1999 HEALTH BUDGET: BRIEFING TO NCOP
INPUT TO SELECT COMMITTEE ON SOCIAL SERVICES – NATIONAL COUNCIL OF PROVINCES IN PREPARATION FOR THE HEALTH BUDGET VOTE: 1999

1. THE PRIMARY HEALTH CARE APPROACH AND EQUITY
The PHC approach involves the provision of primary care within a holistic context, recognising that health is more than the provision of health services. It involves strong inter-sectoral collaboration and community participation. The district health system was selected as the vehicle to provide primary health care in our country (progress on the development of the district health system is outlined in the next section).

The focus with regard to the provision of PHC services have been on increasing access to care (free care at the point of delivery and the building of more clinics and the purchasing of more mobiles which are outlined elsewhere in the report of the Department). In addition, nurses have been trained in both management and clinical skills – the latter to ensure that primary health care nurses are trained to handle all first level health issues.

Areas that more work is required on are: (a) community participation; (b) inter-sectoral collaboration; and (c) improving the quality of care rendered. With regard to community participation many health facilities have community committees and boards however the level of participation needs to be strengthened. Inter-sectoral collaboration is particularly difficult to achieve as international experiences illustrates. However, it is hoped that the district health system will, as it matures, provide the institutional framework to improve the level of inter-sectoral collaboration necessary to ensure healthy communities.

Some work has been done in attempting to improve the quality of care provided. The adoption of Batho Pele, the training of health personnel, the drafting of a health charter for patients, the strengthening of community health committees, clinic committees and hospital boards will collectively assist in improving the quality of care that we provide.

With respect to shifts in expenditure a recent view conducted by the National Department of Health revealed that:

(a) nationally the share of public spending devoted to health services has risen each year (from 11% in 1995/6 to 12,4% in 1997/8);

(b) the proportion of health spending allocated to basic district health services rose in 7 provinces and for the country as a whole between 1996/7 and 1997/8; and

(c) real spending per capita of district health services rose in all provinces, and for the country as a whole. at the same time, real spending per capita on academic health services was maintained at a steady rate.

2. CLINIC UPGRADING AND BUILDING PROGRAMME (CUPB)
Since the new Government came to power in 1994, it committed itself to the upliftment of the previously disadvantaged communities. This was mainly achieved through the application of RDP funds. With regards to health service provision, the new Government decided to focus on Primary Health Care, this policy leading to the increased requirement for clinics on a national basis. As a result, one of the programmes funded by the RDP was the Clinic Upgrading and Building Programme.

The First Phase of the Clinic Upgrading and Building Programme commenced in the 1994/95 financial year, followed by Phase Two in 1995/96 and Phase Three 1996/97. Final activities related to Phase Three are still currently underway.

The nine provincial health departments supplemented the RDP funds, while the Independent Development Trust also invested in a clinic building programme, that formed part of the overall CUPB programme. The total government expenditure on the CUPB Programme, (including the Shopping List) up to 31 December 1998 amounts to R757 080 281 with the RDP contribution totalling R285 00 000 (37.64%). The rest of the money was provided by the provinces’ own capital programmes.

Progress on the CUBP since 1994 may be summarised as follows:

A further division in provinces is as follows:

Of the new clinics built, 92% are commissioned already in operation. The remaining 8% (41 clinics) have not been commissioned yet, either as a result of no staff being available or no equipment available.

Since this information is of 19 January there already be some improvement in these figures. We know that its usually takes four months before full commissioning after a clinic has been built.

Number of clinics completed and commissioned per Province since 1994 as at
19 January1999

As a direct result of the CUBP nearly 20 000 temporary jobs in the building industry were created mostly for people from local communities:
In addition 11 000 permanent posts were created at new clinics. Most of these were filled by absorbing staff from hospitals and elsewhere.

Herewith a summarising overview:

The above employment figures were extrapolated from information received from KwaZulu-Natal. The employment created by the IDT visiting points is not included.

Future perspective
RDP funding for the CUBP ends in March 1999. A further 59 clinics will be built and commissioned between April 1999 and June 2000, with funding being committed out of the alternative sources available.

