Paper into legislation.Mr. Ellis asked about the status of the National Health Bill and whether any of the input received during these hearings would inform the drafting of this bill. The Department of Health responded that the Bill will likely be tabled during the 1998 session. Nine high-ranking colleagues from the Department of Health would attend all the hearings, listen carefully, and incorporate appropriate input into their contributions to the development of the bill.Citing a desire to use time efficiently, Dr. Nkomo stated that all MPs with questions should ask them at this time. Dr. ___ would then respond to all the questions at once.Mrs. A. Tambo of the ANC expressed concern that the needs of the elderly and their caregivers were not adequately addressed in either the White Paper or the RDP. She noted that the UK has a system that provides home-based support for the elderly, particularly those suffering from Alzheimer’s disease, and for the people who care for the elderly. She asked if South Africa could employ a similar approach.Dr. R Rabinowitz of the IFP made several points:On the issue of HIV/AIDS, she stated that policy should be changed to reflect South Africa’s need to move beyond awareness raising to a more proactive approach emphasizing behavior change. She suggested that HIV/AIDS needs to be treated more as a public health crisis than as a human rights issue. She recommended introducing legislation that makes it a crime not to divulge one’s serostatus to a sexual partner if one is HIV positive.On the issue of collecting health data, she suggested that the information could have multiple uses in addition to informing top policymakers and administrators. She suggested that the database be used to prevent illegal aliens from using South African health care facilities.On the issue of community health committees (CHCs), she observed that CHCs are often not legitimate representatives of the public, but rather politicized institutions. She suggested careful review of this concept and the implementation strategy devised to operationalize it.Last, she indicated that community health workers (CHWs) are not mentioned in the White Paper. She expressed the belief that CHWs play crucial roles in addressing a wide range of community health needs, including problems arising from HIV/AIDS, needs of the elderly, and others. She noted that NGOs could in some cases provide these CHWs, but that NGOs needed clearly stated government policy supporting placement of CHWs in order to source funds to support the CHWs.Dr. K.R. Meshoe of the ACDP asked how the shift in emphasis from tertiary to primary care in the health care system would be advanced. He also asked what role tertiary institutions would play in the new health system.Mrs. M.A. Njobe of the ANC asked what plans the Department of Health had for making the medical field, and particularly doctors, more demographically representative of the nation. She noted that this was particularly important because black doctors are more likely to practice in the rural areas, which currently are severely underserved. She commented that the Demographic Health Survey planned by the Department was very important and urged them to carry through with the plans. She noted that psychiatric service provision has been neglected in South Africa, and she expressed concern that psychiatric care would continue to be marginalized if it was made the responsibility of the provinces.Dr. E.E. Jassat of the ANC noted that considering the critical shortfall of medical professionals in the country, efforts were needed to prevent graduates from South African medical institutions from leaving South Africa. He also suggested that reforms were needed that would more readily allow qualified doctors from other countries to practice medicine in South Africa, particularly in the rural areas.Mrs. J. Chalmers of the ANC expressed concern about the confusion in provincial administrations about the division of responsibilities between the health and welfare departments, particularly vis-a-vis psychological care for the mentally ill. She noted that there were many clinical psychologists in the country who spoke Afrikaans or English, but few who spoke African languages. She suggested that efforts be made to increase the number of clinical psychologists who speak one or more African languages. She asked about the current status of the demarcation of districts by the Department of Health, asking also when they would be finalized. She expressed concern that in her province, the Eastern Cape, the funds of one sector were siphoned off to pay for the overruns of another sector.Mr. M. Ellis of the DP strongly supported the approach of allowing health care institutions to retain a proportion of the payment they receive. He asked what proportion the collecting institutions would receive and how the proportion returned to the central government would be used. He asked what relationship was envisioned between the current medical schemes and the proposed national health insurance program. He asked how the national health insurance program would be financed, expressing concern that it might be funded out of a health tax paid by the employees, the employers, or both.An unidentified member of the ANC asked how traditional healers would be incorporated into the health care system.Dr. Ntsaluba of the Department of Health responded to several of the queries. He stated that increasing the number of black doctors is a high priority for the Department. To that end, the Department does not seek to close Medunsa. Instead, the Department is working to determine what problems Medunsa faces so that they may be addressed.He noted that the problem of high expenditure in tertiary institutions will be relieved to an extent through the decentralization process, but indicated that other measures were necessary.He noted that Department is currently exploring models for community-based care, not as a means of shifting responsibility for the sick away from the health system but rather as a way of supplementing the system and maximizing the effectiveness of the investment of South Africa’s limited resources for health.Finally, he indicated that the Department is reviewing ways of incorporating traditional healers more fully into the national health system.Dr. Nkomo indicated that more time would be set aside later in the week for the Department to address questions that were not answered today.Presentation 2: Chamber of Mines of South AfricaDr. MAC La Grange, Health Advisor to the Chamber of Mines, presented the submission of the Chamber. She invited members of the committee to visit health facilities operated by South African mining companies, stating that some observers have compared them to the U.S. health system. She stated that the major issue which South Africa must contend with in transforming its health system is finding the ways to achieve primary health coverage for all without jeopardizing the high quality care provided by the existing health care system.Dr. La Grange indicated that the submission of the Chamber would focus on the parts of the White Paper that affect the Chamber directly. She pledged that the Chamber was willing to cooperate within the guidelines of the White Paper. She expressed hope that public/private sector relationships around health would take the form of voluntary cooperation rather than regulation. However, several provisions of the White Paper suggest that the government is seeking to extend its control over the private sector. Also, she observed that the White Paper does not fully acknowledge the important role that occupational health providers play in the overall health system.As a provider of health services to its employees, the mining industry should be exempted from contributing to any national health insurance program that may be developed. The Chamber suggests that the Department of Health open a more broadly consultative process as it develops a national health insurance scheme.A representative of Anglo-American spoke briefly after Dr. LaGrange finished, echoing several of her sentiments. He added that Anglo was concerned about the trend towards reregulation and would like to see evidence regarding the increased costs brought by deregulation which are cited as grounds for the reregulation initiatives.Dr. Nkomo suggested that instead of allowing questions, the third presentation would be made; then MPs could ask questions of both sets of presenters.Presentation 3: Concerned Medical Schemes GroupMr. A Gore of the Concerned Medical Schemes Group stated that the private sector generally and medical schemes in particular have an important role to play in promoting the nation’s health. He expressed concern that the White Paper indicates that medical schemes will be required to operate within a restrictive regulatory framework. The Group believes that this kind of approach will lead to a decline in the number of people who are covered by private schemes.He strongly refuted the claim that deregulation of medical schemes has been detrimental, indicating that the number of persons enrolled had risen and that costs had been controlled. The group believes that rates will rise substantially if the government forces medical schemes to accept any person regardless of health. However, the Group does agree with the principle that once a person has joined a scheme, her/his rates should not be based on her/his health.Questions and Discussion Based On Presentations 2 and 3Dr. Rabinowitz of the IFP stated that her party agreed with most of the concerns raised by the Chamber of Mines. She asked how the Chamber would suggest that mistrust of the private sector by the government be reduced.Mrs. Tambo of the ANC asked the difference between the Chamber of Mines and the mining houses. She asked if the Chamber contributed in any way to the payment of workers’ health costs. She asked about the other social policies of the Chamber, particularly in education.Mr. Ellis of the DP asked if the presenters felt that the private sector had been adequately represented in the White Paper formulation process. He also asked what type of relationship the presenters foresaw between the medical schemes and the national health insurance program.An unidentified ANC member asked how the Chamber of Mines intends to address the needs of people with disabilities. She expressed concern over the mining houses’ practice of ‘dumping’ patients no longer able to work into the public sector facilities. She asked what criteria currently are used to determine eligibility for medical schemes. She asked how the private sector would benefit from the White Paper and the transformation it envisions.Another unidentified ANC member expressed concern that the private sector is not cooperating with the transformation process. At this point Mr. Ellis of the DP interrupted to object to use of question time for the purpose of making political points. The Chair chided him for interrupting and eventually restored order. The ANC member asserted that the Chamber needs to provide better care for miners who have been disabled. She asked what plans had been made to deal with the pensions of people who die of HIV/AIDS.Response by the Chamber of MinesDr. La Grange and the representative from Anglo-American explained that the Chamber of Mines is an association of the mining houses of South Africa. The Chamber does not provide health services itself: this is undertaken by each mining house. They noted that the mining houses provide a wide range of health services to employees, including tertiary health care if necessary. They recognized that the issue of ‘dumping’ is a real problem and requires review. The mining houses are interested in comprehensive care packages, but find them very expensive. Most mining houses do not currently offer coverage to dependents of employees. This is being reviewed. The Anglo representative believes that the best way to overcome public-private mistrust is by working together as much as possible and by arranging forums like these that allow for exchange and dialogue.Response by the Concerned Group of Medical SchemesThe Group believe that medical schemes face three key issues:What to do with today’s old?What to do with tomorrow’s sick?What to do about the millions of South Africans whose health care is not funded?The group does not oppose all reregulation, but believes that the community rating system is too simplistic and will cause three problems:1) Consumers will not see value for money and will be less willing to pay2) Costs will rise as more vulnerable people move into the system3) Young people may opt out of the system, so increasing the burden on the middle-aged and the old.Representatives from the Group expressed a desire for closer involvement with government in policy formulation. They expressed optimism about the prospects of public/private sector cooperation in the future.After thanking all participants for their contributions, Dr. Nkomo closed the meeting at 1:45 p.m.Meeting reportHEALTH PORTFOLIO COMMITTEE25 June 2002SOCIAL HEALTH INSURANCE POLICY DEVELOPMENT: BRIEFINGChairperson: Mr L V Ngculu (ANC)Documents handed out:Inquiry into Social Security Aspects of South African Health SystemSocial Health Insurance Policy Development Powerpoint PresentationSUMMARYThe Committee learned with consternation that the World Health Organisation had rated South Africa at position 175 out of 200 countries sampled world-wide on the budgetary allocation to the health sector. This rating was attributable to high inequalities that existed between the private and public sector medical provision. The public sector with a budget of R30 billion serviced 37 million people whilst the private sector with a budget of R40 billion served seven million people. The Committee felt that this rating was due management problems as witnessed during oversight visits to provinces.MINUTESPresentation by Brenda Khunoane, Director Social Health InsuranceMs Khunoane informed the Committee that the Government had commenced charting out the policy process by setting up four committees namely; the Finance Committee (1994), the National Health Insurance Committee (1995), Departmental Task Team (1997) and the Social Security Committee of Inquiry (2000).Ms Khunoane explained that the National Health Insurance Committee proceeded on the understanding that the Constitution provided that everyone has a right to access to health care services including reproductive care. The Constitution obligates the State to take reasonable legislative and other measures, within available resources to achieve the progressive realisation of these rights and that no one may be refused emergency medical treatment.On the current policy context, Ms Khunoane pointed out that the public and private sector need to enter a joined venture to solve inequalities that exist between them. She said that the former with a budget of R30 billion services 37 million people whilst the latter with a budget of R40 billion serves a mere 7 million people.Ms Khunoane noted that the budget in the public sector has been on a steady decline and that there were internal deficiencies where policy is designed at the national level but implementation depends on the Provincial priorities. She added that centralisation of policy decisions caused disincentive for the Provinces to undertake certain projects in hospitals.Ms Khunoane pointed out that the Committee Report had identified specific problem areas in the health sector. She explained that these areas included the link between policy and implementation-centralised responsibility and accountability and a flawed user fee system. She added that the fee system was such that it created the wrong perceptions among the populace that hospital services were free which should not be the case. The other area is the declining budget for the public health system, which had caused the quality of service in this sector to plummet. The other aspect identified as problematic was the fact that it had become impossible to address inequality due to the foregoing challenges hence the central issue of inequality had been relegated to the very periphery.Ms Khunoane continued that with regard to the private sector, the report noted cost increases and an unjustified tax subsidy that rose with every new scheme. She added that the report had noted the existence of some discriminatory practices in medial schemes and that there was a structural difficulty in linking these schemes to the public sector. She pointed out that the report had further noted that the development of a low-cost market was limited due to high private hospital costs and that there were other intermediary problems like the broker's code of conduct which need to be addressed.Ms Khunoane reported that a study carried out by the WHO on 200 countries on budgetary allocation for the health sector had placed South Africa at number 175 only next to Brazil. She lamented that this poor performance had everything to do with the glaring inequality in the health system. She noted that the amount of money spent on public hospitals had been declining rapidly in recent years and this phenomenon has only been matched by the stead growth of the private sector. This scenario, she explained, could only mean that there had been more money going into the private health sector than what goes to the public sector.Ms Khunoane pointed out that Research findings had proposed a conditional support for a contributory scheme to ensure that additional funding goes to health and there is adequate injection of funds into the public system to improve public efficiency and structural systems in hospitals. It was further proposed to effect differential amenities and not clinical services to improve these products but that care must be taken to ensure that those unable to pay do not get low quality services.Ms Khunoane stated that the key objectives of the proposed reforms was to attract additional resources to social risk pools and entrench systems of cross subsidy while reinforcing the public provider system and restructure the budgeting system at the same go. The proposals were such that the public sector would remain the provider of last resort and that key determinants of policy must be restructured to achieve policy synergy at both national and provincial levels.Ms Khunoane pointed out that the upshot of all these measures was to develop an enabling environment that would prepare the public health budget system. This would ensure a centralised health budget and the creation of units to manage conditional grants. She explained that these measures would prepare the public health hospital system to manage decentralisation and create coherent enhanced amenities in the policy regime. She added that all these would require the injection of financial resources to improve public services and that concomitantly minimum norms and standards must be created in addition to the improvement of human resource management.Ms Khunoane admitted that this process was a huge task, which would not happen right away but that it was a process that would require a systematic approach. In the meantime, however, preparatory reforms would be implemented to introduce a risk equalisation fund and the implementation of the revised tax subsidy. She also alluded to the possibility of a mandatory cover for civil servants and some kind of a state sponsored medical scheme whose character would be such that the state would not necessarily fund but that such entity would be self-sustaining.On the question of the implementation of the statutory mandates, Ms Khunoane explained that this would empower medical scheme membership to only apply to high-income groups and implement voluntary cover for low-income groups. She added that as a result there would be a move towards a pre-paid system for public hospitals, which allows access to enhanced amenities but that non-contributors would be entitled to free services.DiscussionThe Chair pointed out that some of the issues ventilated in the report had been discussed at length during the provincial budget vote in particular the question of conditional grants, conditions of hospitals and the code of conduct for brokers. The Chair noted that upon return from the short recess the very first item on the agenda would be to amend the medical schemes Act in order to make provision for the code of conduct for brokers.The issue of provincial budgetary inequities came out more starkly during the budget vote and that it is a cause of great concern to the Committee. He added that there was a great deal of work to be undertaken in the area of hospital revitalisation noting that it came as no surprise that the country was poorly rated by the WHO in the budgetary provision for medical services.Mrs Mnumzana (ANC) acknowledged the fact that the presentation was a comprehensive in-put noting that members would require time to plough through the report to get sense of what was addressed therein before engaging the Department meaningfully. She added that what has become clear was the direction the Department was taking to address the recurrent problem of inequity in the health system.Mrs Mnumzana (ANC) associated with the Chair's viewpoint that the budget presentations had uncovered disturbing incidences of outright inequity in the health system. She noted with approval the proposal to centralise budget disbursements in order to create synergies in policy implementation.Dr Robinowitz (IFP) congratulated the presenter for her excellent grasp of the issues at hand. She however criticised the report for presenting no options to the suggested solutions. She also faulted the proposal to centralise budgetary disbursements, which she said was not an answer to the perennial problem of conditional grants.Dr Robinowitz applauded reference to minimum norms and standards, which she said was a better approach than just looking at norms and standards generally.Dr Cachalia (ANC) pointed out that the question of poor management and inadequate human resource must be addressed urgently. He urged the Department to find ways and means to register more civil servants into the medical cover schemes. He expressed the view that the medical industry lacked efficient overseeing and that incidences of high management costs, high costs of drugs and high cost of medical cover were rampant.Ms Mathibela (ANC) observed that medical schemes and brokers had maintained structures, which made it very difficult for people to appreciate the importance of a medical cover. She added that many people knew very little about medical schemes and pointed out that perhaps centralising may be the only solution. She urged for a culture of responsibility to be inculcated among the populace by encouraging everyone to pay for medial services be they poor or rich.Ms Khunoane pointed that most issues members had raised were covered in the report. She agreed with members that the question of budgetary inequity was a major problem but was quick to assure members that the Department was seriously and urgently tackling the problem.Ms Khounane said that the issue of centralisation was challenging and explained that the current set up was such that responsibility vested in the national office but without the requisite power to ensure implementation of the mandate upon which responsibility vests. She gave the example of implementing the problematic inter-provincial equity, which is impracticable in a situation where the control of the provincial budget vested with the provinces.Ms Khunoane concurred with sentiment expressed by Dr Cachalia that the issue of inadequate human resources called for urgent intervention. Eleven pilot projects had been set up to provide hospital management with support systems. The government had ordered an evaluation of performance of all areas of management to take stock of developments.On the question of high administration costs, Ms Khunoane said that the registrar was in the process of looking into this issue. She agreed with Dr Chachalia that the cost of essential drugs had increased substantially and pointed that the Department was trying to move away from branded drugs but that this was still under consideration. The Department was encouraging accredited medical schemes to enter into an agreement to purchase drugs together with the government in order to reduce the costs to consumers.Dr Luthuli cautioned that the Department must tread carefully on the issue of centralisation noting that this might turn out to be a source of debilitating bureaucracy. She concurred with the Chair that the poor rating of the country by the WHO came as no surprise since the committee had witnessed a great deal of management problems during its oversight visits to provinces.The Chair agreed with Ms Luthuli that the question of centralisation must be explained thoroughly and put in its proper perspective for members to comprehend the context within which it is set. He added that in his view, measures are put in place to address the immediate concerns regarding the health system in so far as how well and first to arrive at redressing the vexing question of inequity.The Chair encouraged members to thoroughly acquaint with the report during the recess period so as to absorb its depth. He pointed out that the report would inform the Committee's deliberations in the next session.The meeting was adjourned.Meeting reportHEALTH PORTFOLIO COMMITTEE7 June 2005SOCIAL HEALTH INSURANCE: DEPARTMENT BRIEFINGActing Chairperson:?Ms M Madumise (ANC)Documents handed out:Department briefingSUMMARYThe Department of Health presented on the proposed Social Health Insurance model. Detail was provided on the key strategic challenges, the policy context, comparisons between National Health Insurance (NHI) and Social Health Insurance (SHI), and the objectives of SHI. Risk equalisation and income cross-subsidies were outlined. Members asked numerous questions, including on possible sanctions for unco-operative schemes; plans to revive public hospitals; provincial and rural-urban disparities; the decline in the use of public hospitals; the claimed evolutionary process from SHI to NHI; high inflation and fraud within private medical schemes, and the containment of outpatient costs at public hospitals.MINUTESDepartment of Health briefingDr K Chetty (Department Deputy Director-General: Health Service Delivery) referred to the lengthy planning process regarding the formulation of the social health insurance policy. The matter was complex and required broad-based consultation with relevant government departments, such as the Treasury, and other stakeholders. The presentation focussed on agreed aspects and ignored certain issues still to be determined through discussion. The subject had generated significant debate within the media and confusions had to be clarified. The position on private sector medical schemes was explained and the distinction between social health insurance and national health insurance was clearly outlined.Ms B Khunoane (Department Director: Social Health Insurance) outlined the key strategic challenges to facilitating universal access and adherence to World Health Organisation (WHO) principles. The number of recipients of private and public healthcare varied, with the private system serving a relatively small number as compared to the public sector. The membership of medical schemes had not grown in the interim and specialists and private hospitals had received increased payments. Medical aid schemes ignored public sector facilities in general. The intention was to converge sectors and provide more balanced service delivery.Ms Khunoane elucidated on the distinct characteristics of the national health insurance model versus the social health version. The NHI model operated efficiently within a developed state context, while the SHI approach was more appropriate for a smaller pool of contributors. The objective was to create a NHI system after the entrenchment of SHI systems in an evolutionary process. SHI intended to render affordable universal cover and remove access barriers. SHI would consider risk-related cross-subsidies, income-related cross-subsidies and mandatory contributions. Risk equalisation would be promoted across medical schemes, and lower prices for delivery would be encouraged through enhanced competition. She further explained the tax expenditure subsidy framework and proposed next steps.DiscussionMs S Rajbally (MF) asked what additional subsidy income the Social Health Insurance policy would receive.Ms B Ngcobo (ANC) asked what sanctions could be imposed on medical schemes that contravened legislation, and whether public sector hospitals could be revived to attract more medical scheme patients.Dr Chetty responded that the National Revenue Fund was a major contributor towards public sector funds and that other donor grants had been organised. The Council for Medical Schemes (CMS) regulated the industry and ensured compliance in an interactive manner. The unethical behavior of medical schemes had been addressed in recent years and further discussions would occur. Public-private partnerships would be considered as part of the hospital revitalisation programme, and public hospitals would encourage an increase in-patient numbers. Certain public hospitals had improved service delivery and the public sector should become designated service providers for all medical aid schemes.Mr S Njikelana (ANC) asked whether the department had considered the disparities between rural and urban areas in addition to the obvious differences between public and private sector service delivery. He asked whether local government facilities had been included within an appraisal of the South African health system. The decline in use of public hospitals by medical schemes was a concern. He sought clarity on the reasons for this trend. He asked which areas of service within the public sector continued to be utilised by medical schemes. He proposed that representatives of the Department attend an upcoming Committee meeting with the Board of Healthcare Funders to gain additional insight. Clarity was also sought on progress in primary healthcare. He provided the example of Cuba as a developing country that had a National Health System model, and asked for evidence of the proposed evolution from Social Health Insurance schemes to a conventional national system.Mr I Cachalia (ANC) referred to rising contribution fees and decreasing benefits over the past decade within medical schemes, high levels of fraud and private hospital bias. He asked whether these issues had been considered in advocating Social Health Insurance as a suitable model. He queried what proportion of the population would benefit from the envisaged system.Ms Khunoane replied that the Department was aware of persistent service disparities between the rural and urban areas. Inequalities also remained between provinces and weaknesses would be addressed over time. The role of municipal expenditure towards clinics and other health service had not been included in the presentation, but the Division of Revenue Act provided detail. The decline in public sector hospital use had many causes, including the growth in the private hospital industry and the low regard shown by medical scheme patients towards the public sector.She continued that the public system needed to improve their billing methods as medical schemes required accounts within three months of treatment in accordance with the Medical Schemes Act. The administration component of public hospitals would have to be improved. The public sector suffered unnecessary costs when patients did not disclose medical scheme membership status upon admittance. Public hospitals could not refuse treatment in line with constitutional principles. Specialised services within the public sector were used by private practitioners and medical schemes, particularly within academic hospitals. Cost escalations for primary care had occurred within medical schemes due to contract agreements with private primary care providers.Primary care would be included within risk pools created by Social Health Insurance, and growth in the industry could be expected. The presentation had focused on health policy issues but debate on the merits and demerits of the proposed model would have to include political economy policy positions, such as current government macro-economic policy. Studies had confirmed the evolutionary path experienced by industrialised countries from SHI to NHI where smaller systems had converged into large national beneficiary pools. The Department was aware of extensive fraud and cost escalation within medical schemes, and the Council for Medical Schemes was investigating. The Department would strive for reasonable prices within the private scheme system and the National Health Act permitted intervention by the Minister where necessary.Dr Chetty confirmed that the inequities in service distribution would be addressed and human resources would be a prime focus point. The recent rural allowance paid to health practitioners within the public sector had facilitated an increase in personnel within rural areas. The Department had considered empirical studies comparing SHI and NHI applications and related successes, but this had limits due to varying socio-economic contexts in different countries. She recommended that private hospital representatives make a presentation to a future Committee meeting where explanations on escalating costs could be provided. Recent pharmaceutical pricing regulations had caused a shift in costs towards private hospitals and other services by private companies.Ms B Ngcobo (ANC) asked how a public sector bill was paid if medical schemes refused to pay on the basis of delays. Clarity was sought on the role of traditional practitioners within the proposed system and the current rating by the World Health Organisation.Dr Chetty stated that a new electronic billing system was under consideration for the public hospitals that would provide centralised billing and accurate records. Incentives would be created for hospitals to submit accounts to medical schemes more timeously. Improved records would also assist in addressing cross-border discrepancies. Pre-payment arrangements with medical schemes could be considered. Registered traditional practitioners would receive a practice number from the Board of Healthcare Funders that would initiate access into the health system. Traditional services could be provided within medical scheme packages in accordance with demand. The poor rating within the last WHO rating study had been due to high inequalities between the public and private sectors in terms of resources and the number of beneficiaries.Ms R Mashigo (ANC) asked what role the Department of Social Development had played in the discussion process to install a revised health insurance system.Ms Rajbally asked how the costs of outpatient fees in public hospitals could be controlled in the interests of the indigent and unemployed.The Chairperson asked how medical schemes could be prevented from exhausting the allocated funds of patients and dumping them onto the public sector. She asked for detail on the extent of the consultation process around the development of the policy, and how the abuse of schemes could be discouraged.Dr Chetty responded that outpatient fees at public hospitals were governed by a uniform fee schedule composed of certain categories determined by socio-economic circumstances. The public sector had to provide healthcare to citizens irrespective of ability to pay. The presence of cash within the system did increase the likelihood of fraud and corruption, but regular audits within provinces would be conducted to monitor activities and prevent unlawful practices. Any anecdotes of corrupt activities known by Members should be forwarded to the Department. Legislative amendments would be initiated to reduce ‘dumping’ and discourage unnecessary expenditure by medical schemes.Ms Khunoane replied that the consultation process had occurred for some time. A 2001 study had focused on the types of services desired by low-income earners and their willingness to contribute some payment towards service delivery. The study revealed a clear understanding of needs and a strong social solidarity stance. Benefits should be widespread and the public displayed a commitment to contribute to payments, although the agreed amount was variable. The Department would quantify a package of benefits and discuss fiscal issues with the Treasury. Consultations had occurred with organised labour and other stakeholders, but many had fallen out of the system over time. The Social Development Department had been part of a broader consultation process focused on the restructuring of the social security system.Mr Njikelana recommended that the Department consult with information technology experts to expedite the improvement of the billing system. He noted the movement away from NHI and asked for the Department's strategy on non-contributors. The danger of cartels between medical schemes and service providers should be considered. He advocated a stronger emphasis on public participation within the policy planning process.Dr Chetty replied that SHI proposed that contributions be paid by the employed, with the indigent covered by the state. The creation of one pool of beneficiaries was not planned at this stage. The model would concentrate on adding the employed currently uninsured into the system, and create income cross-subsidies. The danger of cartels would be addressed by various regulators,such as the Competition Commission. A potential conflict of interest between service providers and laboratory services could be prevented by pressure to unbundle subsidiaries where necessary. The Health Professions Council could intervene in such situations.The meeting was adjourned.National Health Insurance Green Paper; Safety and Security in public hospitals: Departmental briefings16 August 2011Chairperson: Dr B Goqwana (ANC)Meeting SummaryThe Committee received a briefing from the Department of Health on safety and security in public hospitals. The Department had conducted a safety assessment as part of the Core Standards of Health, which had demonstrated significant weaknesses, also proven by a number of incidents where staff or patients had been injured or killed due to poor security. The National Health Council (NHC) had conducted similar studies with the same conclusion. The NHC proposed several interventions. In the short term it would appoint a task team, improve physical security, including installation of closed circuit television, would conduct an audit on the status of facilities and develop an action plan. In the medium term, norms and standards would be developed, contracts enforced, and security officers would be upgraded. For the long term, the NHC aimed to develop a career path for security personnel, and to create new health establishments that were designed to have better safety. Some of the current challenges included lack of playback facilities by the cameras, lack of clocking to ensure regular patrols, and the need for proper fencing and pruning of gardens to ensure clear visibility. Security was generally not seen as part of the healthcare institutions’ core business, and was thus not included in annual performance plans, and no cluster existed for it at provincial level. Au audit of some provinces had revealed particular weaknesses and strengths, and it was decided that the system in KwaZulu Natal, which was operating effectively, would be shared with other provinces, and a security audit would be done, using a standardised approach. Terms of reference would be developed. Members asked about the use of private security companies in public health facilities, and questioned the viability of using private companies as opposed to establishing in-house security. They asked for statistical information on the number of safety incidents in public health facilities, asked whether armed or non-armed guards should be provided, and sought an explanation in regard to the role of police. They also highlighted instances where hospital management was linked to security tenders.??They sought an explanation on the role of police in public health facilities, and insisted that the problem of masterkeys must be addressed.?The Department then briefed the Committee on the Green Paper on?National Health Insurance (NHI), saying that this would represent an innovative system of healthcare financing, with far reaching consequences to the health of South Africans. The NHI would ensure that everyone had access to health services that were appropriate, efficient and of good quality. The NHI would improve service provision, promote equity and efficiency, and ensure that everyone had access to affordable and quality services, regardless of their socio-economic status. The statistics for coverage by the private and public sector, and their funding, were outlined. It was noted that the public sector was under-resourced, relative to the size of population that it served and the burden of disease. The longer waiting times, and lower clinical consultation times occasioned by shortage of personnel brought risks of error. The current two-tier healthcare system was described as unsustainable, destructive,?very costly, highly curative and hospital-centric. The key challenges included the quadruple burden of disease, quality of healthcare provided, the distribution of financial and human resources, high costs of healthcare and the out-of-pocket payments and co-payments. Other challenges were of an administrative nature.The NHI aimed to provide quality healthcare for all, and to?pool risks and funds so that equity and social solidarity would be achieved through the creation of a single fund. It would try to mobilise and control key financial resources, and to strengthen the under-resourced and strained public sector, so as to improve health systems performance. The first steps towards implementation would be through ten pilot sites in 2012, and these sites would be selected using a number of criteria from the audits.?Regulations would be drafted to define levels of hospitals and the appropriate skills requirements to manage hospitals and public health facilities. A?Ministerial Task Team would be set up to advise on District Specialist Teams. An audit?of Community Health Workers had been completed, and there would be retraining and re-skilling. It was intended to phase in the full system over 15 years.Members noted that they had a number of questions to ask, but the Chairperson pointed out that this was only an initial briefing, that time was short, and that although questions could be asked now, the Members would have further opportunities to go into the issues in depth. It was agreed that written answers would be provided. Many Members indicated their support for the proposals, but others were dubious about its viability and asked how the?pooling of funds would be administered, why there was resistance in principle, to a two-tiered public health system, and whether dissenting opinions had been noted in the Green Paper. The independence of the?Office of Health Standards Compliance was questioned,?as well as the costing and what package of services would be provided. The position of the private sector and direct approaches to specialists was also questioned, as well as concerns expressed about how the fund would operate. Another Member pointed out that the public hearings would impact upon the policy and that it would be useful for Members to see comparative studies.??addressing gaps in the health system and in achieving equity in the sector.Meeting reportSafety and Security in public hospitals: Department of Health BriefingMs Malebona Matsoso, Director General, Department of Health, briefed the Committee on safety and security in public health facilities. The Department had conducted a safety assessment as part of the Core Standards for Health. That assessment had demonstrated weaknesses in the safety and security at health facilities. There had been a number of incidents where staff or patients had been injured or killed due to poor security provided in health facilities. In addition to that, Dr Aaron Motsoaledi, Minister of Health, had invited the South African Medical Association (SAMA) to make a presentation to the National Health Council (NHC) on safety and security issues affecting their members. These findings had concurred with the Department’s own audit findings, which led the NHC, after deliberations, to recommend that steps must be taken to address safety and security at public health facilities.?The NHC had decided, in the short term, to appoint a task team, to improve physical security, including the installation of closed circuit television (CCTV), to conduct an audit on the status of facilities, and to develop an action plan. In the medium term, the NHC had decided to develop norms and standards, enforce contracts, and upgrade security officers’ positions to appropriate levels. In the long term, the NHC aimed to develop a career path for security personnel, and to create new health establishments that were designed with better safety in mind.In line with the NHC resolution, a task team had been convened in July 2011, and most provinces were represented on it, except the?Western Cape, Limpopo and?Gauteng. An external security expert from Passenger Rail Agency of South Africa had been invited to attend. The National Intelligence Agency, South African Police Service (SAPS) and South African National Defence Forces (SANDF) were also part of the task team. A follow up meeting was scheduled for August.A number of provinces had conducted audits or assessments on safety and security.?Mpumalanga?had conducted its assessments with a focus on hospitals. KwaZulu Natal (KZN) had conducted a detailed assessment and followed it up with operational plans. The?Free State?had targeted known hotspots and developed improvement plans based on those hotspots. The?North West?had focused on certain facilities. The security measures that had been implemented in some provinces were reactive to incidents that had taken place.One major problem was that the master keys of some institutions were still being held by unknown individuals. CCTV cameras in some institutions were not strategically placed, making it more problematic to provide effective security and safety. In addition, cameras in some facilities only played live footage, with no playback option for later viewing. Often, there were no clocking points to prove that patrols did take place as planned. Proper fencing was required, as well as cutting back of trees and grass to enable a clear view of the premises. Security functions were generally not seen as part of the core business of health institutions, and were not on most Annual Performance Plans. There was no line function or security cluster at provincial level. Some provinces did not have provincial security managers and security officers doing similar work in provinces were appointed at different levels.However, there were some areas of good practice that had to be commended, and should be shared across all provinces.??KZN had had some success in enforcing service level agreements and imposing penalties for poor performance. Most provinces cited poor contract management and lack of enforcement, when highlighting the problems that affected security in their public health facilities. In other provinces, the reverse was true, and the awarding of contracts was decentralised to district level, with provincial officials not involved in the entire process yet having to supervise the district officials. There was sometimes a lack of skill around safety and security at district level. Contracts were not enforced. Sometimes the security guards were requested to play the role of porters, meaning they had to leave their stations unmanned when responding to such requests, and this then gave rise to other problems. Late payment or non-payment of security guards by service providers also put the security personnel into a vulnerable position, and made them easily susceptible to bribery.To remedy the security situation, the NHC had decided that the KZN service level agreements and penalty clauses should be shared with all Head of Departments as an example of a good way to deal with security issues. A security audit would be conducted across all provinces, using a standardised approach and methodology. The NHC also decided to use the available provincial reports as a basis to develop a process for systematic and structured security audits directed at national level. The terms of reference for the consultant/s or team to conduct the audit would be developed and the Director General would sign off on these.DiscussionThe Chairperson thanked the Department for its presentation, and noted that the Committee had sought a progress report on safety and security because Members were concerned with the safety of medical staff at public institutions, given the number of incidents