Mpumlanga, Eastern Cape and Western Cape Provincial Health Budget: briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
5 April 2005
MPUMLANGA, EASTERN CAPE AND WESTERN CAPE PROVINCIAL HEALTH BUDGET: BRIEFING

Chairperson: Mr L Ngculu (ANC)

Relevant Documents:
Mpumalanga Department: PowerPoint presentation
Mpumalanga Department Achievements in MECs Policy and Budget for 2004/05
Eastern Cape Department: PowerPoint presentation
Western Cape Department: PowerPoint presentation
Department of Health, Western Cape Provincial Government Media Release (see Appendix)

Western Cape Department of Health website

SUMMARY
The Mpumalanga Department presented its priorities and strategic plans for National Health Service for the outer years and challenges. Member expressed concern about utilisation of grants, and asked for clarity on a number of issues including immunisation coverage, HIV/TB, measures to address challenges, and morbidity and mortality rates.

The Eastern Cape Department presented its programmes, policy mandate, as well as focused areas to address challenges. Members felt the information given was inadequate for a meaningful engagement. Of concern was why some critical issue had not been addressed earlier, and clarity was requested on their comprehensive plan for HIV/AIDs.

The Western Cape Department presented its focused areas, challenges, capital assets and programmes. Members asked for clarity on a number of issues, which included the cost of Anti-Retroviral Treatment per patient.

MINUTES
Mpumalanga Briefing
The MEC (Member of Executive Council) for Health and Social Services in Mpumalanga, Mr Pogisho Pasha, said application of strategies for institutional transformation had been successful and all health facilities had been audited successfully the previous year. The Department would continue with the implementation of health delivery services and strengthen Emergency Health Services (EMS). Key priorities for the current financial year included health promotion programmes, extend rollout of comprehensive HIV/AIDS, improve infrastructure in addition to hospital revitalisation. There had been a drastic reduction in reported malaria cases and an expanded programme on immunisation. A major challenge had been addressing recruitment and retention of health professionals. Three hundred student nurses had been enrolled for various categories of health professions.

Mr H Verachia (Head of Health and Social Services Department) said they had received technical assistance from the Italian Cooperation around Health Information Systems. R2.2b had been spent out of the R2.384b for the past financial year. The Medium Term Expenditure Framework (MTEF) budget was expected to increase by R3b in the next financial year, as well as significant increases in HIV/AIDS grants. It provided health care services to patients from Swaziland and Mozambique.

Discussion
Mr I Cachalia (ANC) asked about the percentage of the 2005/6 budget allocated to personnel expenditure and how it compared to the previous year? What proportion of conditional grant was allocated to health? If there was to be any under expenditure, which grants were affected?

Ms M Madumise (ANC) wanted clarity on the percentage of immunisation coverage in the province.

Mr R Mnisi (Chief Financial Officer) replied that not all conditional grants allocated would be spent and there would be a roll over. Hospital revitalisation and provincial infrastructure grant would be under spent because of current capital projects that were ongoing.

Ms G Mathebula (Chief Director Primary Health Care) reported 82% immunisation coverage in the province.

Ms S Rajbally (MF) asked about the percentage of reported malaria and diarrhoea cases in the province. How was the process of strengthening participation of all stakeholders unfolding? How participation was structured between the Department and communities?

Ms N Nkabinde (UDM) wanted clarity on under expenditure of HIV/AIDS grants. What measures had been put in place to address challenges of recruitment and retention?

Ms B Ngcobo (ANC) commented about Mpumalanga being rural and asked about the response time in Emergency Medical Services. She also wanted clarity on decreasing morbidity and mortality rates in choice of termination of pregnancy and general reproductive health issues.

Ms R Mashigo (ANC) asked about causes of child and maternal death, and their intervention?

Mr P Pasha said comparatively in 2003 there was a decrease of 16% in reported malaria cases compared to previous years. The Department had engaged with various stakeholders and partnerships had improved. There would be a Consultation Summit on community and stakeholder participation in all programmes to enhance these partnerships further. The challenges of recruitment and retention persisted in spite of incentives introduced in certain parts of the province. Regarding medium and long-term human resource development, the Health Services Training College had been established to train students in the province and had allocated bursaries to various health professional.