3) HOSPITAL REHABILITATION & RECONSTRUCTION PROGRAMME
A vital component of hospital transformation is the Hospital Rehabilitation and Reconstruction (Hospital R & R) Programme. The neglect of proper maintenance over many years and the consequent serious state of disrepair of public sector hospitals is well known in all the provinces. Based on a National Health Facilities Audit, coordinated by the CSIR in 1996, Cabinet was informed in December 1996 that about R10 billion would be needed over a period of 10 years to replace or repair the hospitals. An estimated additional R5 billion would be needed over the same 10 years for normal maintenance to prevent further deterioration. The audit include all hospitals and 108 community health centres but excluded clinics.

The Hospital R & R programme was approved by Cabinet as a capital programme in direct response to the results of a National Health Facilities Audit. The programme is aimed at ensuring that a network of hospitals will be developed which is appropriate to the needs of the South African population well into the 21st century.

For the first year of implementation (1998/99) an allocation to the total value of R100 million was made available for equitable distribution among the nine provinces. These funds are additional to the normal Provincial Budget and may not be used for maintenance or clinics. Instead, the main purpose of the funding is to help provinces achieve structural change in line with current government policy and the White Paper on Health and aims at achieving equity of distribution of hospital services.

FUND ALLOCATIONS TO PROVINCES 1998-1999

The criteria used for allocating funds to each province included:
- the provincial population
- an estimate of the population dependant on public health services
- the existing number of beds (capacity available)
- the adjustment to be made to achieve equity of 3 beds/1000 population
and
- the relative conditions of existing facilities based on the National Health Facilities Audit.

A new Director for Health Facilities Planning was appointed in August 1998 and is supported by existing staff at national and provincial levels and two EU-funded Technical Assistants to implement the programme.

Three workshops have been held to start implementing this multi-year programme in cooperation with the provinces.

Of the R100 million an approximate amount of R80 million will be spent by the end of this financial year on specific projects which have been identified in all the provinces. The remaining R20 million has also been committed to specific projects. MTEF allocations were approved by Cabinet on 18 November 1998 and are as follows:

By 15 February 1999 six provinces have submitted draft strategic plans and the appointment of a panel of consultants has been approved by the National Tender Board and is in the process of being advertised. A survey is underway aimed at identifying the provinces needs with regard to assistance required - e.g. in terms of human resources and training as well as in the area of Information Technology, the establishment of appropriate data bases and the development of organisational structures and systems related to health facilities planning.

The Directorate also facilitates relationships between the various stakeholders involved, including for instance contact with other directorates like the one dealing with disabled people as well as with national and international specialists.

The following challenges with regard to the Hospital R & R programme are highlighted:
- South Africa is suffering from a lack of people with appropriate skills and experience in the field of strategic and health facilities planning. Training and capacity-building is therefore urgently required.

- The funding available for the Hospital R & R programme does not make provision for maintenance - whether back-log or ongoing. This may defeat the purpose of the programme, if not addressed appropriately through annual budgetary commitment by the provinces.

The impact of public-private partnerships has not been taken into consideration.

Long-term budget planning must make provision of the funding required for the Hospital R & R Programme over a period of approximately 10 years.

Future perspective
Robust and flexible strategic plans are awaited from all provinces. These plans are aimed at providing a long-term vision for the development of Health Facilities in each province, in line with the objectives of the White Paper on Health.

4. NEW ACADEMIC HOSPITALS

4.1 New Durban Academic Hospital (NDAH)
In the late ‘80's work commenced on designing a new academic hospital for Durban. This design was completely revised after the 1994 elections in order to incorporate changed needs. In 1997 the phased construction on the New 846-bed Durban Academic Health Service Complex began. A R200 million grant was provided by the National Department of Health towards the project during the 1998/99 financial year. Commissioning of the hospital is assisted by a specialist consultant from the United Kingdom. Also, a Commissioning Manager has been appointed.

The total estimated cost of the project is R1,12 billion, including equipment.

CASH FLOW OF TOTAL PROJECT INCLUDING FEES AND EQUIPMENT
Prior 1 March 1998 R269 440 000,00
1998/1999 R200 000 000,00
1999/2000 R246 976 000,00
2000/2001 R273 000 000,00
2001/2002 R132 752 000,00
TOTAL PROJECT COST R1 122 680 000,00

The following challenges with regard to the New Durban Academic Hospital are highlighted:
- No Chief Executive Officer has been appointed to date.
- Details staffing profiles and budgets must still be drawn up.
- Staff training must be accelerated.
- Clinical content and management issues must be finalised.