of violence at those institutions. There was also a concern that in some cases management in public institutions were involved in some of the security companies who had been awarded the tender to provide security services, and were not keen to replace them when something went wrong. He highlighted a case in?Mpumalanga?where a doctor had been attacked by a patient, and said that although it was difficult to have security personnel in a consulting room, due to patient / doctor privilege, he maintained that patients should be searched to ensure that they did not take weapons into a consulting room. He asked whether the use of private security companies in health facilities was necessary, and whether or not this could not be done internally.Ms Matsoso responded that there was a need to look at the cost of outsourcing security against having the capacity to do this internally. The Department of Labour had called for the ending of outsourcing of provision of security. However, this issue was still being debated at Cabinet.?Mr M Hoosen (ID) asked whether there were statistics available around incidents of violence in public health facilities.Dr Itumeleng Funani, Technical Advisor, Office of the Director General, Department of Health replied that because that the task team had only held an initial meeting, and was yet to interrogate provinces on their statistics, the answer could not be given. However, these questions would be asked of the provinces, and statistics would be garnered as the task team conducted deeper investigations on safety and security.Ms M Segale-Diswai (ANC) commented that the briefing on security was long overdue. She asked whether the security measures mentioned in the briefing would cover the clinics as well as major hospitals. She pointed out that n some cases there were aged security guards put to guarding public health facilities, and asked how this could be addressed. She wanted to see a pricing comparison for armed security as opposed to unarmed security companies. She also sought clarity as to which health facilities were focused upon by the North West Province.?Ms Matsoso replied that it was clear from the NHC report that all provinces needed to comply with safety and security standards, to reach uniform security levels in public health facilities. The norms and standards agreed to would ensure that security was provided to both patients and staff in public health facilities. Where construction was taking place at public health facilities, there was little delineation between security personnel and construction workers. The Department was of the view that public health facilities needed to have the capacity to manage private security company contracts.Dr Funani replied that safety and security at clinics or primary healthcare facilities was a weakness that the Department had also identified. In some provinces, such as Mpumalanga and the North West, safety and security was only addressed at a hospital level, and that was problematic. Safety and security at primary healthcare facilities needed to be strengthened, and would be tackled in the assessment as the task team progressed with its work. The task team was also looking into the rotation of security guards, in order to prevent stagnation and ineffective provision of security. He further explained that the type of contracts entered into with the security companies would be geared to the nature of the threat, when determining whether armed or unarmed security personnel should be deployed.?Ms E More (DA) asked how the Department was going to maintain the functioning of CCTV equipment at health facilities, pointing out that this was costly. The issue of master keys needed to be addressed, as it was critical to addressing security. She asked if it would not be prudent for the Department to adopt a uniform approach to the use of security companies by public health institutions. She asked whether it was cheaper to outsource security. or to have an in-house security team for public health institutions. She wondered if the public hospitals were to blame for not paying security companies timeously. She also commented that it would be useful to add tracking mechanisms to hospital equipment, to stop theft.Ms Matsoso responded that there was a need to look at the cost of outsourcing the provision of security against having internal capacity to provide security. She reiterated that the Department of Labour had called for the ending of outsourcing.Mr D Kganare (COPE) suggested there was a need to assess whether it was more productive to have armed or unarmed security guards.Dr Funani added that the issue of CCTV management was dependent on the budget, and whether it would be possible to extend those to include CCTV as an essential, not optional, item.The Chairperson agreed that it was important to secure health equipment so as to prevent accidental use of needles or wrong medication.Ms T Kenye (ANC) asked whether there were timeframes for the implementation of the task team’s short term measures to address security in public health institutions. She asked whether there were skills development programmes relating to security provision at public health institutions. She also asked why there was a lack of security managers at certain public health institutions. She asked what measures were in place to establish who was in possession of master keys of certain public health institutions.Ms Matsoso responded that the Department recognised that it could not divorce management issues from the security issues that affected public health facilities. The Department welcomed the comments and suggestions on management and how to address these issues.Dr Funani replied that the task team had to submit a report to the Minister of Health by the end of November 2011. There were clear indicators for each aspect of the assessment to take place, to assist with reaching the time targets.The Chairperson said that part of the responsibility of security personnel at hospitals included preventing the theft of hospital equipment and medication. Some security officers colluded with people who stole drugs from hospitals, and that was another problem for the Department to consider as it went forward in its work.?Ms Matsoso responded that she was aware of such cases or incidents where the management was in cahoots with security companies.Mr Kganare commented that the Committee was digressing from the main issue, which was the security of patients and hospital staff.The Chairperson commented that the Committee needed more information from the Department, and Members should ask as many questions as they wanted, and these could address a broad scope, because Members would need to feed back the information to the communities they represented.Mr Kganare thought that private security companies had to be included in any assessment of public safety and security at public health institutions. In some cases, private companies underpaid their staff and a strike would result, which again had a negative effect on safety and security. If CCTV technology was to be broadly introduced in public health institutions, then technicians would be needed to monitor the equipment. He suggested that better use be made of the Sector?Education Training Authorities (SETAs), who could assist in providing such technicians.Mr G Lekgetho (ANC) noted that this presentation had not mentioned police involvement, and??that may be helpful in addressing safety and security issues.Ms Matsoso replied that a policy decision would need to be taken whether to involve private security companies in public health facilities. The Security Cluster had made it clear that it was not possible for the police to be available, on a fulltime basis, to provide security in hospitals.Dr Funani responded that the Department had taken note of the concerns raised by members over the lack of involvement of the police. South African Police Services (SAPS) were part of the discussions, at a task team level, and the Department would be guided by their opinions. Certain functions in the provision of security could not be carried out by security guards and police involvement may be needed.?Ms M Dube (ANC) commented that the provinces that had not participated in the task team review needed to provide reasons for their failure to do so. She asked whether there were policies to replace security personnel who arrived at work drunk.Ms Matsoso replied that, in line with the KZN model, fines would be imposed on guards who were drunk, and further punitive measures would be pursued. Dismissal was the ultimate measure, should there be repetitive disorderly conduct.Ms B Ngcobo (ANC) asked who was responsible for creating career pathing for provision of security in public health institutions. She asked whether the Department of Health had a statistical record of incidents relating to safety and security in public health institutions. She asked whether the Department conducted forensic audits of security companies to assess their ability to provide security. She asked how medicine could be stolen from hospitals if there was effective security in those hospitals. She also asked to what extent the Department could safeguard the security of clinic personnel working after hours.?Ms Matsoso replied that the Department was in the process of conducting audits on 4 210 public health facilities, and by the end of July, the audit on 876 had been completed. At an appropriate time the Department would brief the Committee on the outcome of those audits.Dr Funani said that career pathing was mainly addressed at the public level by management, but once a formal decision had been taken on whether to outsource or use in-house security, more could be done to ensure that career pathing was taken up seriously. Due to the fact that the task team had only held an initial meeting, and was yet to interrogate provinces on statistics, including whether there had been a decline in incidents, it could not yet comment in depth.Ms H Msweli (IFP) commented that more needed to be done to prevent the theft of drugs from hospitals, and agreed that CCTV technology would be a key way in preventing that theft.The Chairperson said that the Committee had held an oversight visit to Limpopo, where it had assessed security, and had been generally satisfied with what it had seen. People in communities with clinics should take responsibility for looking after the well-being of those clinics, as they benefited their community.Ms Segale-Diswai asked what was meant by “hotspots”.Ms Matsoso replied that hotspots were areas where incidents of violence at public health facilities were high.Ms Kenye recommended that audits and assessments be done in rural areas as well.Ms Matsoso replied that the audits would incorporate rural areas.?National Health Insurance: Department of Health (DOH) briefingMs Matsoso and Dr Yogan Pillay, Chief Director: Strategic Planning, Department of Health, briefed the Committee on the main highlights of the recently released Green Paper on the proposed National Health Insurance (NHI).They noted that the?NHI represented the introduction of an innovative system of healthcare financing, which would have far reaching consequences on the health of South Africans. It would ensure that everyone had access to health services that were appropriate, efficient and of good quality. The NHI would improve service provision, and would promote equity and efficiency, to ensure that all South Africans had access to affordable, quality healthcare services, regardless of their socio-economic status.The South African health system in its current form was inequitable, with only the privileged few having disproportionate access to health services. The current system was two-tiered, with a private health insurance sector for those who could afford it, and a public sector system for those who could not. The private sector covered 16.2% of the population, with a relatively large proportion of funding allocated through medical schemes, various hospital care plans and out-of-pocket payments. The private sector provided cover to private patients who had purchased a benefit option with a scheme of their choice, or who were covered as part of their employment conditions. People were subsidised by their employers in both the State and the private sector. The public sector covered 84% of the population, and was funded through the fiscus. It was often plagued by poor management systems and oversight, especially in hospitals. The public sector was under-resourced relative to the size of the population that it served, and the burden of disease. There were less human resources than in the private sector, leading to longer waiting times and lower clinical consultation times, which increased the risk of error.Four key interventions needed to happen simultaneously to successfully implement a healthcare financing mechanism that covered the whole population, such as the NHI. There needed to be a complete transformation of healthcare service provision and delivery. The entire healthcare system would have to be totally overhauled. There must be radical change of administration and management. Finally, there should be provision of a comprehensive package of care, underpinned by a re-engineered Primary Health Care.South Africa’s two-tier healthcare system was unsustainable, destructive,?very costly, highly curative and hospital-centric. The key challenges in the South African health sector were the quadruple burden of disease, the quality of healthcare provided, the distribution of financial and human resources, the high costs of healthcare, and the out-of-pocket payments and co-payments. The public health sector also faced other challenges, including cleanliness, safety and security of staff and patients, long waiting times, staff attitudes, infection control and drug stock-outs. Meantime, the?cost of private healthcare was out of control, at the expense of members of medical schemes, and the cost of public healthcare was escalating at the expense of the fiscus.The public sector costs were driven by the?compensation of employees, pharmaceuticals, laboratory services,?blood and blood products and equipment.?A number of medical schemes in the private sector had collapsed, had been placed under curatorship or had merged.?Schemes had reduced in number, from over 180 in 2001, to about 102 in 2009. To sustain their financial viability, schemes tended to increase premiums at rates higher than the Consumer Price Index.?The NHI would aim to?provide improved access to quality health services for all South Africans irrespective of whether they were employed or not. It aimed to pool risks and funds so that equity and social solidarity would be achieved through the creation of a single fund. It would procure services on behalf of the entire population, and would efficiently mobilise and control key financial resources, and strengthen the under-resourced and strained public sector so as to improve health systems performance.The socio-economic benefits would include an increased output. A healthy person worked more effectively and efficiently, and could devote more time to productive activities. There would be a broader knowledge base in the economy, and the gains to education would increase as life expectancy increased. This in turn would increase work life and savings, as a result of increased life expectancy,?which?may result in earning and saving more for retirement.The NHI would cover all South Africans and legal permanent residents. Short-term residents, foreign students and tourists would have to obtain compulsory travel insurance, and produce evidence of this upon entry into South Africa. Refugees and asylum seekers would be covered in line with provisions of the Refugees Act, 1998 and International Human Rights Instruments ratified by the State.Primary healthcare services would be delivered according to the following three streams:-?District-based clinical specialist support teams, supporting delivery of priority health care programmes at a district-?School-based Primary Health Care services-?Municipal Ward-based Primary Health Care AgentsThe healthcare benefits emanating from the NHI would be prevention, promotion, curative, and community outreach, and there would thus be community-based services as well as school-based services. In-patient and outpatient hospital care would be provided for, including specialist and rehabilitation services. Prescription drugs, emergency care, mental health services, oral health services, basic vision care and vision correction would be further benefits of the policy.As part of the overhaul of the health system and improvement of its management, hospitals in South Africa would be re-designated, so that they would fall into categories of district, regional, tertiary, central or specialised hospitals. Each level of hospital designation would be managed at a newly defined level with appropriate qualifications and skills as defined by the National Health Council.A draft Bill on Office of Health Standards Compliance (OHSC) would soon be tabled in Parliament. This aimed to establish an independent OHSC, which would have three units dealing with inspection, an ombudsperson,?and the?certification of health facilities.?The District Health Authority would be given the responsibility of contracting with the NHI. This Authority would be?supported by the NHI Fund’s sub-national offices, to manage the various contracts with accredited providers, and would also monitor the performance of contracted providers within a district.The NHI’s principal funding would come from a combination of sources, including the national?fiscus, employers and individuals. The NHI revenue base would be as broad as possible, in order to achieve the lowest contribution rates and?generate sufficient funds to supplement the general tax allocation to NHI.?Private?medical schemes would continue to exist side by side with the NHI,?and they may also provide top up cover. No one would be allowed to opt-out of the NHI.?The first steps towards implementation of National Health Insurance in 2012 would be to run pilot schemes, when ten districts would be selected for piloting. The Department of Health would conduct audits of all healthcare facilities. Criteria for the choice of these ten districts would be set from the results of the audits, as well as the demographic profiles and key health indicators. The selection of the ten districts would be based on the several factors, including health profiles and demographics, the health delivery performance, management of health institutions, income levels and social determinants of health and compliance by institutions with quality standards.Regulations would be drafted to define levels of hospitals and the appropriate skills requirements to manage hospitals / public health facilities. A?Ministerial Task Team would be set up to advise on District Specialist Teams, led by the Chairperson of the Confidential Inquiries into maternal, neonatal and deaths of under-five year olds. An audit?of Community Health Workers had been completed, and retraining and re-skilling would be undertaken.In 2010 there were 150 509 registered health professionals in South Africa. These numbers had remained static between about 1996 and 2008, when there was also a decline in key categories such as specialist and specialist nurses. There was inequity, between rural and urban areas, in the ratio of health professionals to each 10 000 people. The ratios also differed between public and private sectors. There were various ways to assess the “shortage” of health professionals. The counting of vacancies in the public sector was neither an accurate nor realistic indication. It would cost billions to fill the public sector vacancies that existed at present. Instead, staffing requirements should be based on service plans informed by norms and needs. It was evident that South Africa had a nurse based health care system, as 80% of health professionals were nurses.?South Africa had considerably less doctors, pharmacists and oral health practitioners (and other health professional categories) per 10?000 people than other comparable countries.?District and provincial profiles had been developed, with districts ranked from best to worst-performing??over the 26 selected indicators. A score of between 1 (the best performing) and 52 (worst performing) was allocated. Where districts had the same value, the same score was given, resulting in the last value actually being reflected as lower than 52. The attached presentation showed districts with the lowest scores as performing well, and those with the highest scores as performing poorly.It was reported that the?NHI would be phased-in over a period of 15 years. This would include piloting and strengthening the health system in the following areas:-Management of health facilities and health districts-Quality improvement-Infrastructure development-Medical devices, including equipment-Human Resources planning, development and management-Information management and systems support-Establishment of the National Health Insurance FundDiscussionThe Chairperson said that because this briefing by the Department was an initial report back on the Green Paper on the NHI, Members should comment, but not ask questions, as there would opportunity for that at a later date.Mr M Waters (DA) said that he had lots of questions to ask.The Chairperson said that there would be a platform for questions to be asked at a later date, but stressed again that this briefing was an initial engagement.Mr Waters disputed that assertion, and said that it was normal procedure to ask questions after a presentation.Ms C Dudley (ACDP) said that the Committee should be permitted to ask questions of the Department.Mr Hoosen asked the Chairperson why he was restricting the questioning of the Department.The Chairperson responded that the Committee was running out of time and again said that the briefing was an initial one, with plenty of room for comment and questions allowed at a later stage. He proposed that he and the Director General should decide which questions the Department could respond to on the day, and which would be responded to in writing by the Department.Mr Waters raised a point of order, and said that the Chairperson had no right to arbitrarily decide which questions could be answered and which would not. The questions he would ask had nothing to do with the Chairperson. He expressed his view that an open debate on the NHI was necessary.The Chairperson said that it was his duty to guide the Committee with a view to time constraints; he was not trying to impose his will on the Committee or muzzle debate.??Ms Kenye shared Ms Dudley’s view.Ms Segale-Diswai said that the Committee should be permitted to ask clarity seeking questions.The Committee agreed to ask questions of the Department with the possibility of getting answers from the Department in written form at a later date.Mr Waters asked what criteria the Department would use in delineating the different hospital districts under the NHI pilot project. He asked why the Department had removed the media review from its website, and enquired if the Department was opposed to debate on the NHI.??He asked whether the OHSC would be independent from the Department, since it would be appointed by the Minister. He commented that there was no definitive way of assessing the costing for the NHI, but the Department should present what package of services would be provided in the NHI. He asked why the Department was opposed to a multi-tiered system. He asked whether there had been opposing views to the NHI recorded in the Green Paper. He asked what methodology was used when the costing for the NHI was done, and whether private costing was taken into consideration. He sought clarity on whether there would be a restriction on the quantity of services the private sector could provide when the NHI came into full operation. He asked how the centralised fund operated by the State would function, and whether there would not be a conflict of interest if it reported to the Department of Health.The Chairperson commented that people should not become paranoid when addressing the issue of the NHI. This was a policy that was initiated principally in order to provide healthcare to the majority of the country. The NHI was not cut and dried, and there would be further opportunity to comment and debate the policy.Ms Dudley asked how the reality of the United Kingdom’s healthcare system had impacted upon the Department’s thinking on the NHI. She commented that direct access to specialists would be difficult, and sought an explanation on how the Department would approach that.Mr Kganare commented that the NHI was an emotive topic, because universal coverage was the basis for the policy. Some people were opposed to the NHI simply as a matter of ideology, based on their class origins. He supported the NHI because he represented the working class. When people quoted authority-based on comparative studies they disadvantaged their fellow members, because not everyone was privy to those comparisons. Public hearings on the NHI were yet to be held and these would be important in developing the policy.?The Chairperson suggested that the Committee researchers should put together all comparative studies, to assist members in deliberating on the NHI.Ms Dube agreed with Mr Kganare that certain people represented a particular group and were personalising the NHI debate, which she thought they should not do.The Chairperson commented that the NHI was a broader issue and the health sector currently was not sustainable.?Ms Kenye expressed her satisfaction that the NHI had been presented to the Committee. She sought clarity on the pooling of funds and the revenue stream, and how it would be administered.?The Chairperson said that in the two and a half years he had been in Parliament, the NHI debate had been the most interesting debate in which he had participated.Ms Segale-Diswai also thanked the Department for its briefing and said that the NHI was a very important policy, which would bridge a large gap.?The Chairperson said that another date would be set aside for the Committee to discuss the NHI. He asked the Department to respond to the questions asked in writing. He pointed out that there were still severe disparities in South Africa, seventeen years after democracy. The NHI would be vital in addressing gaps in the health system and in achieving equity in the sector.The meeting was adjourned.National Health Insurance follow up, Childhood Cancer Foundation on challenges & solutions, Directorate of Radiation Control progress report23 August 2011Chairperson: Dr B Goqwana (ANC)Meeting SummaryThe Committee held another meeting with the Department of Health so that Members could ask further questions on the Green Paper on National Health Insurance(NHI), which was presented in the previous week. Members asked if the NHI Information System would share a common database with the Department of Home Affairs, South African Revenue Service and South African Social Security Agency. They wondered how illegal immigrants claiming free treatment would impact on NHI; how the Department of Health planned to deal with the situation if more than one hospital of the same category was in a particular district, whether doctors were likely to be asked to relocate, and what would happen to the existing Government medical scheme. They also asked who would facilitate and monitor provincial funding, whether it was possible to have the required personnel to cover the wards. They enquired whether the human resources strategy had also investigated the financing model, how NHI would be administered, and what percentage of funds would go towards paying for administration of the NHI.Members also asked what interaction had taken place between the private and public healthcare providers, how pilot projects were budgeted for and monitored, and how the Department of Health would ensure that there was not overcrowding at private hospitals. They wondered if the Department of Health had capacity and skills to deal with the public health institution problems. Members further asked what the NHI service package would cover and include, and if the Department of Health was on track with regard to the time frame for the drafting of legislation. Certain of the questions asked related to policy, and here the Department of Health indicated that it was not possible to deal with them as yet, because wider consultation was required. Comments from stakeholders including service providers and users, would enrich the content and policy issues in the document.The CHOC Childhood Cancer Foundation of South Africa gave a presentation on its history and background, noting that it was formed of parents of children who suffered from cancer, and was thus mainly made up of volunteers. Some of the challenges and solutions for childhood cancer were presented. CHOC believed in treating the child and not the illness. It was aiming to have a presence in all provinces, although it was not represented in all as yet. It owned seven houses around the country for parent/s and their child during the treatment years. It also supported child-friendly wards at the hospitals, offered information and handbooks for parents and children in various languages, offered psychosocial and emotional support to families, and funded transport for those who would otherwise be forced to abandon treatment. It was noted that although South Africa had world class treatment centres and used international protocols, it struggled with limited resources. The primary funding focus for CHOC was on public sector hospital, and funding paediatric doctors and nurses to attend conferences, improvement of treatment centres; and funding for the Childhood Cancer Registry 2000. It needed to develop stronger relationships with the Departments of Health and Education. It had implemented a “Warning Signs Project”, in conjunction with the South African Children’s Cancer Study Group (SACCSG) which had resulted in more children being diagnosed and treated earlier. Although survival for childhood cancer sufferers tended to be better than adult cancers, this rate, in South Africa, was lower because of lack of awareness and late diagnosis. CHOC urged that children, even up to their twenties, should be treated in paediatric oncology units, by specialist paediatric oncologists using paediatric protocols, as this improved their recovery prognosis, and was pushing for children at least up to the age of 15 still to be treated in these wards, instead of being moved at age 12. It was prioritizing the production of a coherent plan and National Childhood Cancer Policy, and urged that childhood cancer should be included in an Integrated Management of Childhood Illness Policy. It was also critical to establish Hospital Schools. Models for treatment were being proposed. Tertiary grants were not always reaching childhood cancer, although this would be a focus at the UN Summit in September 2011. A strong relationship between the National Childhood Registry and Children’s Cancer Registry was needed, to collect reliable data.Members asked if there was a genetic predisposition to childhood cancer, if CHOC was involved in the rehabilitation of these children, what the symptoms of childhood cancer were, and what the most common types of childhood cancer were. They called for more information on the Children’s Cancer Registry. Members also asked how rural areas in the North West could hear about CHOC, asked if CHOC was working with other charities and how it generated funding.The Department of Health finally updated the Committee on progress made on the Directorate on Radiation Control. The Ministerial Task Team on Regulatory Function Related to Radioactive Sources had established six working groups, would shortly be holding interviews of medical physicists, and would shortly be presenting their reports to the Minister. The reports of the first three working groups, whose focus areas were defined in the briefing, would determine how the other three groups would work. Basically, the groups were working on how to address lost radioactive sources (including those used for road, soil and medical testing) and a strategy for public awareness. These sources were categorised on the?International Atomic?Energy Agency?(IAEA) guidelines, and it was reported that only one lost source in South Africa was identified as dangerous, and this was mapped and buried underground, with no further investigation deemed necessary, whilst the remained fell into the category of unlikely, or most unlikely, to be dangerous. Members were not pleased to hear that the Department would not search for these latter sources, asked if the IAEA knew about them, and what its reaction had been, and expressed their concern that it was possible to combine sources and create war weapons. They enquired why the Hawks had paid the DoH a visit, and called for quarterly update reports.Meeting reportNational Health Insurance (NHI) Green Paper: Further meeting with Department of Health (DoH)Chairperson’s opening remarksThe Chairperson reminded Members that in the previous week, the Green Paper on the National Health Insurance (NHI) had been presented by the Department of Health (DoH). Public hearings would be conducted by the DoH, and Members had strongly expressed their view that these hearings should be held widely, in both rural and urban areas. Members also felt that they had not received enough information on the NHI, nor on how health insurance systems in other countries were funded. The DoH had subsequently compiled documentation setting out the position in other countries and this was currently available. The purpose of engaging with the Department at today’s meeting was again so that Members could ask questions of clarity. The Committee, in its oversight over the DoH, had agreed that the state of the health systems in the country left much to be desired. The Green Paper would be discussed, but it must not necessarily be assumed that it was the best way forward, and the Committee must be open to ideas. The problem with regulation in the past was linked to the then-government policies. The current approach focused on engagement through hearings, debate and understanding of concerns, in an attempt to find solutions that would ultimately ensure that all citizens benefited from the country’s taxes for health care.DiscussionMr M Waters (DA) said that he was concerned that having deliberations on the Green Paper, which was a substantial document, would take time away from the other items on the agenda for this meeting, and he felt that this very important document justified a meeting of its own.The Chairperson said that unlimited questions had been permitted the previous week, and the purpose of this meeting was that Members should be able to seek clarity on issues. The Committee could not go beyond the three months afforded for their deliberations on the Green Paper. However, a final decision on the time period would be guided by what transpired during the current deliberations.Mr M Hoosen (ID) said that the NHI issue had been a long time coming, and expected that there would be a number of public hearings and questions for debate. He also wished, on behalf of his party, that the questions he had posed previously were aimed at ensuring that people really would benefit from the NHI, and at trying to improve weaknesses in the current system. He had understood that every citizen would be issued with a card, and asked how illegal immigrants would be accommodated within the NHI plan,Mr D Kganare (COPE) asked whether NHI Information System would share a common database with the Department of Home Affairs (DHA), the South African Revenue Service (SARS) and the South African Social Security Agency (SASSA).Ms Precious Matsoso,?Director-General, Department of Health,?replied that DoH had engaged with the Departments of Home Affairs, Social Development (on social grants), Science and Technology, and with the Centre for Scientific and Industrial Research (CSIR) and that preliminary scoping work had been done on a one-card system. This was based on the system in France, where one card was used for social services, pension and health. Results of the scoping work would determine when and how the system would be implemented.Mr Hoosen said that although the Green Paper was still in the design phase, his concern was that the country had a problem with the large number of illegal immigrants. This would have an impact on how NHI would be rolled out and how effective it became.Mr Kganare believed that it would be a mistake not to budget for illegal cross-border beneficiaries. The reality was that as long as foreigners had access to the country, they would access the health service.Ms Matsoso replied that ‘cross-border beneficiaries’ specifically made reference to political asylum seekers and refugees who had a legal status. There were also illegal immigrants with no official legal status. DoH was exploring the option of contingency funds and was learning from other countries who had had similar experiences. The design was not yet final.Mr Hoosen said that he understood that hospitals would be designated into different categories. He asked how the DoH planned to deal with the situation when more than one hospital of the same category was in a particular district, such as more than one specialist hospital. Similarly, he asked if doctors would have to relocate if there was an oversupply of medical practitioners.Dr A Pillay, Acting Deputy Director-General, Department of Health, replied that in each district there would be facilities and district hospitals but tertiary and quaternary level hospitals would always be placed in one of the districts. NHI did not expect that private health care providers would be forced to move as their work would be market-related and they would be contracted to the district health authorities and work as part of the NHI in those particular areas.Mr Hoosen believed that the NHI success would depend on how well the public healthcare system was upgraded, so that it could offer the same level of healthcare services as the private sector. Unless there was a turnaround in the public healthcare system, there would be more people wanting to be treated at the better equipped private healthcare institutions, and a number of the public healthcare institutions would not be supporting the number of patients that they were currently supporting.Mr Hoosen asked what would happen to the existing government medical scheme once the NHI was in operation. He could not foresee that government would continue to support the existing medical scheme.Ms Matsoso replied that the role of the medical schemes was referred to and described in the policy document and further consultation with the stakeholders should make it clearer.?Dr Pillay added that NHI was still in the planning phase and it was premature to discuss the state medical scheme and how it would be rolled out.Mr Waters read out questions conveyed from Ms E More (DA) who was ill and could not attend the meeting.Ms More had commented that the DA welcomed universal health coverage. However, she commented that the NHI would serve more than 50 million people and the scale of administrative services required would be huge. She noted that Discovery Health employed more than 3 000 people to serve 2.5 million members. Given the failure of state-owned entities, she questioned whether it was likely that the intended objectives would be achieved.Ms More had further asked how the NHI would be administered, who would be responsible for the administration, and if the NHI would have the capacity, infrastructure and skills to administer NHI effectively, efficiently and economically.Ms More asked if the DoH had the capacity and skills to deal with the public health institution problems while simultaneously piloting the NHI, given that it had so far been unable to fix the current ailing health care system.Ms More asked what the NHI service package would cover and include.Ms More pointed out that procurement problems facing the hospitals would make it difficult for the poor to get service at public hospitals. Currently government hospitals did not offer quality service to the poor and this was why quality service tended to be associated with the private sector. Her opinion was that everyone would try to use private healthcare institutions, as opposed to public healthcare institutions. She asked how the DoH would ensure that there was not overcrowding at private hospitals.Ms More also questioned how DoH would ensure that people crossing the border illegally would not abuse the system by presenting themselves for health care and then disappearing without paying.Ms More pointed out that since 2009, most of the public facilities had the same complaints and challenges that were raised during the Committee’s oversight visits. The MECs of Health promised to fix problems but little changed.Ms More recommended that, rather than trying to introduce new systems, the government should rather concentrate on mainstreaming, addressing staff shortages and promoting better and friendly staff attitudes towards patients. It should improve the ailing procurement system, infrastructure development, primary health care facility infrastructure and working systems. It must also address Pre-Departure Medical Screening (PDMS) and Occupational Health, fully establish the hospital standards and compliance, determine the Chief Executive Officers’ qualifications and performance, and determine level of qualifications and skills performance required to run each facility. It should also deal with shortage of consumables and quality equipment, and deal with HIV/AIDS programmes.Some of these questions were answered in response to other Members’ questions.Ms Matsoso said that the Minister of Health had requested that 15 million South Africans should be tested for HIV in one year. Between June 2010 and June 2011, 13.9 million South Africans were tested. If this was not evidence of meeting the resolve to improving the health status in SA, then Members were welcome to offer additional alternative suggestions.In the first year of the three-phased approach over 14 years, with the assistance of the National Treasury Technical Unit, DoH had received 400 proposals from experts who were willing to assist with problems of the public health facilities. It was hoped that by 1 October, most of the experts would be available to work in all the audited public facilities for which data had been validated.She noted that infrastructure had been delivered, while access to health care in the broader sense had been neglected. DoH was currently assessing how to improve access to facilities and services. The four-fold approach included therapeutic, physical, financial and quality access.??Mr G Lekgetho (ANC) said that he was happy that there would soon be public hearings across the country. He hoped that there would be an emphasis on reaching the rural people. NHI was intended to bring health services to the poor, both black and white, by removing obstructive legislation which benefited the few in the past. The NHI was long overdue and was doing what the DA failed to do until 1994.Mr Waters objected to this comment by pointing out that the DA had never been in power.The Chairperson called Members to order and requested that Members should not refer to other parties but rather direct questions to the DoH.Ms M Segale-Diswai (ANC) said that she understood that the NHI would offer decent healthcare to both the poor as well as those who had been privileged, and it would be a cornerstone to universal coverage. She agreed with Mr Hoosen that there was a political battle in the meeting the previous week, and yet it was important that everyone raised their concerns about the introduction of the NHI. In her opinion, there had been poor delivery of health in the past and Members needed to understand each others’ concerns and move forward on the same wavelength. Health care for the people was a right which was not negotiable.Ms B Ngcobe (ANC) said she looked forward to the DoH, through its public hearings, addressing the broad strata of society, which could be done by making information available in as simple a form as possible, involving role players, using the home language of the people in their area, and mobilising people to buy in to the NHI.Mr Kganare said that NHI was more about financing health care than providing health care. The financial model should be linked to the quality of care that could be provided. He asked who would facilitate and monitor provincial funding cuts, whether the impact of inter-provincial funding had been addressed. He pointed out that at the moment, Limpopo was spending some of its funding on individuals receiving services in hospitals in Gauteng. He also wondered what interaction there might have been with DHA in this regard.Ms Matsoso replied that DoH worked closely with National Treasury and had met with the Appropriations Committee on the previous day to address the cost and possible sources for financing NHI. There were three models of financing health globally: a publicly-driven process, such as was used the United Kingdom (UK), or through an NHI which may have a combination of public and private, and through insurance which had a strong private involvement. Public input would assist with deciding what model was most desirable for South Africa.Mr Kganare asked if the human resources strategy had examined what financing what would be needed to ensure delivery of appropriate personnel to deliver public health care and if NHI had established the required personnel to cover the wards on an annual basis as the process unfolded.Ms Matsoso replied that in the South African health care system, 80% of health care providers were nurses. The norms and standards for nurses, doctors and other categories would be published. DoH had identified 27 occupational clusters for the rendering of quality services and had made projections achievable over short, medium and long term. DoH was aware that over the past 16 years, the institutions had produced exactly the same number of doctors (1 200 per annum) but the demands and burden of disease had increased. The question was how to drive the Human Resource Strategy. An innovative approach would be to invest in human resources, especially using those from disadvantaged backgrounds. DoH was responding as to whether to recruit health care workers from other countries or produce more of its own, or have a combination of both, and what this meant in terms of investment. She added that South Africa had a lot of skilled people and resources and that the World Health Organisation used South African experts and studies to inform global policy. Thus there was no way that South Africa could be such a resource for the world and not for its own people.Mr Kganare also asked if there was more information on the comparison between public and private health care, with regard to the cost of medical procedures, such as circumcision. The assumption would be that the public health care providers would be paid by government, but this was not clear. He also asked if implementation of the NHI would mean that there would be a possibility of increased litigation.These questions were not answered.Mr Kganare asked what interaction had taken place between the private and public healthcare providers.Ms Matsoso replied that DoH had compiled a list of all stakeholders who would be consulted and this process had begun. DoH would not only consult with NHI stakeholders but Human Resources for Health Strategy which would impact on NHI. Also, a schedule was in place for road shows in the provinces for direct engagement with communities. Over the 14 year period, each of the three phases would require public input and consultations would continue throughout the process. She added that DoH would consult with private sector stakeholders, civil society, labour and members of the community, and media would be used to reach out to communities so that they understood how NHI would affect them.Mr Kganare asked what percent of funds would go towards paying for administration of the NHI.Dr Pillay replied that it was important to understand that private medical scheme administration checked each claim and that the NHI approach would not check each line item but would agree on a tariff for the service. NHI expected administration to cost a maximum of 3% and thereby not expected to consume resources for NHI.Mr Kganare asked if the DoH was on track with regard to the time frame for the drafting of legislation for the NHI regulations being rolled out.Ms Matsoso replied that legislative drafting would follow the policy process. Once the Green Paper had been converted to a White Paper and became policy, then DoH could begin the legislative drafting on policy elements. The DoH had agreed on a global approach. The US health services were largely privately driven; services in the UK were