Department and Minister of Health briefing: Strategic Plan 2018 & Annual Performance Plan 2014

Meeting report

Department of Health Strategic Plan 2018/19 and Annual Performance Plan 2014/15 to 2016/17
Dr Aaron Motsoaledi, Minister of Health, tabled and presented upon the Strategic Plan of the Department of Health (DOH), outlining the alignment between the National Development Plan (NDP) 2030, the Medium Term Strategic Framework (MTSF) priorities and the National Department of Health (Doha) Strategic Plan 2014 – 2019. The NDP goals for 2030 noted the increase for average male and female life expectancy at birth to 70 years. Tuberculosis (TB) prevention and cure should be progressively improved, and maternal, infant and child mortality, and prevalence of non-communicable diseases should be reduced. Injuries, violence and accidents were to be reduced by 50% from the 2010 levels. The health system reforms should be completed, and Primary Health Care (PHC) reforms deployed to provide care for families and communities. It was hoped that universal health coverage would be achieved. Overall posts should be filled with skilled, committed and competent individuals.

The MTSF priorities noted strides in the prevention and management of HIV and AIDS, reduction of  maternal, infant and child mortality was reduced, improvement of health facility planning and infrastructure delivery. It was hoped to reduce health care costs. Other priorities included an efficient Health Management Information System for improved decision making, improved quality of health care, a  re-engineering of Primary Health Care, and achievement of Universal Health coverage through the implementation of the National Health Insurance (NHI). Health management and leadership, and human resources for health should improve.

The DoH Strategic goals 2014 – 2019 included the following priorities:
- the prevention of the disease and reduction of the disease burden, and promotion of health
- Improvement of health facility planning by implementing norms and standards
- Improvements to financial management by improving capacity, contract management, revenue collection and supply chain management
- Development of an efficient health management information system for improved decision making
- Improving the quality of health care by setting and monitoring national norms and standards, re-engineering primary health care by increasing the number of ward based outreach teams, contracting general practitioners, and district specialist teams, and expanding school health services
- Improving human resources for health by ensuring appropriate appointments, adequate training and accountability measures.

The Minister said that the health sector derived its vision and mandate from the NDP 2030. By 2030, South Africa should have raised the life expectancy of South Africans to at least 70 years; progressively improved TB prevention and cure; reduced maternal, infant and child mortality; significantly reduced prevalence of non-communicable diseases; reduced injury, accidents and violence by 50% from 2010 levels; completed health system reforms; have primary healthcare teams to provide care to families and communities; provide universal health coverage; and fill posts with skilled, committed and competent individuals.

The Minister commented on the National Health Insurance (NHI), saying that universal health coverage should be achieved through the phased implementation of the NHI law by 2015/16 and the National Health Insurance Fund creation by 2016/17. Health care in the private sector should be regulated by establishing a National Pricing Commission and legislating methodologies for calculating fees. The Functional National Pricing Commission was to regulate health care in the private sector and establish a revised and legislated methodology for the determination of the dispensing fee.

The re-engineering of Public Health Care (PHC) should contribute to health and wellbeing of learners by screening for health barriers to learning, which meant Grade 1 learners and Grade 8 learners receiving health screening. Improved access to community based PHC services and quality of services at primary health care facilities required there to be 3 500 functional ward based Primary Health Care Outreach Teams by 2018/19. Improvement in access to disability and rehabilitation services would be achieved through the implementation of the framework and model for rehabilitation and disability services, with 52 districts implementing the framework and model for rehabilitation services by 2018/19.

The Improved quality health care priority envisaged the improvement of district governance and strengthening management and leadership of the district health system with 3 760 primary health care facilities with functional clinic committees or district hospital boards by 2018/19. Improved access to quality PHC services should be reached with 2325 (75%) primary health care clinics in the 52 districts qualifying as Ideal Clinics by 2018/19. The DOH would ensure that the Port Health services were rendered in line with the International Health Regulations, with 75 ports of entry compliant with the International Health Regulations by 2018/19.
 
Speaking to the aim for accelerated delivery and improved quality of infrastructure, the Minister said that the DOH would improve quality of health infrastructure in South Africa by ensuring all new health facilities were compliant with health facility norms and standards. The DOH would ensure that provinces complied with norms and standards for health infrastructure, and those would be linked to the Conditional Grant, with a 30% budget allocation for the maintenance of existing infrastructure and the implementation of health facility planning.