Future perspective
Building operations are scheduled to be completed by March 2000.
First admission of patients at New Durban Academic Hospital is scheduled for January 2001.

4.2 New Umtata Academic Regional Hospital
The New Umtata Regional Hospital is being developed adjacent to the existing Umtata Hospital. A national grant amounting to R100 million was provided for the 1998/99 financial year by the National Department of Health, which is contributing R164 m towards the total cost. The balance is paid for by the province. The total estimated cost is R367 000 000,00

The following challenges with regard to the New Umtata Academic Hospital are highlighted:
- The project is currently running behind schedule, which means that only approximately R23 million of the national grant will have been utilised by the end of the current financial year.

- No robust commissioning strategy or team is in place as yet.

This is being attended to between the National Department and the province.

Future
Building operations are scheduled to be completed by November 2001.
First admission of patients at the Hospital is scheduled for April 2002.

5. DEVELOPMENT OF THE DISTRICT HEALTH SYSTEM AND EQUITABLE DISTRIBUTIONS OF RESOURCES.
A review of district health development was conducted in October/November 1998. The report that follows provides an overview of what has been achieved to date and lists some of the challenges facing us in ensuring the development of well-functioning health districts.

Demarcation and establishment of health districts
The rationale and process for the establishment of a DHS was outlined in the 1995 document ‘A policy for the development of District Health System for South Africa’, and later summarised in the "White Paper on the Transformation of Health System in South Africa".

Provinces began with the process of demarcating district boundaries in 1995. Currently a total of 42 health regions and 174 health districts have been defined. The three statutory options for facilitating district governance are still national policy, although most provinces have opted for a mixture of Provincial and Local Government, dropping the Statutory District Health Authority option. In all the provinces, the lack of a legal framework has been identified as an obstacle to the formation of integrated health districts.

Several provinces have defined organograms for their districts (EC, FS, MP, NW and NP). All provinces have established structures for community participation, at clinic and hospital level. In addition, strategies to train and orient health workers towards Primary Health Care have been drawn up and implemented.

Province-local government co-ordinating structures
The following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local government: NP (MECCOUN: which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which established a Provincial District Health Systems Committee composed of provincial and local government officials; GG which has a structure in which the MEC meets with local government councillors and also has a Provincial District Health Systems Committee made up of provincial and local government councillors; NC which has regular meetings with local government; and WC had a Ministerial Committee with various sub-committees (these committees have not met for the last six months given the uncertainty of local government transformation but were recently asked to reconvene by the MEC of health). Neither the NW nor MP has established similar structures at the time of writing this report.The following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local government:NP (MECCOUN: which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which establish__

The following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local government:NP (MECCOUN: which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which establish__•following provinces have formal structures to co-ordinate activities between the provincial Department of Health and local governmentNP (MECCOUN which includes the MEC, local government councillors, the head of department and local government officials); EC which has a structure composed of provincial and local government officials which meets quarterly; the FS is in the process of discussions with stakeholders on how to structure their participation in DHS development; KZN which establish__•

5.1 Managerial systems and processes

5.1.1 Health management structures
All nine provinces have appointed regional managers (mostly at director level) with support staff. Several provinces have appointed district managers. These include: EC (15); MP (16); NP (24); NW (16). In the other provinces Interim District Health Management Teams or Interim District Co-ordinators have been appointed.

5.1.2 District planning
All provinces have reported that district level health planning is in progress. In some provinces (e.g., NP), plans are ready for implementation; in WC districts have conducted situational analyses; in KZN district planning has commenced with the appointment of interim district co-ordinators; and in the EC provincial strategic plans have been converted into district level operational plans.

5.1.3 District Health Information System
The District Health Information System (DHIS) is an important strategy to improve management and service delivery, within the framework of the National Health Information System for South Africa, has been accepted by all provinces. All provinces are involved in developing strategies for information collection (by Community Health Coordinators in NW, and use of Routine Monthly Reports in the EC and WC) and information exchange. A provincial DHIS directorate has been established in GG. Only the EC and WC have implemented a coherent plan to develop a district-based information system. All other provinces have expressed an interest in the strategy and software used by the EC and WC and the use of a similar strategy in these provinces is likely to increase the pace of the development of a DHIS in these provinces in 1999.