publicly driven and other countries had a combination of both. Demands of South Africans would drive the policy that was required and would form the basis on which legislation was drafted.Mr Kganare asked for clarification on whether pilot projects would be budgeted for and monitored on a national or provincial level.Ms Matsoso replied that in the following week DOH would submit their request for the pilot projects grant to National Treasury and the outcome would determine the basis for project implementation.Ms Matsoso also said that since the process was iterative, comments from stakeholders, including service providers and users of services, would enrich the content and policy issues within the document.She noted that certain questions could not be answered as they were policy positions which required wide consultation.The Chairperson concluded that the Committee was encouraged that the public and private sector would be heard and would accept the document as an ongoing process. Comments from the Committee would be made in writing. The hope was that re-engineering of the system could improve primary health care, which was currently inadequate.Childhood Cancer Foundation South Africa: Briefing on Childhood Cancer challenges and solutions in South Africa (CHOC)Mr Mzwandile Khanya, Chairperson, CHOC Childhood Cancer Foundation of South Africa, tabled a document setting out some of the myths and facts about childhood cancer (see attached document).Mr Julian Cutland, Former Chairperson, CHOC Childhood Cancer Foundation, said that this organisation (CHOC) started in Johannesburg in 1979, and its membership comprised parents who had been through the trauma of having a child diagnosed with a life threatening illness. It became a national organisation in 2000. There were currently divisions of CHOC in all major centres.?CHOC was an acronym for Children's Haematology Oncology Clinics, the cancer treatment clinic at the Johannesburg General Hospital.In the 1960s, the survival rate of cancer patients was 20%, but as a result of clinical trials, the survival rate had increased to 75%. In South Africa, there were about 1 000 children with cancer who went undiagnosed and untreated, in each year, and the survival rate was lower than in other countries due to non-recognition of signs and late diagnosis. Also, often a child was sent to an adult cancer oncologist only to find that the family would run out of the available medical aid, about six months later. Childhood cancers were different from adult cancers in types, frequency and treatment protocols. They were not lifestyle-related; and they were generally not preventable. It had been accepted worldwide that children had to be treated in paediatric oncology units, by paediatric oncologists, and using paediatric protocols. This was typically at major tertiary/academic hospitals. Teenagers and adolescents treated in paediatric units did better than those treated in adult units, and there was a trend in some countries for specialist teenage cancer units.Treatment consisted of a combination of chemotherapy, radiation and surgery, depending on the stage and type of cancer, but it was generally intensive and done over a period of one to three years. Regular visits to the treatment centre placed a wide range of demands on the family, in terms of time, financial, emotional, and spiritual needs. These demands were exacerbated when the child was from out of town. CHOC believed in treating the child and not the illness, and this included giving family support. South Africa had world class treatment centres and used international protocols, but struggled with limited resources.Mr Francois Peenz, Chief Executive Officer, CHOC, said that CHOC offered psychosocial and emotional support to families through other parents, volunteers and social workers, and funded transport for those who would otherwise be forced to abandon treatment for lack of finances. The primary focus was on public sector hospitals, through funding of medical equipment and maintenance of medical units and support for doctors and nurses to attend international and national conferences, where South African doctors presented their research and were world leaders, improvement of treatment centres, and funding for the Childhood Cancer Registry 2000.CHOC cooperated with government and a number of non government organisations (NGOs) and was part of the?International?Confederation of Childhood?Cancer Parent?Organizations (ICCCPO). CHOC owned seven houses around the country (five from the Danone Project) and rented two more, for parent/s and their child during the treatment years, and was currently investigating the option of increasing the number of rooms in the Western Cape. CHOC also supported child-friendly wards and offered information and handbooks for parents and children in the various languages.The ‘Warning Signs Project’, which was started a few years back in conjunction with South African Children’s Cancer Study Group (SACCSG) had led to more children being diagnosed and treated.?Ms Tiisetso Tshehle, Social Worker, CHOC, described the challenges of culture in oncology, how these challenges could be overcome, and the benefits of cultural competence.Professor Mariana Kruger, SACCSG, CHOC?and Executive Head of the Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Children’s Hospital, said that currently the worldwide trend was that paediatric oncologists should be looking after children diagnosed with cancer until they reached 27 years old. It was important to note that the South African Constitution defined a “child” as a person under 18 years of age. However, the public hospitals in South Africa had an upper age limit for children’s wards of only 12 years. Children and teenagers reacted differently to disease, when compared to adults, and did much better when treated under paediatric protocols. The SACCSG and South African Paediatric Association (SAPA) put in a strong plea that children up to the age of 18 should ideally be treated in paediatric units. In order to make this practical for public hospitals, they asked that children in South Africa at least be treated in paediatric units until the age of 15 years. A separate space for teenagers in adolescent units was also a goal.Another problem was that not all provinces had treatment centers and certain specialised treatments could only be done at one centre. A model for satellite centres was being addressed, so that children did not have to attend a tertiary hospital for follow-up treatment. There were tertiary grants paid to provincial hospitals to assist with providing treatment, but in practice the funds did not always reach childhood cancer, which was a relatively rare disease. This was a global problem. HIV/AIDS had been a focus for international funding in Africa. During the United Nations (UN) Summit in New York in September 2011, the issue of more international funding for non-communicable chronic diseases, particularly childhood cancer, would be addressed.The National Cancer Control Plan had been introduced, as it was important that cancer was a reportable disease, to know the burden of the disease. Currently there were no national statistics available from 2000 onwards. However, the Department of Paediatrics and Child Health and the SACCSG had started a Tumour Registry in 1987, and the data up to 2007 was currently under analysis. It was important that, in the event that the Department of Health did recognise childhood cancer as a ‘Notifiable Disease’, it must then link the Tumour Registry with future planning, according to the statistics and epidemiology of the disease, such as the impact of radiation on diseases.Professor Kruger then outlined the priorities. Firstly, there was a need to produce a coherent plan and National Childhood Cancer Policy (NCCP), and to ensure that children were treated by paediatric oncologists in paediatric wards. There was further a need to recognise the burden of cancer, and create awareness of the huge number of childhood cancer long-term survivors. Childhood survivors could go on to lead a normal adult life, and would benefit South Africa’s future workforce. Childhood cancer should be included in an Integrated Management of Childhood Illness Policy, to create awareness in medical staff, from primary care level to tertiary and quaternary care, and so that communities could become aware of childhood cancer. Hospital schools were also critical, and in this regard she pointed out that there were still tertiary hospitals without schools. This would require partnering with the Department of Education. Tygerberg Hospital School was one of the best in the country, and she invited Members to visit it.Mr Khanya concluded that CHOC’s focus was that all children should be diagnosed, treated effectively and have their needs supported. There was a need for concerted and interactive support by all role players and a need to develop a stronger public-private partnership with the Departments of Health and Education, to streamline important issues in the right direction.DiscussionThe Chairperson said that he was happy that the DoH was present during this presentation, and hoped that when NHI was implemented, there would be support and greater awareness, probably with support from SAPA, for childhood cancer. He asked if there was a genetic predisposition to childhood cancer.Prof Kruger replied that medical science was continuously addressing genetic predisposition to childhood cancer, as it was always better to prevent rather than have to treat a disease. Genetics did play a role, as cancer was uncontrolled growth of a cell. Something must happen to the control mechanism of growth of the cell, that caused it to go wrong, and if there was something on top of that (a second heat), then a cancer could develop. In acute lymphoblastic leukaemia - the most common cancer - and retinoblastoma, there were clearly genetic abnormalities and sometimes the cancer could be treated. However, some cancers had been identified but treatment was unknown.A British study in the 1980s and 1990s on the reasons for childhood cancer had made certain findings on the immune response and genetic make-up of children, originating from the embryonic phase. Thus cancer in young children was more aggressive than adult types of cancer, but was more curable than adult cancer. There was much ongoing international research, including research by South Africans, on that particular aspect.Ms Segale-Diswai asked how rural areas in the North West could hear about CHOC and whether CHOC was working together with the Cancer Association of South Africa (CANSA).Mr Khanya replied that CHOC had a presence in areas where there were treatment centres. The aim was that it should reach all provinces. It was not yet represented in the North West Province. Although CANSA concentrated on adult cancers, it did reach more people in the country and thus CHOC had signed a Memorandum of Understanding (MOU) with CANSA to partner for utilisation of resources where possible.Ms Ngcobo asked where the seven CHOC houses were located.Mr Khanya replied that the houses were near treatment centres. He listed them as Saxonwold, near Charlotte Maxeke Hospital, (previously Johannesburg General), Diepkloof, Soweto??(near to Baragwanath Hospital) and Pretoria, in Gauteng, and near Inkosi Albert Luthuli Academic Hospital in KwaZulu Natal. In the Western Cape, it had offices in Plumstead and a lodge at Tygerberg. It was also based in East London??in Eastern Cape.Mr Peenz added that parents had approached CHOC to start a parent group in Limpopo and CHOC had agreed to this request.Ms Ngcobo asked whether CHOC was involved in the rehabilitation of children with cancer.Mr Khanya replied that CHOC funded a group of childhood cancer survivors in Johannesburg, who were involved in activities to uplift children with cancer.Mr Cutland added that physical rehabilitation of survivors would be done primarily through the hospitals. Wheelchairs, crutches and practical needs were supported by CHOC.Prof Kruger emphasized that physical rehabilitation was being conducted in the hospitals and although this was a focus area for public health, there was a shortage in this service in South Africa.She emphasised that the success story of paediatric cancer of South Africa was that the majority of survivors contributed to the workforce as teachers, lawyers, and in all other service professions.Ms T Kenye (ANC) asked if volunteers at CHOC earned a stipend and if they worked on a temporary or permanent basis.Mr Khanya replied that CHOC was an organisation of parents who were motivated to make a difference, and the majority were volunteers who were not paid. There were different aspects of volunteers, and in some cases, they were paid.Ms Kenye asked how CHOC would receive funding for renting two additional houses and for paying social workers.Mr Khanya replied that there were a number of projects for funding. The last house in Diepkloof was funded by the “CHOC Cows”, who were individuals who cycled in events to raise money. They also cycled to sponsor national awareness of the warning signs and symptoms of childhood cancer.Mr Peenz added that the “Cows” was started three years ago by a parent who had lost a child, and wanted to give back after receiving support from CHOC. In that year, eight “Cows” cycled in the Kfm 94.7 Cycle Event and raised R270 000. The following year, 130 “Cows” cycled, and raised R2.3 million. Last year, 274 “Cows” cycled and R4 million was raised. These funds were raised from the public. Platinum Life donated a percentage of insurance. There were many other initiatives he could describe, which would require more time than the meeting allowed. At the Berg River Marathon, for example, 16 individuals handed out childhood cancer awareness pamphlets to children along the course of the event.Mr Lekgetho said that CHOC’s participation in the Green Paper on the NHI was important and urgent.Mr Waters asked if CHOC had engaged with the DoH with regard to updating of the cancer registry and if CHOC had shared its registry with the DoH, so that it could contribute information related to the allocation of funds. If so, he wondered what the DoH response had been. The Registry would be crucial for the DoH to determine childhood cancer requirements and fund allocations to meet those requirements. He asked if CHOC could share, from its Registry, what types of childhood cancers were most prominent.The Chairperson asked CHOC to elaborate on the impact of CHOC interaction and asked if conclusions could be drawn from analysis of the data on the Registry.Professor Alan Davidson, SACCSG and Head of Paediatric Oncology, Red Cross Children's Hospital, said that the Children’s Cancer Registry (CCR) had been fully functional since 1987, and information was being contributed by all paediatric oncology centres in South Africa. However, there were challenges when children were treated privately, and surgeons did not report the case to the Registry. Furthermore, the National Cancer Registry (NCR) was a pathology-based registry, and at the turn of the millennium, most private pathologists had stopped submitting data after concerns were raised about patient consent. Recently, legislation initiated by the Working Group had been passed to deal with the issue of cancer as a reportable illness, and this would hopefully allow the Registry to catch up on the missing data and have accurate figures for the future.He explained that the rollout of the legislation was not as simple as it appeared. The CCR was written into the draft legislation so that there would be a definite relationship between the NCR and CCR for the future. However, in the final draft, the reference to the CCR was removed, so it was currently not catered for in any legislation. There was still a need to maintain the relationship. From the CCR point of view, the purpose of having data was to enable planning and allocation of resources. It was hoped that the CCR would have access to the data collected on children under the age of 15 years, as there would be reports to the NCR that were not reported to the CCR. At present, paediatric oncologists were double-reporting to both the CCR and NCR. However, the complex history of the CCR would not necessarily affect the future outcome, which was about maintaining relationships. Professor David Stubbs, the Chairperson of SACCSG, was part of the Working Group, and would ensure that this relationship was maintained.Professor Davidson concluded that he hoped that it was clear that it was important for Members to support the DoH with regards to the registry and collection of data. The mere fact that there was legislation in place did not necessarily ensure that those people in the hospitals would fill out the forms.Ms H Msweli (IFP) asked what the symptoms of childhood cancer were. She asked who funded CHOC transport, who received the money for transport. She also enquired who monitored the process of treatment; and whether the Department of Education or the DoH were responsible for teaching children about cancer.Professor Kruger listed some of the warning signs for childhood cancer. These could include an unexplained fever which did not respond to antibiotics, sudden abnormal swelling or mass appearing on the body, continuous pathological pain which wakened a child, after s/he had fallen asleep, a white spot in the eye ball, sudden change of gait, speech, and writing (which tended to be indicative of a brain tumour), fine point bleeding of the skin, or skin that bruised easily, and severe nose and mouth bleedsShe asked the Committee to support CHOC in displaying posters of these danger signs at Primary Healthcare Clinics throughout the country.Professor Davidson re-emphasised that a checklist of the obvious warning signs for childhood cancer, as a non-communicable disease, should be included in the Integrated Management of Childhood Illness Policy, which was currently being considered. In this way, the primary care physician or nurse could be alert to the signs, and refer up the chain rapidly to cut down on any time delay for treatment.The Chairperson said that he would have liked to have continued the meeting. What CHOC was doing should have been done by the DoH. This clearly showed the gaps in the health services and Primary HealthCare in the country. It was enlightening to find that there were people volunteering passionately, without payment or any corruption with regard to financial resources. He was sure that all Members would like to see an NGO in every province and hoped that the DoH could invite CHOC to work with it. This Committee would assist wherever possible.Directorate on Radiation Control: Progress ReportMs Matsoso said that the Ministerial Task Team on Regulatory Function related to Radioactive Sources had established six working groups (WGs) to streamline the activities and to ensure effective work.The first three WGs dealt with the focus, and work on these would inform the actions to be taken by the other three WGs. WG 1 focused on the structure and capacity of the unit, based on the audit that was done, and would address the strategic functions, structure and future position of the Directorate of Radiation Control (DRC) and Sub-Directorate of Radio-Nuclides. WG 2 had met more than once to discuss their function to address lost sources, and how to reassure the public about the risk of lost sources. This was the most active group. WG3 was responsible for a Self-Analysis Tool (SAT) Action Plan which would then be used for WG 4 stakeholders involved in the regulatory control of the radio-nuclides mechanism, and the legislation that would be required. WG 5 would address international relations and obligations. WG6 would address anything that may have been overlooked in new developments in National Radiation Monitoring and Control.WG 1 and WG 2’s??preliminary work had been completed, and draft reports had been prepared for the Minister. WG 3 was expected to complete its report by the end of the following week, at which time all three reports would be submitted to the Minister. Based on those reports, the Task Team would then determine the work of WGs 4, 5 and 6.Members had raised serious concern about the registry of lost sources. A figure given by one member suggested that there were 360 missing sources. The WG 2 had confirmed that there were 267 missing sources, and had categorised them according to their risk.Dr J (Seppie) Olivier, Director of Radiation Control, Department of Health, explained that the categorisation scale for lost-source danger was in accordance with the?International Atomic?Energy Agency?(IAEA) guidelines. These were in turn based on the Dangerous Principle, which looked at the various actions and possibilities, including whether a source was metal or poisonous, the radiation characteristics, the decay, half-life, and determined certain dangerous values (‘D values’) for various nuclides. Based on this, an interpretation of the danger was then given, ranging from Category 1 - extremely dangerous, to Category 5??-most unlikely to be dangerous.Of the lost sources currently on the Register, one fell into category 3. This dangerous source was lost underground, and was marked on the national map. No further investigation was deemed necessary. All other sources were category 4 or 5 (unlikely, or most unlikely to be dangerous). 60% of lost sources were in category 5. Lost sources were primarily soil, moisture and asphalt gauges, which were small portable instruments used in road building, agriculture and related industries. Due to their relative portability and the fact that they had to be taken from point to point, they were often orphaned, stolen or lost. WG 2 would make recommendations on what would be done about these lost sources. It was unlikely that a search would be required for sources from category 4 and 5, which had been missing for up to 30 years. Not all countries could provide details on lost sources in category 4 and 5 as they were not included on their control regime, so that they would not know when something was missing.Ms Matsoso said that recommendations from WG 1, 2 and 3 would be shared with the Committee after they had been approved by the Minister. WG 1 had seriously reviewed the capacity recruitment strategy.DiscussionMr Kganare asked what progress had been made with regard to attracting qualified human resources since 22 June 2011.Mr Hoosen said that he felt that the issue of lost radioactive sources was a “time bomb” and that the DoH was not taking the issues as seriously as they deserved. There appeared to have been little progress since the previous meeting on the 22 June 2011.Ms Matsoso said that the first meeting of the Task Team was in February 2011, and as an immediate response, the Task Team had established the six working groups and a Chairperson had been appointed. Four CV’s of competent medical physicists, who had been head-hunted, were received, and interviews would be held in the following few weeks. The DoH had not been able, to date, to recruit appropriate experts in the field because it was trying to attract them at Level 9. Experts were included in the Task Team and some were leading the Working Groups, and working with the DoH on a continual basis, but the capacity of the Secretariat was a concern. The immediate response was to attract qualified people who could work in the Secretariat.WG 2 had made information on the lost resources available, and the recommendations of the WG 1, 2 and 3 reports would be shared with the Committee in the next two weeks.Mr Hoosen asked for clarification as to whether the DoH would issue a search for category 4 and 5 lost sources, and how long it would take for the lost sources to be found.Mr Waters commented that he was absolutely amazed at how little progress had been made. He asked for clarity as to whether the lost sources had a low risk of radioactivity, and for assurance that they did not pose any health impact on the public. He asked when the sources were likely to be found, and how the DoH could??justify not searching for all lost sources when it was under an international obligation to know where each source was located.Mr Waters asked if the IAEA had been informed about the lost sources. If so, he wanted to know when this was done, and what the response of the IAEA was. He also asked if the IAEA had offered to give assistance and what the DoH believed the role of the IAEA should be with regard to lost sources.Dr Olivier replied that there was nothing strange about the number of lost sources. This was a natural occurrence around the world. It was practically impossible to trace some of them and many on them were on the database only because final documentation of disposal records had not been submitted to the DoH. Those that were lost through malicious actions were reported to the Registry through security agencies but had not been found. Some of the lost sources had been lost for many years. There was an option of using experts physically searching for them with instrumentation, but rather than saying that it would not happen, he preferred to say that the recommendations of the report would guide the Task Team on exactly what to do. Indeed, there was the option of asking the IAEA to assist. Dr Olivier said that that if sources were removed from their containers or swallowed, they would have effects on health, but misuse of those on the lower end of the scale would not threaten life. The report would elaborate categorically on the risks per item and event.The IAEA had a number of bodies to whom lost sources were reported. In the past, the DoH had made use of the Illicit Trafficking Database, through the Nuclear Energy Corporation of South Africa, but now had a contact in its own office through which the sources were reported. DoH did not expect a response from the IAEA, as what had been described was regarded as a usual occurrence throughout the world. If there were any higher-risk sources lost, the DoH would contact the IAEA.The Chairperson asked if the lost sources could be used as a type of war weapon.Dr Olivier replied that they could be used for malicious purposes. A number of them, together with an explosive, would cause widespread economic problems and limited health effects. Over the past ten years the IAEA had upgraded its approach to securing of sources, so that were unlikely to be lost in any way. The DoH had also secured enormous cooperation with the IAEA leading up to the World Cup 2010. IEAE provided for safeguarding of category 1 and 2 sources, which included cobalt units at hospitals, three operational irradiation plants and two facilities that made use of radiation processes for developmental research, and which were actively involved in sterile insects projects for safeguarding of orchards. These processes were not implemented by the DoH, due to lack of staff.The DoH, as the regulator of Radiation Control, would, however, implement a range of measures to enhance its capability to safeguard the loss of sources, within national and international capability. IEAE guided these regulations, and was in agreement that it would never be possible to prevent all theft. If someone really wanted to get to a source, they would.Dr Emma Snyman, Deputy Director: Radiation Control, Sub-Directorate: Radio-Nuclides thanked Ms Matsoso for her insight and personal support to the capacity problem. Problems had to be addressed over a period of six years. Lost sources would be addressed in the report. However, the real issues were not the lost sources, but the capacity and structural problem of the Sub-Directorate. The WG 3 report would include all the deficiencies identified by the Self-Assessment Regulator Tool (SAT), which was guided by the IAEA.Mr Waters asked for the reason why the Hawks had visited the DoH around the issue of lost sources.Ms Matsoso replied that the Task Team required support from the stakeholders, which could strengthen regulator capability. The Hawks had visited to discuss how it could support regulatory functions of Radiation Control.The Chairperson was happy that the DoH had given support to the Task Team, but said that there was clearly much work still to be done. The fact that the lost sources could be used to cause harm was of concern. He requested quarterly reports on the status of the lost sources.The meeting was adjourned.National Health Insurance Pilot Project: progress report from Department of Health; & challenge assessment by Department of Performance Monitoring and Evaluation23 July 2013Chairperson: Dr B Goqwana (ANC)Meeting SummaryThe Department of Health (DoH) briefed the Portfolio Committee on the progress made in the implementation of the National Health Insurance (NHI) Pilot Project over 12 months. The eleven districts included: Eden (Western Cape), Pixley ka Seme (Northern Cape), OR Tambo (Eastern Cape), Gert Sibande (Mpumalanga), City of Tshwane (Gauteng), Amajuba, uMgungundlovu and Umzinyathi (KwaZulu-Natal), Vhembe (Limpopo), Dr Kenneth Kaunda (North-West) and Thabo Mofutsanyana (Free State). The April 2013 rapid appraisal enabled progress to be assessed and provided a framework for future monitoring. The DoH believed that if money for each district was ring-fenced for that district, and when the right people were appointed to run the districts, NHI would succeed.The pilot districts incorporated 764 Public Health Care (PHC) facilities, which included mobile units and Community Health Centres. The facility assessments were focused on infrastructure, the Workload Indicator of Staffing Need, essential equipment, access to drugs and pharmacy services, transport costs, and other minimum requirements. Office of Health Standards Compliance follow-up inspection scores for 385 PHC facilities showed a slight fall in health facility standards in the majority of pilot districts, largely due to more robust tools being used in the follow-up inspection. It was reported that Gert Sibande, City of Tshwane and Vhembe had spent only 55%, 52% and 50% of their conditional grants respectively. All others, however, had spent over 78% of their grants, and Pixley ka Seme had overspent by 14%. DoH was motivating strongly for creation of a district health authority that had a dedicated budget and the authority to plan and execute responsibly. It was seeking to contract services of general practitioners (of whom there were 300 contracted so far), specialists, pharmacists and other professionals.Members asked if the district managers were ready to be accounting officers or whether they still had to be trained; if the Leadership and Management Academy training was relevant to NHI officials; what happened to the existing chief executive officers at hospitals and how the new skills criteria would be different; if revenue collection would be part of the chief executive officer’s performance indicators; and if performance of hospital boards had been assessed. They also asked how DoH planned to purchase services of specialists, such as anaesthetists, in the rural areas; what the rationale was for the Office of Health Standards Compliance not being independent from the DoH; how the Public Health Care referral system would be marketed; why the large sums of conditional grants had not enabled the building of hospitals to be completed; and at where exactly the problems in the OR Tambo and Dr Kenneth Kaunda districts existed.The Department of Performance Monitoring and Evaluation then presented on Outcome 2: a healthy life for all South Africans, and identified a number of NHI challenges, including inequitable distribution of resources in the national health system; a shortage of health professionals in the public sector; limited expenditure on the NHI conditional grant (which had subsequently, to boost spending, been split into a direct component to provinces and an indirect component, managed by the national department); huge infrastructure and maintenance backlogs in some districts; concerns about quality of public health; spiralling private health care costs; and historical inequities between the private and public health sectors. It was reported that the lack of progress in the previous financial years towards unqualified audits was largely due to weak asset management and supply chain management in provinces.Members asked what was being done to improve the shortage psychiatrists and hospital beds in the psychiatric hospitals; asked if any other avenues for revenue had been explored to fund the establishment of the NHI; what plan was in place to reduce the maternal mortality rate; and to what extent the department followed up on drug abuse. The Chairperson concluded that health promotion and the role of the Office of Health Standards Compliance were vital, and a good balance was needed with of delegation of power. In future, the Committee would be deliberating on monitoring of remunerative work outside of the public sector (RWOP). One of the major challenges would be whether board members and clinical committees had the skills to direct and manage a hospital or whether they would be driven by the very people who they were supposed to be driving.?Meeting reportNational Health Insurance: Progress Report on pilot districts by Department of HealthMs Malebona Matsoso, Director-General, Department of Health, said that in April 2012, when the eleven National Health Insurance (NHI) pilot districts were identified, the Department of Health (DoH or the Department) had not yet established whether it would purchase services, how it would engage the private sector and how it would introduce a district health authority. Therefore a number of models were tested during the following twelve month period. The April 2013 rapid appraisal enabled progress to be assessed and to provide a framework for monitoring.Results of the appraisal of the eleven districts were tabulated (see attached document). The eleven districts included Eden (Western Cape), Pixley ka Seme (Northern Cape), OR Tambo (Eastern Cape), Gert Sibande (Mpumalanga), City of Tshwane (Gauteng), Amajuba, uMgungundlovu and Umzinyathi (KwaZulu-Natal), Vhembe (Limpopo), Dr Kenneth Kaunda (North-West) and Thabo Mofutsanyana (Free State).The key areas appraised were: NHI management, hospital reform, quality, Primary Health Care (PHC) re-engineering, infrastructure and equipment, human resources, health information, District Management Teams, conditional grants, referral and contracting of private service providers. Monitoring and evaluation would be performed at a later stage when impact assessment would be conducted.Full-time NHI Project Managers were in place in Pixley ka Seme, Gert Sibande, Vhembe and Dr Kenneth Kaunda, while the other districts had interim managers only.Dr Kenneth Kaunda did not meet the score for district hospitals, defined as having 50 beds or more, and having services provided in alignment with prescribed regulations and an established catchment area. No data was available for uMgungundlovu.Eden, Pixley ka Seme City of Tshwane, Umzinyathi, Vhembe and Dr Kenneth Kaunda hospitals all met the score for appointment of Chief Executive Officers (CEOs). At OR Tambo, only two of the nine district hospitals had a full-time CEO appointed. After receiving these results, the DoH ran a leadership programme at the Leadership and Management Academy for all CEOs, and gave all CEOs 100 days to correct problems relating to their particular hospital’s maternal mortality and infant mortality rates and other matters of concern. Follow-up assessments showed that CEOs could solve problems by reorganising services - without injection of further resources. CEOs from Eden and Thabo Mofutsanyana districts were not sent to participate in the programme.The Office for Health Standards Compliance (OHSC) overall score for the facilities audit showed that the outcome for hospitals was much better than that of clinics. No data was available for the hospitals in Amajuba, uMgungundlovu and Dr Kenneth Kaunda as they had not yet been inspected. The differences in the baseline audit results and follow-up OHSC inspection scores for the 385 PHC facilities showed a slight fall in health facility standards in the majority of pilot districts, but this was largely due to more robust tools being used in the follow-up inspection, using “risk-of-death” based tools. While the methodology was not the same, the scores were still useful. Improvements in scores in Thabo Mofutsanyana, Pixley ka Seme and Gert Sibande were related to the facility improvement teams having devoted time to these PHC facilities.DoH had come up with a clinic prototype for general operation for the facilities. By end of June 2013, 589 of 609 facilities had been assessed for standard equipment and availability of medicines.City of Tshwane and Dr Kenneth Kaunda had the full complement of specialist teams, while other districts did not. The most difficult specialist to attract was the anaesthetist. DoH was currently preparing a model contract to attract specialists in the private sector. In the first phase of the pilot, DoH had been focused on contracting of private providers, with specific reference to GPs. In some facilities, there was simply not enough working space for GPs.Ward-based outreach teams did not reach 25% of the full complement of teams in place in OR Tambo, Gert Sibande, City of Tshwane, Amajuba, uMgungundlovu and Thabo Mofutsanyana. KwaZulu Natal (KZN) had a development system of its own for outreach teams, which was actually more organised than was reflected in the results. Eden and uMgungundlovu had achieved 100% of the required number of school health service teams, while Pixley ka Seme, OR Tambo and Vhembe had not established more than 12% of the requirement. Amajuba had achieved 92% and the other hospitals fell within the range of 28%-60% of the requirement.DoH wanted to ensure that district officers were trained in the National Health Information Repository and Data Warehouse (NHIRD) and these officers were provided with the required infrastructure before they were required to process information. The first phase required rolling out of the training. The second phase, beginning in August 2013, would involve the processing of patient registrations and linking of information between the facilities.Ms Milani Wolmarans, Policy Coordination and Integrated Planning official, Department of Health, explained that training in the NHIRD had been delayed by the need for collating information received from the Census 2011 and the updated information received from the Space Agency on geospatial coding, as well as mapping of all private service providers in the country. All district management teams would be trained on information processing and how to use the information for purposes of planning and addressing the need of the district populations, through gap analysis.Ms Matsoso continued that DoH had completed annual district health expenditure reviews and had found problems in the way in which district health was financed, particularly in the public sector. A “post office” approach was in place, where district managers did not have authority to determine budgets nor make decisions on how money should be spent and monitored. DoH was motivating strongly for creation of a district health authority which would have a dedicated budget, and whose authority would be styled as an accounting officer, with planning responsibility and the authority to execute.Ms Matsoso moved on to speak of the performance. There had been under-performance on the NHI conditional grants by Gert Sibande, City of Tshwane and Vhembe, who had, respectively, spent only 55%, 52% and 50%. All others had spent over 78% of their grants, with Pixley ka Seme having overspent by 14%.DoH had designed referral protocols and reorganisation of emergency transport, which was currently a weak link in the health system. Results would be shared on how transport in the Free State impacted on patient care, particularly in relation to maternal mortality.As of 31 March 2013, assessment of facilities for GPs services had not been completed. However, DoH would share the results which had been obtained up to June 2013. The facility assessments were focused on infrastructure, personnel and the Workload Indicator of Staffing Need (WISN), essential equipment, access to drugs and pharmacy services, transport costs, and other minimum requirements. In total there were 764 PHC facilities in the 11 pilot districts, which included mobile units and Community Health Centres.A prototype for improvement of pharmacy services would be announced. The problem was that medicines were available but were not at the clinics. Either a clinic did not order or the depot did not deliver. At hospital level, direct delivery was being proposed. For clinics, recommendations were being made.Challenges were identified for each facility and were being addressed specifically. Most of the facilities did not have a service improvement plan to address areas of weakness arising from the assessments; deadlines by NHI coordinators and District Managers were not being adequately met; the three streams of PHC facility teams (district clinical specialist/ward-based/schools) were not yet complete; and health staff were insufficient. WISN norms and standards were being used to motivate for increased funding.In summary, DOH had begun to engage provinces on feedback sessions and would develop and monitor progress. NHI management and coordination was in place and District Health Management Teams (DHMTs) were realigning their priorities. DoH was currently calculating the services required per catchment population. DoH sought to purchase services and this NHI model would be different from the current system. The contract model would not be confined to GPs, but would extend to pharmacists and other professionals. So far, 300 standard contracts had been written for GPs but there were also special contracts for GPs who would work in rural areas. Recruitment would be incremental, as only those facilities ready to accommodate GPs could be used.DiscussionMs B Ngcobo (ANC) asked if the district managers were ready to be accounting officers or whether they still had to be trained.Ms Matsoso replied that DoH had been working with the Health Systems Trust to assess the capacity of the district managers, as well as the team within the district office. She reiterated that because of the way district health had evolved in South Africa, district managers had acted more like coordinating officers. In order to effect change, the district head had to see the total needs of the district and take into account all resources and service providers - public, private, civil society and public health - in that district. While serving a population of two million people, it was necessary to look at the demographic profile, the health indicators and how to respond to those indicators. For example, a mining or farming industry would need health services designed to respond to those industries. The person running the district must be senior enough to oversee all these aspects.Ms Ngcobo said that in their oversight work, Members would like to see a pilot district in each province. She asked if DoH was now ready for this, as previously the districts were not ready for oversight visits.Ms Matsoso replied that indeed Members could visit the pilot districts. There were health service performance indicators per facility and per district, and service delivery profiles which would assist Members with their oversight work. Ms Wolmarans would provide Members with the access codes and PIN numbers to access the profile of the district, from baseline to current status. WISM work had been completed at district level and it would be clear to see how each facility should be staffed. Expenditure on human resources differed from province to province, but the balance between spending on human resources and on services was important.Ms D Robinson (DA) asked how NHI would be rolled out on a large scale to the entire population when there were so many problems in the pilot project. It was necessary to look at funding models, staffing and facilities. She asked how DoH planned to contract or purchase services of specialists such as anaesthetists, for the rural areas.Ms Matsoso said that it was not yet necessary to commit to a massive recruitment drive, while some doctors were in training, and there were also already doctors in the private sector who would respond to the purchase model. DoH had met with South African Medical Association to work on future models of purchasing and contracting doctors, as well as with nursing groups and Labour. It had also met with pharmacy groups to come up with proposals to solve the drug stock-out problem.DoH had to assess what was scalable to rural areas. Some services were specific and confined to peri-urban, rural and urban models. However, with GP contracting, one option was being explored where GPs could cover a certain number of clinics in the morning, when they were most needed, and return to their private practices in the afternoon.Ms Robinson commented that in some rural areas, the quality of equipment was poor and basic facilities such as electricity and clean water did not exist at all.Ms Kenye asked why PHC refurbishment had not been completed. It appeared to be neglected although it was the focus of the 10 point plan for PHC.Ms Matsoso replied that DoH had recruited clinical engineers, on a pilot basis, to repair equipment at facilities.Ms H Msweli (IFP) asked how much money had been spent on the three pilot projects in KZN and how far the projects had progressed, as well as how projects in other provinces, which were not pilot projects, had progressed.Ms Matsoso replied that the KZN grant was specifically for the two districts and did not include Amajuba. KZN did its own allocation for Amajuba and therefore there was no NHI report on that spend. Each of the two districts had spent 78%.Mr D Kganare (COPE) asked what was the rationale was for not taking the same road as England, where the OHSC was independent from the DoH.Ms Matsoso responded that inspectors had been trained and the UK training used as a mock inspection for the officers to refine their tools and see how the system worked and be ready when the offices were established. Once the board was established and a CEO was appointed, the Ombud and certification units (and other units) could be set up and people employed. DoH had completed its work in that regard.Mr Kganare asked how the PHC referral system would be marketed so that people understood that the quality of service at PHCs would be the same as that of hospitals.Ms Matsoso replied that at least forty case studies had been analysed. Officials from Thailand would be visiting South Africa the following weekend to train the NHI officials on PHCs and marketing. Thailand had established a commission and invested heavily in health promotion, rather than curative services. Thailand could share the “nuts and bolts” of practical implementation of such policy. In addition, a team from the African Development Bank and Ghana, which had also implemented NHI, would be involved in the debate.Mr Kganare asked how DoH would mitigate the impact of re-categorisation of NHI facilities.Ms Matsoso replied that this was a sensitive issue. Typically, people in the community wanted to be seen by a doctor at a hospital. The DoH had introduced a transitional phase for provinces, which had two options: either the small hospitals could increase the number of beds to 50; or they had to start educating the public on the fact that they would be a community centre and not a hospital. The latter option would be more difficult.Mr Kganare asked what happened to the existing CEOs at hospitals, and how the new skills criteria would differ. He also asked if there would be conflict of interest between district managers and project managers in a particular district.Ms Matsoso replied that once the Act was signed and the board appointed, the board would have to engage DoH with regard to existing staff. All CEOs were assessed and therefore the profile of all CEOs was known. The CEO profile for a specific hospital was given, and DoH had received about 2?000 applications for those posts. The majority of applicants had post-graduate degrees but despite qualifications, they were not necessarily people who had a diverse background of work and were skilled for the job as CEO of a hospital. Hospitals involved catering, cleaning, security and other type of services. Management skills were required, and clinical services had to be understood, as well as the administrative arm which dealt with human resources, finance and IT. The biggest weakness in public hospitals was customer service, the very place where people needed the most care. She added that a central hospital would need to be run by a senior person at DG level. Tertiary hospitals would be run by people at director level and regional hospitals would be run by people at chief director or at director level. The pilot project would be run by a project manager. During the project, district