Mr H Verachia said they had an understanding with University of Pretoria and South African Military Services for the training of Primary Health Care (PHC) nurses to strengthen service delivery. There had been other interactions with NGOs and civil society organs to assist with delivery and the creation of awareness. The launch of the Provincial Aid Council aimed to strengthen partnerships. Intensification of the monitoring of hospital boards would ensure meaningful community participation.

He indicated that a few interventions had been introduced in terms of ACTs, Prevention of Mother to Child Transmission programme (PMCTC), and funding of Home Based Care (HBC) due to problem of there being a large number of non-government organisations (NGOs) and HBCs. Currently there were in excess of 430 HBC organisations in the province, which had created the situation where the Department had to do a careful screening that caused delays and a resultant under spend of the HIV/AIDS grant. There had been in mprovements such as 86 new ambulances and the appointment of new staff to deal with the response time of EMS, however they were still faced with major challenges.

Mr K Micheal (Chief Director: Hospital Services) reported that the response time for EMS in most rural areas of the province was on average two hours. He indicated that this figure was captured before the introduction of additional vehicles in twenty-three stations. There had been significant improvements in EMS for the past three months. The infant mortality rate in the province was currently at 43.3 per 1000 and child mortality rate was at 69 per 1000. The general mortality rate was at 150 per 100 000 which was higher than the national norm. They had identified these as problems related to issues of recruitment and retention of skilled professionals. Some interventions to deal with the problem of retention included the setting up of 12 training sites for doctors and primary health care nurses in hospitals where they worked, and a telematic training programme. The Department also placed its community doctors on the tenth notch of the salary scale as part of its retention policy.

Ms G Mathebula reported that the Integrated Management of Child Illnesses (IMCI) had been expanded to include community awareness programmes on management of medical conditions during pregnancy, breast and cervical cancer, termination of pregnancy. There was a low Measles rate of 0.006% with a zero Measles mortality rate and zero Polio cases had been reported in Mpumalanga. Negotiations were far advanced to take over Forensic Services from the SAPS. It had delivered over and above what it promised by appointing 23 EMS Station officers and 57 emergency care practitioners, R5 600 000 worth of equipment and 12 000 insecticide-treated nets distributed to communities in the high risk areas. A service level agreement had been signed with the Bureau for the Prevention of Blindness and Disabled People of South Africa.

Mr R Mnisi reported an 8.5% increase in the personnel budget for the current financial year, and Mpumalanga received 14% of the national budget in terms of health component of conditional grant.

The Chairperson noted a constant increase in conditional grants and expressed concern about under spend for almost all grants for the previous financial year and an indication of under expenditure in hospital revitalisation and infrastructure development for the current financial year. He wanted to know if the avalanche of NGOs was the only reason for under expenditure of HIV/AIDS grant?

Ms P Tshwete (ANC) asked about the security of health professionals? What was the process with rural allowances? When would classification be completed and was there money for it?

Dr R Rabinowitz (IFP) asked how much of the donor funding was managed through National and Provincial Treasury and how much was made available to NGOs and Community Based Organisations (CBOs)? What were the strategies to attract health professionals to rural areas? How attractive was telemedicine in rural areas?

Mr P Pasha replied that one of the commitments last year was to have 80% of Community Health Centres operational on a 24-hour basis, however the challenges of attracting health professionals to the rural areas had been immemse. Security availability at health facilities had been improved tremendously but they had to do more to improve the structure of health service delivery.

Mr H Verachia said there had been a re-classification in December 2004 in terms of certain norms and standards, which touched on all areas of the province. There was no funding for NGOs and CBOs in Mpumalanga by international agencies via the Department and there had been no request for such funding.

Mr K Michael said telematic programmes that ran in the province related to transmission of radiology and had proven to be effective and successful. Surgeons looked at scans in Pretoria and decided if patients had to be transferred. It currently transferred less than 50% of patients. Other components of telematic programmes would be embarked on this year, where interactive training programmes would be rendered to doctors and other health professionals. Other training courses were provided free of charge as a retention policy.

Mr I Cachalia commented that conditional grants were important and expressed concern that under spending would impact negatively on service delivery. He asked if there was a monitoring mechanism.