5.1.4 Training
Extensive management training has been undertaken by all provinces using a number of agencies (e.g. universities, NGOs, and Technikons). Training of district health managers has been done through the Oliver Tambo Fellowship and DFID run programmes (e.g., in the NC). In the WC, training in budgeting and personnel management have been conducted by the UWC School of Public Health. MP has been implementing management training with CHESS and AMREF.

Some provinces have also reported extensive PHC training for nurses (clinical management). However, there appears to be a lack of consensus on the scope and practice of nurses operating in the clinical domain, e.g., the diagnosis and treatment of common complaints. Basic training remains largely hospital based. There is also a lack of uniformity in the treatment guidelines and PHC tools which are being used at present, e.g. in some districts both the old and new Road to Health Cards are being used and academic institutions sometimes use different treatment guidelines to those used by the health services.

5.1.5 Service provision
All provinces have noted successful implementation of curative services, although there is concern over the slow progress made in the integration of Provincial and Local Government services in some provinces. Specific problems are in the integration of curative and preventive service (NP) and staff integration between health workers employed by Provincial and local government (all provinces). Problems with the integration of services in former Homelands were cited in EC and NP.

The lack of enabling legislation was viewed as an obstacle to integration (FS, NW and WC) while the existence of multiple negotiating structures has also been cited as a problem (GG). Inadequate planning between Province and District, between Hospital and Clinics, and between Province and Local Government has also contributed to problems in the provision of integrated health services.

Improved mechanisms and strategies in service provision are being tried in most provinces through the use of demonstration districts. The ISDS is working in all nine provinces. Five provinces are involved in a Learning Site Districts Approach (promoting successful initiatives in one district with minimum external resources).

Strategies for integrating district hospitals with other district health services need more attention.

With regard to improvements in service delivery the EC has reported a 20% increase (to 84%) in the availability of EDL drugs at clinics. This improvement was the consequence of improved communication and stock management. We need to complement this pattern by increasing the availability of trained pharmaceutics personnel.

5.1.6 Community involvement
In nearly all the provinces, structures to enable communities to participate in health service delivery have been defined. These include clinic committees, Health Forums, and Local Interim Coordinating Committees. In some provinces district level structures exist and these include the RDP and District Health Forums.

5.1.7 Resources management
In the case of finance, several provinces have delegated responsibilities to Regions and Districts. In a few instances (FS, MP, and NW), a limit of R10, 000 to purchase supplies has been set for regions and districts. Others (EC, GG, KZN, NC, and NP) allow Regions and Districts to make recommendations, but the Province does all approvals.
With regard to personnel management, some provinces (FS, MP, NC, and NW) have allowed Regions to make recommendations, leaving approval to the province. In the case of EC and KZN, the responsibility for staff management is shared between Province and Region, while NP has not specified any kind of delegation as yet.

The WC permits regional directors to manage all services (finance, personnel, and procurement) within the limits of their own budgets. Both EC and NW have reported budgetary allocations to districts.

The financial management system used by Local Government is different to that of the public sector. This may create problems should districts be managed by local government but be monitored by the province. Attempts should be made to harmonise all systems between local government and the provinces to ensure that the national health system can be smoothly managed.

6. PROGRESS REPORT ON HIV/AIDS/STD’s.

INTRODUCTION.
The HIV/AIDS epidemic is well established in South Africa and continues to spread relentlessly. Currently 3.2 million people are infected and projections indicate that within three years almost a quarter of a million South Africans will die of AIDS each year and that this figure will have risen to more than half a million by 2008. HIV/AIDS contributed to infection as the second most common cause of maternal deaths in the First Interim Report on the Confidential Enquiry into Maternal Deaths in 1998.

A Review of the National AIDS Programme was done in 1997 and the following recommendations were made;

increase political commitment
- increase resources and build capacity
strengthen initiatives with persons with HIV/AIDS
- strengthen inter-departmental and inter-sectoral support
protect human rights, reduce stigmatization

FUNDING OF THE HIV/AIDS AND STD PROGRAMME
The Departmental budget was increased from R14 million in 1994/1995 to R106 million in 1998/1999 inclusive of the budget for the Government AIDS Action Plan. Five key focus areas have been identified.

A . Life Skills and HIV/AIDS education in schools.
A learning programme for secondary school learners has been developed and introduced into the schools. The programme aims at increasing learners’ knowledge, developing skills, promoting positive and responsible attitudes and behaviour, as well as providing motivational support regarding HIV/AIDS issues.