managers were assessed. The Health Systems Trust had completed a study to assess whether the capacity of the district managers was desirable and how best to build capacity.Mr Kganare asked if the Leadership and Management Academy training was relevant to NHI officials and whether it was an accredited course.Ms Matsoso replied that the training provided was not yet designed specifically for hospital management. DoH was making a case for this type of formal training and the International Hospital Federation was working together with the Academy to come up with suitable accredited models of training.Mr Kganare asked if revenue collection would be part of the CEO performance indicators.Ms Matsoso replied that DoH was passionate about designing a proper revenue collection model. If tools were not in place, revenue collection would not happen. Four district hospitals were assessed in the pilot phase, and issues such as lack of basic administration, finances, computers and cabling were thwarting revenue collection. Trained graduates, who were currently unemployed and resident in the districts, had been recruited, with a specific brief to attend to revenue collection at hospitals as part of the 100 days exercise toward 100% revenue collection. The performance of CEOs would be measured in this respect. Incentives for revenue collection, such as retention of a proportion of the revenue should the target be exceeded, had been proposed to achieve the 100% target.Mr Kganare asked if the Inspection Unit had been properly staffed and how DoH ensured that the inspectors did their job properly, and also asked how the WISM staff were appointed; if the Certification Unit would do the same work as the Inspection Unit, and if there would be two or three components to certification.Ms Matsoso replied that after the Bill had been enacted, the board would be responsible for appointment of staff.Mr Kganare asked why the large sums given by way of conditional grants had not enabled the building of hospitals to be completed.Ms Matsoso replied that DoH had the responsibility of monitoring performance of the provinces in terms of the conditional grants. The district managers were not aware of the grant details. DoH had proposed that the district managers should be informed of the budget at the time of the annual expenditure review and told how it should be spent.Mr Kganare asked if security issues had been included when considering infrastructure.Ms Matsoso replied that security was included in the National Core Standards. In-house security was the predominant security, and information would be shared with the Members on the options and preferences between in-house and outsourced security services.Mr Kganare asked what the problems were at OR Tambo and Dr Kenneth Kaunda, whether it was at the level of the DoH, provincial department, district, employees or environment of the district.Ms Matsoso replied that the problems at the two districts were caused by a combination of lack of support by provinces and lack of capacity at district level.Ms T Kenye (ANC) asked what mechanisms were in place to assist facilities with a service improvement plan to address the weaknesses found in the assessments.Ms Matsoso replied that a service improvement plan and quick monitoring tool was in place and these would be shared with Members.Ms Kenye asked if performance of hospital boards had been assessed and what training would be offered to capacitate them to improve their work.Ms Matsoso replied that DoH had not started with hospital boards, except for those which related to central hospitals. However, responsibilities were applied according to the way the Act was written. Since these were government structures, the criteria for appointment of people to clinic committees and hospital boards should be determined in the Act. This would also relieve the problem of role definition and interference with the running of the institutions.The Chairperson said that money had to be injected into the pilot project to establish whether NHI would work or not. While universal coverage would remove the inequalities and differences between rural and urban and public and private healthcare, he asked for assurance that NHI would, in fact, work.?Ms Matsoso replied that within the existing environment, NHI would obviously not work. DoH had the view that if all the money for a district was ring-fenced for that district, and not touched by other districts, that may result in a shortfall. However, if people with the proper profile were appointed to run the districts, there were many great opportunities ahead, and NHI could succeed.The Chairperson concluded that despite the challenges identified in the pilot projects, it seemed that the DoH was promising the Committee that NHI would succeed in offering universal coverage to all South Africans and thereby improve the health indicators of the country. He said that matters of particular importance included health promotion, the amendments by the OHSC and the fine balance of delegation of power. Another issue which would be discussed in a future meeting was monitoring of remunerative work outside of the public sector (RWOP). Lastly, a big challenge would be whether board members or those in clinical committees had the skills to direct and manage a hospital or whether they would be driven by the very people who they were supposed to be driving.Outcome 2: Department of Performance Monitoring and Evaluation assessmentMr Thulani Masilela, Official responsible for National Development Plan Outcome 2, Department of Performance Monitoring and Evaluation (DPME), noted that Government Outcome 2 envisaged a healthy life for all South Africans. He presented an overview on life expectancy, the status of child and maternal health, HIV, AIDS and TB, and quality of healthcare.While progress had been made with re-engineering of the health care delivery model, he noted that significant challenges remained. These included: exodus of trained medical practitioners to other countries and shortage of local health professionals and medical specialists; limited expertise in intersectoral action to address social determinants of health; and limited public awareness about benefits of health promotion and prevention. Medium to long term strategies included the Cuban Medical Training Programme and increased intake of medical students at universities.In an attempt to strengthen management of the health system, regulations had been promulgated for minimum competency criteria for hospital CEOs. 102 new hospital CEOs were appointed in January 2013, the Health Leadership and Management Academy had been established; and national monitoring of non-negotiable provincial budget components had been introduced to ensure appropriate expenditure. Additional management challenges included: limited delegation of powers by provinces to district and facility health management; poor maintenance of infrastructure, lack of cleanliness, weaknesses in infection prevention and control, patient safety problems, staff attitudes and insufficient capacity for patient registration and drug management; and inadequate governance and management at district and sub-district levels.Establishment of the OHSC had enabled the introduction of core health service delivery standards, and monitoring had commenced.A serious area of concern was the state of financial management in the sector. In 2009, only North-West, Western Cape and the DoH received unqualified audits. Lack of progress in the previous financial years towards unqualified audits was largely due to weak asset management and supply chain management in provinces. The audit process for 2012/13 was still in progress.He referred to the indicators for the NHI Pilot discussed earlier, and confirmed that there was inequitable distribution of resources in the national health system, coupled with a shortage of health professionals in the public sector. There had been limited expenditure of the NHI conditional grant – but this grant had subsequently been split into a direct component (to provinces) and an indirect component (managed by national) with the aim of accelerating expenditure. Other challenges included huge infrastructure and maintenance backlogs in some districts, concerns about quality of public health services, which was being addressed by the establishment of Health Facility Improvement Teams; spiralling private health care costs; and historical inequities between the private and public health sectors.According to the World Bank’s World Development Indicators 2013, South Africa had the second highest health outcomes, after Botswana, within SADC. However, South Africa was ahead of Botswana in addressing malnutrition. Within BRICS, only India’s health outcomes were lower than that of South Africa.He noted the table on page 19 of the attached document, pointing to consistency between the 10-point plan 2009-2014, the National Service Delivery Agreement outputs (2010-2014), the Millennium Development Goals (2000-2015) and National Development Plan targets for 2030. Over the next five to fifteen years, the focus would be on continuity, but with accelerated delivery.DiscussionThe Chairperson highlighted that this presentation was under the auspices of the Minister in the Presidency, not the Minister of Health.Ms Robinson commented that the current month was Mental Health Care Month and that South African society was plagued with violence, abuse and crime - factors which were often the result of instability or problems with mental health. The Committee had noted, during oversight visits to provinces, that there was a serious lack of psychiatrists. She appealed to the two departments present to be aware of this need. She proposed that presence of psychiatric nurses at the primary health care level would help to identify problems and treat children before they reached puberty and problems associated with mental illness escalated. Another issue was that there were not enough beds in the psychiatric hospitals. She asked what was being done to improve the situation.Mr Masilela replied that DPME was aware of the 5-year comprehensive strategic plan set forth by DoH which prioritised the above concerns. The DoH could provide the specific details to the Committee. A society that was not functional had a higher prevalence of mental illness, HIV, violence and other factors.Ms Matsoso added that since DoH had briefed the Committee on DoH mental health services, it had drawn a list of all the mental health facilities which required attention, including infrastructure such as beds. Teams had been sent to deal with the infrastructure issues in the previous week. DoH was working with the disability sector to ensure that it was equipped with psychiatrists and this sector included the mental health sector.Ms Kenye asked if any other avenues for revenue had been explored, to fund the establishment of the NHI and whether public-private partnerships had been explored in the NHI pilot project to boost resources.Ms Masilela replied that the avenues for revenue were documented in the DoH documents.Ms Matsoso replied that DoH would refrain from commenting on funding options, precisely because it would like to leave sources of revenue in the hands of National Treasury, which had to juggle what funds were available. She added that countries that had shown growth in development after world wars or recession were those that invested in health.The Chairperson commented that increasing life expectancy meant that increased geriatric health services were to be expected.Mr Masilela added that people were living longer with HIV, due to ARV drug treatment. It was encouraging that in the group of 15-24 years old, there was a reduction in prevalence of new HIV infections.Ms Robinson asked what plan was in place to reduce the maternal mortality rate.Mr Masilela replied that the DPME was aware of the 5-year strategy plan which included reduction of maternal mortality rate and that the DoH had implemented the Campaign on?Accelerated Reduction of Maternal Mortality in Africa?(CARMMA).Ms Matsoso added that the results of the CARMMA strategy implemented in the Free State showed positive outcomes.Ms Msweli asked to what extent the DPME followed up on drug abuse, which ultimately contributed to the need for hospitalisation.Ms Masilela replied that the DPME was directly involved in the monitoring of progress with drug abuse interventions and met weekly with an inter-ministerial task team, led by the Department of Social Development. The team was established in Gauteng as a direct result of the President’s visit to Eldorado Park on the 14 May 2013, after he had received a letter from concerned residents. The Revised National Drug Master Plan (2013) on demand reduction, supply reduction and harm reduction had been implemented by various departments which reported to the inter-ministerial committee.The meeting was adjourned.Preparations for National Health Insurance (NHI) pilot districts: briefing by Minister of Health25 February 2014Chairperson: Mr B Goqwana (ANC)Meeting SummaryThe Minister of Health, Dr Aaron Motsoaledi briefed the Committee on the progress made by the Department on the National Health Insurance (NHI) pilot districts. According to the World Health Organization (WHO,) a health care system needed to have six building blocks, and health systems financing was one of the building blocks for South Africa’s National Health Insurance (NHI) initiative. The NHI system would be implemented in phases, and would be complemented by a reduction in the relative cost of private medical care.? The system would also be supported by better human capacity and systems within the public health care sector.? The main thrust of the NHI included strengthening the capacity of the public health infrastructure to provide effective, safe and quality services. Infrastructure included staffing, buildings, technologies and utilities such as water, power and financing. ?Health infrastructure entailed public investment, and government needed to explore innovative ways of harnessing the resources of the private sector, non-governmental organizations and communities.The Department had commenced with the NHI piloting of 11 districts. The pilot included the re-engineering of the primary healthcare system, which had three streams.? These were the school health programme, the municipal ward-base primary healthcare agents, and the district specialist health teams. The Department was also looking to contract general practitioners (GPs) to work in public clinics.? An Infrastructure Optimization Tool Kit was being applied for the selection of clinics to be built in four provinces -- the Eastern Cape, Free State, Limpopo and the Mpumalanga NHI districts.? The Department had compiled a District Hospital Assessment Report for each facility under the NHI project.? The assessment included the building structure (walls, doors, roofs etc), building wet services (plumbing, drainage, and sanitation), electrical, civil infrastructure (roads, fencing, cleaning and site keeping) and mechanical equipment and installations. The following district hospitals had since received infrastructure upgrades: Pretoria West District Hospital, Jubilee District Hospital, Odi District Hospital, and Tshwane District Hospital.Members asked whether there would be a uniform design for the clinics, to reduce costs.? Would there be adequate training for staff at the pilot clinics? ?What was being done to resolve security problems at clinics, particularly those in rural areas??? Could the loss of staff from public health facilities to the private sector be reduced??? Was the Department taking sufficient action to deal with HIV/AIDS, tuberculosis and the “sugar-daddy” issue??? The Minister was also asked whether any action was being taken on the proposal by a Member of Parliament that dagga be legalised for use in the treatment of cancer.Meeting reportThe Chairperson welcomed the Minister of Health to the meeting, together with Members of the Committee.Briefing by Minister of HealthDr Aaron Motsoaledi, Minister of Health, thanked the Committee for the invitation. He said according to the World Health Organization (WHO) a health care system needed to have six building blocks, and health systems financing was one of the building blocks for South Africa’s National Health Insurance (NHI) initiative. The NHI system would be implemented in phases, and would be complemented by a reduction in the relative cost of private medical care.? The system would also be supported by better human capacity and systems within the public health care sector. ?The main thrust of the NHI included strengthening the capacity of the public health infrastructure to provide effective, safe and quality services. Infrastructure included staffing, buildings, technologies and utilities such as water, power and financing. ?Health infrastructure entailed public investment, and government needed to explore innovative ways of harnessing the resources of the private sector, non-governmental organizations and communities.The Department had commenced with the NHI piloting of 11 districts. The pilot included the re-engineering of the primary healthcare system, which had three streams.? These were the school health programme, the municipal ward-base primary healthcare agents, and the district specialist health teams. The Department was also looking to contract general practitioners (GPs) to work in public clinics.? An Infrastructure Optimization Tool Kit was being applied for the selection of clinics to be built in four provinces -- the Eastern Cape, Free State, Limpopo and the Mpumalanga NHI districts.? The Department had compiled a District Hospital Assessment Report for each facility under the NHI project.? The assessment included the building structure (walls, doors, roofs etc), building wet services (plumbing, drainage, and sanitation), electrical, civil infrastructure (roads, fencing cleaning and site keeping) and mechanical equipment and installations. The following district hospitals had since received infrastructure upgrades: Pretoria West District Hospital, Jubilee District Hospital, Odi District Hospital, and Tshwane District Hospital.The WHO service availability and readiness assessment methodology provided a standard health facility to assess, map and monitor service availability and readiness. It was designed to support a health facility census with a focus on the core functional capacities and the availability of services. The key topic areas and core functional capacities of a facility census of service availability and readiness included:? Identification, location and managing authority of health facilities;? Availability of basic medical equipment, such as weighing scales, thermometers and stethoscopes;? Availability of a health workforce? Availability of general medicines;? Availability of diagnostic facilities;? Availability of general injection, sterilization, disposal and hygiene practices; and? Availability of specialized services such as family planning, maternal and newborn care, child health, HIV/AIDS, tuberculosis, malaria and chronic diseases.Dr Motsoaledi said the Department had commenced with the NHI piloting of 11 districts. The pilot included the re-engineering of the primary healthcare system, which had three streams.? These were the school health programme, the municipal ward-base primary healthcare agents, and the district specialist health teams. The Department was also looking to contract general practitioners (GPs) to work in public clinics. ?An Infrastructure Optimization Tool Kit was being applied for the selection of clinics to be built in four provinces -- the Eastern Cape, Free State, Limpopo and the Mpumalanga NHI districts.The Department had compiled a District Hospital Assessment Report for each facility under the NHI project.? The assessment included the building structure (walls, doors, roofs etc), building wet services (plumbing, drainage, and sanitation), electrical, civil infrastructure (roads, fencing cleaning and site keeping) and mechanical equipment and installations. The following district hospitals had since received infrastructure upgrades: Pretoria West District Hospital, Jubilee District Hospital, Odi District Hospital, and Tshwane District Hospital.Dr Motsoaledi gave a summary of the Department’s work with the ideal type of clinics and said that in total, 102 clinics had been built.DiscussionThe Chairperson thanked the Minister for the presentation. He agreed that one of the main reasons why access to universal health had failed was the lack of infrastructure. ?Equity in infrastructure was crucial to achieving this universal goal.Ms M Dube (ANC) asked whether there would be some uniformity with the clinics being built and upgraded.Ms M Segale-Diswai (ANC) asked whether the Department would be providing adequate training for the staff who would be employed in the pilot clinics. In order to involve local communities in the NHI initiative, she suggested that a community indaba be held in all communities. Local community members could also be well educated about the Department’s plans during these engagements. ??Many appointments of security companies for local community clinics were centralized at provincial offices, and as a result, the nursing staff for these clinics had no one to complain to. The centralization of security companies caused problems at the local community level.The Chairperson asked whether the medical staff who were leaving public health facilities for the private sector, were leaving for financial reasons. If not, what where some of the other reasons for this?Ms S Kopane (DA) asked about the progress the Department had made towards attracting private general practitioners to work in public clinics. How many doctors from private hospitals where willing to join the NHI initiative? How far was the Department in finalizing the White Paper? What were the total costs of changing and/or upgrading the current infrastructure? How was the Department planning to upgrade the current filing system at local clinics in order to accommodate the ideal prototype clinic?The Chairperson asked what the lifespan of these prototype clinics was. How would provinces be budgeting for the maintenance of these new structures?Ms D Robinson (DA) also asked about progress on the White Paper. According to a presentation by the Department, HIV/AIDS patients were increasing at an alarming rate throughout the country. How was the Department looking to improve on its capacity to accommodate this growth? How were the campaigns for HIV/AIDS prevention being adequately promoted? How was the Department dealing with the alarming number of youth pregnancies? How were safe sex practices being promoted? ?Were there specially trained staff at these new clinics, to deal with these challenges? ?What plans did the Department have for educating men on the “sugar-daddy” issue”?The Chairperson reminded Members about a recent debate in the media around a suggestion that young girls be given some incentives for not having sex until they were 25 years old, or until marriage. How would the Department respond to this suggestion?Ms R Motsepe (ANC) thanked the Minister for the presentation. She asked how the Department would be monitoring the construction of the projects. How long would the NHI project take? ?She informed Members that there was a new phenomenon among the elderly -- to use condoms as a remedy for arthritis.? Had the Department any plans to conduct further research on this? ?What plans did the Department have to improve and educate current community health workers?The Chairperson said the Committee would be very interested to know about the progress made by the Department concerning matters of legislation. How far was the transformation of the Medicines Control Council (MCC)? What other pieces of legislation were in the Department’s pipeline?Ms B Ngcobo (ANC) asked whether newly-qualified nurses were still being sent to work in rural schools. Why were doctors and nurses no longer wearing their white uniforms -- was this no longer a requirement?The Chairperson said the Medical Research Council (MRC) was receiving more money from donors than from the Department. He raised a concern that the MRC would then be reporting more to these donors than to the Department, because more funding for research came from the donors.Mr D Kganare (DA) thanked the Minister for the presentation. He said some dentists in Rooderport were interested in becoming part of the NHI, but they did not have access to the relevant information. How was the Department bringing private hospitals on board to the NHI? How would the NHI be linked to the licensing of private hospitals? What projections did the Department have concerning the full rollout of the NHI process? Was it possible that the Department would include the issue of private security at its MinMec?The Chairperson said according to the presentation, the NHI pilot was focusing on eight districts.? What plans were in place to include the rest of the remaining districts?Ms Ngcobo said TB was another serious problem on the African continent in general. What plans did the Department have to tackle this problem? ?Had the Department made financial provision for the maintenance of the clinics with their expensive equipment? ?What would be the cost of building these clinics, and what was their lifespan? ?In some of the provinces there were clinics which had been built by private companies and/or private organizations, but some were either very small or dilapidated. Were these private clinics included as part of the NHI upgrades? ??Accommodation for clinic personnel, especially in rural communities was a serious challenge -- how was the Department planning to address this? How would new personnel be attracted to these rural communities?The Chairperson explained that in the rural areas, there were different kinds of private clinics.? Some used to be private hospitals -- missionary hospitals built for local communities, and which were not for profit. An example of this was one which was built at Lusikisiki in the Eastern Cape -- the clinic was built by Anglo American for the families of the mine workers.Dr Motsoaledi thanked Members for their engagement with the presentation. He said that the Department would be using a uniform structure for the NHI clinic project. ?The Department had found that each contractor for building a clinic had a unique design, and this was very costly for the Department. As a result, it was moving away from this practice.? There would be one design which belonged to the state. He made an example of the design which was used by the Western Cape Health Department to build the Khayelitsha hospital.? That design was owned by the state. ?A decision had therefore been taken at MinMec that hospitals at district level would have one design. Tenders would be issued only where technical issues, such as topography, were involved. He agreed that some designs would not work well with topographical matters, such as soils in some areas, and in these cases a new design would be used.On the question of professionals leaving public health facilities to join private ones, he said the matter was not unique to South Africa.? It was a global phenomenon. ?Skilled people all around the world moved to greener pastures and there was not very much governments could do about this. Canada, for example, was one of the main countries which lost doctors to the United States. A resolution had been taken by the WHO, however, that no first world country must actively recruit health workers from developing countries.?? However, the Sub-Saharan African region had been declared a crisis area by the WHO because not all countries were compliant.The Chairperson asked what other plans the Department had in place for improving infrastructure.Dr Motsoaledi replied that part of the resolution was that the Department would follow the service conditions put in place by the WHO, such as providing good accommodation and transport for staff etc. He argued, however, that no African country could ever compete with the Middle East in terms of taking care of health personnel, and unfortunately this was one of the main countries to which South African health professional moved.On the question of private security companies being centralized at head offices at provincial level, he agreed that centralisation was a challenge. This meant that the tenders were being issued from elsewhere, and local clinics had no say in this. He agreed that local clinics scored very low on security capacity. Security companies received very big tenders from the Department but the money these security companies paid security guards was appalling, and this did not motivate security guards to work optimally. ?In one hospital, the service provider was receiving R500 000 from the tender, while security guards were being paid R1 200 per month. The Department was, however, exploring the suggestion of removing security companies and paying security guards directly. A resolution had therefore been taken at MinMec that each hospital should appoint its own security provider.The Department was still struggling with the question of recruiting general practitioners to local community clinics. ?Many of these private practitioners argued that the conditions of the local clinics were not good, so they would wait for the improved, “ideal type” clinics. Salary improvements were also another concern for private practitioners. The ideal type clinics pilot had been costed. The accurate figures would be forwarded to the Committee. On the question of the filing system, he agreed with the Member’s suggestion that the current one be upgraded to include the NHI system. ?In 2012 the Department had looked for unemployed graduates who had qualifications in finance, human resources and information technology.? 400 of them had been given training on public service, and then given internships by the European Union on behalf of the Department. These interns had computerized the whole filing system of the Department.Dr Massoud Shaker, Head: Infrastructure, National Department of Health, replied to the question on infrastructure and explained that maintenance was very expensive due to the fact that on average it took the Department five years to complete a building.? Therefore by the time the structure was completed, the building was already deteriorating. ?The longer it took to complete the building, the higher the maintenance costs.Dr Motsoaledi said provinces should be encouraged to spend money on infrastructure maintenance, rather than on building new hospitals or clinics. Therefore, with the conditional grants allocated to provinces, provinces would be mandated to spend at least 30% of this allocation on maintenance, rather than on building new structures.With regard to the White Paper, he asked the Committee to wait for a report from the Minister of Finance. He replied to the school health question, and agreed that the matter was of serious concern.Regarding the use of condoms as a remedy for arthritis, he said it would be very costly for the Department to conduct research on all new innovations. The Department had established the National Health Research Committee (NHRC,) which was chaired by Professor Bongani Mayosi, the Head of Medical Research at the University of Cape Town. This committee was responsible for assessing the relevance of new medical research.On the question on white uniforms, he said a resolution was taken in 2010 that all nurses needed to wear white uniforms.The Department had started preparing for the NHI in 2002, and it was anticipated that the whole process would take 14 years. Therefore 2016 was the completion date. He said the National Development Plan was one of the main guiding documents for attracting the private health sector to work with the NHI system.? One of the main priorities of the Department, however, was to do away with the exorbitant fees at private health institutions. ?The pilot for the ideal type clinic would be rolled out in all provinces, except for the Western Cape.On who was responsible for maintenance, he said the Department was busy training people who would be responsible for this area. ??The lifespan of the new ideal clinics was 50 years. ?Clinics, such as those in Lusikisiki, which were built by private organizations, were still managed by government and would therefore be included in the Department’s upgrades.On the question of nurses who were allocated to work in schools, he said the Department was hiring retired nurses to assist newly-qualified nurses. However, the number of nurses was not enough to cover all schools. Nursing teams were therefore rotating schools for the rollout of the school health programme.TB around the Southern African Development Community (SADC) region was a big problem -- 80% of the TB in the world was found in 20 of the countries in the world, and all BRICS countries were part of this 20. 80% of all people who died from AIDS were killed by TB. The Department was therefore heavily committed to fighting against the disease.The Chairperson thanked the Minister for the responses.Ms Segale-Diswai asked what decision the Department had taken on the Member of Parliament’s proposal to legalize dagga for medicinal use.Dr Motsoaledi said it was not the first time that a proposal had been brought before the Department for dagga to be legalized for medical purposes, but the most recent proposal was seen as controversial, because it had come from a high profile individual. ?This also made it difficult for the Department to address the proposal. The proposal was very sensitive. ?Individuals were allowed to apply to the MCC to be granted individual rights to use a non-medical substance such as dagga for treatments of various illnesses, such as cancer.The meeting was adjourned.?National Health Insurance (NHI) Pilot Districts: progress report by Minister of Health20 August 2015Chairperson: Ms M Dunjwa (ANC)Meeting SummaryDr Aaron Motsoaledi, Minister of Health, and a delegation from the Department of Health provided an update about the National Health Insurance (NHI) pilot sites. The programme focuses on the development of infrastructure for primary healthcare systems and the recruitment of doctors and specialists for clinics. Minister Motsoaledi emphasised the importance of efficiency in human resources management in building up the public health sector. He explained the Department’s consultations with both the World Health Organisation (WHO) and Harvard University in pursuing the NHI programme.The Department presented the design for an ideal clinic, and is working to complete construction on such clinics in the ten pilot districts; 106 structures have already been completed. The districts were chosen as ?representative of the country’s widely diverse demographics, so they therefore vary in size, population, and level of poverty. The Department is working on construction and budgetary matters in conjunction with the Department of Public Works and the National Treasury. Though it has been challenging for the Department to attract doctors and specialists to work in the clinics, the Department has many methods of recruitment as well as training programmes in place for former or current clinic volunteers. Efforts are also underway to address the critical issues of wait times and school health care services.The Committee had many questions due to the complexity of creating a national health care system, but generally lauded the Department’s efforts and its focus on primary healthcare. Members asked general questions about the influence of business on public health, oversight of and budgeting for programme spending, the Department’s ability to build public confidence in the programme, school healthcare services, and doctor recruitment as well as specific questions about x-ray machines in clinics, examples of clinic construction projects being behind schedule, recruiting doctors from SADC countries, and clinic security.Minister Motsoaledi noted that many funding issues would be clarified in the soon-to-be-released White Paper, pending work by Treasury on the White Paper. He gave examples where Australia had cracked down on the tobacco industry and said that the Department is working with and drawing funding from the private sector for public health initiatives. The Department will build confidence in the NHI programme over time as the public becomes familiar with the programme. The foreign recruitment of doctors is highly contentious, and Minister Motsoaledi noted that, worldwide, there is a general shortage of doctors. The Department is working with Treasury on infrastructure matters and grant money allocation. He told the Committee that the clinics had x-ray machines and proper security measures, and again emphasised the importance of HR structures.Meeting reportOpening RemarksThe Chairperson commented that today’s meeting is very important because it involves the health of the people. She referred to the country's past history that must be corrected by the health sector. She commended Minister Motsoaledi for creating one of the most effective programmes in South African history.Briefing by Minister of HealthDr Aaron Motsoaledi, Minister of Health explained that at the beginning of the NHI project, the Department estimated that the process would take 14 years. Pilot sites were chosen according to a mix of both size and poverty levels of such districts. He noted that because KZN is so much bigger than other provinces, it got a second location. The programme had four targets:- Infrastructure Development- Contracting GPs to work in Public Clinics- Re-engineering the Primary Healthcare System- Quality of Health Services.Minister Motsoaledi said that all these tenets emphasise the primary healthcare system: the people must be able to go to clinics and receive quality care. Minister Motsoaledi noted that, although the Department probably will not meet the NDP goal of 11 million healthcare workers, it has raised the number of workers significantly.At a WHO meeting in Tunisia in 2012, Dr Luis Sanbo of the WHO helped African leaders tackle the concept of Universal Health Coverage. The first step is improving infrastructure, from staffing to waste management. Therefore, the DOH has assessed the status of infrastructure of each district. Minister Motsoaledi presented charts cataloguing the status of each building in each district. Vhembe has mostly small structures, but generally good status. Tambo, on the other hand, was mostly in the red and thus needed re-building. The Department has, in the past, struggled with DPW to get these improvements made.Minister Motsoaledi presented the architectural diagram of an ideal new NHI clinic, designed by specialists from various fields. This design will also aid current clinics in remodeling. He explained that clinics must have separate consulting rooms for doctors lest the doctors distract the nurses. As of yet, 106 of these structures have been completed.After this construction, the Department began the slow process of contracting GPs. Minister Motsoaledi noted that it is difficult to motivate doctors to work in a clinic or in a rural area, but that direct contracting has helped recruitment. The charts showed the exact breakdown of doctors hired in each district. Three options for contracting were tested:?- Direct Contracting through the NDOH- Service Provider- Western Cape OptionMinister Motsoaledi noted that Cuba has some of the best healthcare in the world, and that Cuba recently ended mother-to-child HIV transmission. He then explained the various treatment options for diabetes, and stated that the best yet least glamourised treatment option is good diet and exercise. This example shows that it is difficult to glamourise and promote primary health care so as to provide primary care at the quality level of a country such as Cuba. However, public perception must be improved in order to re-engineer primary health care.The Department chose seven professions that must be present in each district: a midwife, an anesthesiologist, a family physician, an obstetrician, a pediatric nurse, a pediatrician, and a PHC nurse. A report on these specialists is being constructed at the moment.Minister Motsoaledi reminded the Committee of the HIV epidemic of the late nineties and how the response was unplanned and mostly done by volunteers. The legacy of this has caused many people today to want jobs in primary healthcare, but they come from a variety of levels of training. The Department is creating standards for worker qualifications, from HIV and TB to mental health and immunisation practices. In KZN, all of the former workers were trained together under one roof for the pilot programme.To improve school health services, 27 mobile PHC trucks, 17 oral health mobiles, and 3 eye care mobiles have been commissioned. In order to ensure that kids are successful in school, health care must address eye and mouth health, immunisation, illegal substance issues, HIV prevention, and reproductive health. HIV prevention and reproductive health education is still controversial, but the other three are working well. Out of 280 000 children screened at this point, one third had some kind of speech, hearing, or sight issue.The NHI project aims to improve healthcare systems and administrative practices. Nurses currently spend too much time filling out registers. The NHI plan reduce the number of registers from 56 to 6, which will reduce waiting time and increase patient interaction time. The project has found that an Automated PHC Patient Information System to make the system paperless will greatly improve efficiency and more efficiently use the space of small clinics.Today, over three million South Africans are on ARVs and go to clinics; the infrastructure is not keeping up with the increasing number of patients and thus waiting times are a critical problem. In addition to improving registers, the project aims to improve chronic medication dispensing by allowing a service provider to handle chronic medication. Admittedly, this is logistically difficult with patients who have more than one condition. Another area for reform is the process of hospital reimbursement.Minister Motsoaledi informed the Committee that the Department has completed its part of the White Paper, but the Treasury and the Cabinet have work to do before it is published.DiscussionMr A Shaik Emam (NFP) thanked the Department and observed that it is the Department’s inability to appoint provincial officials that causes bad wait times. He asked whether enough is being done for disease prevention and health promotion? He noted that the advertising on the media overwhelmingly advertises for unhealthy foods and practices. He observed that staff attitude is a problem, but recognised that the Department is trying to attract motivated health care workers. He said that the private sector might need to play a greater role in healthcare. He observed that clinics would take time to address historical gaps in healthcare. He noted that there are GPs available in SADC states, and asked whether they will ever be used.Dr W James (DA) said that he supports the emphasis of primary health care and the building of clinics. He noted that infrastructure delivery schedules are a constraint. He shared complaints from five clinics being constructed in the Free State that contractors are being overpaid, though he noted that these are not necessarily NHI pilot sites. What is the Department doing to oversee the flow of money? He lauded the example of Cuba, but noted that training for the future of mid-level workers will be necessary; what is being done for this? He noted that the NHI grant has been cut, and that a national health care system will be enormously expensive. Why has the money currently allocated not been spent?Dr P Maesela (ANC) observed that, even if children are checked at school, they then have nowhere to go for treatment; how is this being solved? He noted that nutritional education is lacking, and should be run by the Department rather than contractors. He asked why the Western Cape is opting out of the NHI and noted that many specialists do not want to go to rural areas. He suggested that all schoolchildren should be given cell phones.Mr H Volmink (DA) asserted that universal health coverage is a moral imperative. He noted that NHI is a vehicle to achieve this, and that the government must be willing to change this vehicle. Should the 14-year timeline be revised? How will the lack of confidence in healthcare and confusion about NHI be reversed? He noted that preventative healthcare to target major health risks like smoking must improve; how has preventative care been integrated into the NHI system?Mr I Mosala (ANC) welcomed the 12 month progress report and pointed to page 4 of the document concerning conditional grants and asked how close is the government to reconciling differences between Treasury and Health on the grant? Will we have a new approach created next year? He noted that only 55% of expenditures noted in the presentation were for medical equipment. Why is there a disjuncture between national practices, provincial practices, and district practice in relation to infrastructure spending? What will the progress be for the 2015/16 financial year on infrastructure development? Where is the information from the Western Cape? What was the impact of the district specialisation; can we have a report on this as well as on other specific NHI programmes?Dr H Chewane (EFF) lauded the emphasis on primary healthcare as a gold standard. Will clinics have x-ray facilities? He said that many patients who need clinic services also need x-ray services. He said that the Department should relook at outreach workers to reach rural patients who otherwise would not seek care until the late stages of a condition. How does the Minister feel about tender? He noted that incidents of assault on doctors have occurred; are you considering security for these clinics?Mr S Jafta (AIC) asked why the pace of recruitment of GPs is slow, especially after the inclusion of service providers? What is the Department doing to encourage learners to become GPs? He said that the Tambo district of the Eastern Cape needs urgent attention.Ms C Ndaba (ANC) supported the hiring of service providers to deliver chronic medication as a solution to wait times. She was impressed by the Department’s performance in Vhembe because she saw a clinic there with all the specialists necessary. However, she noted that on oversight visits, providers had complained about establishment records preventing staff from appointing extra help, what is the Department doing to address this?Minister Motsoaledi reminded the Committee that the NHI is a new concept to the country, and that each country has different health coverage with the goal of equal access to care. He assured Mr Volmink that the programme will gain momentum and recognition.Minister Motsoaledi recognised the complexity of balancing business interests with health interests. For example, the Minister of Health in Australia took great strides and faces legal challenges from the WTO on her efforts to curb smoking. He gave an example of shops selling sweets in the checkout line and noted that the Department has taken efforts against salt, but not sugar. These issues, if too many people have diabetes for example, will be beyond Minister of Health ability to fix. A commission must be established that will include the Deputy President and representatives from private industry to address these dire health issues. Minister Motsoaledi in 2010 encouraged private healthcare to improve HIV care and investment in human capital; they agreed and this shows that public and private can work together. Funding raised by the private sector has sponsored PhD programmes in infectious disease research and trained CEOs for hospitals.As for getting doctors from SADC, Minister Motsoaledi said that most countries worldwide have shortages of doctors; he quoted that there is a shortage of 4 million doctors worldwide. The WTO arrived at a resolution that countries must not recruit doctors from developing countries; this conflicts with other bodies who assert that labour must be free to move anywhere. Though South Africa is a stronger economy than other SADC countries, it is hotly debated whether South Africa should recruit specialists. The EU as well as private hospitals already attract these specialists, but developing countries do not want to lose their doctors.Minister Motsoaledi said that he was very aware of the infrastructure money issues raised by Mr James. He complained that Treasury has the authority on this issue, even though Health has the responsibility. Health has fought with Public Works to charge or terminate contractors and ensure that they finish on time, but Health lacks authority. As for mid-level workers, training and planning has only begun recently.When the White Paper is released, it will be clear that NHI progress has been split into three phases and it will be