Ms M Njobe (ANC) asked about any reduction in Sexually Transmitted Infections (STIs) and teenage pregnancy? Was a 24-hour service operational?

Ms S Rajbally asked why monies that were being under spent in certain areas were not being made use of in other areas that needed additional funding?

Ms M Madumise wanted clarity on the effectiveness of the Direct Observation Treatment Strategy (DOTS) system in the cure of tuberculosis (TB).

Ms Ngcobo asked how the Department was managing Multiple Drug Resistance (MDR) to TB and how much of its budget went into cross border health care services in and outside the country?

Ms G Mathebula replied that the 24-hour service had not fully taken off because of fluctuation in staffing levels. 86 primary health nurses had been enrolled at the Witbank Hospital, which was piloting the ARV module and on completion they would be licensed to dispense. They had seen a reduction in STIs, but still grappled with teenage pregnancy in isolated areas.

Mr K Micheal said that MDR had not been researched for many years. The National Department in collaboration with CSIR, Medical Research Council (MRC), US Centre for Disease Control (CBS) and Harvard School of Public Health had set up research centre units to investigate TB transmission and airborne infections. The unit in Mpumalanga had 36 beds, which was not sufficient to research all cases. MDR in the province related to the low case cure of TB. DOTS was one of keys to prevention of MDR. The problem was related to the stigma of TB and AIDS and one of the interventions was to try and de-stigmatise. They were working on the cure rate and there had been an improvement and a reduction in TB MDR.

Mr H Verachia said they reported on a monthly basis to Provincial Treasury and on quarterly basis to the Provincial Security Council. Regular reports were also being provided to National Treasury on expenditures and constraints. Lack of capacity of human resources had been the underlining factor for under spending. However constraints did not negate the fact that conditional grants had to be spent within the stipulated time. There were conditions attached and it was difficult to use unspent grants in other areas. For the financial 2005/6 it was committed to spending all designated conditional grants. Again the move from provincial to the establishment of Department Tender Boards last year was delayed and this impacted on spending.

Ms M Madumise asked if delays in procurement contributed to under expenditure of grants?

The Chairperson wanted clarity on comprehensive HIV/AIDS plans and Community Health Workers and HBC organisations.

Mr H Verachia said accounts were sent to National Treasury or Gauteng for cross border patients and payments were made on a regular basis after accounts had been submitted. In terms of patients from Swaziland and Mozambique and other areas of the province they negotiate for the provision of those kind of services at a fee. There had been instances of delays in tenders for procurement. Together with the Provincial Treasury they had set up a Value Chain Management to assist with timely procurement. A task team had been designed to empower HBC organisations. Community Health Workers were a group within the HBC. He said they would provide the Committee with a list of projects and organisations that are funded in this current financial year.

The Department had rolled out eight of the twelve ART sites identified last year and had identified ten more sites. By March 2006 they would have rolled out 22 sites.

The Chairperson wanted to know the spread of those twelve sites in the province. What were the national statistics?

Mr H Verachia replied that the twelve sites identified were spread across three districts in the province and the eight sites in operation are spread across two districts. He was not sure of the national statistics.

Ms R Rabonowitz wanted to know how many people were served by those sites?

Mr H Verachia replied that the Committee would be provided with that information since it was updated on a regular basis.

Eastern Cape Briefing
Mr L Boya (Superintendent General, Health) outlined the health challenges that the province faced and the targeted deliverables it aimed to achieve. The key focus areas for 2005/06 financial year were identified,
as were Budget and Conditional Grants figures. He then went through their eight programmes and listed the objectives and targets for each of them. He reported that the department had operated under a tight fiscal environment that was intended to control over expenditure. Human resources remained a critical challenge (see document for detail).

Discussion
The Chairperson referred to the increase in budget allocations for the various programmes but noted that the presentation did not cover last year for comparison. How were they tackling the challenges of recruitment and retention?

Mr I Cachalia asked if there was any anticipation of under expenditure of the conditional grants. What was the comprehensive plan on HIV/AIDS? Were they receiving any donor funding for HIV/AIDS? If so how much would be transferred to NGOs?