The training of teachers commenced in November 1997, to date more than 10 000 teachers have been trained. Education materials were printed and distribute to all secondary schools.

In 1999, a pilot project of a similar nature is to be piloted in the primary schools.

Financial assistance was granted to NGO’s providing programmes for youth-out-of-school.

B. STD Management.
The Department has conducted training courses in the Syndromic Approach to STD Management for groups of health service managers and clinicians at provincial level. To date the Department has trained over 600 managers and 500 clinicians.

In 1999 training will be conducted in the private sector by way of Continued Professional Development Seminars. Training will be extended to Traditional Healers. The Department has appointed two Traditional Healers to assist in the implementation of this programme. To date over 400 traditional healers received basic courses in HIV/AIDS/STD’s and TB.

Production of Sexual Health Promotion Materials.
A wide range of materials has been produced by the Directorate. Examples of these include Flip-charts for community education on STD’s Protocols for the management of STD’s Training manual on the Syndromic Management of STD’s.

C. Barrier Methods.
The number of condoms distributed has increased from 90 million in 1995/6 to 140 million in 1997/8.

To improve on the procurement and distribution of these, a policy document has been prepared. A barrier methods consultant will be appointed to monitor the quality of condoms, their procurement and distribution in the provinces

The Female Condom
Research on certain aspects of the Femidom is being done by the Reproductive Health Research Unit. Results of this will inform the Directorate on the feasibility and sustainability of freely providing the Femidom to the public. The use of the female condom is being piloted in 18 sites in the various provinces. Mpumalanga and Northern Province will start next month. The pilots look at the reason for continued use, and for discontinuing. In general, there was an initial high demand, but this has fallen down to low but sustained levels. The province that is persistently showing high usage is Kwazulu-Natal, probably because many people have had relatives and or friends dying of AIDS.

D. Care, Counselling and Support
30 Lay counsellors were trained and appointed in every province. This area was identified as one of the weaker spots in the National AIDS Programme.

Plans to improve include the training of more lay counsellors. Increasing the capacity of existing sectors like NGOs and CBOs to provide this service.

Pilot projects for Home-Based care will commence in five provinces in 1999. A best practice model will be identified from these, consultation with all relevant stakeholders will be held to determine norms and standards of care. Extension to other provinces will follow this process.

Mother-to-Child-Transmission.
Advice has been given to the provinces on modifying maternity practices in order to reduce mother-to-child transmission.

Discussions on the use of alternate forms of feeding are going on with regard to the feeding of children of HIV positive women. Currently, women are informed of the risks for transmission to the child through breast milk. These discussions are part of the broader discussions on infant feeding.

HIV is also being included in the Integrated Management of Childhood Illnesses.

Partnership against AIDS and political commitment.
The Government has demonstrated its unquestionable commitment to fight the epidemic by establishing the Inter-ministerial Committee on AIDS. This Committee is chaired by the Deputy President, consists of Ministers and Deputy-Ministers and meets monthly to review progress and tackle issues around HIV/AIDS.

In October 1998, the Deputy President launched the Partnerships Against AIDS where all South Africans from the various sectors were invited to join hands in the fight against the epidemic. All the pledges that have been received are being followed up in order to escalate the response to the epidemic.


7. INTEGRATED NUTRITION PROGRAMME - PRIMARY SCHOOL NUTRITION

INTRODUCTION
The primary school nutrition interventions of the INP are being developed from the Primary School Nutrition Programme (PSNP). Its implementation followed the announcement by President Mandela that "a nutritional feeding scheme will be implemented in every primary school where such a need was established" during the State of the Nation Address on 24 May 1994. It was one of 100 day Presidential Lead Projects of the Reconstruction and Development Programme (RDP). The focus areas of the PSNP were school feeding, nutrition education and health promotion through interventions such as parasite control and micronutrient supplementation.

A comprehensive school nutrition programme should follow a holistic approach whereby the health problems affecting a child’s active learning capacity, and therefore, school achievement, are assessed and analysed to design comprehensive responses. This is because a child’s active learning capacity is negatively affected by, amongst others, hunger, low energy diets, parasite infestations and micronutrient deficiencies. School nutrition interventions, therefore, aim to:

• To contribute to the improvement of education quality and general health
• To improve nutrition knowledge, perceptions, attitudes and behaviour amongst primary school learners, their parents and their teachers
• To enhance broader development initiatives.