reviewed whether the timeline will be kept. The first phase, or preparatory phase, will last five years and is almost complete. The second phase is to erect structures: payment systems, districts, etc. The final phase, lasting four years, will involve the establishment of the NHI itself. Minister Motsoaledi said about Qatar that they have been working on their NHI since 1992. Universal Healthcare will represent a major transition in human history.Minister Motsoaledi explained that the Department is working with Treasury to allocate Grant money to National and Provincial levels fairly. Provinces require that there be a register in order to allow training at universities. Some of these issues must be changed in the White Paper. The first two years were difficult, but now buildings will be constructed and things will get easier. To implement NHI, a total re-organisation of the system will be necessary.Minister Motsoaledi explained the introduction of an essential equipment list; this list includes x-ray machines. Primary Health Care has been improved significantly and successfully in KZN in order to address the prevalence of AIDS, and UN representatives have lauded the progress there. Each district has an MEC to advocate for its needs.Minister Motsoaledi informed the Committee about Harvard University’s lecture series for Ministers of Leadership in Health. The lecture found human resources, procurement, and supply chains are all generally subpar in developing countries. If these areas improve, healthcare in the country will improve.Minister Motsoaledi asserted that Health MECs will always be chosen by the Premier of that particular province. He said that this is a constitutional issue. HR, as shown by Harvard, is the first and most important building block.Minister Motsoaledi assured the Committee that violence in hospitals is not a new issue, and the NHI will freshly strengthen security. The MEC for Health and MEC for Safety and Security must work together and pay their security staff better so there will not be such a high turnover of security personnel. The healthcare provider must know their security personnel.Minister Motsoaledi explained that there are actually too many applicants for medical school admissions; we do not have enough medical schools. He agreed that Tambo needs extra attention, and he said that he has personally spent time there to work out HR structures.Minister Motsoaledi observed that studies on the number of doctors per population are not conducted properly or transparently. In fact, frequently there are too many doctors rather than too few. These studies now account for prevalence of sickness and poverty levels, among other demographics using a specific mathematical formula. This will take time and work with Treasury to iron out budget issues and provide the necessary specialists.The Chairperson emphasised that these matters deserve time and consideration. Minister Motsoaledi will visit the Committee again on 2 September to continue this event.The meeting was adjourned.High Level Panel Recommendations for Health Sector: Prof Shisana briefing07 November 2018Chairperson: Ms M Dunjwa (ANC)Meeting SummaryThe Committee was briefed by Professor Olive Shisana, Head of the High Level Panel (HLP), on the state of the health sector in South Africa, and the challenges faced with the implementation of the National Health Insurance (NHI) scheme.She said those with the worst access to health care were people in the lowest socio-economic group. Poor people were less likely to access good health care, despite the fact that it was very much needed. They would be found making use of services at primary health care (PHC) facilities and community hospitals, and seldom visited tertiary and academic hospitals, even when those services were available in the area. The poor were faced with several challenges to access health care. The cost of traveling was a barrier, as the health care facility could be far from where they lived.? Medical scheme contributions remained unaffordable to them. Another challenge was the low morale of staff and their attitude towards patients.Prof Shisana gave a detailed presentation on the principles the NHI sought to achieve, the benefits of a National Patient Information System, the role of community health workers, membership of medical aid schemes, and the challenge of providing adequate medical facilities in rural areas.Members recounted experiences indicating concern at the quality of health care available to poor and rural communities. They asked why courses from emergency medical services (EMS) paramedic personnel had been stopped, as they provided a vital service. They laid the blame for the current “crisis” in the health sector on poor management and leadership. They recognised that the population was growing while financial resources were shrinking, and questioned why there was no control over foreign nationals receiving free medication at local facilities. The NHI had been piloted for nine years, and a Member asked if it would remain a pilot scheme for ever.Meeting reportHigh Level Panel (HLP) Recommendations: HealthProfessor Olive Shisana, Head: High Level Panel (HLP) said the main thrust of the presentation would be on the implementation of the National Health Insurance (NHI) scheme, taking into consideration factors such as the state of health care of the South African population and access to health care.South Africa had exceeded its targets for improving the health status of the population. Life expectancy at birth had exceeded the 2014 targets by 2012, while the overall adult mortality rate had also decreased much faster, so there had been fewer deaths and funerals in the country. Under-five mortality, infant and neonatal mortality, had decreased by 10%. These dramatic changes had been ascribed to the government’s programmatic efforts which led to widespread availability of free antiretroviral therapy, free prevention of HIV transmission from mother-to-child programmes, and free immunisation against pneumococcal pneumonia and rotaviral diarrhoea in infants. However, during this time, problems with non-communicable diseases, such as diabetes, hypertension, cardiovascular and cancer had increased.Health rights were entrenched in the Constitution -- ‘everyone has the right to have access to health care services, including reproductive health care’ – but the HLP had many questions as to why there was inequitable access to health care. Those with the worst access to health care were people in the lowest socio-economic group. Poor people were less likely to access good health care despite the fact that it was very much needed.Specialist referral services remained less available to the poorest people. The poorest people would be found making use of services at Primary Health Care (PHC) facilities and community hospitals. The poor seldom visited health care at tertiary and academic hospitals, although these services would be available in the area. However, the poor were faced with many challenges, such as accessibility to tertiary and academic hospitals. Although these facilities existed, the poor continued to be unable to access them at the same level as those people who had the resources.? The HLP found that more challenges were faced by the poor when their medical aid insurances lapsed, even though they could still make use of the public sector higher level services.High levels of unequal access to health existed in the lowest socio-economic group in certain provinces compared to people living in the Western Cape or Gauteng, who received better health care.? People who lived in the rural areas of the Eastern Cape and Limpopo were faced with the worst access to health care services.???The poor were faced with several challenges to access health care. The cost of traveling was a barrier, as the health care facility could be far from where they lived.Medical scheme contributions remained unaffordable to them. A general practitioner (GP) might be located near to them, but these services remained unaffordable to them.They were then forced to travel past the nearest GP to go long distances to a clinic where they were most likely to receive health care for free.Another challenge was the low morale of staff and their attitude towards patients. The morale and attitude of health care workers should be noted with serious concern. Staff might be unhappy with their working conditions, which results in a negative impact on services rendered to people. An estimated 16% of the South African population has medical aid.National Health Insurance (NHI)Professor Shisana said that the views expressed by people from all walks of life throughout the country’s nine provinces called for the implementation of a National Health Insurance (NHI) scheme. Strong submissions were made at public hearings, particularly from the Congress of South African Trade Unions (Cosatu), who called on the government to implement the NHI as a matter of urgency. Cosatu had expressed the view that it was necessary to ensure health services for poor people.Although there was no unanimity on the population’s views, the overwhelming majority of South Africans said they wanted a NHI scheme. The written submissions from FirstRand, Econex, the South African Institute of Race Relations and Medi Clinic, and comments made at public meetings, indicated that the implementation of NHI would hold many risks, such as challenges with funding.These risks and challenges referred to had been articulated in the Government White Paper on the NHI, which was already a policy for the country, and both views had been presented. The written submissions made by several sectors which expressed risks and challenges for the implementation of the NHI, remained the views of a minority. The overwhelming number of submissions from the public gathered from throughout the nine provinces during a road show, were in favour of the implementation of a NHI.????There had been consensus that NHI should seek to achieve the following principles:The right to access health care: The NHI would ensure access to health care, as it was considered to be an important service which the State must be able to provide.Social Solidarity: The NHI would provide financial risk pooling to enable cross-subsidisation between young and old, rich and poor, as well as the healthy and the sick. This would mean people taking care of each other as South Africans. The solidarity principle would also serve as a guide towards the development of the NHI.Equity:? The NHI would ensure a fair and just health care system for all. Those who were ill should get services first.Health Care As A Public Good:? Health care should be seen as a social investment and not as a commodity of trade to be sold for profit.Affordability:? Health services should be procured at a reasonable cost. Should the cost be prohibitive, this could lead to the NHI not being able to offer health care to the whole country.Efficiency: Health care resources should be allocated and utilized in a manner that optimised value for money. The HLP had made it very clear that resources allocated to the NHI should be used appropriately.Effectiveness:? The health care interventions covered by the NHI would result in desired and expected outcomes in everyday settings. South Africans traveling through the country and in a need of health care, would see that the same treatment one would receive in Dzidane would not be inferior to the treatment received in the Western Cape.Appropriateness:? Health care services would be delivered at appropriate levels of care through innovative service delivery models and would be tailored to local needs. The health care services should take into account the cultural and social requirements within a particular area.Professor Shisana said in line with the concerns raised by the HLP, recommendations were made to Parliament to express its support for the introduction of universal health care coverage, underpinned by these eight principles.?National Patient Information SystemSouth Africa needed a unified health system to monitor equitable service provision to ensure that every citizen received the same standard of health care, whether in the public or private sector. Such a system could not materialise without a National Patient Information System. This would merely serve to monitor whether the services provided by the NHI throughout the country would be the same, equitable and accessible to the people.The National Patient Information System would also work in the interest of Parliament, with information on the following:Whether government was indeed eradicating the legacy of apartheid in terms race;Access to health care;How government was dealing with the gender issue;Distribution of aid;Whether the patient belonged to a medical aid or not;Where the patient lived in a rural or urban area/public or private facility;The social and economic status of the patient.The HPL would like to see the above variables legislated, to assist in finding out whether the government was getting anywhere near to ending the existing inequality in the health sector. The data systems of the public and private sector should be collated and placed on a data base which would enable the patient to access health records throughout the munity Health Care Workers?Professor Shisana said the HLP had expressed concern that South Africa was not moving at a fast enough pace to improve primary health care service delivery, and called on the government to institutionalise the ward-based outreach teams, the community health workers (CHWs). Community based care and health care could be improved with the implementation of the Community Health Programme. International evidence had proved that CHWs had made considerable contributions to improved health outcomes.???The long-term sustainability of a universal health system should be closely linked to the effectiveness of preventive and promotive interventions. This should be seen in the light of the growing burden of morbidity related to non-communicable diseases, such as diabetes and high blood pressure.The role of community health care workers was to reduce the burden on the health system by visiting and treating people at home with matters they could treat, and training people at the home level to test their blood pressure and sugar levels themselves. The CHWs had proved to be effective and key providers of preventive and promotive health services.The HLP had made recommendations that Parliament introduce legislation to allow CHWs to be formally employed within the public health system, and that they should be based at all Primary Health Care levels.At a recent health summit held about two weeks ago, the HLP made two recommendations. It had called for legislation for integrated and comprehensive data on resources and services. It had agreed? that South Africa needed one health system to ensure that everyone received the same level of health services from throughout the country.? The HLP was not talking about downgrading the current health system, but rather about improving it.Medical aid schemes had made submissions to the HLP on factors which had led to the raised cost of medical insurance. These included the requirement that each medical aid retain 25% of its annual expenditure in reserves, which they believed caused the bankruptcy of many medical aid schemes, as they were unable to invest the 25%. That situation had to be re-evaluated to establish whether the risks could be more efficiently managed, for capital to be utilized, and the Council of Medical Schemes should consider reducing the fees to consumers.Reforming health care system to improve qualityA the meeting on 24 August 2018 and the subsequent health summit, where the President and Deputy President made presentations on the health system, the HLP had admitted that the health system remained in a crisis.To sort out the health system, the following recommendations were made:??To centralise the allocation of health care resources, as once resources left the national government and went to the provinces, premiers might decide to allocate health money elsewhere.Establish public agencies for strategic services, quality assurance and other functions outside the Department of Health (DoH). A quality assurance body, known as the Office of Standard of Compliance, had been formed to ensure the delivery of services, and their quality. A proposal was made for a strategic partnering, which had become a global method along with a national insurance fund.? It was also known as strategically purchasing services, a fundamental change from the way in which the health system was currently operating. Such a National Insurance Fund to which the money was directed, would be responsible for allocating the money to a specific service provider on a contractual basis. The service provider would be responsible for delivering the quality services as required.To build more clinics and hospitals, especially a new hospital for Gauteng. The HLP noted that during the government’s first five years, the state had managed to build about 700 clinics, which was more health facilities than what had been built now.???Concerns had been raised by the HLP that many doctors and nurses could not find employment due to insufficient budget in the public sector. The HLP recommended that the private sector be allowed to train and employ doctors and nurses along strict training guidelines. The employment of doctors and nurses in the private sector could assist with the alleviation of acute shortages of health care professionals in the country.Professor Shisana said the lowest socio-economic groups in the poorest provinces continued to make the least use of health services. This could be due to the fact that of inadequate facilities, inadequate human resources and shortages of essential medicines. The HLP had made the following recommendations to Government:To build institutional and management infrastructure and skill levels of the public health sector by decentralizing the management authority to the individual public hospitals.To centralise the allocation of healthcare resources, by giving the power and authority to the individual hospital or clinic to do repairs where necessary.That the Department of Health establish public agencies for strategic purchasing, quality assurance and for other functions.Membership of medical schemesThe HLP health summit had discussed two recommendations on the whether membership of medical schemes should be voluntary or mandatory.The first recommendation was that medical schemes should be mandatory for the employed; those who refused would obviously have a problem in terms of accessing medical care. The employer should offer a panel of various medical schemes to employees to choose from. The HLP also discussed that it should be mandatory for employees to belong to a medical scheme to subsidise medical care for the poor.The HLP also made a suggestion for a two tier system:That the employed be compelled to pay for themselves through a medical scheme; andThat the National Health Insurance cater for the poor.Based on international evidence, the HLP raised concern that membership of mandatory medical schemes could lead to inequality in health care between the unemployed and the employed population group. The inequality would arise from those who earned more enjoying a better health scheme, while those who earned less would register with a cheaper medical scheme. The unemployed group would not have access to quality medical care.Professor Shisana said the HLP suggested that clear lessons should be taken from what was happening in other countries such as in Latin America, Germany, South Korea, etc, who started with a system in which only the employed were covered by a medical scheme. These countries had difficulties in changing their health system as people questioned why they should pay for health care for others. The HLP had reminded the health summit that social solidarity could not be implemented under a mandatory medical aid scheme system.The HLP advised it would be better for South Africans to decide whether they wanted medical aid or should not be forced to have it. The HLP made the following recommendation to Parliament:That Parliament address the matter by setting up an Independent task team.Such a task team should include all role players in the private and public sectors,That the task team should evaluate whether there should be legislation on voluntary or mandatory medical aid.Maldistribution of health care professionalsProfessor Shisana said concerns were raised by the HLP at the Health Summit that many health professionals were employed in the private health sector, whereas they could assist with improving the quality of health care in the public sector. Health professionals were mostly located in urban areas, especially metropolitan areas, whilst there remained a lack of health professionals in rural areas.A similar situation existed with community pharmacies, which were also mostly located within particular provinces in urban areas, and not as much in rural areas. There were eight times more pharmacies in resourced districts than in under-resourced areas. The HLP also called for the certification of newly qualified health professionals and for the regulation of licences to new pharmacies. The HLP admitted that the call might be viewed as controversial, but it was a necessary method. Based on the above concerns, the HLP proposed amendmends to the Medicines and Related Substances Control Act and the Pharmacy Act, and made the following recommendation to Parliament:That Parliament enact legislation which required the National Health Act regulations to be developed and promulgated to introduce a certificate of need for newly certified health professionals.That it also enact legislation to regulate the licences of pharmacies to ensure that new pharmacies should be located in areas where needed.???DiscussionMs E Wilson (DA) agreed that government has decreased adult mortality and infant under five mortality. There was a growing population in South Africa, but health services have not grown at the same pace, which was a serious concern. The Constitution states that the state must take reasonable legislative and other measures within the available resources to achieve progressive realisation of citizens’ health rights, but the country did not have these “available resources.” It was severely under-resourced. A basic right was that “No-one may be refused emergency medical treatment,” but currently there was one Emergency Medical Services (EMS) professional paramedic per 25 000 South Africans. It was severely challenging. The EMS had started with I, 2, and 3 courses, and the paramedics worked through a whole range of short courses.? As they took these courses, they had built up qualifications and gained the expertise to deal with certain situations to become an EMS. There was now a situation where all of these short courses had been stopped, and one could no longer take short courses to qualify. One had to go to universities, special colleges, or the Cape Peninsula University of Technology (CPUT).In the Free State, 200 students had gone to qualify as EMS and care workers, but the curriculum had been found to be not acceptable, and none of these students could be certified.? There were a lot of complaints. Many people had over the years completed lots of short courses and could no longer offer their services as medical care personnel, which they did voluntarily as they cared about their community. They were no longer recognised as a professional, which was a concern for me.Equity required the NHI to ensure a fair and just health care system for all. However, she had visited a clinic in Limpopo last week where three babies were born over the weekend by a cellphone torch light. There was no electricity, no water, the fetal monitor and sonars were not working; there was not an incubator and the suction machine was not working. One of the babies were born in severe distress because it could not be monitored while being transported from Mokopong to Mkalakwena That baby had died because the staff had not been able to pick up that it had to be born by caesarean section because of the level of distress., and not by normal birth.? She was terribly concerned when she hears that members of her community had been subjected to treatment like that in their local clinic.One had to look at the resources first, because one could not institute a NHI if one did not have adequate resources to do it. One of the issues raised had been to get the private sector professionals to assist in the public sector, particularly in the rural areas. The Department was currently sitting on R56 billion of medical malpractices cases, excluding the legal fees. The Committee visits hospitals on a regular basis, and some of the conditions it uncovers are quite horrific. One could not encourage health professionals to work in the public sector if they have to work under those conditions and expose themselves to potential malpractice cases. The could not work in an area which is under resourced, with no fetal monitor, and where machinery does not get calibrated and does not work.On the one hand, the health sector is severely under-resourced -- no money for infrastructure, no money for building hospitals, and no money for proper equipment for the health facilities. One the other hand, poverty has increased, and unemployment is at the highest level ever in this country, so one situation was being created, while another situation was collapsing as a result. A lot more had to be done. South Africa cannot progressively improve its health system without progressively improving the resources and infrastructure. She was pleased that the HLP agreed that the health system was in a critical situation and on the verge of collapse.Ms L James (DA) said she did not think that there was anyone in the Committee who could refuse health care to communities. They were aware that health was in a crisis, and commended the HLP for making very good recommendations. How did the HLP think the NHI could be implemented? Would it remain a pilot forever, especially looking at the challenges? For how long would it remain a pilot, because the NHI was desperately needed by the people?? She fully supported the community health worker programme and said that no country could rely on a curative system only, as it was too expensive. There had to be prevention and management as well. She supported the educational interventions, especially in public health facilities, as people did not know how to manage their high blood pressure, how to manage as a diabetic, how to inject themselves and how to take their medication. People really needed education and also monitoring, so there was communication between the people and the facilities. It took some parents a long time to understand that their child was on drugs, as they often thought the child was sick (umfunyani). More education and advice on health was needed so people could manage their wellbeing without going for treatment for petty illnesses.Dr P Maesela (ANC) commented that an NHI was supposed to cover everybody, regardless. Health was a constitutional right, but if one still wanted to have an elitist grouping somewhere, one could have one’s own medical scheme. Those who have would always victimise those who do not have. If the NHI is compulsory for everybody, one can go where one wants to get treatment and the insurance will pay. Individuals could also always pay extra for an extra consideration -- like having your cake and eating it. He recommended that the emphasis should be placed on communal health centres, instead of regional and tertiary health facilities. These should be well equipped and of high quality so that medical personnel can be trained to deal with specialised situations that cannot be dealt with at the policlinic level. He also urged that training should be carefully related to the country’s needs, to avoid a waste of resources.Mr A Mahlalela (ANC) said that one of the reasons the use of health services was the lowest amongst the poorest was that health services were inaccessible to most of the poor, and those in rural areas. How would the implementation of the NHI address this matter? The NHI would not change the socio-economic conditions of these people -- they would still remain poor – so the challenges that make it difficult for them to access health care services would still be there. He asked how the NHI would address challenges of the staff morale, which was a big problem. Interventions should be put in place to enable them to do their work, raise their morale and create a conducive environment to provide services to the community. He commented on the issue of affordability in the mandatory medical scheme, saying that the biggest problem was the affordability, and the result was that poor people would not be able to join.? Another challenge was that health professionals were unwilling to work in rural areas, so conditions should be improved to draw them to these areas. He questioned whether it should be mandatory for health professionals to work in rural areas, commenting that it was within their rights to decide where they would like to work and stay. He supported the proposal by the HLP to have community health care workers absorbed into the health system, but said he was not sure if this would require legislation so that they could become part of the public service. ?Mr S Jafta (AIC) said he also wanted to check what could be done to boost morale and improve the attitude of the staff.The Chairperson said there were urgent health sector issues which the HLP should have raised in its document. It was a known fact that management and leadership were the key factors in the health environment, and she had failed to pick up what the HLP expected from Parliament, and what the recommendations were which the HLP wanted Parliament to address. Ms Wilson had described the challenges which were happening, and she had just received an sms that two babies had died in a particular province because there was no oxygen. She asked Professor Shisana what she thought Parliament ought to have done, or should be doing. She was of the view that it was not all about resources, but also a lack of leadership. She quoted the HLP’s statement that “the health sector is in dire straits because the population has increased,” and said the health sector had been accused of not providing proper health care to foreigners in the country. Had the matter of foreigners come up during the HLP’s hearings, and what would it suggest for South Africa to improve on the situation?????Ms Wilson referred to the recommendation that the health budget needed to be re-assessed. It had been cut by R9 billion, which had caused a severe impact because sick people could not work and sick children could not learn. When one could not offer health services, it had a major effect on children’s educational progress. She remarked that there were no recommendations on prioritising health, why it should be prioritized, and reasons why budgets should seriously be re-assessed. The point she wanted to raise, which was also mentioned in the Auditor General’s (AG’s) report, was that the biggest struggle was the total lack of leadership, capacity and ability to manage. These were important factors, and that recommendation was not there.???????????HLP’s responseProf Shisana said the HLP was clearly engaging with health on a multi-sector basis, and not just dealing with health separately. This was why the Presidency had brought together all the government departments that had anything to do with health, whether it was public works, education, public service and administration, or health. The realisation was that one could not deal with health separately without taking into account other factors. The President’s approach now was to bring all the partners together, and therefore there had been a meeting on 24 August with the key stakeholders. At that meeting there had been an agreement that there was a crisis in the health system, so some of the questions being raised were within that context of a multi-sectoral approach.Replying to Ms Wilson’s concerns on the state of the clinic in Limpopo where a child had died because there was no electricity or water, she said these were issues which could be addressed in the health sector only if one broke it down together with other sectors. The provision of electricity and water was the responsibility of other departments, and that was the real challenge to the health system.Regarding the NHI outsourcing, Prof Shisana said no facility could become part of the NHI unless it had met the requirements of the Office of Health Standards Compliance (OHSC). This meant that all aspects of management, leadership and infrastructure-related requirements, had to be certified before the facility would be contracted. Facilities would be required to demonstrate that they had enough human resources, infrastructural equipment and trained people, and understood what they were supposed to do to ensure they would deliver quality services on the basis of primary and secondary care levels.On the question of paramedics and community health care workers, she replied that wrong decisions had been made to recognise only certain professionals as health professionals. She said the health workers -- the doctors and nurses -- viewed paramedics and community health workers as not being qualified enough, and had failed to realise the dangers and detriment to society when they pushed them aside. Commenting on the training and courses which paramedics and community health workers underwent, she admitted there were no clear curricula as to what community health workers and paramedics should be learning and where they should be placed.The HLP felt it was necessary to have legislation on community health workers in order to deal with them and ensure that the Health Professions Council recognised them. There existed professional jealousy among doctors and nurses which influenced them to protect their own turf, saying that health workers’ education allowed them to do only certain things. To eliminate this situation, the legislation of the Council should be changed to allow other professionals who were helpful to the health system to be recognised.Replying to the question about malpractices and legal cases against the state, Prof Shisana said the electronic information system on patients would be an option to reduce the number of cases. Such a data system would provide the patient’s complete medical history, and was less likely to go missing compared to files which were taken from one facility to another.Regarding the implementation of the NHI without resources, she said it would be implemented at a facility which had received its licence and accreditation. This would take place on a progressive basis and there would be no “big bang” approach due to the lack of resources.? It would take place facility by facility, and as the budget for health was increased.Referring to Ms James’s question as to when the NHI would be implemented, Prof Shisana agreed that the Department of Health had been piloting the scheme for nine years, which had not worked out. Reasons for the failure could have been that the Minister had experienced many obstacles and now that the President had taken leadership of the NHI, it was starting to take traction. National Treasury and the HLP had met to look at ways on how to implement a budget for NHI, and Treasury had provided the HLP with a document containing guidelines as to how government would fund the NHI. Once the Bill got adopted in Parliament, hopefully soon, it would allow the NHI to set up a Fund. There would be a quality improvement plan, which had been presented to a meeting of all key stakeholders in August on how the plan would improve health services. The plan was focused on standards to provide quality care according to international standards. It would be implemented at every facility and enable a well-functioned hospital to train a very poor clinic, which was unable to provide quality care. This particular clinic would then be monitored over a period of five years, to assess whether it had become sustainable and if the quality of health care services had improved.Referring to the status of community health care workers, Prof Shisana said said the HLP recognised the need to improve their skills and to develop an appropriate curriculum. They were busy with processes to train community health care workers in a more structured way with a common curriculum which would allow them to be incorporated into the health menting on Mr Mahlalela’s concern on the implementation of the NHI, she said everyone should be clear that the NHI was a national policy. Medical schemes would provide complementary services without duplicating the services provided by the NHI. The HLP agreed that medical schemes should be voluntarily and not mandatory.She said there were many community health care centres throughout the country which were supposed to provide comprehensive health services, beyond what the clinics were providing. On human resources, she said the Department of Health had a strategy for human resources, but not an operational plan to provide the necessary training.Responding to the question as to how the NHI would make health care accessible in rural areas where resources were scarce, she said the provision of resources started with Members of Parliament. South Africa spent about 8.5% of the gross domestic product (GPD) on health, and some of this money was paid to some MPs by the government to have health care in the private sector.? The NHI wanted to bring back the money which could be used to provide health care to people in rural areas. If people were concerned about equality and equity, then it had to start at Parliament. She called on MPs to demonstrate to the nation how much care they had for the rural and unemployed people. Thereafter, government could approach other spheres and entities like the South African Police Service (SAPS), Eskom, Transnet, etc, to bring money into the NHI. She said there was enough money in the country, but it was not being spent well due to fragmentation.Prof Shisana attributed low staff morale to the fact the some staff members were owed money by the state for overtime work, or the implementation of salary increases, or that the infrastructure at the health facilities were not in good condition -- such as leaking roofs, and lights which were out of order in the theatre. The NHI would be responsible for ensuring that the certified facility was capable of providing good services and was accredited to provide quality health menting on health professionals who refuse to work in rural areas, the HLP suggested that people in rural areas should be trained in health care to serve the people where they lived. The Cuban programme had medical students to Cuba for training and on their return they served their own rural areas.On the question of too many doctors concentrated in certain areas only, Prof Shisana questioned why licences continued to be issued to doctors who trained in such areas. The NHI would also produce a contract to doctors, stating posts available only in the rural areas. Conditions and infrastructure at rural health care facilities should also be of good standard to make it comfortable for doctors to work there, but it remained a choice for doctors whether to work in rural areas or not.Medical schemes argued in favour of the high costs, as they reported that more and more people visited doctors for minor illnesses. Prof Shisana commented that medical schemes tried to justify the high costs for reasons they believed in. However, what was obvious was that medical administrators were able to purchase very expensive and luxury vehicles, yet medical schemes were supposed to be non-profitable. The HLP had called for the cost of medical schemes to be reduced, even before the implementation of the NHI.Regarding leadership and management, she agreed that management needed to undergo changes. The NHI Bill which had been circulated for comment, had outlined a new model for management at hospitals. The Bill had recommended that chief executive officers (CEOs) at hospitals be given the authority, responsibility and autonomy to run their hospitals on the budget provided to them.On the issue of foreign nationals who received free medication in South Africa, she said it was a known fact that at the end of every month, many foreigners entered South Africa to obtain free antiretroviral drugs. In order to put a stop to this practice, the NHI would introduce an identity system which would be linked to the patient information system, which would then identify whether the patient was South African or not. However, legitimate foreigners and asylum seekers would have access to medication, and tourists should have their own medical insurance.On the question of the NHI budget, Prof Shisana said there was a need to investigate why the cost of building government clinics was much higher than that of private clinics. In this way, government could easily identify the wastage and it would help to determine a budget for the NHI.Ms James expressed concern as to how clinics would be certified without having a budget, and to make sure staff would get paid. She also asked for clarity on the position of environmental health practitioners at clinics, as they formed part of prevention and interventions.Mr Mahlalela asked when the NHI would be implemented. He hoped there would be no procrastination over the implementation.Responding to Ms James’s concerns as to how clinics would pay their staff without a budget, Prof Shisana it would mean re-prioritising the budget to address the problems health facilities might have, such as shortage of staff, equipment and the infrastructure. Specialists would be deployed to facilitate training and provide expert advice on matters involving patient referrals.? She confirmed the need for environmental practitioners, as they were very important. The HLP also had a general plan which brought in an international funding organization with experts from countries who had implemented the NHI, to share their expertise.She assured Mr Mahlalela that the implementation of NHI would take place very soon.The Chairperson said the Presidential Health Summit had been the first of its kind to be held in South Africa, which brought together all role players in the health sector. She urged those in the health sector to work together as a family and not in isolation. The issue of health workers “protecting their turf” indicated a mentality that was of no assistance to the development of health care in this country. She would like to ask the Office of Health Standards Compliance who cared for the carers.? She noted an incident where health workers at a hospital in Johannesburg had been physically assaulted by visitors who had come to see a patient.She commended the Office of the Presidency, the Department and all other role players who had ensured action on the NHI. She suggested that the Office of the Presidency and the national Department of Health also address the nation to provide citizens with a clear understanding of the processes leading towards the implementation of the NHI.????The meeting was adjourned.Hospitals: Western Cape & Gauteng Departments of Health06 June 2018Chairperson: Ms M Dunjwa (ANC)Meeting SummaryThe Western Cape and Gauteng provincial Departments of Health briefed the Committee on hospital services in their provinces.The Western Cape’s long term vision was not to focus on illness, but rather on wellness. It had recognised that health was a function of more than one department and had been diversifying its approach to providing healthcare. Although the Department was working hard to provide efficient healthcare to the population, it was facing many challenges. These stemmed mainly from budget cuts, and it had had to initiate programmes to cut costs. There was a R1 billion backlog with regard to the maintenance of infrastructure. Tygerberg Hospital had been identified as needing to be replaced due to its infrastructure problems and the service pressures it had to cope with. The Department had partially outsourced laundry services in order to cut costs as well as mitigate risks. It had been working on extending the life cycle of medical equipment in order to offset operational costs and redirect capital. Attacks on ambulances were also a major problem.Members asked questions about the management and governance stability of the Department, and were particularly concerned about how it was mitigating the safety risks to emergency medical staff, as well as the possibility of the replacing of Tygerberg Hospital. They also questioned what the Department was doing to facilitate transformation at the senior management level.The Gauteng Department of Health (GPDH) was strongly criticised for failing to submit its presentation documents on time, with the Committee emphasising that in order to perform its oversight responsibility, it had to have the information beforehand in order to engage the Department. Although the GPDH apologised, Members from the DA and EFF decided not to take part in the meeting.? With only a few Members present, the GPDH highlighted some of its key achievements. Life expectancy in Gauteng was said to be on the increase, and there had been an arrest in the growth of accruals – it had paid off the suppliers it owed R10 million and less, and had committed to pay off the ?big suppliers within 24 months. The lessons it was taking from Esidemi were being used as a guide for the Department. However, its budget was not able to sustain the significant burden of disease in Gauteng province.The internal challenges facing the GPDH included the high turnover of leadership, under-funding, a rise in medical litigation, ineffective decentralisation, sub-optimal involvement of patients, their families and stakeholders, and poor labour relations. Its decision on payment of bonuses had led to some of its employees resorting to vandalism. ICT projects were being hampered by the shortage of funds. With infrastructure, one strategy for improving finances was to hold off on new projects. The cost of employment was high, taking almost 60 % of the budget. This was attributed to the implementation of the occupation specific dispensation (OSD) and generous above inflation wage settlements over the last decade, without a commensurate increase in the budget.Meeting reportWestern Cape Department of HealthDr Mbombo, Member of the Executive Committee (MEC): Health, Western Cape, introduced the briefing on hospital services in the province by saying that unemployment, inequality and poverty probably impacted more on health than any other factor.Dr Beth Engelbrecht, Head of Department (HOD): Health Department, said it was important to show leadership at every level, even at the lower levels. The Department’s long term vision was captured in Healthcare 2030, and the focus was on wellness not on illness. The goal behind the whole of society approach was to positively change the story of people in the Western Cape. To do so required safety, social services and education.The Department remained under significant service pressure. It was doing the best it could with what it had. Violence had a massive impact on the life expectancy of men. One of the biggest pressures in the health system was the patient waiting times. The Mowbray Maternity Hospital was impacted largely by old infrastructure.Dr Keith Cloete, Chief of Operations: Health Department, said that the leading natural causes of diseases in the Central Karoo area were very much diseases of poverty. There were many hospitals in the rural areas, but they were much smaller. Tygerberg hospital was the one which experienced the most pressure in the whole province because of its size and location, and the smaller hospitals connected to it.The attacks on ambulances had been particularly worrying for the Department.The Department was implementing electronic referral systems so they would be able to monitor patients better at the primary healthcare level.Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, said that the Department had been working over the last few years to become a values-based organisation. There had been a focus on improving staff attitudes and the supporting work environment.Dr Engelbrecht said that the Department was working on optimising service potential and the operational efficiency of medical equipment. Clinical engineering skills were extremely scarce skills, so clinic engineers had to work across the board.In the Department’s budget, greater emphasis had been put on facility and infrastructure maintenance. All the strategies were to ensure that the Department could make the most out of what they had. The Department had made a conscious decision not to outsource the laundry services completely, as it was too sensitive an issue. It was working at reducing its linen losses.The big challenge was that the Department had a maintenance backlog of R1 billion. For the 2017/18 financial year, 50.24% of the budget was allocated for maintenance. The Council for Scientific and Industrial Research (CSIR) had assessed Tygerberg Hospital and said it needsed to be replaced due to its physical condition, sustainability and functionality. Even after the Department had spent R700 million on Tygerberg hospital, the maintenance work was not visible as it had been spent on sewerage, water and gas lines. It would cost around R10 billion to replace the tertiary part of the hospital, and the province was motivating the National Department to assist financially.Dr Vallabhjee said that the Department had recognised that information technology and information systems were very important, and had therefore developed a long-term vision for it. The systems they had implemented were not an end in themselves, but rather a means by which the Department could become more efficient. In the Province, they had a data centre and a unique identifier which could assist in tracking patients across the entire healthcare system.DiscussionMs E Wilson (DA) asked what the figures for wasteful and irregular expenditure were.Dr Engelbrecht said that in 2016/17, the Department’s fruitless and wasteful expenditure had been R7?000. In the past year, they could not find anything. The Department had worked hard at reducing irregular expenditure to a point now where it was below the level of materiality.Mr W Maphanga (ANC) asked how the Department was dealing with the Office of Health Standards Compliance’s (OHSC) findings in the Province. Were any changes being implemented?Dr Mbombo said that the OHSC uses its own measurements, and they had not necessarily been a reflection of the whole system.Dr Engelbrecht said that there were structures in place for accountability for finance and patient outcomes and the achievements of targets. There were also oversight visits done by senior management. Every hospital was required to take the OHSC’s reports very seriously. They were obliged to provide an improvement plan and were held accountable for the improvement processes they put in place. The OHSC also followed up on where the improvement plans had been implemented.Mr Maphanga asked what the status of the oncology services in the Province was.Dr Engelbrecht said that oncology started at the primary care level. The Department was looking at the whole spectrum of care and not only at the high end.Mr Maphanga asked how soon the Department envisaged the implementation of the strategies for improving patient experiences of care. Did it feel that the approach to improving staff attitudes would suffice, or should other be avenues explored? When would the review be available for Healthnet pickup points within the Metro? When would the electronic referral system start to function? How did the Department plan on mitigating the main challenges regarding the demand for higher wages?Dr Engelbrecht said that when negotiations took place at the national level for salary increases, there was no link to the budget that the province received.The Department had to work very hard to compromise between appointing more people and being able to afford increased wages. Staff safety, and particularly that of Emergency Medical Staff (EMS), was a major concern. There had been cases where staff Members had not been able to work efficiently due to post-traumatic stressMr T Nkonzo (ANC) asked for details on how the Department was eradicating wasteful expenditure.? What was the distribution of non-profit organisations (NPOs) and Community Care Workers (CCWs)?Had anything been done which had justified the decline in attacks on ambulances from January? Had there been any convictions? A case had been taken to the Western Cape High Court to indicated that the impact of that type of crime transcended petty crime, due to its impact on society. There had now been three people who had been sentenced to 12 years in prison for stealing a cellphone, but it remained to be seen whether that would have an impact on attacks on ambulances.Dr P Maesela (ANC) asked what people-centred care was. Does universal health coverage refer to the National Health Insurance (NHI) scheme?Dr Mbombo said that universal health coverage was an international initiative which no one could rationally reject. The difference between universal health coverage and the NHI was about the funding methodology.Dr Maesela asked if all clinics had clinic committees.Dr Mbombo said that they now had provincial legislation which recognised all committees at healthcare facilities and hospitals.Dr Maesela asked general progress in the Western Province, and why there was outsourcing, given the national policy focus on in-sourcing?Dr Engelbrecht said that they had to look at how best to render services with the resources that they had.Dr Maesela asked what transformation was like at the executive level.Dr Enegelbrecht said that the Department recognised that transformation at the senior level was a challenge. There were other factors beyond the control of the provincial Health Department, such as the Department of Public Service and Administration (DPSA) requirements for promotion. The whole of government needed to assist in this regard. The Department was working hard to ensure that they could change its profile, however.Ms S Kopane (DA) asked if CCWs were linked to healthcare facilities, and whether they were monitored by professional people.Dr Mbombo said that CCWs in primary healthcare facilities were linked to the facilities. In some cases there were professional nurses who monitored CCWs.Ms Kopane asked if the Department of Health was working with the provincial Department of Social Development (DSD) with respect to CCWs.Dr Mbombo said that they did work with the DSD as part of the broader strategy for health delivery.Ms Kopane asked for clarity as to the vacancy rate and its challenges.Dr Engelbrecht said that the Department defined vacancy rates for posts based on those that it had funds for. A 4% rate was largely reflective of the turnover.Ms R Adams (ANC) asked about the challenges of governance in the Department. How had it followed up on the Auditor General’s findings? How were infrastructure needs prioritised in the Province? How were the visits of CCWs being monitored?Dr Engelbrecht said that as part of the Healthcare 2030 plan, they were looking at infrastructure.Mr A Mahlalela (ANC) asked what the challenges in governance were. What was the Department doing about the governance challenges? How would it monitor the outcome of the strategies being put in place to enhance patients’ experience? What was the reason behind the difference in the internal assessment by the Department and the assessment by the OHSC, especially with respect to clinics in the Metro?Dr Engelbbrecht said that when the full report was presented, they would be able to see the full extent of the difference between the Department’s internal assessment and the assessment of the OHSC.Mr Mahlalela asked what the current situation was with regard to stock and system management at medical supply depots.Dr Engelbrectht said that they had a very tight payment system to check that their payments were made within 30 days. They were working very hard to ensure there were no delays in payments caused by invoice issuesMr Mahlalela asked what the share of the budget spent on primary health care (PHC) was.Dr Engelbrecht said that PHC received 40% of the budgetMr Mahlalela asked what the Department was doing to reduce pharmaceutical waste?Dr Engelbrecht said that they were even monitoring where the waste was being handled. The Department of Environmental Affairs (DEA) was working with them on doing inspections.The Chairperson asked from whom the Department was receiving medicine donations.Dr Engelbrecht said that because of the shortfall of the HIV grant, the National Department had given them donations of stock that it had sourced. They regarded that as donations, but it did go to the patients.The Chairperson asked for clarity around outsourcing.He also asked what had happened in the case where a patient had gone missing and was found decomposed.?Dr Engelbrecht said that the patient had a very advanced and incurable cancer. He had gone missing at Stellenbosch Hospital. The nurse had gone out for 15 minutes to fetch linen, and when she returned the patient was missing. They had called SAPS and searched the hospital, but no one had thought of looking in the ceiling, where the body was found.The Chairperson wanted to know what was happening at the GF Jooste hospital in Manenburg.?Dr Engelbrecht said that GF Jooste Hospital was a district hospital, and they were replacing it with a regional hospital due to the load of cases in that community. It would be the Klipfontein Regional Hospital. A site had been identified, and the business case had been submitted to the National Department of Health, and they were awaiting the final outcome. There have been engagements with relevant stakeholders.The Chairperson asked if the Department thought that demolishing Tygerberg Hospital would be cost effective. Why had the Department moved from wanting to refurbish Tygerberg Hospital to wanting to demolish it?She asked the Department about the allegation that they had stopped training nurses.Dr Engelbrecht said that the non-training of nurses was absolutely not the case.The Chairperson asked for clarity as to how the Department tracked patients using the unique tracking number.Dr Engelbrecht said they had 14 years’ experience working with the unique patient identifier in the province. They had worked very closely with the National Department in developing the national system.?Dr Maesela asked for more clarification on transformation.Dr Engelbrecht said that at the senior management service (SMS) level, 8% of the province’s staff was black.? The Department looked at identifying mechanisms to expose candidates for transformation in order to push them through. Every vacancy was seen as an opportunity to contribute to transformation. An example of how they were handicapped by the national Department was that it was national policy that one could not become an SMS member, or even short-listed and interviewed, unless one had fiver years’ experience in a deputy director post. There were also people in the Department who had been serving for years, and that contributed to the Department’s profile. There was also a need to balance transformation with institutional memory and governance stability.The Chairperson said that they would follow up the issues of transformation with the relevant parties.The morning session was adjourned.Gauteng Provincial Department of Health (GPDH)The Chairperson said that she had been informed that GPDH did not have the presentation documents ready, and that Members had not been presented with copies of the documents. She requested that arrangements be made to print the hard copies and have the copies e-mailed to them.Ms Kopane confirmed having received the document on e-mail, and that the document comprised 68 pages. She was of the opinion that GPDH was undermining their oversight authority and that it was not the first time it had come before the Committee ill-prepared. She said that on behalf of other Members of the DA, the party was not going to take part in the meeting.Dr S Thembekwayo (EFF) added that should the meeting continue, then it would fail to include advice from the content advisors, and confirmed that the EFF would also not be taking part in the meeting.Mr Mahlalela advised that the Committee should hear from the GPDH before taking a position on the matter.Dr Gwen Ramokgopa, MEC: Gauteng Department of Health, responded on the failure to submit the documents on time. She said the GPDH had been made to understand that the presentation would be on the annual performance plan (APP) and the budget, the documents of which had already been tabled and were public documents. The impression by the GPDH had been that it was to present a high level summary. She apologised for the miscommunication, and requested that the GPDH be allowed to present, and the Committee could deliberate on what had been presented at a later date.Mr Mahlalela said that the GPDH had not been asked to present on the APP, and the letter which had been sent to them had requested a presentation on specific areas. He added that the Committee should allow GPDH present, however, and the deliberations on what was presented could be done at a later date.Members from the DA -- Ms Kopane and Ms Wilson -- left the meeting, as well as Dr Thembekwayo from the EFF. The GPDH was thereafter allowed to present.Dr Ramokgopa began by highlighting a major achievement for the GPDH. An assessment had been done on the performance of the Gauteng provincial government, including the Department of Health, by independent panels and it had been discovered that life expectancy in Gauteng was on the increase. The success could be attributed to the control and management of HIV Aids.She also addressed the issue of socio economic determinants of diseases, including crime, drugs and unemployment, which were key determinants of ill health. On crime, she informed Members that the casualty sections at the hospitals were usually over-burdened at mid-month and end-month when people had been paid. The incidence of crime contributed significantly to interpersonal violence and accidents which overflowed during these periods of the month. She also advised that drugs contributed heavily to adolescent mobility and mortality.Though Esidemi had been an initiative of Mental Health, there were certain lessons which the Department had taken from the situation. These included the following:Realistic pricing of mental health carers -- the amount paid to non-governmental organisations (NGOs) to be reasonable in relation to patient care, so as not to compromise the quality of care;Risk assessment, thorough checking of NGOs’ capacity for licensing, type, and the number of patients that they could safely care for ;Adequate staffing for the care of mental health care patients;Policy decisions needed to be widely shared and discussed before implementation;Technical and clinical experts must be used where needed?to ensure patient safety and care.Other reflections by the GPDH included the monitoring and support of NGOs to assist them to meet minimum requirements for licensing. Some NGOs had had to be closed down where they did not meet the requirements and presented a risk to patients. She also pointed out that the GPDH wanted to ensure the Mental Health Review Board functioned as it was designated to by legislation in order to make the GPDH accountable. The health ombud had indicated that there had been undermining of board governance, and that the GPDH needed to monitor the mental health review boards to ensure core standard were complied with and maintained. There should also be a structure for consultations between the NGOs and the GPDH to avoid communication breakdowns. This would also include consultations with the family committees.On external pressures, she said that Gauteng had the largest population and that the budget had not increased to meet the population growth, including high rates of immigration and urbanisation. There had also been a 5% increase in the demand for public health services because of the increase in the quality of care. The National Health Insurance (NHI) dispensation would assist, but the GPDH was the most affected by cash constraints. She gave a comparison with other provinces, and pointed out that Gauteng was the worst hit, as it had experienced cash depletion as early as September of every year. There was need to align budgets with cash so that there was continuity of services.Previously, accruals had been building up by R2 billion every year since 2014/2015, but the GPDH had intervened and prioritised front line services, and the intervention had assisted in stabilising the accruals. It was not possible for any budget to carry this current burden of disease. The GPDH had an equivalent of about 10 epidemics at once including HIA/ Aids, tuberculosis (TB), maternal and neonatal heath, children’s health, diabetes, hypertension, inter-personal health, mental health, motor vehicle accidents, and cancer.She also pointed out that there had been research in the Gauteng city region on the impact of inequities, and it had been discovered that Gauteng still accounted for a large number of people who had medical aid, although the number was decreasing.Professor Mkhululi Lukhele. Acting HOD GPDH took Members through the internal challenges facing GPDH, which included the following:High turnover of leadership;Under-funding of the GDH;Rise in medical litigation;Ineffective decentralisation as a consequence of the cash constraints;Sub-optimal involvement of patients themselves, their families and stakeholders; andPoor labour relations. To deal with this, the GPDH had had a labour summit in the previous month.He also took Members through the top 20 risk factors the GPDH was facing, which formed part of the risk dashboard. The risks were as follows:Inadequate access to quality health services for mental health patients;Increase in maternal, new born, infant, child morbidity/ mortality;High death rate due to an increase in the number of HIV and TB infections;Inadequate resourcing of the Primary Health Care (PHC) reengineering programme. Gauteng was doctor-centric, and the GPDH still had to work on the community to start embracing primary health care;Serious adverse events;Poor quality of essential medical services’ referral/call system due to incorrect usage of the system;Shortages in pharmaceutical supplies;Ageing infrastructure and health technology;Non-adherence to prescripts;Lack of standardised information technology (IT) platforms to enable the provision of quality health care;Delays/late payments to suppliers (30 day payment period);Inadequate human capital management;Inability of supply chain management;Financial losses due to litigation;Inability to achieve medium term expenditure framework (MTEF) revenue collection targets. The GPDH was second in the province in terms of revenue collection, but it aimed to improve more on that;Fraud and corruption was still high;Fruitless and wasteful expenditure;Irregular expenditure; andInability to function in the event of disaster.He took Members through a graph comparing PHC headcounts for the years 2016/2017 and 2017/2018, which showed that there had been an increase of about 20 000 over the two years. The increase had been similar for out-patients.On complaints management, there had been an increase in meeting the target, and currently complaints were managed within 25 days.The TB default rate was high, especially in Sedibeng and Tshwane, and the GPDH had sent people to these areas to track the defaulters. There had been a slight dip in respect of access to medicine because some of the suppliers had not been able to provide the medicine, but patients had still got treatment, although it had been at a higher cost.Dr Lukhele gave an overview of the ICT projects which comprised the Health Information System (HIS). The Payment Clearing and Settlement (PAC) system had proved to be helpful, and the major challenge facing ICT infrastructure was the shortage of funds.On infrastructure, one strategy for improving finances had been to hold off on new projects. There were, however, some completed projects and other new projects which were under construction. The 2018/2019 priority was to upgrade hospitals to level 3 for Occupational Health and Safety (OHS). The GPDH was engaging the Department of Infrastructure Development (DID).The GPDH had five laundry services, some of which were based at the hospitals. The DID helped with the maintenance of the laundries, and the GPDH was working to improve the 52% efficiency of the laundry services.Ms Kabelo Lehloenya: Chief Financial Officer (CFO): GPDH, said that patient care was usually put at risk by accruals. Previously accruals had been going up by R2 billion every year, but the GPDH had been able at arrest the growth. Based on the recommendation of the intervention task team (ITT), the GPDH had received R1.5 billion from the Gauteng provincial treasury to settle accruals for the 2018/19 financial year. It had been able to deal with the accruals by paying off all those it owed R10 million or less, which comprised the small, medium and micro enterprises (SMMEs). There were, however, those who had not been paid because the invoices had been received but had not yet been matched. It had also engaged the big suppliers -- about 39 of them -- and had committed to pay these suppliers within 24 months. This would cut across three financial years. Should any other resources become available then GPDH would be able to pay the suppliers sooner. The provincial treasury had so far given the GPDH R4.8 billion to settle accruals.The GPDH reported on a cash-based system and not on an accrual basis, and had a target of spending 1/12 of the allocated funds, which translated to around 8.3%, every month. However, it had spent 9% in the month of April 2018 because of the accruals.? If GPDH were to exclude accruals, then cash payments had been 6%, which was impressive because it reflected controls within the Department. A financial intelligence tool was being developed which would ensure that what was reported was what had been incurred in the course of the month, in comparison to the cash availability. Central and tertiary hospitals were the main budget consumers.On compliance, the GPDH was fencing the budget to restrict it to current year needs, and was working on making payments within 30 days of receipt of invoices, as demanded by the Public Finance Management Act (PFMA).On the medico legal payment status, the GPDH had made payments of R125 million in the current year. There were various mechanisms it would put in place to deal with this, as the Minister had made it clear that the Department should not disadvantage patients because of paying claims.On improvements in the financial system, she said that previously GPDH had been requesting three quotations. It was, however, coming up with a method of standardising prices. It was also improving and converting requests for quotation (RFQs) to suppliers to contract, which would enable it to review contracts and control prices.There was a committed team looking into the area of irregular expenditure. This was being done together with the South African Institute of Chartered Accountants (SAICA). The GPDH was also doing away with month to month contracts which were not cost efficient. In terms of inventory management, if an item was not in the plan then it would not be bought.The financial intelligence tool alluded to earlier would help the institutions to become accountable. The approach adopted was that entities were not allowed to spend more than what they had.Services for health care waste management were outsourced to three companies, and these companies had been selected in an equitable manner. One of the companies, Buhle Waste, was a black-owned company, while another was Seane Medical Waste, which was an SME company. Both companies had been doing good work. The Department spends about R91 million per annum on waste management, and generates about 4.7 million kg of waste each year. The collected waste is removed and treated at a private approved treated plant.The GPDH spends about 60 % of its budget on salaries. For the current year, the amount spent on salaries was 57.5%, which translated to around R 26 billion. This was primarily because of the wage shock and employment surge. The implementation of the OSD and generous above inflation wage increases over the last decade had seen a wage shock in the health sector. The cost of a full time equivalent (FTE) employee had increased by an average of 10.6%. The headcounts had also increased, and the Department had added 25 000 employees over the decade. Money had had to be taken away from essential services to fund the cost of employment. She gave an example of last year, after the medium term adjustment budget, where R1.1 billion had been taken away to fund the cost of employment.Professor Lukhele said that the Department was investigating irregular expenditure, There had been a slow purchase of medical equipment because the bidding committee was not sitting regularly. It was currently outsourcing security, but it would do a security analysis to consider other options. as it had been discovered that the money paid to the security companies was not paid to the workers.The GPDH had four central hospitals and was sharing some of the workers with the universities. It was engaging the universities and work was in progress to finalise multilateral and bilateral memorandums of agreement (MOAs).The intervention task team had discovered a bloated team in the central office and a decision had been made to send some of the workers to the frontline. The GPDH was also working to include women and persons with disabilities in the Department, and to make appointments on a permanent basis. It had paid performance-based pay progressions to employees on salary levels 1 to 12 in December 2017. On 8 May 2017, it had tabled options to the unions on the intended payment of performance bonuses.The Department had 30 clinics providing 24 hour services, it was aiming to increase the number to 33. On contracting of community health workers, it had not been able to absorb them because of finances. It had, however, been paying them through Smart Purse Solutions, which had been effective.On governance and leadership, the GPDH had been looking at the clinics’ governance structure and the goal was to decentralise through five districts so that each district was able to handle its delegation. A task team had been established to oversee the decentralisation.Dr Ramokgopa said that the recovery plan for the GPDH would consist of the following areas:Reshaping the operations design and governance and stewardship for improved service delivery;Drive uniformity of performance and modernise information management and use for integrated decision making;Prudent fiscal discipline across all facilities;Strengthen human resources; andStrengthen clinical and non-clinical service outputs and outcomes.She stressed that the GPDH did not have a moratorium on posts and that it would prioritise critical posts. The majority of workers were patient-based, and the Department had decided that those who had performed above level four or five required recognition. It was difficult to justify not giving bonuses to other employees, but the GPDH had to prioritise the main areas. It was also not complaining about OSD, but there should be an equivalent increase in the budget. National grants to Gauteng had also been on the decline. She confirmed that she had been having meetings with the vice chancellors to see how the budget for the Department of Higher Education could assist in the training of health professionals.The GPDH welcomed the State Liability Amendment Act, since it would provide interim relief, but the budget should not come from the money set aside for patientsMr Mahlalela thanked the GDH for the presentation, but pointed out that the following areas had not been extensively covered:Pharmaceutical management system;Planned patient transport;Referral system;Medical equipment;Medicine availability; andGovernance and leadership.The Chairperson commented that the challenges experienced earlier in the afternoon could have been avoided. She reminded the GPDH that she was always available and that should it feel that the time given to them to prepare had not been adequate, they could always have asked for the meeting to be rescheduled. She confirmed that a communication would be made to the GPDH on when the deliberations on what had been presented would be done.The meeting was adjourned.Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health13 June 2018Chairperson: Ms M Dunjwa (ANC)Meeting SummaryThe Portfolio Committee on Health met with Northern Cape (NC), Limpopo, Free State and KwaZulu-Natal (KZN) Departments of Health (DoH) to receive presentations on the status of their hospitals, after having received a briefing from the Accountant General on their budget allocations. The meeting also sought answers to questions based on the recent report from the Office of Health Standards Compliance (OHSC).Highlights of the brief of the NC DoH included the reengineering process that had been focused on innovative ways to plan and re-align the budget, and the steps taken to reduce its accruals and capacitate the pharmaceutical section to ensure better service delivery. It also provided an overview of the health facilities, the status of care quality, medical equipment in each hospital, medicine management and availability, infrastructure planning and maintenance, progress on its human resources plan, challenges on emergency medical services and transportation, its governance and leadership, its financial systems, and delegations and referral systems.The Committee expressed concern about the statistics in the OHSC report, and asked the DoH questions about issues involving its specialists; accruals; emergency service personnel; the status of ideal clinics, the district health system, primary health care (PHC) and the burden of disease; the functionality of its 14 hospital boards; and its referral system. The Committee requested it to forward detailed written reports on the Kimberley mental hospital challenges, its Central Chronic Medication Dispensing and Distribution (CCMDD), its Institute of Certified Records Managers (ICRM) accreditation of district hospitals, its disaster preparedness, and its responses on OHSC report and medico legal claims.Limpopo DoH reported on its governance and leadership strategy, the district health system planning framework, its health care restructuring plans and its referral system. Other highlights included the its inability to cope with the burden of disease due to the unhealthy eating patterns of the community and the challenges of running 24-hour medical services, and the prevalence of diseases such as malaria and HIV/AIDS. There was a shortage of human resources, as it struggled to fill clinician and nursing personnel posts due to National Treasury (NT) under-funding. The chronic under-funding also resulted in equipment shortages, high pharmaceutical accruals, failure to upgrade infrastructure in facilities despite the higher number of patients being treated, a depletion of goods and services and an increased burden of medical-legal contingency liabilities. It asked for the Committee’s assistance to liaise with NT for the establishment of an academic hospital to resolve the issue of employing specialists in the Limpopo DoH.The Committee again referred to the statistics in the OHSC report, and expressed their concern over surgery backlogs, cancer patients and the attitude of clinical and nursing staff. It asked the DoH questions about its use of DDT in combating malaria; vacant clinical and nursing posts; strategies to recruit specialists and registrars; and infrastructure in mental hospitals. The Committee mandated the Department to address the attitude of health workers at public hospitals, malnutrition in the province, and to follow up on patients’ complaints.Both the Free State and KZN Departments said that the OHSC assessments had been done on a few poor facilities, and were not a representation of all the facilities. They both committed to correct the deficiencies that were identified in the report.FSDOH reported that it had strengthened the household approach to promote access to health care, and had consequently reduced the number of people coming through the facilities. It had conducted its own self-assessment and found that out of 32 hospitals, only four had scores of 80 % and above. It would focus more on improving the worst performing facilities. It also confirmed that it was busy with the roll out of the central chronic medicine dispensing and distribution programme (CCMDD). It was unable to retain specialists due to the long process of filling posts.? It had the State Information Technology Agency (SITA) providing the infrastructure network for the Department, although the progress had been slow. The TB defaulter rate was remaining high in Mangaung Metro, despite showing a decline in the other four districts.The Committee advised FSDOH to avoid exorbitant costs, such as the use of private ambulances in public facilities. It criticised the inadequate stock of contraceptives, but was informed that contracts for contraceptives were done at the national level and at times when the demand was high, the suppliers were unable to deliver. The Department was commended by the Committee for being the only province that reflected on school health and the MomConnect programme.KZNDOH reported that a new regional hospital, Pixley Ka Isaka Seme had been established and a new academic central hospital was still in the conceptual phase. There had been difficulty in attracting and retaining medical specialists at regional and tertiary hospitals in the rural areas and this had caused a strain on the KZNDOH referral system. It also reported that it had an aging fleet of ambulances and had a strategy to incrementally replace them The CCMDD had been rolled out in all 11 districts, and over 1.1 million patients had been enrolled in the programme. Financial delegations have been revised to empower the CEOs to procure up to a maximum of R 500 000 directly at institutional level, but the head office still did a lot of oversight. All hospitals have network connectivity, and attention had been given to all PHC sites to make provision for data-based connectivity services ?by the end of the 2018/19 financial year. There had been instability in top management due to the attrition of HODs, DDGs and CFOs. All of the posts had been advertised -- some more than three times.The Committee welcomed the progress on oncology at KZNDOH, and commented that it could see an improvement in the Department, compared to the previous periods.Meeting reportThe Chairperson welcomed Members, the teams from the four provinces’ Departments of Health, and said the Committee’s major concern was that after receiving briefs from the Accountant General, it needed to receive detailed briefings on the status of the hospitals in each province. The Committee had received a report from the Office of Health Standards Compliance (OHSC), and would be asking questions about the hospitals, based on it.Northern Cape DoH: BriefingMs Fufe Makaton, Member of the Executive Committee (MEC): Department of Health, NC, provided a broad political overview. She said the NC DoH had gone through a re-engineering process for the 2018/19 financial year. She had engaged the community and the DoH when she had joined in February 2018 and had observed that the staffing budget was inadequate, and that it had negatively impacted on service delivery in the Province. The reengineering process had focused on innovative ways to plan and re-align the budget. This had involved engagements with the Premier to reduce accruals that had negatively affected service delivery. The reengineering process had also identified the cost-saving drivers in the already tabled budget, and had capacitated the pharmaceutical section to ensure better service delivery.Ms Thembi Mazibuko, Acting Head of Department (HOD): NC DoH, gave an overview of the health facilities in the province. These included 126 fixed primary health care clinics and 33 community health centres, 11 district hospitals, one specialised, one regional and one tertiary hospital respectively. She described the status of care quality, the medical equipment in each hospital, medicine management and availability, infrastructure planning and maintenance, progress on its human resources plan, challenges on emergency medical services and transportation, its governance and leadership, its financial systems and delegations and referral systems.She also highlighted NC DoH risk management profile, the state of its laundry services, its security services, its information communication technology (ICT), the status of its health care risk waste, and updates on tuberculosis and primary health care. She said that the 5% reduction in the Department’s budget allocation had led to a shortfall estimated at R1.8 billion. She also gave details of the employment and training curriculum of community health workers.DiscussionMs E Wilson (DA) asked about the number and types of specialists in the province. She asked the MEC to confirm the kind of accruals she started the financial year with, and also requested updates on wasteful expenditure and medical legal cases.Dr P Maesela (ANC) asked if the NC DoH had a chief financial officer (CFO). Why had R12.6 million been allocated for maintenance repairs in 2017/18? Did it have enough competent pharmacists and pharmaceutical centres? Did it have outdated medicines or stock-outs? He asked why it was taking long to repair its lifts and why it did not have outlined plans, with costs and time frames, on its maintenance projects. He sought clarity on why the NC DoH had 86 operational ambulances and 688 personnel. He wanted an update on respiratory diseases, an explanation of its process of referrals, and why it had a 49% high risk for obstetrics. Was laundry and security presently outsourced? What was the time frame to upgrade to in-sourcing?Dr S Thembekwayo (EFF) observed that the OHSC report had identified that the leadership and corporate governance of NC DoH was at risk, so she asked the team to state the contingency plans to reduce the risks in this area by at least 50%. She expressed concern over how it recruited its leadership, because the OHSC report criticised the leadership in charge of clinicians for not having documented job descriptions for departmental and sectional heads. The OHSC report also indicated that medicine physical stock supply did not correspond to inventory stock, so she asked NC DoH to state the steps to curb the trend. The report also indicated that it either did not have disaster preparedness plans, or they were outdated. She expressed concern that the continued acting position designations affected staff performance. Why had a new contract been signed for outsourcing security in November 2017? She also asked the team to confirm if catering and gardening were still being outsourced?Mr T Nkonzo (ANC) observed that eight of the 11 district hospitals provided 24-hour operating theatre access, and asked if these hospitals experienced challenges with referrals from regional hospitals. He asked how many lifts were being maintained. He wanted feedback on the functionality of the 14 hospital boards that had been appointed, and also asked about the time frame for the establishment of the review boards at mental hospitals.The Chairperson asked the team how it would increase the number of emergency service personnel and how they would be trained. She asked about the status of ideal clinics and the district health system, and the challenges with self-referrals at the primary health care (PHC) level. She observed that 121 PHC structures had been appointed and asked about the integrated approach in place to ensure that the facilities were not clustered in one area. Were all 14 hospital boards functional? What were the timelines for establishing mental health review boards (MHRBs), particularly its training and induction time frames? Why did the Department not have information technology (IT) staff when unemployed graduates from institutions in close proximity were available? She asked the team to provide a breakdown of its burden of disease, particularly tuberculosis and mental health. She also asked which district hospital had attained Institute of Certified Records Managers (ICRM) accreditation. She asked the team to send detailed written reports on Kimberley mental hospital challenges, centralised chronic medication dispensing and distribution (CCMDD), ICRM accreditation of district hospitals, disaster preparedness, and responses on the OHSC report and medico legal claims.Northern Cape DoH responseMs Makaton committed to submitting the reports itemised by the Chairperson, and said that her team would visit the OHSC to address the complaints. The inspection report submitted had been for the 2016/17 financial year, but the DoH was awaiting the 2017/18 report, and she promised that there would be improvements on the governance issues itemised in the OHSC report. She had now been registered on the stock visibility register on drugs, so she would be able to monitor the stock as well. The earliest time frame for in-sourcing was February 2019. She had not indicated that she was already working with stakeholders on Emergency Medical Services (EMS) training -- the DoH had been able to convert some vehicles to ambulances, and this had allowed the province to employ more EMS staff and capacitate them as well. The report on ideal clinics had been completed and would be sent to the Committee. The recruitment of IT personnel had been suspended because they would be sourced after jointly completing the Department’s organisational structure with the Department of Public Service and Administration (DPSA). It had put plans in place to improve its EMS, and was compiling its mental health report which would be submitted to the Committee after it was completed in July 2018.The Chairperson said she had asked for feedback on the mental health institution because there were challenges with the construction of the facility.Mr Stephen Jonkers, HoD: DoH, said the confirmation of acting positions would be done after the organogram had been approved by the DPSA. The outsourced security appointed in September 2017 had been advertised in 2014, while all cleaning and laundry services were in-sourced. A task force team had been initiated to work on the R1.4 billion medical-legal claims, and it had made big strides in dealing with the cases. Some of the cases had been going on since 2014. Most were due to cerebral palsy. A lot of the cases were still in court, and the Department would provide detailed written reposes on the cases to the Committee.Dr Dion Theys, Medical Director: DoH, gave the statistics of Health Professions Council of South Africa (HPCSA) registered doctors in the province. He said there were 30 specialists, of which 27 were in Kimberley hospital, and three in Upington. The Department had been struggling to fill the position of a lead specialist obstetrician and gynaecologist for some time. Although it did not have a lead specialist, the facilities undertook operations and babies were delivered. Statistics had shown a slight increase in cardiac arrest cases at Kimberley hospital, which was a tertiary hospital that offered referrals on cases that could not be treated without specialists. There was no lead cardiologist in the province, but as from 1 August 2018 a lead nephrologist would take up the registrar’s position. The DoH had an oncology specialist, two radiologists and one paediatrician. There were three specialists at the Dr Harry Surtie regional hospital, one general surgeon and two paediatricians. The DoH had a three-year maintenance contract in place with service providers, had regular routine maintenance on laundry facilities, and was currently running a fire fighting equipment maintenance programme. Maintenance activities also existed for the Department’s buildings and structures.Mr Daniel Gaborone, CFO: DoH gave feedback on the accruals, and committed to send detailed reports to the Committee.Ms Wilson asked for an update on medical claims.Mr Mothuli Ntulelo, Director: Monitoring and Disaster Management, said the Department had 86 ambulances and 688 personnel because the personnel worked on a shift basis, and four shifts were maintained. EMS standards mandated that eight personnel be attached to one ambulance. The DoH needed about 120 ambulances, so it was working on increasing its EMS personnel to 960. It had a college in the province that trained students. It was presently seeking to be accredited to train 54 students and was planning to get accredited for two-year courses.The Chairperson requested that the reports on EMS should contain statistics that reflected age, gender, race and category of staff.The MEC asked the Chairperson to provide a timeframe for presenting written reports to the Committee. She said National Treasury had sent a memo on accruals that had included queries on irregular and wasteful expenditure to her office, and committed to give the Committee feedback on the memo.The Chairperson remarked that she was pleased with the first impression she had received on health services in the Province. She recalled that she had communicated the case of an accident patient and the MEC had acted swiftly to give the patient a referral, because the facilities to treat the patient were not available where the accident had occurred. She said the MEC still needed to sort out issues of dirty institutions, time wastage and an environment that was not conducive to healing at the hospitals. People complained about the attitude of porters, general assistants and cleaners.She advised the MEC to work on its EMS because it was not the only province that had bad roads and long distances. It needed to address the issues of the medical legal claims and improve on its HR management.Limpopo DoH: BriefingDr Phophi Ramathuba, MEC: Health, Limpopo,? referred to the Department’s governance and leadership, the district health system (DHS) planning framework, its health care restructuring plans and its referral system. She said that clinicians in the province could not cope with the burden of disease due to the unhealthy eating patterns and the challenges of running 24-hour medical services, because the province initially had four-roomed houses that could not accommodate lots of clinicians and nursing personnel. Limpopo was also challenged by a shortage of human resources, as it struggled to fill clinical and nursing posts. National Treasury (NT) did not understand that the DoH had to appoint more nurses to assist with treating patients.A security alliance had worked in areas where Traditional Councils had assisted with securing hospitals in the province. The attitude of nursing staff could change with training, because they were presently overburdened with the roles of cleaners and health registration personnel. An analysis of the value of additional doctors in Limpopo had made its leadership decide that it was better to post doctors to district hospitals, rather than employ them at the national hospitals.She gave an update on the referral system, and said that there had been an increase in the unnatural deaths of people in the age range of 15 to 59 as a result of diabetes and hypertension. She attributed these unnatural deaths to unhealthy eating patterns and the lack of exercise in the community. Hospital CEOs were now called to account for maternal deaths. Although there had been a reduction in deaths due to malaria, there were still challenges in malaria management because of DDT shortages.The challenges in the Department were the budget deficit, unsuitable policies, and inappropriate staffing, which limited the critical clinical personnel due to limited funding from NT. Limpopo needed an academic hospital that would attract specialists to address complicated cases. Total maternal deaths in the Province had reduced from 225 in 2014 to 185 in 2017, and a state of the art mental hospital had been commissioned in Ledwaba, Limpopo. She said pharmaceutical medicine delivery and management models did not address each other, so she appealed to the Committee to intervene on malaria drugs, because it was a sole-sourced item. Also, most of the pharmaceutical depots obtained drugs through transversal tenders controlled by NT, so NT should give the Limpopo DoH the difference on the drugs’ quoted prices, because it facilitated the supplementary contracts.Limpopo DoH was challenged with speciality medical equipment. Presently, oncology and renal dialysis equipment was outsourced through public private partnerships. The 45-minute target on EMS and patient transport was a challenge due to bad roads and long distances within the Province. Ambulance thefts had been addressed through the installation of tracking devices, but some ambulances had been destroyed by the community during protests. The key HR interventions were restructuring, prioritising and rationalisation and filling of its critical core and non-core positions such as cleaners, ward attendants and porters to improve service delivery.Mr Justice Mudau, CFO: Limpopo DoH, said that the Department’s year-on-year equitable share allocation had been slightly reduced in 2018/19 compared with 2017/18. To accommodate the slight increase in compensation of employees (COE) allocations, there had been a reduction in allocations for goods and services, transfers and subsidies, and payment for capital