The Minister noted that the DOH aimed to reduce the maternal mortality ratio to under 100 per 100 000 live births by 2018/19, and reduce the neonatal mortality rate to under 6 per 1 000 live births. Access to sexual and reproductive health services would be improved, with 55% of women having access to a combination of contraceptives by 2018/19. The DOH aimed to ensure that more than 70% of females were screened for cancer of the cervix at least once every 10 years by 2018/19, with the provision of Human Papilloma Virus Vaccine to at least 80% of grade 4 girls, to protect them from cancer of the cervix by 2018/19. In 2015/16 the programme would include Grade 5 Girls. Prevention of Mother to Child Transmission (of HIV) coverage to pregnant women would be expanded, by ensuring all HIV-positive antenatal clients were placed on Anti-retrovirals (ARVs) and there was a target to reduce the positivity rate to below 1% by 2018/19. DOH would ensure that a greater percentage of HIV positive pregnant mothers received ARVs by 2014/15, increasing to 100% by 2018/19. It aimed to reach a 1% PCR test positive rate for infants at 6 weeks of age.

The Minister noted the implementation of the E-Health strategy systems, designed for a National Integrated Patient Based Information System, with the appointment of the Ministerial Advisory Committee on E-Health due by September 2014. He also took Member through the plans for the Health Information Normative Standards Framework, which included the Health Facility IT Infrastructure. In the first phase, there would be 700 PHC facilities in NHI Pilot Districts, and the next phase extended to other Districts. There would be implementation of the Health Patient Registration System and Patient Administration to improve efficiency and reduce waiting times. Further implementation included the integrated electronic Health Data Collection System, finalization of E-Health Strategy and policy guidelines, and the implementation of recommendation on PHC Patient Information Systems assessment

Department of Health Strategic Plan 2018/19
Ms Precious Matsoso, Director-General, Department of Health, outlined and explained the programmes for the DOH. For Programme 1: Administration the strategic objectives of the Department were to ensure effective financial management and accountability, to develop and implement the ICT Governance framework for the Department, to provide support for effective communication, to ensure efficient and responsive human resources services to the Department; and to improve and coordinate integrated planning for health. The challenges for Programme 1 included liquidity and use of financial resources, the integrity of financial information; adequacy and suitability of ICT infrastructure; effective and appropriate internal and external communication; and critical skills attraction, retention and development.

Programme 2 covered the National Health Insurance, Health Planning and Systems Enablement. Its purpose was to improve access to quality health services through the development and implementation of policies to achieve universal coverage, health financing reform, integrated health systems planning, reporting, monitoring and evaluation and research. The strategic objectives were to achieve universal health coverage through the phased implementation of NHI, to regulate heath care in the private sector; strengthen revenue collection; implement E-Health strategy; ensure research contributed to the improvement of health outcomes; develop and implement an integrated monitoring and evaluation plan; and establish a coordinated disease surveillance systems, ensuring that South Africa met the international obligations.  The challenges in this programme included financing of various service delivery improvement programmes, the capacity to manage the health system, health sector cost fluctuations, collaboration level with the private sector, and empirical evidence of conditions to support the formulation of regulation.
 
Ms Matsoso said that Programme 3 covered HIV/ AIDS, TB and Maternal and Child Health. The aim of this programme was to decrease the burden of disease related to the HIV and TB epidemics; to minimise maternal and child mortality and morbidity; and to optimise good health for children, adolescents and women. This was done through the three overarching strategies of setting policies, guidelines, norms, standards and targets; supporting the implementation of these; and monitoring and evaluating the outcomes and impact of this implementation. Generally, these objectives were aimed at the reduction of maternal morbidity and mortality; reducing neonatal morbidity and mortality; improving access to sexual and reproductive health services; expanding the PMTTC coverage to pregnant women; improving TB prevention, diagnosis and treatment in correctional services facilities; increasing access to Multi-Drug Resistant (MDR-TB) treatment. The challenges to be overcome in Programme 3 included provincial and district prioritisation and implementation of the most important interventions that would have the greatest impact on maternal mortality, such as the recommendations of the NCCEMD; the fact that poor infrastructure in hospitals was preventing optimal neonatal care in the form of respirators and piped air at correct pressure; the need for collaboration with the Department of Correctional Services (DCS) around implementation of TB services in correctional services facilities. The new contraceptive implant had a poor reputation because of poor quality of care, such as failure to remove it when side effects were detected. The HPV vaccine immunisation faced the challenge of possibly being un-sustainable because of poor integrated school health programmes. Prevention efforts to date had failed to reduce the number of new HIV infections and the numbers of patients on HIV medication may grow so large that management of health facilities becomes difficult.