Ms S Rajbally suggested that perhaps there was a need to re-prioritise issues such as poor quality of healthcare and institutions and lack of accommodation in order to retain staff. She asked why so much time had elapsed in addressing concerns.

Ms N Nkabinde noted that there was not a current possibility for comparing preliminary expenditure and felt the information provided was not adequate.

Mr L Boya replied that the growth in the budget did not reflect the environmental issues. There were restrictions on non-health matters. The capacity issue hampered the ability to procure essential tools. They had had to re-prioritise. Challenges were to do with the quality of the environment and the availability of human resources. Priorities had been captured in the programmes. There had been an increase in bursaries from 6 to 38 in an effort to address the skills problem. Infrastructure was planned for over a three-year basis because of a roll over from the previous year. Rebuilding the department had been a mammoth exercise. Some of the identified areas had been dealt with, others were progressing and some were yet to be tackled.

M P Vazi (Acting Chief Operating Officer) reported an over spend of the previous budget (R5.1b) by one billion rand including a provincial overdraft of R 41 million. This had to be rectified by an under spend of the current financial year’s budget (R 5.4b). There were significant increases in budget allocation to health services. HIV/AIDS allocation showed a roll over from the previous year. Fifty additional sites would be added to the current fifteen sites to increase access to comprehensive care treatment.

The Department was providing funding for HIV/AIDS in the amount of R18 570m from its equitable share in addition to conditional grants. Donor funding was direct and indirect. The Danish government had provided R17m through the United Nations Development Programme (UNDP) to three provinces (Kwa-Zulu Natal, Eastern Cape, and Limpopo) and R4m to the EC Aid Councils. The German Development Bank had channelled funds through the South African Development Bank (SADB) for the revitalisation of hospitals. Canadian Research Data Centre had given R24m for technical support and training programmes, a R26m European Union Partnership for Health funding was to be implemented by NGOs with the Department, and there was United States Agency for International Development (USAID) funding for the implementation of a consortium to assist the Department on technical issues. Mr B Mjamba (Chief Director) added that the Department had a Service Level Agreement with the NGOs.

The Chairperson said there was a lot to follow up on and to find mechanisms to address concerns such as why austerity measures affected health services delivery. He also noted particularly the appalling accommodation conditions for staff in the rural areas and the contradictory strategies.

Western Cape briefing
Mr Pierre Uys, MEC for Health, said there had been a shift in the current financial year towards effective primary health care delivery that was captured in its District Health Programme. The current budget had grown by R1 billion compared to the previous year as a result of the introduction of new programme called Health Facilities Management. Monies from the Public Works Department had been transferred to health for infrastructure and hospital development. He noted that last year’s budget had to be adjusted by R100m from provincial treasury. Conditional grant spending had been on target.

He reported that 27% of the budget had been allocated to health services. Other income sources came from own revenue, which was topped up by own equitable share. The Global Fund grant amounted to R51m for the treatment of TB and the roll out of the HIV/AIDS programme. They had not been successful in achieving demographics. R10m would be spent to roll out a communication centre to deal with disaster management. Of concern was that targets were not being met in terms of Emergency Medical Services (EMS) in the metropolitan area and there were delays in the completion of hospitals and other training facilities. They would be taking over TB hospitals in some metropolitan areas. Major progress had been made in the hospital revitalisation programme.

Discussion
The Chairperson commented that there was no indication of under spending for the previous financial year and wanted to know how they had fared in terms of expenditure.

Ms B Ngcobo wanted to know which NGOs had been funded by the Department to provide training and treatment of HIV/AIDS patients.

Ms M Madumise asked why it had taken so much time to control cases of TB in the province and if they used the DOT system.

Mr I Cachalia commented that it was encouraging to know they and used the conditional grants optimally. He asked about the per capita expenditure on health. Were they likely to over spend or under spend? Were there any other sources of revenue to be collected? How much of the budget would be given to NGOs and what were the criteria to be used? What was the monitoring process?

Mr P Uys replied that the expenditure for the previous year would be made available to the Committee. According to him they were 100% on target, however he could not say if they were likely or unlikely to under spend this year. 44 000 TB cases had been reported but this was not comparable to other provinces. The cure rate in the province was higher at 72% but lower than the WHO target of 85%. It rate for MDR was lowest in the country. HBC had been launched the previous year.