assets. The chronic under-funding had resulted in a shortage of specialist services, equipment shortages, high pharmaceutical accruals, a failure to upgrade infrastructure in facilities despite a higher number of patients being treated, a depletion of goods and services and an increased burden of medical-legal contingency liability. Despite these challenges, Limpopo DoH had developed a turnaround strategy approved by the executive committee (EXCO), which involved reducing the medical-legal contingency liability.DiscussionMs Wilson expressed concern over the use of DDT to combat malaria, because the Stockholm Convention had banned its use. She was also concerned about the surgery backlogs and the fact that cancer patients had to wait for 12 months to be referred because there were no oncologists. She asked for an update on challenges due to seizures and delivery during births. She corrected a purported reference of the MEC to a statement that HIV and AIDS was a black man’s disease, and said that it affected all races. She was worried by the OHCS report that the Giani training centre was disgusting, and people were leaving. The transportation of patients in emergency conditions were inadequate and Limpopo did not have disaster management in place, despite the fact that it shared borders with a country which had issued an alert on cholera. She also expressed concern about the attitude of clinical and nursing personnel, and attributed this to the increase in medical legal contingency liability. The increase in the mortality of young people could be attributed to malnutrition and starvation, not necessarily the unhealthy eating habits as mentioned by the MEC, because 60% of the Limpopo community survived on grants.Mr Nkonzo asked the team to state the strategies to fill the vacant clinical and nursing posts, and to provide action plans and timelines to resolve the challenges of the Limpopo DoH.Dr Thembekwayo said the OHSC report on patients’ rights and dignity had indicated that the average domain score was less than 50%. It had mentioned that patients were not treated in a caring and respectable manner because there were no records. The Limpopo DoH also did not have patient satisfactory surveys on clinics and hospitals, so the Committee could not ascertain if the patients were being treated in a satisfactory manner. The OHSC report on patients’ rights and dignity average domain score on continuity of care was 26%. This was evidenced by the fact that the files of patients transferred to other hospitals did not have referral letters. Also the average domain score on complaints management was 34%, which showed that patients were not monitored correctly. She also expressed concern over patients’ waiting time and waiting areas. The food services’ average domain score was 45% and one of the hospitals served only “pap” (porridge) without any accompaniment. She asked why security was still outsourced, and asked for timeframes on in-sourcing. She asked if cleaning, gardening and catering was still being outsourced and the timeframes for in-sourcing these services.Dr Maesela asked for updates on the mission hospital and the strategies to recruit specialists and registrars into the Limpopo DoH. He asked the team to state strategies to upgrade its infrastructure to enable it cope with the increased number of patients, and its strategy to address the shortage of clinical and nursing personnel.Limpopo DoH responseThe Limpopo DoH acknowledged the report of OHSC in its infancy, because such surveys had not been done before. Although the report considered a three year sample size of 17%, and had looked at the worst performing hospitals in the province, the Department had taken note of the complaints and was committed to making improvements. The Committee should note that the report had indicated that provinces like the Western Cape (WC), which had better systems, had shown no improvements, which indicated that greater challenges existed. Also, the OHSC reports showed that there was attrition in urban provinces like the WC, although it was more apparent in rural provinces like Limpopo.The Limpopo DoH had the drugs, but they were not being distributed and this would be addressed. The report had raised concerns on the attitude of clinical and nursing personnel, but they behaved behave better when they were in private hospitals, and the DoH would also address this. The OHSC report had shown that provinces like Limpopo that did not have teaching hospitals had oncology challenges. The province had only one oncologist, but the DoH had signed contracts with private hospitals to alleviate the oncology challenges.The Department had noted the complaints of ill-treatment in district hospitals, but requested detailed information from the Member to ensure that it could handle the situation. It had a complaints box that was opened jointly with the management of hospitals, but it also received SMS’s that were not detailed, so detailed reports from the Members would go a long way to addressing complaints. A lot of patients bypassed out-patient care because the PHC facilities were not enough. Each CEO would account for PHCs under their control.The interventions on the turnaround strategies were explained. The posts of senior clinical and nursing personnel were been filled by restructuring, as mentioned by the MEC. The DoH had started electronic filing to curb the problem of the space needed to house the files. New categories of food service aids, supervisors and managers were being introduced to create employment opportunities in the community. A dietician position had been added to the new organogram. Ideal clinics would address patients’ experience of care through the surveys that would be conducted.It was not advisable to employ registrars if clinical and nursing staff had not been employed. The, DoH had therefore sought the assistance of NT to build central hospitals, and academic hospitals would be next in the drive to build clinical and nursing capacity. The infrastructure in place did not allow the Department to fulfil targets on child and adolescent psychiatry, so they were presently accommodated in the adult section.Dr Ntsie Kgaphole, Head of Department (HoD) said the team had noted the names of personnel who had been complained about, and the necessary action would be taken. The action plans for revamping the Department would be shared with the Committee after presenting it to the EXCO. Postings were being prioritised, and doctors who had completed their internships were being posted to areas where they were needed most. Equipment maintenance had been awarded to service providers. Local authorities had given a piece of land for a Musina hospital, so the national DoH was addressing its establishment.Dr Ramathuba said the team had a strong Facebook and Twitter presence, so it responded to accident communications by involving EMS personnel. Acting employees were placed on probation for 100 days and were made permanent after they had turned things around. The Bela Bela clinic structure had not being handed over to the Department because there was a contention between the Department of Public Works and the contractor.Musina Hospital was part of the National Health Insurance (NHI) challenge because it had few facilities, but despite this, it had recorded zero maternal deaths. She had to give an award to the midwives at the hospital that had delivered triplets safely and without complications for a patient that had come from across the border, without even knowing the patient’s medical history.She agreed that poverty contributed to malnutrition and disease, so the team had created the dietician post to assist the community to eat properly and exercise. The older generation did not die early from diseases like diabetes, because they ate right, and grew beans and vegetables. The new generation, however, ate junk food and did not exercise, so they died early as a result of diseases such as diabetes.Malaria had increased when DDT was banned, but the World Health Organisation (WHO) had exempted DDT for use in public health. The WHO’s position was that DDT was banned in agricultural use, and this position could be forwarded to the Committee. The other product used to substitute DDT had led to more deaths, because the female anopheles mosquito had developed resistance to it.She corrected the impression that she had said AIDS was a black man’s disease. The City Press had had to issue a retraction on their earlier story. Her contention had been that HIV/AIDS was prevalent amongst the black race, but the funding was with whites. Black people lived in poverty and engaged in sleeping with older men, which was why HIV/AIDS was prevalent amongst them. There were no white home-based carers or lay workers, so if HIV/AIDS was to be addressed, funding should be placed where it was needed.The Chairperson said the country needed to sit down together to address certain issues by speaking about them to ensure that people were healthy and embraced healthy eating habits. The DoH needed to address the attitude of health workers at public hospitals, because when the same health worker worked in a private hospital, he/she behaved better. Malnutrition needed to be addressed. The older generation ate right and exercised, so they did not die early, while the younger generation received grants, did not eat right or exercise, so the burden of disease was high and they died earlier. She asked the MEC to give her numbers so that the Committee could follow-up on complaints.The OHSC report of 2016/17 had been informative, and the Committee was awaiting the 2017/18 report. She informed the MEC that the only weakness in Limpopo’s brief had been that it had referred to issues that it had dealt with before, but had not informed the Committee of the progress it had made in resolving the issues. She requested that the Limpopo DoH submit written reports within 14 days on areas where the Committee needed more information.Free State DoH: BriefingDr David Motau, HOD: FSDOH, said that at a time when health was under strain, the Department used the district health system based on PHC principles. PHC services were rendered through different settings within the communities, such as households and schools. Hospital services were provided through 25 district hospitals, four regional hospitals, one specialised psychiatric hospital, one tertiary hospital and one central hospital. EMS was crucial in ensuring consistent accessibility of the different levels of health care through the referral system. Comprehensive priority health programs were rendered across all the levels of the health care system, and included HIV/AIDS, maternal, TB, child and women’s health, as well as communicable and non-communicable diseases.To promote access to health care, FSDOH had strengthened the household approach. In this way, it had been able to reduce the number of people coming through the facilities. He informed the Committee that there was proper alignment of other districts when it came to access of health care, except for Mangaung metropolitan hospital. On access to antenatal care, FSDOH was doing well except for the small Xhariep district.FSDOH had conducted its own self-assessment on the quality of health care, and had found that most of the facilities performed below 80 % -- out of 32 hospitals, only four had scores of 80% and above. The Department would focus more on improving the worst performing facilities. On the overall performance of ideal clinics during 2017/18 year, it had improved slightly in terms of numbers, but it was not where it wanted to be. On patient safety/clinical governance and clinical care, FSDOH was committed to focusing on facilities that were not doing well. ?The medical equipment acquisition plan had been developed and a bid for various equipment had been concluded in 2016. The contracts awarded included the maintenance plan for a period of five years. Redundant and obsolete equipment in the facilities had been identified, collected and put in a central place in preparation for disposal.Dr Motau took Members through the audit findings on the management of pharmaceuticals. The Auditor General of South Africa (AGSA) had previously expressed a qualified opinion on accounts payable due to differences between supplier statements and accounting records of the trading account .Pharmaceuticals were procured, warehoused and distributed from the medical depot, which was licensed with the NDOH and Medicines Control Council (MCC) until 2021. Health facilities were allocated budgets with which they procured their own medicines from the depot. FSDOH was busy with the roll out of CCMDD process. Challenges in the process include external pick up point (PUP) contracts being signed late, patients losing interest, rejected/script renewals and the change to new service providers which affected new enrolments.He reported on the progress in addressing AGSA’s findings, and the interventions which the Department had implemented:Improved turnaround time for payment of claims to improve cash flow;Vacant posts filled – four pharmacists have been added to the team;Depot Treasury task team had submitted its report;Depot licensed and registered with MCC/NDOH and the South African Pharmacy Council (SAPC). The licence expires in 2021;No progress on the acquisition of IT infrastructure and equipment for Rx solution;Implementation of a Stock Visibility System (SVS) in 94 % of the facilities;Pharmaceutical and Therapeutic Committees (PTCs) were running, but the challenges at the district level were the shortage of staff and inept attitude among the staff.He gave a breakdown of the medicine availability per hospital and the medicine availability at level 2 and 3 hospitals.On Human Resources FSDOH had a total staff establishment of 21 617, but only 17 151 had been filled, so there were 4?466 vacant posts -- a vacancy rate of 20.66 %. In 2017/18, 1 744 had left because of retirement, attrition and resignations. It had been unable to retain specialists due to the long process of filling posts.? Submissions needed to be approved by Treasury, and the process may take from two to six months. Posts not filled within six months were abolished, as per Department of Public Service and Administration (DPSA) guidelines. The medical training platform for FSDOH was at Universitas Hospital, FSDOH had signed an MOU and there were joint appointments between the University of Free State (UFS) and FSDOH. All four regional hospitals were accredited by HPCSA as training platforms for medical interns.The one psychiatric hospital had total staff of 730, and the key positions at the hospital were psychologists, psychiatrists and nurses .The Department was revising the HR plan for 2018/19-2020/anisational development had commenced with the restructuring of the staff establishment. Performance was managed in terms of the Performance Development and Management System (PDMS) policy. Recognition of improved qualifications had been implemented since 2013. Overtime requests were approved prior to working and there was strict adherence to 30% of the official’s basic salary. In-sourcing of kitchen staff in Bongani, Manapo and Free State Psychiatric Complex (FSPC) hospitals would be completed by the end of July 2018. In-sourcing of security staff in Bongani, Mofumahadi, and Manapo Mopeli would also be completed by the end of July. There had been an improvement in governance and leadership, and the Department was working on the challenges.FSDOH had two financial systems that addressed patient information and revenue collection:A sourced system, which provides patient information, clinical information and billing of patients;A Patient Archiving and Documentation System (PADS), developed in-house, which is used for admission and billing of patients.All institutions and district offices had access to financial systems. The Department required a full complement of administrative personnel in order to effectively administer daily activities. Officials that were operating the systems were trained by provincial Treasury prior to commencement of their duties. The reliability and credibility of the PADS system was still not adequate, since system crashed and recovery was difficult due to lack of support. Budgetary control on the procurement of pharmaceuticals was still not effective, since it was done manually. FSDOH had the State Information Technology Agency (SITA) providing the infrastructure network for the Department, SITA had been requested to assist, but progress had been slow.Dr Motau referred to the Department’s budgeting process, and gave an example of conflict with Treasury over the compensation of employees (COE). In spite of a Treasury instruction for COE to be reduced by 0.05% in 2016/17, COE had been increasing from 63 % in 2011 /12 to 66 % in 2017/18, leading to a crowding out of goods and services.FSDOH had been working hard and after 13 years it had been able to get an unqualified opinion from the AG. The total irregular expenditure for 2016/17 had been R4.416 billion. Investigation was progressing currently, and more than R1 billion of irregular expenditure was expected to be finalised in 2017/18.It had a plan to incrementally train EMS personnel to a level where these personnel needed to be in terms of the regulations. It needed 274 ambulances, and would be adding 15 more ambulances in this financial year. On aero medical services, a total of 60 hours were available to be used for flying with patients or specialists, and unused flying hours were carried over to the next month. The aero medical service was used for intensive care unit (ICU) transfers, major incidents and outreach programmes.Provincial EMS capacity had been improved, and a total of 1 498 officials had been trained. Dedicated PHC ambulances had been introduced at some clinics to improve the waiting time for referrals.One strategic risks identified for 2017/18 was the contingent liability of R1.9 billion for medical negligence claims. Dr Motau informed the Committee that the Department had uncovered a scam involving employees and lawyers sifting through patients’ files to identify possible negligence claims. It was developing a strategy to mitigate all the risks.On Laundry services, linen availability was monitored and 73 % average availability had been attained during 2017/18. Key challenges included aged equipment, shortage of staff and poor implementation of linen management procedures in the laundries and health services.Iintegrated security systems had been installed at Pelonomi tertiary hospital, Boitumelo regional hospital and Sinorita Ntlabathi District Hospital. The in-sourcing process would be completed by the end of July 2018.FSDOH had two directorates dedicated to the Priority 3 of the NDP and the implementation of the eHealth strategy, the IT support directorate and the information management directorate. All 33 hospitals had connectivity. The Department was currently rolling out high speed broadband and additional funding of R28 million had been allocated to help improve IT infrastructure connectivity. In collaboration with SITA, FSDOH would implement a provincial virtual private network to improve connectivity between all facilities.Health care waste management was outsourced. Buhle Waste was servicing four health districts, while Ecocycle Waste was servicing Xhariep district. The pricing structure was charged per kg, and the service providers were monitored on a quarterly basis. On monitoring of health care risk waste (HCRW) one of the findings was that one of the service providers had not adhered to the conditions of contract. FSDOH had intervened and was monitoring the service provider through environmental health practitioners who were appointed as waste management control officers.On Infrastructure planning, FSDOH carried out capital projects and also did upgrades and refurbishment of previous projects. He provided a list of free state Infrastructure projects completed and operational and FSDOH Infrastructure projects currently in planning and under construction. As a result of the execution of facility maintenance processes, recent improvements had been made and contractors had been appointed who would do maintenance and refurbishment work in the five districts of the province.The districts had created hubs to support facilities with minor maintenance issues, and staffing of the artisans was under review. A maintenance call centre had been established by the DPW. FSDOH would develop similar call centre by the end of July.TB prevalence was estimated to be 10% of the total population. The defaulter rate remained high in Mangaung Metro, despite showing a decline in the other four districts.PHC had been strengthened by the implementation of NHI processes, with five streams of PHC re-engineering, ward-based outreach teams (WBOTs), district clinical specialist teams (DCSTs) and contracting of private general practitioners. However, Mangaung metro was still struggling. The challenges to the district health system in strengthening primary health care included the following:Inability to recruit and appoint fully fledged DSCTs;Shortage of school health teams;Medical equipment and aging infrastructure affecting compliance to service standards and ideal clinic status.The number of CHWs trained to date was 1 452, but there was a group that had been trained but was not competent, and FSDOH was working on a strategy to exit them. There were two master trainers for the whole province. All enrolled nurses who were not on the Personnel Administration System (Persal) were contracted through non-profit organisations (NPOs), and they were therefore paid by NPOs on a monthly basis.The Free State executive council, led by the Premier, had visited KZN to establish partnership relationships. The council had resolved, in line with Operation Hlasela, to incorporate the principles of SukumaSakhe .The process to establish war rooms in various municipalities had started and the district offices were involved. There was resounding political support, evidenced by the involvement of the executive authority in activities such as:Back to care initiatives;Healthy life style exercises;Public debates on various issues related to legislation to reduce trans fatty acids and salt in processed food;Regulation of foods sold during school hours;Issues relating to therecent emergence of listeriosis and rabies.DiscussionMs Wilson asked for an update on the number of specialists in the province – how many FSDOH had against what it needed. She asked for an update on oncology and what the approximate waiting time was, from diagnosis to actual treatment. Regarding medical claims, what was being claimed against FSDOH, and the nature of the claims? She referred to the OHSC report and while she understood that the facilities assessed were a small percentage of the facilities, those facilities assessed were performing very badly and the FSDOH was sitting with a crisis, with major failings in leadership and governance. The accruals were disconcerting, with only 40% going to goods and services and 60% to COE. It was concerning that FSDOH could not deliver on goods and services. She wanted to know what was happening to the people involved in the irregular expenditure -- whether there was consequential management. The condition of pre-hospital emergency medical services in the province was alarming, the incidence of TB was still high, and critical district specialist positions were vacant.Dr Thembekwayo referred to the OHSC findings and said that even though only the worst case scenarios were used, inspection and re-inspection had been done at some of these facilities to confirm the position. For clinical support services and pharmaceutical services, the average score from the report was above 50 %, but the report listed some of the deficiencies, and one shortcoming was that a delivery schedule for medicine and medical supplies was not available. From that finding in the report, she said that there was a correlation between the OHSC report and the presentation from FSDOH, which stated that pharmaceuticals’ availability across various pharmacies and the depot was difficult to determine and manage centrally. She wanted to know why there was difficulty at the depot. On clinical efficiency management, she requested FSDOH to take note of its deficiencies and work to overcome them. On disaster preparedness, it had scored below 20 %, and she wanted to know why disaster management plans were not available. On communication and public relations, the OHSC report stated that there was staff dissatisfaction, and she wanted to know why the staff was not considered in matters pertaining to them. The report indicated that security services were a key challenge, as most of the clinics were without security staff. It had also indicated that toilets and bathrooms were not cleaned. She asked whether cleaning services were in-sourced or outsourced. The OHSC report had also found that the procedure for the procurement of food was not available. She asked FSDOH to respond to the findings.Mr Nkonzo asked what the latest Auditor General’s report had said. He wanted more details on the challenges of security services and infrastructure. He commented that the presentation on medical availability at the depots as at 31 May 2018 was not so bad, and requested FSDOH to give the Committee an assurance or a plan of what it was going to do to maintain that situation. He observed that availability of contraceptives was at 56%, and said that there was need for further improvement. He commented on the 4 800 vacant posts and asked which of those posts needed to be filled immediately, and whether there were any critical posts not filled. On the in-sourcing of services, he commended the province for what it was doing and said that FSDOH was the only province that had a report which told the Committee the action plan on in-sourcing. He also commended the Department for the training of officials before commencement of duties. On the EMS, he asked why FSDOH had approved the purchase of only 15 ambulances against a shortfall of 144 ambulances.Dr Maesela said that out of 32 hospitals, only four had performed above 80%. Facilities that were in remote areas were not working well, yet the services were needed more in those areas. He wanted to know why the rate of vacancies was high, and why there was a challenge in recruiting medical specialists. On FSDOH not complying with legal and regulatory requirements, he said that this should not be up for discussion, and that it had a responsibility to abide by the regulations. He asked whether ICT was outsourced or in-sourced. What was it was doing to reduce COE, despite the Treasury directive? The presentation indicated that there were facilities with private ambulances, but he advised FSDOH not to spend money on exorbitant costs such as private ambulances. He added that all the Department’s identified ten risks could be dealt with, and that it must prioritise and deal with them.The Chairperson asked FSDOH to clarify the matter of private ambulances being used in public facilities, and the cost of such services. She said that FSDOH was the only province that had reflected the medical legal claims and given the categories. It was also the only province that had reflected on school health and MomConnect. She noted, however, that it had not specified the districts. She asked if FSDOH had engaged the Department of Basic Education, and if these programmes had a bearing on matric results. She asked whether it could look at CHWs and consider those that had the capacity to be trained further. She also asked it to provide the ages of the CHWs who were not passing the exams. She asked why FSDOH was silent on its relations with labour unions and also asked for an overview of Manapo hospital.FSDOH’s responseMs Montseng Tsiu, MEC: FSDOH, responded on enrolled nurses who were on stipends and their capacity to be trained further, and clarified that FSDOH had been referring to community care givers (CCGs). Some did not have a matric qualification, and the Department was looking to see if it could absorb them as cleaners. The CCGs that were being trained were those with a matric qualification. She also confirmed that FSDOH had a plan to absorb enrolled nurses in the Department.Dr Motou responded on the question of the status of Manapo hospital. It had realised that there was a problem of leadership at the facility, and had overhauled the management and made sure systems were in place. The hospital was now running properly. FSDOH would be training some of the Cuban students at that facility. He agreed that there was a problem with leadership and governance. For orthopedics, the OHSC report said there was a risk, and the FSDOH was working on an improvement plan to get its house in order. Regarding the number of specialists across the province, he asked to present the figures to the Committee in writing. He informed the Committee that he had in the previous day signed the appointment of spinal specialist.On the status of oncology patients, he responded that the Department had 400 patients awaiting radiation treatment, and that the radiation must be done by September 2018. FSDOH had two machines but one had expired, so it was going to explore leasing a machine to deal with oncology.On litigation, the medical legal claims were approximately R2 billion, and the claims range from medical negligence to cerebral palsy -- the details would be provided to the Committee in writing. The FSDOH would also provide a report on how it was dealing with the OHSC report.Regarding the budget, he confirmed that the COE was crowding out the funds available for goods and services. The COE was influenced by labour agreements and issues around conditions of service. The challenge of the COE was going to continue until FSDOH had the requisite skills in its facilities. FSDOH would work with the universities, to see how they could assist. The universities could also assist with issues of outreach.In response to the OHSC report, he said that FSDOH had delivery schedules in place. He agreed that the inability to fill posts was affecting performance. It had made a point of appointing managers who would lead the districts, and with training and monitoring it should be able to improve. He confirmed that disaster management plans were there. Communication with staff was key and FSDOH would make sure it did that. He confirmed that there was a challenge of safety and security across the facilities.He responded that there was a moratorium on the province, where FSDOH filled only clinical posts and not critical posts. It was not appointing drivers, armed guards and cleaners. On contraceptives, he agreed that the figure was low and informed Members that the contracts for the contraceptives were done at the national level, and at the time when the demand was high and the suppliers were unable to deliver, FSDOH had ended up being given permission to buy out.On the irregular expenditure, there had been consequence management, but he pointed out that the expenditure went back to 2009 and that some of the people to hold accountable were no longer in the system.FSDOH would provide details on the in-sourcing of services to the Committee in writing. The IT systems were not integrated, and he asked the Committee to intervene to have the matter with SITA resolved.He agreed that FSDOH had to adhere to legal and regulatory requirements. He confirmed that FSDOH had a strong relationship with the labour unions, and that there had been no strike in a long time.Ms Tsiu thanked the Committee, and said that the engagement had assisted FSDOH to know which issues need more focus.The Chairperson asked FSDOH to include an update on infrastructure in the written report. She added that there should be no distinction between clinical and critical posts, and that every person in a facility counted. She confirmed that the Committee would assist and engage Treasury. She also emphasised the importance of communicationKwaZulu-Natal DoH: BriefingDr Sibongiseni Dhlomo, MEC: KZNDOH, said challenges in the health sector needed constant attention by innovative leadership. The Department required the support of the Committee on the funding for health. Whenever KZNDOH was in need for funds, the response given was that it must prioritise to avoid overexpenditure. The areas that eventually suffered in most cases included the EMS, staffing and infrastructure. KZNDOH had a proposal for a minimum staff establishment and was working to strengthen contract management in order to reduce irregular expenditure. The plan was to go back to the basics, where health institutions provided comfort.Dr Musa Gumede, HOD: KZNDOH, said that the province had a total population of about 11 million people, with 10 municipalities, one metropolitan municipality and 54 local municipalities. Life expectancy for males was 57.8 years, whereas for females it was 63.5 years.On patients’ rights and access to care, he said that services were provided in each of the districts. KZNDOH had one central hospital, three tertiary hospitals, regional hospitals, district hospitals and specialised hospitals. It had proposed a number of new hospitals to increase access. A new regional hospital, Pixley Ka Isaka Seme had been established, and a new academic central hospital was still in the conceptual phase.Difficulty in attracting and retaining medical specialists at regional and tertiary hospitals in the rural areas had posed a challenge for the referral system. KZNDOH had an aging fleet of ambulances and had a strategy to incrementally replace the ambulances. There were 75 EMS bases and 12 communication centres, one provincial health operations centre,which was computerised, and 2 588 paramedics were employed in the province. A major challenge for the EMS was the manual booking system and problematic IT links.On complaints management, KZNDOH? had rolled out the implementation of the national guideline to manage complaints, and the resolution of complaints within 25 working days had improved from 56 % to 75 %. It had picked up the negative attitude of health care personnel and the long waiting time for service, and it was dealing with poor standards of care. It was also using media, especially radio, to promote patients’ rights. He added that missing patient records contributed to insufficient information when attending to medical negligence cases.On clinical governance, only two hospitals did not have appointed hospital board in place, and mental health review boards had been appointed in four districts. The Department was reviewing all district health councils. Following the municipal elections in 2016, all DHCs that were in place had had to be dissolved, as new members had come into the district.All CEOs at level 13 and above were subjected to a competency assessment process prior to appointment. The vacant CEO posts were all in the process of recruitment. 75% of all hospitals had conducted self-assessment on national core standards. On the management of pharmaceuticals and medicines availability, the Provincial Pharmaceutical Supply depot coordinated demand management and forecasting, acquisition management, warehousing and logistics, safe disposal of pharmaceutical waste and transaction management. The department was using the electronic stock management system, and the stock visibility system (SVS) allowed it to know when stock was low. The OHSC had measured processes, not stock, and KZNDOH was not short on stock. Anti-retroviral medicines stock was moved between facilities to meet patient needs. On expired medicine the department would roll out Rx Solution to all clinics to better manage the pharmaceutical stock at clinics. It had also installed back up generators to some clinics as an NHI initiative, to assist in preventing the damage of cold chain pharmaceuticals. The appointment of pharmacists’ assistants had also been factored into the minimum staff establishment for clinics. The Central Chronic Medicine Dispensing and Distribution Programe (CCMDD) had been rolled out in all 11 districts, and over 1.1 million patients had been enrolled on the CCMDD programme. He confirmed that there were challenges in the depot, but the new method of delivering drugs directly to facilities and to patients would assist.On medical equipment, previously KZNDOH had no service level agreements with original equipment manufacturers (OEMs). The Department had entered into service level agreements with the OEMs or their agents for life support equipment. It was also looking at improving technicians to ensure it had people with skills to deal with assets. Financial delegations had been revised to empower the CEOs to procure up to a maximum of R500 000 directly at institutional level, but the head office still did a lot of oversight.On ICT Interventions, all hospitals had network connectivity. Focus had been given to all PHC sites to make provision for data-based connectivity services -- internet, intranet, email -- by the end of the 2018/19 financial year.On the state of the district health system in strengthening primary health care, KZN leadership and governance, 10 of the 11 districts had a permanent full time district director with the remaining district director post (King Cetshwayo district) in the process of recruitment. In an effort to further improve local health service co-ordination and accountability, the Department was exploring the implementation of a sub-district model. The adoption of community health workers into full time employment was negotiated at national level, but the province had included all community care givers on PERSAL.He gave a report on the progress towards adoption of Operation Sukuma Sakhe (OSS) and said that the Department had appointed a focal person who was responsible for monitoring the programme.On oversight and leadership there had been instability in top management due to the attrition of HODs, DDGs and CFOs. All of the posts had been advertised -- some more than three times. KZNDOH had aligned the performance agreements of all SMS members and CEOs with the strategic and operational plans. It was looking at the organograms to assess whether it could deploy some people from head office.The Department had a provincial task team to assist it in undertaking internal control assessments. The team had commenced in February 2018.There was an audit log which it was following and it needed to work and build capacity of internal controls. The Department had fully fledged and functional risk management committee (RMC) headed by the HOD. Each hospital had an operational risk register and the Department had a consolidated risk register. One if the top ten strategic risks identified was the unauthorised doctors working outside the public sector. On operational management, a lot of posts had not been filled, and KZN had deliberately decided to increase its funding to train specialists.DiscussionMs Wilson commented on the shortage of EMS vehicles, and advised that if KZNDOH did not have disaster plans in place, it would face a lot of legal claims. The negative attitude of health care personnel needed a lot of work. She also asked if the Department could look further into the issue of missing patient records, as it could have a link with the high number of medical legal claims. She wanted to know what was being done concerning the BCG vaccines for TB, and who the supplier was. She commented that drugs were valuable, and if there was no stock count, KZNDOH would not know if the drugs were there. With 63 % of the budget going to COE, KZNDOH would not be able to deliver appropriate medical services. The R7 billion maintenance backlog was massive and the infrastructure would fail. She asked the Department if it could specify which specialists were part of the 395 available, and if it could clarify the surgery backlogs at the hospitals. She commented that there was a shortcoming in the organisational structure -- the HOD was working in an acting capacity, and the supply chain manager had also been out since 2011. She welcomed the progress on oncology and commented that previously a lot of people had died because of negligence.Dr Thembekwayo said that the OHSC report had been taken from the worst performing clinics in the hospitals and could thus not be generalised. However, re-inspection had been done by the OHSC, with no improvement. She requested KZNDOH not to forget the worst scenario cases. On patients’ rights, the average score from the OHSC report was 61%, and the deficiencies noted were that minutes of patients survey satisfaction reports were not available, staff satisfaction surveys were not conducted, there were no ablution facilities for disabled persons in the hospitals, and a disaster management plan was not available. She advised KZNDOH to go back and address the issues raised.Dr Maesela commented that contradictions were an indicative of development, and thanked KZNDOH for the turnaround.KZNDOH’s responseDr Dhlomo said that the Human Rights Commission (HRC) had recently commended KZNDOH for the work it did, and despite disputes it would go on to provide services to the people. On EMS, he said that an ambulance costs approximately R1 million, and KZNDOH needed to purchase 500 ambulances. Once it bought them, it had to allocate them to the hospitals and replace them every 12 months, and these costs placed huge pressure on the budget. He added that there were no stock outs in the clinics, the system adopted was transparent, and KZNDIH encouraged the CEOs to visit the clinics.Dr Gumede commented on the scarcity of skills. KZNDOH was testing what the NHI would require, and it wanted the R100 million given to be used to strengthen the system instead of having to outsource. It had a plan to replace the ambulances in tranches and identify districts that had fewer numbers. The Department had taken note of the worst performing facilities and would go to each of them and correct the issues. He confirmed that BCG 1 was a challenge, but when the stock was available, the facilities usually contacted the people.Mr Phumelele Shezi, Acting CFO: KZNDOH, commented on the irregular expenditure. The Department had a treasury intervention team who assisted in preventing irregular expenditure by strengthening controls. It had devised a turnaround strategy. The supply chain management was run on a manual system, so if one lost a requisition, the whole transaction became irregular. The intervention team would assist it to procure an electronic system. The financial misconduct team had been reconstituted. On accruals, it had a burden of unpaid invoices. It had, however, been able to produce a saving plan through proper market research and strengthening of supply chain management.Ms Wilson asked KZNDOH to advise the Committee in writing how much the medical claims were.The Chairperson commented that there had ben an improvement in the KZNDOH report compared to their last presentation. It was good to start by first acknowledging that there was a challenge. She agreed with other Members that there was a difference in comparison to the previous time the KZNDOH had presented to the Committee.The meeting was adjourned.Hospitals: Mpumalanga, Eastern Cape & Gauteng Departments of Health12 June 2018Chairperson: Ms M Dunjwa (ANC)Meeting SummaryThe report of the Office of Health Standards Compliance (OHSC) featured prominently in the meeting, with the Committee wanting to find out what the various provincial departments were doing in response to the OHSC findings. The provincial Departments of Health of Mpumalanga, the Eastern Cape and Gauteng pointed out that the assessments had been carried out on the worst performing facilities in their regions, and that the findings did not necessarily reflect the position at all the facilities. They all confirmed, however, that they would intervene and address the issues raised in the OHSC report. Challenges that cut across the three departments included a shortage of funds, large sums of accruals, shortage of specialists, medical legal claims, inadequate repair and maintenance of infrastructure, and inefficient emergency medical services (EMS) systems.For Mpumalanga, a major concern was the security situation, as there had been many cases where members of communities had attacked nurses during the night. ?The Mpumalanga Department of Health (MDOH) had intervened and unilaterally decided to deploy armed guards. Another challenge was that some people were bypassing primary health centres and going directly to hospitals, which prompted the Committee to ask why this was happening. Other issues raised included poor response times, the illegal dumping of medical waste, the cure rate for tuberculosis remaining static, the use of DDT to combat malaria, and the use of the centralised chronic medicine dispensing and distribution (CCMDD) system to assist in the distribution of chronic medicine.Members told the MDOH of complaints they received about health services in the province. These included long waiting times at the hospitals, care givers who had been working in hospitals for over 20 years and were still being paid as little as R 3 000, ?the poor quality of food in certain hospitals, the negative manner in which the staff in hospitals, especially nurses, talked to patients, and the lack of privacy for people living with HIV AIDs, The Department was asked to respond to these complaints.The Eastern Cape Department of Health (ECDOH) reported that it had 66 district hospitals offering 24-hour services. The province had the highest number of health facilities, but these were old facilities that were not designed for current needs. It had introduced a number of initiatives in high risk areas and as a result of the interventions, the incidence of tuberculosis (TB) had been decreasing in the province. All newly diagnosed TB patients were now provided with a National Health Laboratory Services (NHLS) lab track, which would assist in tracing TB patients moving from one facility to the other.The Gauteng Department of Health (GDOH) touched on areas left out in a previous presentation. It said was taking lessons from Life Esidimeni, and had a risk register on issues it could pick up. It confirmed that the payment of Life Esidimeni claims would be from the Gauteng provincial government, and not necessarily from the GDOH. The Department reported that a mid-term review had indicated an increase in life expectancy, and that it was close to attaining a zero transmission of HIV/Aids from mother to child. Concerning following up on lost TB patients, community health workers were reported to be assisting in reducing TB defaulter rates. The national programme of registering citizens in preparation for the National Health Insurance (NHI) scheme would also help the GDOH, since there would be one database.Meeting reportMpumalanga Department of Health (MDOH)?The Chairperson began by stating that health was an emotive sector, and the Departments and the Committee had a responsibility to ensure people received health care services as outlined in the Constitution. The Committee had an oversight responsibility. She requested the Departments to be honest with the Committee on the challenges experienced on the ground.Mr Gillion Mashego, Member of the Executive Committee (MEC): MDOH, said the Department had a responsibility to provide a longer and healthy life for all South Africans and to raise the life expectancy to at least 70 years. The security situation was currently not looking good. Members of the community had in many cases attacked nurses during the night. Community members in some cases fought each other and when injured, demanded to be given preference at the hospitals. He mentioned an incident where one of the doctors in one of the facilities had been attacked. The MDOH had made interventions and had unilaterally decided to deploy armed guards. It would in the meantime look at ways of providing better security at the facilities.There was shortage of staff, and the current budget was not enough to engage new personnel. The MDOH had taken the matter up with the Premier and Treasury, and it had started advertising some posts. It had decided that money that should have been spent on overtime staff would instead be used to employ new staff. It was also seeking specialist staff members outside the Republic, and it was also looking at some of the South Africans who had been sent outside the country to study medicine. It had been sending a batch of 10 students outside the country to study, but the number had now increased to 28.MDOH had in the past received complaints on emergency medical services (EMS). It was intervening and was currently doing an assessment of how many vehicles it had and how many the Department needed. It also had a system to monitor the movement and response time. It was planning to integrate its transport system with the EMS.On infrastructure, the Department had inherited dilapidated structures and was busy with renovations, and was building some structures from the scratch. It was currently