Discussion
Mr I Mosala (ANC) congratulated the Minister and the Department of Health for moving forward in terms of health matters, although there were lot of challenges. He asked how many ambulances were allocated and operational to the districts, in order to improve on the management of the maternal issues, and whether there competent people appointed who were skilled and specialised for that purpose.

Mr Mosala also asked what progress the Department had registered since the launch of the NHI and how long that pilot project would go on.

Mr Mosala enquired what financial contribution may be made to the mining sector and was concerned about the Compensation Commission for Occupational Diseases. He noted that documentation given to the Committee indicated that there were particular problems with mining and TB, and enquired if mining companies were contributing anything to the prevention and treatment costs for TB.

Mr Mosala asked whether there was any moratorium at any stage on erection of new buildings, especially hospitals, except in rural areas under the Presidential Lead Projects, and what the provincial spending position was.

Mr Mosala asked if there had been any improvement on the situation where older men had been infecting young girls with HIV. In respect of lifestyle disease, he asked why DOH was not making it compulsory for Parliamentarians to eat healthier food, so Parliament could lead by example. He asked whether they were winning the battle where sugar daddies were infecting young girls with HIV.

Mr Mosala asked whether South Africa was close to setting up its own herbal or traditional medicine manufacturing company, led by Government, or whether it would be remaining dependent on imported medicines.

Ms C Ncube-Ndaba (ANC) commended the detailed report. She was worried about the decreased allocations to Primary Health Care (PHC), particularly since many of the programmes were in primary health care, and enquired whether some matters might be negotiable, or stand over for a later stage. She was pleased with the reports on the Human Papilloma Vaccine.

Ms Ncube-Ndaba believed it was correct that provinces should give their plans to the Department when they wanted to erect new buildings, but suggested that there was a need firstly to look at the existing structures and possible renovations.

Mr H Volmink (DA) thanked the Minister and the department for their presentation. It was clear that the quadruple burden of disease was quite heavy and there were lot of steps to be taken still to meet that challenge. He concurred with Ms Ncube-Ndaba that the reduction of the budget for primary health care was a concern. There were about 14 million household in South Africa and DOH was going to need about 10 000 outreach teams to register all those households for implementation of NHI, which was a monumental task. The concern was that that area was budgeted under PHC, yet there was shrinkage in that area. He asked whether the Department was confident in meeting the target by 2018/19.

Mr Volmink noted that another important point was stated by the Minster relating to the shifting from the curative to the preventative mode of service delivery. Critical to that was health promotion and allowing the communities to develop skills to take care of their own health; however, once again, there as a reduction of 5.6% of that budget, and that was a huge concern.

Mr Volmink noted that the NHI strategy had been released but those forecasts were very ambitious, which made him worried that DOH might not reach the targets. He asked whether the Department had looked at other areas, for example, clinical associates, middle level workers and models from other countries, to fill up those gaps, and, if so, whether this was reflected on the plans and budget.
 
Mr N Matiase (EFF) noted that the NDP made very bold and ambitious undertakings, but there was confidence that the programme for improving the health in the country would mitigate the challenges that had been observed over the last 30 years. He asked what the Department was doing in terms of integrating community health workers into the health system. He asked whether the Department had thought about establishing state owned pharmaceutical companies to look into issues of purchasing and storing of procurement of medicinal products, to avoid wastage.

Mr F Mahlalela (ANC) asked what the reason was for Free State’s very low rate of life expectancy as indicated in the strategic plan, and what the challenges were. Speaking to life-style diseases, he wanted to know whether there was any regulation of the salt content of food purchased from restaurants.

Mr Mahlalela asked how the Department would reach the target  of 3 000 ward based committees by 2018/19, because currently it was at 1 500, as indicated in the Annual Performance Plan.

He asked for clarity on improvements with regard to the norms and standards for health care services.

Mr Mahlalela repeated earlier questions about the actual dates for implementation of the NHI. The presentation stated that the National Insurance Fund would be created by 2016/17, and he asked if that was also the beginning of the implementation or if there were still processes that would follow and if there would be a final assessment on the pilots to see how DOH would roll out throughout the country.