Prof K Househam (Head of Department) reported a possible over spending in administration and district health and HIV/AIDS programme. A tender process had been put in place to enable HBCs that needed critical support to apply for funding. Plans were being made to ensure EU funding was allocated from the Department budget over time.

Mr K Cloete (Director HIV/TB) reported that R1118m in total had been allocated to HIV/AIDS, and another R12.7m for volunteer counselling, R4.23m for HBC and R9.2m for Hospice care. A range of organisations had requested funding and monies were being advanced on a monthly basis. Non-performing organisations had to negotiate and prove themselves before monies were given to them. 23 HBC organisations had received EU funding amounting to R75m. Further allocations would be made. In-house training was provided and accredited through the national training course.
Gross figure total pop of 4,8m divided by 7.8 b which is R1200 per capita but that figure needed to be put into context is that 28% on medical aid and go to private sector and secondly and that enlarged portion of funding only western cap but for falsely high figure adjust 1.2 b portion therof goes is for patients for other porvinces less than r1200

Prof K Househam indicated that the gross per capita expenditure was R1200 per person and included conditional grants but this did not take into account treatment for patients from other provinces at Tertiary and if this was taken into account then it was less than R1 200. Per capita expenditure for primary health care ranged from R160 - 240 as it varied from area to area. Per capita expenditure had increased yearly.

The Chairperson commented that the per capita expenditure was a policy concern that needed to be addressed.

Dr R Rabinowitz asked if the tender process was linked to government in terms of ART? What was the cost of ART per patient? How many sites were available and what was the number of people being treated? How much of the EU funding went to the National and Provincial Treasury?

Ms R Mashigo asked about the general mortality rate and the facilities for intervention?

Mr P Uys replied that it cost R96 per month per patient for first line ART treatment with generics. The EU funding was based on a contract. Mortality rates differed within different regions. 53 ART sites were operational with 12 000 patients on treatment.

Prof Househam replied that the infant mortality rate was based on census data and was 31 per 1000 in the Western Cape, 35 in Cape Town, 44 in Khayelitsa, and 13 in the South Peninsula.

Mr Cloete said the ART tender had taken effect on the 1 March and best price had been negotiated. They had saved 25% on the tender. Drugs that were not on tender had been purchased. The EU grant was negotiated by the National Department for five provinces and released to provincial government to spend accordingly.

Dr R Rabinowitz asked if the drugs that were not tendered for were generic or patent? Was there any resistant to drugs?

Mr K Cloete replied that the first line drugs were procured on tender, while second lines were bought in smaller amounts. Drugs were both generic and patent. A detailed process had been put in place to assess emerging resistance and how to minimise it through medicine control and drug surveillance.

The Chairperson asked how they had dealt with their equipment backlog. Why was EMS not being transferred to outer areas?

Mr P Uys reported an amount of R 160m for the purchase of equipment. Last year they had experienced negative publicity about Tygerberg Hospital because of backlogs in maintenance and equipment but they were dealing with it and there had been improvements. EMS in non-metropolitan areas had all been transferred. Some had resigned in the City of Cape Town and had applied for the provincial service. It was fully operational and integrated under the province.

Dr B Engelbrecht (Director General) said equipment included maintenance and there was a backlog of R330m. A lot needed to be done in terms of provincial allocation of equipment to the rural areas. Prof K Howsehan added that the facilities needed upgrading in Tygerberg.

Ms P Tshwete asked if the Department was involved in TB care and if SANTA was still operational?

Ms R Rabinowitz asked whether the HBC was for TB or HIV/AIDS?

Mr P Uys replied that SANTA was not operational and that they had made use of other organisations. Mr K Cloete said two to five million had been spent in the metropolis by three organisations on TB care. They have had problems with the performance of SANTA. A National guideline on training manual made provision for ART in homes, and was developing a policy towards integration.

The Chairperson said there was a need to a follow up on the interaction.

The meeting was adjourned.

Appendix:
Department of Health, Western Cape Provincial Government Media Release
Budget provides welcomed relief on health services

1 December 2004

Western Cape Health Minister, Pierre Uys, welcomed the relief earmarked for his department in the Western Cape Adjustment Appropriation Bill tabled by Finance Minister, Lynne Brown, in the Provincial Legislature today (23 November 2004).