building four hospitals. It was using innovating building technology (IBT) to make it cheaper, and had built 28 IBT structures. Maintenance had previously not been taking place as it should have, so MDOH had set aside R25 million for the repair and maintenance of boilers, R28 million for the maintenance of other equipment such as generators, and R5 million for the drilling of boreholes. The Department of Public Works would assist MDOH to improve its infrastructure.MDOH had built 87 out of a target of 287 primary health care (PHC) centres of ideal status, and the goal was to increase the number to 116. Its focus was more preventive than curative, and in order to achieve this goal, PHC outreach teams had been established. This would assist in reducing maternal and child mortality rates. Under the school health services, school learners were screened and learners with medical conditions were picked up and transferred to nearby PHC facilities and hospitals. A challenge identified was that some of the people were jumping from PHCs and going directly to hospitals. Another challenge was the long waiting time experienced at the hospitals.Mr Mashego reported on some of the positive indicators, and said that the number of children under five years with diarrhoea cases had improved, cervical cancer screening had improved, maternal and child deaths had reduced and there was availability of medicines in all the facilities. He added that MDOH was on course to handle all issues raised by the Auditor General on irregular expenditure and immovable assets. The plan for MDOH was to avoid a qualified opinion as it increased its controls.Dr Savera Mohangi, Head of Department (HOD): MDOH, gave a budget summary and indicated that the Department had received a budget increase of R1.118 billion, or 10.2 %, of which R552 627 was from conditional grants and R565 494 from voted funds. The compensation of employees (COE) budget was 59.3% of the total allocation in 2018/2019, compared to the national benchmark of 62%. To increase access to health care services, the MDOH rendered health services through community-based facilities -- 81 mobile clinics, 228 clinics, 59 community health centres, 23 district hospitals, five tuberculosis (TB) specialised hospitals, three regional and two tertiary hospitals.The TB cure rate was decreasing due to patients not producing sputum at the end of six months’ treatment, hence the need to continue counseling patients throughout treatment. There had been an outbreak of malaria in October 2017 which had accounted for 9 449 cases and 96 deaths.She said that quality care was measured through compliance with the national core standards as set by the Office of Health Standards Compliance (OHSC), and none of the 33 hospitals was fully compliant with the standards. All hospitals were implementing quality improvement plans to address the identified gaps. She cautioned that self-assessments done by the MDOH may be biased, and to address the issue it would have the provincial departments rotating the districts and making assessments. The gaps that had been identified as common to all hospitals were:Clinical audits of each priority programme and health initiative were not conducted.Safety precautions that prevented harm in units where children were cared for, were not observed.Emergency trolleys were not standardized.Policies on handling emergency resuscitations were not available.The protocol on safe administration of medicines to patients was not available.Procedures for patients with special needs or with reduced mobility were not available.Staff-patient ratios were not in accordance with the approved staffing plan.Grounds and pathways were not well maintained, there was inadequate lightning, and no records were kept of inspections done.Medical equipment at the MDOH was being procured on a two-year warranty basis, which speeded up procurement. Maintenance was in-house, with some done outside, although the Department still had a financial challenge with the maintenance of the equipment. It had outsourced the management of pharmaceuticals at the medical depot, and was in the process of installing a warehouse management system there. All the PHC facilities were reporting availability of medicines, using the stock visibility system. On medicines availability, MDOH had accruals for medicine of R373.7 million at the end of 2016/17, and R364.7 million for the year 2017/18. The shortage of drugs was attributed to the short-dated stock received from suppliers, supplier challenges and delayed payments due to cash flow problems. To avoid drugs expiring in the warehouse, no buffer stock was kept. In cases where a specific drug was not available, patients were given an alternative drug. The central chronic medicine dispensing and distribution (CCMDD) system had been piloted in the Gert Sibande District, and had now been rolled out to the other two districts.Regarding human resources (HR), there were a few vacancies in top management. One of the Department’s priorities was to ensure it had a full team of executives, and all chief executive officer (CEO) posts had been filled, except for Lydenburg. Three vacant posts for chief financial officers (CFOs) should be finalised by July 2018. She also commented that there was a high staff turnover. For HR development, the Department was participating in the Nelson Mandela-Fidel Castro (NMFC) medical programme. There were also the 110 students sent to Russia, and the first group of four would be completing their studies in 2020. The total enrollment at the Mpumalanga Nursing College was 662 students for the four-year diploma programme, and a bursary system had been introduced at the nursing college.She summarized the challenges in HR as:An outdated organogram.Shortages of staff, on which the MDOH had done some benchmarking with other provinces.Labour unrest.Safety-related challenges, where the MDOH had responded and contracted armed guards.Non-translation of the nurses to higher posts. A report on this issue was due on 30 June.Dr Mohangi also informed the Committee that the CEO of Themba Hospital had been reinstated. He had been given a warning and his suspension had been lifted.There was a huge deficit on EMS, There was one communication centre per district, and in terms of response time, MDOH was not doing well. The situation could be attributed to a shortage of personnel and a shortage of ambulances. MDOH had appointed 96 emergency staff, and an additional 15 ambulances would be purchased this year. The number of obstetric ambulances had been increased to 24. Patient transport was to be integrated into the EMS. The Department had an EMS college, although it was currently not functional. On governance and leadership, it had a well-established audit and risk committee. It did not have an ethics management strategy and implementation plan. It had established a ?provincial misconduct committee and district financial misconduct and loss control committees. The responsibility of these committees was to investigate and report on all reported incidences of financial misconduct and losses suffered by the MDOH and make recommendations.Regarding the under-spending on conditional grants, MDOH was strengthening the planning and monitoring of the grants. It had received a qualified audited report, and this could be attributed to the inadequate financial personnel over the medium-term expenditure framework (MTEF) period. It had intervened by placing qualified interns in the districts and hospitals .Accruals remained a challenge and it was reviewing, implementing and monitoring a strategy to collect money owed to the Department. It had also conducted reconciliation on funds to be surrendered to Treasury .The main accruals were in medicine, amounting to approximately R842 million.The MDOH referral system was heavily reliant on Gauteng Province. The regional hospitals did not have a full complement of the eight core secondary systems. Although Ermelo Hospital provided eight core domains, the disciplines were headed mainly by Cuban doctors. MDOH was intervening to meet the challenge of patients bypassing PHC facilities by rotating community service health professionals in the PHC facilities. In order to address inadequate skills, it was increasing the pool of doctors by an additional five in the registrar programme, and was also entering into memorandums of understanding (MOUs) with academic institutions and other provinces.Regarding medico legal-claims and the management of litigation, the contingent liability as at 2017/18 was estimated at R7.6 billion. 158 cases to the value of R3.3 billion had been reported over allegations of cerebral palsy suffered by minor children. Mediation had proven to be flexible since it was initiated in the 2016/17 financial year. Through mediation, seven cases had been finalised and the MDOH had paid just under R2 million. Its intervention strategy was to conduct continuous training for health professionals so as to ensure patient safety.MDOH had a risk management unit which identified and coordinated the management of departmental risks and fraud prevention.There were 18 laundries in the 33 hospitals, and the objective was to have in-house laundries in all the hospitals. The plan was to establish an additional two laundries and to procure additional linen. MDOH had engaged the Department of Public Works (DPW) to penalise and terminate poor performance service providers charged with the maintenance of laundry equipment.On security services, there had been an increase in community unrest, so the MDOH was creating awareness through community radio stations on the need to protect health facilities and staff.It was using the patient electronic information system (PEIS).The system had information on a total of about 1.6 million patients. It had improved the patient file management process in PHC facilities through the implementation of the health patient registration system (HPRS).It had outsourced the management of health care risk waste. However, there had been non-compliance with national core standards on storage areas, and cases of illegal dumping, and it had engaged municipalities to monitor and penalise the culprits. All new facilities being built were also complying with national core standards with respect to storage of health care risk waste.MDOH had adopted an infrastructure delivery management system (IDMS) as a vehicle for infrastructure planning, delivery and operations. 16 cooperatives had been appointed for sub-contracting work. The challenges experienced included insufficient budget for maintenance, poor performance of term contractors, and interrupted water supply.TB management was being provided in five hospitals. The hospitals had support from various allied health workers, such as audiologists, occupational therapists, physiotherapists, social workers and radiologists. MDOH was decentralising the management of TB to the PHC centres. The TB cure rate had remained static, despite an emphasis on TB management in the province. It was also engaging the SA National Tuberculosis Association (SANTA) in order to procure the two TB hospitals from SANTA. In some instances, the cure rate was decreasing because it was using the world-based (WB) outreach team to assist in tracing defaulters. On the role of district health services (DHS) in strengthening the PHC centres, MDOH was working on establishing an additional 112 WB teams, although the budget remained a challenge. All newly constructed community health clinics (CHCs) were being built according to ideal clinic status, and R8 million had been set aside for infrastructure.To provide mental health services, MDOH had only 106 beds against a minimum need of 1?214.To combat malaria, it had appointed 330 temporary malaria spray operators to do indoor residual spraying. It was collaborating with neighboring countries by implementing the Mozambique, SA and Swaziland (MOSASWA) agreement on the management of malaria. 47 laboratory-confirmed listeriosis cases had been reported, with 12 deaths.The Department was also experiencing a shortage of cataract surgeon’s and insufficient theatre time for eye operations. On AIDs and sexually transmitted infections (STIs), there had been a steady increase in HIV testing due to intensified community testing and a community campaign contributing to an increase in the medical circumcision rate. Immuniszation coverage of children under one year had increased from 80.2% in 2014/15, to 90.4% in 2017/18. MDOH was contracting non-profit organisations (NPOs), who in turn contract community health workers (CHWs). There were two sources of funding for the NPOs – the expande public works programme (EPWP) grant and the HIV AIDS grant. The main challenge for CHWs was the high illiteracy level, as programme was unable to attract qualified people because it was an informal source of employment. MDOH had benchmarked from KwaZulu Natal on the Operation Sukuma Sakhe and following the benchmark exercise, the Operation Vuka Sisebente (OVS) service delivery model had been launched in 2016.MDOH participated through ward-based PHC outreach teams, whose major role played was to identify challenges during household visits and the referral of such cases to relevant departments.DiscussionMr W Maphanga (ANC) said that the OHSC had reported to the Committee that most of the provinces’ Departments of Health had not improved their performance. He asked whether MDOH had met with the OHSC, and whether any changes were being implemented in response to their findings. He sought clarification on health care waste management, and wanted to know whether the Department complied with the Act (NEMA) and the National Environmental Management Waste Act (NEMWA). He also wanted to know whether there were tenders in place to deal with health care waste adequately. He asked why the malaria fatality rate was the only one that had increased, and what contingency plans MDOH had, now that weather conditions had become unpredictable. He also asked why Tonga Hospital had maintained a status quo of 70%. He sought clarification on the referral system, and asked whether the target of 1 April 2018 had been addressed.Dr S Thembekwayo (EFF) referred to the MEC’s introduction, where mention had been made of patients jumping from clinics to hospitals, and asked whether there had been any efforts to discover what caused this. ?She wanted clarification on the unavailability of beds for patients who needed to be admitted, and gave the example of Evander Hospital, where patients were said to be sleeping on the floor, She wanted to know why this was so, as the Department had given the Committee information on usable beds and unusable beds. Regarding the suitability of candidates for key positions, she commented that MDOH had advertised several times, but had not been able to get suitable candidates, and said that the problem of unsuitability could last for years. If it continued to have a lot of vacant positions, it would not be able to run the province’s health operations. She asked what had happened to the previously employed security guards, and whether MDOH would be adding the armed guards to the security guards already in place, and whether these armed guards would be outsourced or in-sourced.Since the specialist doctors referred to in the presentation were either Cuban or Ethiopian, she asked why South African doctors were not represented. What could be done to address the waiting time experienced in hospitals? She referred to complaints she had received from care givers who had been working in hospitals for over 20 years, and said they were still being paid R 3?000. She wanted to know whether that was the position. She also wanted MDOH to respond to complaints that the quality of food in some hospitals was bad, and the poor attitude of the staff in hospitals, especially nurses and the negative manner in which they talked to patients. She asked about allegations of a lack of privacy for people living with HIV AIDS, and why it took time for patients who were suffering to get taken for treatment in Pretoria. She had also received a complaint that from 1 January 2018, a new committed overtime had been implemented which had left out dentists. This had led to chief operating officers (COOs) cutting out dentists -- yet the dentists had never been consulted. She asked MDOH to respond to the complaint by the dentists.Ms E Wilson (DA) said that the OHSC report on Mpumalanga had been bad, with 35% of the facilities said to be critically non-compliant. Not one entity in Mpumalanga had complied with the requirements. One of the biggest failures, according to the report, was management. The report indicated that instruments in the facilities were not sterilised, which was a priority. According to the report, there was no evidence that mobility and mortality in the facilities was being monitored, so she asked where MDOH got its mortality statistics from, given that there was no documentation. The Department had indicated that it had paid out R158 million on medical claims, and she wanted to know where that money had come from and whether it had been budgeted for. She commented that the Life Esidimeni claims may have to be paid by the provinces, because Gauteng could not pay for all of it, and asked if the province was making plans to pay for that. She also observed that because of accruals, MDOH was starting its financial year in the red, and in addition had irregular expenditure of approximately R3.3 billion. She commented that MDOH could not deliver medical care under such circumstances, and in the last year had regressed. She asked MDOH what it planned to do concerning referrals, since it was currently referring patients to Limpopo, but the facilities in Limpopo were also under pressure.Mr T Nkonzo (ANC) wanted to know the controls being implemented to eradicate the irregular expenditure. According to the Minister of Finance, 8% of the budget was to be spent on maintenance. He asked what was being spent on maintenance and what maintenance policies were there. He asked how MDOH was dealing with contractors who did not deliver, and whether penalties were being applied, He wanted to know how chronic medicine was being distributed and if CCMD was being implemented. He sought clarification on the projected cost of medical legal claims, and asked MDOH to confirm which claims were prevalent.Dr P Maesela (ANC) asked MDOH to go back and look at the OHSC’s and AG’s documents which could guide it to correct what it was doing wrong. He asked what had led to medicals accruals of R370 million, and what consequences were there for failing to pay on time. He asked for clarification on patients being given alternative drugs whenever there was a shortage. He commented that MDOH had a R7.5 billion contingency fund for litigation, and suggested that this money could instead be used to buy drugs. The MDOH did not have specialists because it did not train them, and in such situations, the equipment in the hospitals was not used because there were no specialists. He observed that MDOH was doing badly in terms of infrastructure maintenance, and cautioned that if it did not adopt a culture of maintenance, it would keep on demolishing what it builds.The Chairperson commented that she would prefer it if the medical legal claims were categorised and the Committee was given information on whether these claims related to cases of cerebral palsy, missing records or any other claim. She said the Committee encouraged the in-sourcing of services. MDOH should be more specific on the contracts for services and where some contracts had been terminated, should give it reasons for the termination. She asked MDOH to confirm the numbers of trained Cuban doctors so that it was not reflected to mean that it was using Cuban nationalsMDOH’s responseMDOH responded that those hospitals that had continued under-performing and which had been singled out in the OHSC report did not have a? full complement of management, but the issue of management had being looked at.Regarding the 70% consistency and no improvement at the Tonga Hospital, MDOH had requested that it responds to the Committee in writing.On the unavailability of beds, Evander was not using all the beds allocated to it. However, MDOH would look at all the hospitals and if need be, redistribute the beds.MDOH agreed that it could not fully rely on foreign doctors. It was trying to train its own doctors so that it would be easy to retain them.It was looking at the issue of waiting time at the hospitals in a bid to improve the situation at the facilities.Regarding psychiatric patients who belonged to Mpumalanga and were being treated in Limpopo, MDOH confirmed that it had signed an MOU, but it would look further into the area.On chronic medication and how it was distributed, the Department said that the CCBD system had started in the Sibande District. It had shops and pick-up points that had been registered to collect drugs, and the other two districts had joined afterwards.Regarding medical equipment not being used, MDOH was trying to get into arrangements with universities that could assist with head hunting of specialists.Mr Phaswa Mamogale, CFO: MDOH, responded on unauthorised expenditure and reported that? investigations done in 2017/18 had managed to clear approximately R3 billion. MDOH had now awarded new tenders which were not irregular. Committees had been established to investigate irregular and fruitless expenditure. It had contract management in place for maintenance, and penalties were applied on non-performing contractors. In some instances, contracts were terminated. On whether MDOH budgeted 8% for maintenance, he said that it was unable to meet the required target because of financial constraints .There were about 246 posts that were vacant, and MDOH was in the process of short listing to see if it could get the right candidates. It sometimes had to head hunt.On the dentist issue, the Department had consulted clinical managers and conducted a workshop, and had asked the dentists to submit evidence that the dentists worked overtime, but they could not provide the evidence. The Public Service Commission (PSC) had investigated the matter and had also requested information from the dentists, which was not produced. He confirmed that where dentists worked beyond normal time, MDOH paid for ordinary overtime, and not committed overtime.Dr Mohangi responded on the findings of the OHSC, and said that there were specific institutions that were assessed which were poor performing, and they should not be seen as a reflection of all the institutions.The challenges in respect of malaria were in those areas bordering Limpopo and Mozambique, and MDOH was now ensuring it synchronized the spraying.Previously the MDOH had had guards, but they were not armed. The armed guards were additional. She confirmed that security was an outsourced function.The complaints about the quality of food in some hospitals concerned three weeks when staff members were on strike.Regarding caregivers earning R3 000, she responded that those might be CHWs, since MDOH did not have volunteers.The Department compiled and had information on mortality and morbidity rates in the facilities. It had manual registers which were thereafter entered into the national health information system (NHIS). She said that MDOH did not budget for medical legal claims, but paid for it by decreasing goods and services expenditure. She added that it would not be able to pay for Life Esidimeni claims, and had not received information on whether it would be required to pay.Mr Mashego said the MDOH would go back to the facilities referred to in the OHSC report and correct those areas needing attention. He commented that Free State province was in-sourcing, and MDOH would send a team to benchmark there. It would also go through the reports of the AG and the OHSC and look at ways to improve service delivery. He asked Members to direct complaints received to him and said both the MDOH and the Committee could deal with the issues. He agreed that the infrastructure was not good and that the Department was still correcting errors of the past. It knew the challenges and would work hard to ensure it had clinics that were of ideal status.The Chairperson said that the National Health Act, sec 25, provided that the executive heads must carry out a visit to the facilities. The Committee was required to check that what the Department was doing was being done in line with what was expected of them. The Committee would appreciate getting the written responses on the feedback requested. She also asked MDOH to respond in writing concerning a PHC centre which had been closed.Eastern Cape Department of Health (ECDOH)Dr Thobile Mbengashe, HOD: ECDOH, began by giving an overview of the province. The Eastern cape was spread over 168 966 square kilometers, and two-thirds of the population was under 30 years of age. 12.6% was under five years old. The province had eight health districts, six municipal districts and two metros. It was primarily a rural province, and that had a bearing on the people who sought services from the ECDOH. The poverty rate stood at 52.7 %. Communicable diseases like TB and HIV were the leading causes of mortality. Non-communicable diseases like heart disease and diabetes were also common causes of mortality. Maternal and child mortality rates remained high. During 2017/18, a total of 16.4 million visits had taken place at EC health facilities. There were 66 district hospitals offering 24-hour services. The National Health Insurance (NHI) envisaged outreach programmes, including integrated school programmes.The province had the highest number of health facilities, ?but these were old and not designed for current needs. The referral system adopted was a bottom up and top down system, which was referrals between facilities, and referrals down to the community health facilities. Two major systems of EMS were in place -- one was the response in major urban areas, and the other in rural areas. The two systems were less than satisfactory, but ECDOH was doing better in the urban areas. On the availability of EMS services, ECDOH did not have 416 ambulances on the road -- it only had a 254 patient transport system. It had 2 185 EMS staff, which was not the right number. Challenges in the EMS included geographical coverage and terrain, uneven salary scales when people moved from a local municipality to the province, poor infrastructure for EMS, and scarcity of EMS skills. The action plans in these areas included the recruitment of 100 additional accident emergency assistants (AEAs) by 31 March 2019, and training and upgrading of 96 basic ambulance assistants (BAAs). ECDOH also planned to implement the EMS regulations and to appoint a task team to advise on the regulations.The Department had strengthened its use of electronic inventory management systems on pharmaceuticals and medicine. Improved access to medicine was achieved through CCMD. Expenditure on non-contracted medicines and surgicals by the end of the first quarter had been R101 million, of which 51% was for medicine and 49% for surgicals. The planned intervention by ECDOH was to expand the use of stock visibility and Rx Solution, the prescription assistance programme, and to introduce a new warehouse management system for the pharmaceuticals depots. It also planned to train nurses on good stock management.The province was divided into four regions with four forensic pathology (FP) centres. The challenges experienced in these centres included a shortage of Forensic pathology officers, an increase in the number of unknown bodies, a shortage of dissecting mortuaries in the province, non-availability of x-ray facilities, and a shortage of forensic pathology specialists to cover the full spectrum of the services. The ECDOH followed a 90-90-90 strategy on the management of TB and HIV. The ECDOH had done a number of initiatives in the high risk areas and as a result of the interventions, the incidence of TB had been decreasing. The TB treatment success rate for smear positives had increased from 83% in 2014 to 86% in 2016. In 2014, ECDOH had 6.7% of TB patients lost and requiring follow-up per district. All newly diagnosed TB patients were now provided with a National Health Laboratory Services (NHLS) lab track, which would assist in tracing TB patients moving from one facility to the other.The province had four psychiatric hospitals and three mental units. The challenges in these facilities included few mental health specialists, and funding the gap for infrastructure requirements to develop psychiatric services.Dr Mbengashe also reported on the Tower Hospital investigation. The Department had conducted its own internal investigations and a report on the findings had been submitted to the Minister’s office. The CEO had been placed on special leave, and the ECDOH had instituted disciplinary proceedings on implicated staff. The medical officer who was alleged to have altered medical notes had been reported to the Health Professionals Council of South Africa (HPCSA). The issue around the kitchen and isolation wards had been dealt with and ECDOH would proceed to look at the conditions in other mental institutions.Facilities in the rural areas had had difficulty in dealing with medical waste. The challenge had been in the mixing of ordinary waste with medical waste. The Department was looking at programme priorities forwaste management, which were as follows:Establishment of health care waste committees in all facilities.Training of pharmacists on the management of pharmaceutical waste.Training in the use of waste generators.Facilitating the appointment of waste collectors.Monitoring the segregation and containerisation of waste.Mr Simon Kaye, CFO: ECDOH reported that 99.7 % of the adjusted budget had been spent and that goods and services had been overspent by R23.9 million. Roll overs requested from treasury included equitable share (ES) roll overs and conditional grant roll overs. For the 2016/17 year, the ECDOH had retained an unqualified audit opinion. It had R1.1 billion worth of medico legal claims against it. It had spent R433.5 million on legal fees. The Department was implementing a multi-pronged medico legal strategy, focusing on administrative, legal, clinical and mediation interventions. The Department was also making progress in the defence of medico legal claims, as well as interventions to root out corrupt elements. Some of the strategies adopted included the packaging of electronic management, early intervention to strengthen the capacity of medical defence, and the creation of a medico legal trust. It had also appointed a consortium of legal practitioners to assist the state attorney with defence.Ms N Mavuso, Deputy Director General (DDG): Human Resource and Corporate Services, reported that the macro structure had been approved by the MEC in March 2018 after concurrence by the office of the Premier (OTP) and the Ministry of Public Service and Administration (MPSA), and that it had been rolled out since April 2018. The organizational reform had made provision for a strong district and hospital management team. The number of approved non-clinical posts was 394. The ECDOH had appointed five senior managers, four of whom were women. It had exceeded the employment equity target of 50:50 at the senior management service (SMS) level. The executive management team had been appointed. 84 % of SMS posts were filled. The overall vacancy rate in the Department stood at 9.5 %. Of the total 772 PHC facilities in the ECDOH, 582 had approved clinic committees.Mr Mlamli Tuswa, General Manager: Infrastructure, reported that ECDOH had allocated funds of not less than R500 million for maintaining day to day facilities. Life support equipment was all centrally handled. ECDOH was looking for competent contractors who could maintain this equipment. The intention was to have an internal capacity once the call duration was over. Through an internal contracting arrangement, the Department would move away from reactive maintenance to scheduled maintenance. He took Members through infrastructure plans for mental health units, including Madwaleni, St Barnabas Hospital, Holy Cross Hospital, Cecelia Makiwane Hospital, Komane Hospital, Tower Hospital, Elizabeth Donkin Hospital and PE Provincial Hospital.Dr Mbengashe asked the Committee to note that the health services were under pressure because of the demand for health services, coupled with the impact of medico legal claims.DiscussionMs Wilson commented that the OHSC report indicated that the ECDOH performance was one of the poorest, and that this was reflected in what was seen in the claims. Having accruals of R214 million was a hard way to start the year. She asked whether those were just medical accruals and if so, she wanted confirmation on the figures of the other accruals. She asked how many specialists ECDOH had, the areas of specialty and what the shortage was and how the shortage of specialists affected the surgery backlog. There had been an OHSC finding irregular and fruitless expenditure which had stated that most of the facilities were non-compliant, and she asked ECDOH to respond to this. Did the ECDOH have any information on the media reports saying that the Life Esidimeni claim amount was to be split between the provinces.Mr Maphanga, wanted clarification on the scarcity of EMS personnel, and whether there was a target number. He also noted that the ECDOH had few mental specialists, and asked what was being done to ensure the province was served. He also wanted to know whether the two forensic pathologists for East London had been appointed.Dr Thembekwayo referred to the OHCS report, which stated that the average sub-domain score for pharmaceutical services was low, pharmacies were not functional, medicine and supplies were not procured as required, and stock control systems were not in place. She asked why the ECDOH was planning to expand the use of stock visibility before dealing first with the identified anomalies. The OHSC report on health emergency and disaster had given the ECDOH a score as low as 14 %, and she wanted to know what mechanisms it had for disasters. Security services, garden services, cleaning services were all outsourced -- why the Department not in-sourcing? The province had scored 18% on staff welfare, so how did the ECDOH intend to make improvements on staff wellness? She added that she was impressed with the presented plan of the “journey to operational excellence,” and said it could help improve efficiency.Dr Maesela commented that the report was vague, with no information given on under-expenditure and conditional grants, and also no costs were attached to the infrastructure for clinics. He asked whether the new clinics and new staff accommodation were ideal, or if the Department was just replacing the clinics, and wanted to know whether it had the NHI in mind. He also asked if the audit report for the 2017/18 financial year was out.Mr Nkonzo sought more information on the 66 district hospitals offering 24-hour services—what the spread of these hospitals was, and whether the number could be increased. He also asked for specifics on whether the ECDOH was collaborating with other departments, such as transport.The Chairperson commented that she was surprised that a project at the Elizabeth Donkin Hospital was yet to be completed after more than five years.. She had noted that the ECDOH was the only province that had talked of a solution on medico legal claims. She also wanted to find out the position at Nelson Mandela Hospital, where the catering was outsourced.Ms Helen Sauls-August, MEC: ECDOH responded to the queries on the OHSC report, and reminded Members that the OHSC had made an assessment of 70% of the worst performing hospitals over the last three years.Regarding the gravel roads which made it difficult for EMS operations, a sum of money had been put aside by the Department of Transport to prioritise high priority facilities, but thus far not a lot had been done.Mr Kaye said that the Nelson Mandela Hospital did work on an outsourced service model, as the in-sourcing was more expensive and the financial predicament did not assist. The ECDOH had suffered budget reductions and as much as it would like to insource, the money was not there.On whether the audit report for the financial year 2017/18 was out, he said that the AG was on site and would report by 31 July. The indications at the moment were that it was still unqualified.Dr Mbengashe responded on the question about , and said that most of the hospitals had in-sourced services, and what was mainly being outsourced was security. There had been discussion on how to deal with the cost of security.He said all new clinics were being built to achieve ideal clinic status. He confirmed that ECDOH would provide a list of 24-hour clinics to the Committee in writing.Dr L Matiwane, Chief Director: Hospital Services, said that ECDOH had a clear targeted number of EMS personnel it required -- 10 for each ambulance -- and that it was training for those numbers. It had not appointed the two forensic pathologists for East London and Mthatha hospitals. It had 10 specialists for psychiatry services, however.Mr Tuswa confirmed that the clinics were fully compliant and met the ‘ideal’ standards. The ECDOH would submit the cost of the psychiatric units to the Committee in writing.Dr Mbengashe responded on the question of stock visibility. The reason why ECDOH was expanding stock visibility was to target clinics, and for that it needed to have a system that resided in the clinics. He had not yet read the OHCS report itself, but confirmed that disaster management was done at a facility level and that the provincial disaster plan was there. ECDOH would work with the facilities to ensure the facilities knew what to do when it comes to disasters.On EMS staff, he agreed that they needed support. The 92 posts not filled were in relation to grant posts, but for the others, ECDOH was able to meet the targets because there were no barriers.The Chairperson advised ECDOH to put all issues requested by the Members in writing. She added that EMS were under serious threat and that the Committee would follow up with the NDOH regarding the Elizabeth Donkin project and the Nelson Mandela Hospital. The Committee needed information from the Departments to be able to understand what the situation was.Gauteng Provincial Department of Health (GDOH)The Chairperson asked GDOH to zero in on the areas not covered during the previous presentation.Prof Mkhululi Lukhele, Acting Head: GDOH, began by informing the Committee that GDOH had a procurement plan on medical equipment and the monitoring of assets to ensure the assets were maintained throughout their lifespan. On pharmaceutical and laboratory services as at the end of March 2018, 410 075 patients had been enrolled on the CCMDD programme, against a target of 270 000.There had also been an in-house development of the MSD on-line system, which was an electronic ordering portal and document management system.On governance and leadership, he confirmed that governance structures were in place, hospital boards had been appointed and the GDOH was piloting clinical governance structures. It had started a process of skills assessment and coaching. It was on course to stabilise accruals. The conditional grants it received from the NDOH continue to decreased, this was causing a big strain on its operations.On the referral system, he said that GDOH had fivedistricts, and the O R Tambo clinic in Johannesburg health district was being refurbished to accommodate 24-hour services. The out-patient headcount came mostly through the district hospitals. The GDOH still had unreferred patients, and a number of the patients were referred in line with what was usually expected. The in-patient transfers happened more at the central hospitals.For security services, the GDOH employed a hybrid approach, with the biggest portion being outsourced. Hospitals had partial technology security systems. The Department currently spent R60 million monthly on contracted security services.The Department had a total of 754 CHW teams covering the five districts, with team leaders who were well trained. He also took Members through how many visits were done by the CHWs per household. 8 720 CHWs had been contracted. On the “War Room” sukuma sakhe approach, the province had adopted the deliverology methodology to fast track citizen experience.Dr Gwen Ramokgopa, MEC: GDOH said that the Department was taking lessons from Life Esidimeni, and had a risk register on issues it could pick up. The payment of Life Esidimeni claims would be from Gauteng, and not necessarily from the Department of Health. The provincial government had considered going to Treasury.The GDOH approach was to build on the NHI, There was a mid-term review which indicated an increase in life expectancy, and GDOH was close to attaining zero transmission of HIV/Aids from mother to child. It had identified maternal and neonatal area as key area of focus, as it was an area that contributed to medical legal cases. There had been an objective survey in the province on quality of life, and the GDOH received a high score. Another survey would be done before end of the term.GDOH acknowledged that it needed to strengthen its governance. The Department’s recovery plan also responded to the accrual situation. On governance and stewardship towards the NHI, the problem was that most of the functions were centralised. She added that there had been a panic that GDOH did not have funds, but it did have funds and a budget of R46 billion, but the demand was high.She had recently done an unannounced visit to one of the facilities and had discovered that one unit had been expanded from 32 cots to 64 cots -- but the staff number had remained the same. GDOH had no moratorium on posts, but would fill only critical posts. There had been an outcry from the universities that the GDOH was reducing the funds that went to higher education and that it had not trained 1 000 nurses, as only 700 had been trained. This had been done so that the GDOH could prioritise services.On OHSC report, the GDOH acknowledged that although it had performed better, the facilities identified were the least performing. It had noted the recommendations and would push these facilities.DiscussionMs Wilson referred to the OHSC report which indicated that GDOH had scored 19 % in the area of oversight and accountability. She remarked that there was a huge problem in risk management and ineffective leadership, and the GDOH started its financial years with a serious deficit attributed to accruals. She cautioned that health services could not be delivered for all with the accruals in place. She wanted confirmation on what the figures for irregular and fruitless expenditure were, and a breakdown of the specialists in the facilities and what impact the shortage of specialists had on surgery backlogs.Dr Maesela wanted to know what the GDOH was doing about the community partnership team effort incapability, saying such efforts could not be compensated through funds. He commented that there was a lack of a multi-level disciplinary approach in dealing with the problem of standards. The accruals were an albatross, and the GDOH needed help from whatever source.Dr Thembekwayo commented on the OHSC finding on pharmaceutical services, and said the average score given was 63%. Some of the deficiencies highlighted were that there was no evidence that stock taking had been done for medicine and medicine supplies, and procedure manuals and terms of agreement outlining the supply of documents were not available. She also noted that different committees met quarterly, whereas the council met only once a year. She asked whether it was possible for the council to meet twice a year for sustainability, and to also keep them informed.The OHSC score on communication and public relations was 48%. The staff satisfaction survey showed that the staff felt they were not able to participate in decision making. She advised that staff members should be considered in order to reduce strikes. Staff dissatisfaction also had an impact on health emergencies and disasters, and on staff wellness. There was no evidence that staff participated in staff initiatives. She wanted to know how the GDOH was dealing with the OHSC findings.Mr Nkonzo wanted clarification on CHWs and their stipends, and whether there was a desire to increase them to the minimum wage. He also sought more information on the deliverology of the service intervention unit.Mr Maphanga asked what was being done to aid in the tracing of TB defaulters and whether the correct information was captured in the hospitals.The Chairperson asked how the Nelson Mandela children’s home was helping the GDOH. She also said that the Committee would have preferred if the information on “wage shock” was specific, indicating the sectors most affected, whether the administrative or clinical side.GDOH’s responseDr Ramokgopa confirmed that the GDOH would provide a breakdown of specialists to the Committee in writing. On the surgery backlog, she informed the Committee that she had visited one of the orthopaedic departments, and had talked to patient, and had realised that the same patients sometimes registered in three or more different hospitals. She confirmed that GDOH would look more into this area. It agreed that the organizational effectiveness was weakened with centralisation, but believed the approach currently adopted would assist in stabilisation.Gauteng experienced cash depletion by September every year, yet the patient load continued. GDOH was trying to stabilise organizational recovery. It had a letter from the Wits School of Medicine, and together both parties were looking at how best the country could prioritise areas where there was pressure. The NHI’s universal coverage had a strong component of preventive medicine which would assist.In response to the possibility of the Council meeting more than once a year, she responded that through the provincial health forum, GDOH had community engagements in between. In October 2017, it had had a summit with the stakeholders, and it had also had a labor summit four weeks ago.On preparedness for disaster, she said that was a matter of following up on protocols. GDOH was prioritising the housing of security.On the community health worker stipend issue, the challenge was that the provinces did not have adequate funding, and that it paid the CHWs through a paymaster.On deliverology, the GDOH was benchmarking against the Western Cape. It was a service improvement intervention programme, and included improving the patient’s experience. She added that CHWs would help in reducing TB defaulter rates. The national program of registering citizens as preparing for NHI would also help, as there would be one database.She confirmed that the Nelson Mandela children’s hospital was a state-aided facility with specialists in pediatrics. GDOH had to recruit specialists, who were students, but the specialists were supervised by the doctors who trained them, establishing a clinical governance system that could rotate. The facility was being utilized -- it was a national asset, and the GDOH was also looking at that mode of governance to replicate in other hospitals.On the staff complement, she noted that the wage shock was mainly as a result of the occupational specific dispensation (OSD), and the increases in goods and services had not kept up with OSD.GDOH would provide a list on the wage shock as experienced in different sectors, whether administrative or the clinic sectors.Ms Kabelo Lehloenya, CFO: GDOH confirmed that the amount on fruitless and wasteful expenditure had been R22.8 million for 2017/18, and that the R443 million had been from other years. The GDOH had a plan to regulariae irregular expenditure, and it was looking at consignment stock and month to month contracts. R1.5 billion had been given to GDOH to settle accruals, and there was a strategy to ensure that the current year’s budget was ring-fenced to settle current year expenses. It had a plan to stop accumulating accruals.Prof Lukheleadded that GDOH was ensuring that each facility was run as a business unit to ensure there was no wasteful expenditure. On pharmacy issues, the OHSC had not found evidence that there was no stock taking -- staff members had taken stock but had not documented it, and GDOH would work to correct that. It had identified communication as the weakest link, and would take action to improve on that.The Chairperson commented that the process was empowering to all, and she hoped that as the decentralisation of services to the districts was happening, the managers at the district level were empowered. This would assist in preventing labour disruptions and also empower communities. She commented that only Mpumalanga had raised the issue of health workers being assaulted by communities.The meeting was adjourned ................
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