Mr Mahlalela  asked how the Department defined the functioning of the clinic committees in health care services, and what were the yardsticks that were used to measure them, so that the Committee, during oversight, could determine whether clinic committees were functional.

Mr Mahlalela asked where DOH was standing in terms of ports of entry and what its plan was for this year, and how many it was targeting, to make sure of compliance with the requirement.

Mr Mahlalela called for clarity, for central hospitals as well as 17 tertiary, regional  and specialised hospitals’ compliance, when they should be 100% compliant, if there was a breakdown of who should comply by when.

Dr P Maesela (ANC) thanked the Minister and Director-General for the presentation. He said that he wanted to comment on the mortality rate, and statistics which showed there was stagnation in the population growth in most provinces except two provinces, or in fact there was a decline in population growth. He asked whether that stagnation in population growth was due to health factors or due to high migration percentages. Gauteng and Western Cape were showing high growth in population but the rest of the provinces were low. He also questioned where child mortality featured in that equation, and what were the major drivers of that problem.

The Chairperson asked if there were separate statistics for rural and urban areas, in terms of the reduction of mortality rate.

The Chairperson questioned whether, in addressing life style diseases, it was necessary for people to eat a diet that differed according to their blood group.

The Chairperson also asked abut the relationship was between the Department of Health, the Department of Science and Technology, and the Department of Trade and Industry, particularly in regard to indigenous knowledge and the development of traditional medicines.

The Minister firstly dealt with the questions on ambulances. He was not sure whether the figures were in the presentation, but three years back, in order to decrease maternal mortality, the national Department agreed with the provinces that certain ambulances should be used only for pregnant women, which was why they were called obstetric ambulances. Unfortunately, some provinces had bought the vehicles but failed to plan properly and might use them for other accidents, leaving a woman in labour to suffer. There were such vehicles. KwaZulu-Natal was looking into equipping them like labour wards where the staff could deliver a baby and had the equipment for doing that.

The reason that specific mention was made of Free State improvements in maternal mortality were because there were dramatic improvements in a short space of time. That would not necessarily contribute to the life expectancy statistics, but this was a recent event and was related to how ambulances had been used. The policy was that when phoning for an ambulance, preference would be given to a woman at home in labour, but now ambulances were also recognising that if a pregnant woman was at the clinic and in labour, and the nurse was calling for an ambulance, this was because there were difficulties there; a home labour might equally take place without any particular complications.

 The Minister reminded Members, in relation the NHI launch, that the ruling party had taken a decision in its 2010 Policy Conference that NHI would take 14 years, starting from 2011. The White Paper had broken down the 14 years into 5 years, 5 years and 4 years phases. It should be understood that the concept of universal health coverage was not a single event; the process took a very long time. For example, Britain established the NHS in 1948 and it was still making changes, so it should not be expected that in South Africa there would be a date when it could be said that everything was working perfectly. Mexico started in 2001 and had not yet covered the whole country.

Whilst the White Paper envisaged 14 years, the NDP was actually arguing that it would take 25 years to implement NHI, although the DOH felt that this was too long. In Qatar, in July 2013, the implementation of its NHI began, and this was anticipated to take only 18 months, to December 2013, which was a surprise. However, Qatar had already started discussing NHI in 1992, and the implementation followed now on discussions since then. That was a revolution that changed everything in the country in terms of running health care, and it was a very huge project.

The Minister said that delivery of NHI for the first 5 years was laying the foundation. People believed NHI was just issuing medical aid to everybody. However, DOH was intending to completely change the delivery of health care in the country. The World Health Organisation (WHO) had even given South Africa a template of how to completely change the health care system of the country. In July 2012, the Ministers of Finance and Health attended a discussion in Tunisia on this, when the Director of the WHO in the African Region had said that Africa, to successfully implement this system, needed to lay down a whole infrastructure for the implementation of the free health care system.

Engineers were sent to all the pilot districts around the country where each province had a pilot project, with a template against which to check health facilities for proper condition. Free health care would work if DOH ensured that the infrastructure was in good condition, and checked that all health facilities were ready for the delivery of health care. DOH had asked National Treasury for money at an additional level to solve the problem of infrastructure maintenance, and so DOH was laying the infrastructure foundations for the NHI.