Once approved by the Legislature the Health Department will receive an additional R139,5 million to supplement its R4,74 billion budget for the current financial year. This will be made up of R3,4 million from rollovers from the previous financial year and R136 million from other adjustments.

"The largest slice of the additional funds approximately R104 million will be used to help us deal with the huge increase in demand for our services as a result of rapid population growth and sharp increases in the incidence of communicable and chronic lifestyle diseases. Included in this amount is R29 million donated by the Global Fund to help strengthen and expand our already comprehensive HIV and AIDS programmes.

"A further R20 million will be spent on various items including increasing vaccine levels, improving Emergency Medical Services, enhancing revenue collection, replacing beds and trolleys and shortening waiting lists for patients waiting for ear, nose and throat surgery, cataract surgery, bone marrow transplants and buying high cost consumables like heart valve prostheses," said Health Minister, Pierre Uys.

"The budget relief now in the offing will remove a considerable amount of pressure from health services in the Western Cape. Where some weeks back we were faced with drastic options such as the closure of numerous wards and ICU beds, along with further delays in elective surgery, the funds being reallocated will help ensure that no further service cuts would be necessary this year.

"It also confirms Cabinet and this government's commitment to the spirit of iKapa Elihlumayo and our goal to deliver on a Healthy Home for All. I would also like to commend the management and staff of the Health Department for staying on course during a difficult time and continuing to provide quality health care to the more than 70% of residents of our Province that are completely dependent on the government for health care.

"However, we are not out of the woods yet. I want to stress that ongoing structural changes are essential if we are to achieve our goal of providing equal access to quality health care. This includes directing patients to the most appropriate level of care within the health system as provided for in our Healthcare 2010 strategy."

Uys added there had already been a number of major improvements to the health infrastructure and that the department was close to finalising a new service delivery plan after lengthy consultation with stakeholders. This would define how many hospital beds were required at each level of the service, underpinned by a comprehensive primary health care service. The staffing plan would then follow.

"The bottom line is that we have to use the available funds more effectively because the demand is likely to outstrip budget for some time to come. By early next year we will start to move swiftly towards the restructuring of the service and this should help us meet the ever growing demand for quality health care," he said.

ABOUT HEALTHCARE 2010

The Healthcare 2010 strategy, which was built on a restructuring process that was started in 1994, is to offer patients an improved health care service at the most appropriate level of care with commensurate cost savings.

In practice, public health services in the Western Cape will be moved closer to patients, with a focus on primary-level services, community-based care and preventative care delivered by nurses and general practitioners. At the same time, the delivery of specialist services will be expanded throughout the Province, while special efforts will be made to ensure that specialised tertiary services are well equipped and have highly trained staff.

Health Western Cape provides care for the more than 72% of the 4,5 million people in this province. Our services include:

* Nurse driven primary health care services at 242 fixed clinics and 130 mobile clinics serving our people
* Medical doctors supporting PHC at 64 community health centres
* Hospital care for 135 000 patients at 22 district level hospitals with 600 000 outpatient visits
* Trained emergency medical personnel in fully equipped vehicles travelling 16 million kilometres rendering emergency medical services
* Specialist care to 172 000 patients at regional, psychiatric and tuberculosis hospitals
* Dental care for 160 000 patients
* Highly specialised care for an estimated 110 000 patients from the Western Cape and 90 000 patients from other provinces at our Groote Schuur, Tygerberg and Red Cross hospitals.
* The average hospital bed occupancy rate in the province is 85% and sometimes exceeds 100% (numerous new hospitals are planned as part of Healthcare 2010).
* Up to 35% of patients admitted to hospital are HIV positive, while co-infection of TB and HIV is high, with up to 31% of those who die in hospital being TB positive.
* A survey by the Health Economic Unit of UCT revealed that Tygerberg Hospital was faced with additional expenditure of approximately R50 million a year due to HIV/AIDS.

Issued by: Department of Health, Western Cape Provincial Government
1 December 2004
Source: Western Cape Provincial Government (www.capegateway.gov.za)