The Minister then moved on to questions on  mines and the Compensation Commission of Occupational Diseases (CCOD). The contribution of the mining sector to problems of mine workers and workers was a problem, and mine workers were the most oppressed workers in the country. There were problems with the compensation, and although the CCOD was supposed to compensate for diseases contracted through working in the mines, particularly the gold mines, and problems linked to TB, the laws needed to be changed. The Compensation Commission for Occupational Injuries and Diseases (COIDA) compensated workers other than mine workers for occupational injuries and disease. Old laws governed the position, and there was a question of where the money should come from to compensate under CCOD. The Minister said it should come from mining houses. There was a formula that depended on mining inspections done by the Department of Mineral Resources but the inspections were seldom done, and that had to be resolved. The DOH had now hired a specialist who was working around the clock to correct these issues. New legislation was needed. Meantime, the DOH was dealing with mine workers in four areas - OR Tambo in Mthatha, Kuruman in the Northern Cape, Bekkersdorp in Limpopo, and in Carletonville. Some ex-miners did not even remember the names of the companies they were working for, which made it very difficult to help them on compensation. The State had opened one stop centres, which aimed to help in making sense of the information, trying to supplement it and ensuring compensation claims, physical testing of lung conditions, and rehabilitation where there was lung damage.

The Minister old Members that there had never been a moratorium on building hospitals. There was a need to strike a balance; it was preferable to divide the funding between building new hospitals and revitalising and maintaining existing ones. No moratorium was possible because there must be access to health services.

The Minister commented on the position of young girls and said that in the 14+ age group, there were eight times more HIV-positive girls than boys from the same age-group. The reason was that they were sleeping with older men who were already HIV positive. This was the vicious cycle happening in Sub-Saharan Africa of young girls being infected by older men. When the girls reached their mid-twenties, they would marry the uninfected boys, with the result that their infection was passed on. The Minister said that if South Africa could “cut the sugar-daddy syndrome” it would be possible to win the battle. This, however, was a social determinant, as most of the girls being infected were orphans, whose mothers could have died of HIV, which was why the older men were able to target them.

The Minister noted that the DOH could not force Parliamentarians – but only advise them on menus and diets – to eat healthily.

The Minister said in relation to traditional medicine that Africa had declared a Decade of Traditional Medicine from 2000 – 2010, by Heads of State, but nothing had actually happened in the Continent. Anther new Decade was declared again in 2010, but by the fourth year, 2014, again nothing was happening. The  only country that was advancing in traditional medicine, as well as herbal medicine, was Ghana, which had literally sent people to institutions to train them and give them qualifications. It must be remembered that all medicine was herbally-based before chemistry had become more advanced. The reference to “traditional medicine” was sometimes confusing. The World Health Organisation (WHO), in 2010, had a conference with Ministers of Health in Ivory Coast, where a Professor of Pharmacology in Tanzania, Osibo Casibe, said that the reason Africa was failing in traditional medicine was that although all over Africa there were universities that were testing substances, traditional healers were unwilling to put up their remedies for testing, saying that they wanted their medicines immediately certified. One traditional healer had just petrol bombed the Department of Health offices in Pretoria, in an attempt to force the DOH to accept his herbs without proper tests.

Middle level worker training had recently commenced at Walter Sisulu University and other universities would follow soon. DOH was trying to encourage the concept.

Ms Matsoso responded to questions on the budgets and PHC. The budget had been spread across the different streams. The DOH had four streams of primary health care; one of them was on school health. However, the budget for school health would not appear under primary health care, but under maternal and child care. There was an attempt to integrate, not maintain a silo approach. PHC services were up to district hospital level, in an attempt to improve referral. In the budget the district hospitals would be allocated under a different programme. The main priority was to achieve a more streamlined service but ensure that every programme included some budget for primary health care.

The second stream of primary health care was that of the district specialised teams at district level. That budget would be found under tertiary services, because this was where specialists for training and teaching were allocated. However, budget was  also found under the maternal and child health care including emergency services. She noted that when planning it was not taken into account that users would have to pay for those services.

Ms Matsoso also commented on healthy eating option; the DOH wanted the industry to come up with  healthy options, including facilities selling food being able to have also healthy options upfront. This did not need more money as it was about stakeholder engagement. R98m was a lot of money for facilitator work, but the DOH had seen that based on the Paris Declaration it could actually get development aid and use it in a manner that could facilitate and implement programmes.

The district expenditure reviews reviewed all the expenditure in a province. At national level, DOH did not need to keep a lot of money and preferred that the allocation for districts and primary health care should be in provincial budgets, but the national Department must help the provinces to ensure that there was implementation.

The meeting was adjourned to the following day, for presentation of the Annual Performance Plan.