With regard to primary school nutrition, the INP aims to offer a mix of interventions to address the health and nutrition problems affecting the active learning capacity of primary school learners.

ACHIEVEMENTS
RDP principles such as community participation, local capacity building, participation of small, medium and micro enterprises and local employment, etc. have been supported as can be seen from the following figures:

Categories of suppliers

Source: Provincial Departments of Health
Community participation in project management, food preparation and distribution and food production and supply

Source: Provincial Departments of Health

Local employment opportunities and training

Source: Provincial Departments of Health

The policy guidelines for the PSNP provided a sound framework for school nutrition interventions within the framework of the INP. The strategy adopted for the transformation and absorption of the PSNP into the INP was one of:
• Transforming the PSNP from a vertical programme to being part of the INP.
• Using the PSNP as a spring board for the development of community-based nutrition programmes.
• Developing a package of integrated school nutrition interventions including school feeding, nutrition education in schools, nutrition surveillance using schools as sentinel community facilities for nutrition surveillance and development initiatives. This strategy was confirmed by the findings of the independent evaluation of the PSNP which was done by the Health Systems Trust during 1997. Progress/achievements in this regard include:
• Since its inception, millions of primary school learners in thousands of primary schools benefited from school feeding as can be seen from the following figures:

Source: Provincial Departments of Health

Lunch box campaigns, linked to nutrition education and household food security projects, are held to encourage learners to bring healthy snacks to school.

School food gardens are promoted for the following reasons-
• nutrition education should not just teach correct eating habits, but should also teach how to become self-reliant with regard to food and nutrition needs. Food gardens at schools provide such an opportunity as well as becoming sources of food production. It also provides an opportunity for learners to learn about the food cycle. Through the child-to-child approach, they could become carriers of knowledge into homes and communities; and
• school food gardens provide an opportunity for community and specifically parental involvement through the garden committees. They could also work in the gardens or provide training to learners.

A primary school nutrition education programme has been developed with the intention to have it incorporated in the primary school nutrition curriculum.

Linkages have been established with other development initiatives in the community for example bread baking projects and community food gardens to ensure sustainability. In some instances, school feeding is used as a springboard for the development of these projects e.g. in the case of baking projects.

A Task Team of the PSNP was instrumental in developing a draft policy on community-based parasite control which was later further refined and adopted for the INP. KwaZulu/Natal and Mpumalanga have been identified as pilot provinces for the implementation of a parasite control pilot programme partly funded by the Government of Finland. The pilot projects include both treatment programmes and preventative measures. Mpumalanga milestones include promotion activities such as educational pamphlets, a five episode drama series for local radio, radio talk shows and five advertisement spots. In KwaZulu/Natal, surveys as well as the first round of treatment have been completed.

The PSNP provided learning opportunities with regard to intersectoral action which is an important principle in the INP. Examples include:
Department of Agriculture - food gardens.
Non-governmental organizations (NGOs) - evaluation/development of a nutrition education package/capacity building.
Business sector - suppliers.
Within health - Directorate of Food Control re food safety issues/Directorate of Health Promotion re nutrition education, etc.
Implementing agencies vary from school project committees, which are now being absorbed into school governing bodies, community-based organizations (CBOs) and non-governmental organisations (NGOs).

The PSNP provided the opportunity to learn about the use of a business plan as a management tool. Since 1994, when the concept of business planning was introduced for RDP Lead Projects, capacity has been built to such an extent that project planning and the formulation of business plans are now requirements at all levels for funding in terms of the INP: for community projects, for contractors, for provincial subdirectorates for nutrition and at national level.

The scope of funding for the Conditional Grant, which replaced the RDP allocation for the PSNP, has been broadened to provide for all the key performance area of the INP thus providing seed funds to initiate processes that will lead to a fully operational INP. Budget and expenditure patterns in respect of primary school nutrition were as follows:

Source: Provincial Departments of Health

For 1998/99 - it is important to remember that there is a time lapse between provincial disbursement and recording of expenditure in the records of the National Department.

Programme administrators and teachers reported the following contributions:
• Improved school attendance.
• Decrease in learner drop-out figures.
• Improved concentration and alertness levels.
• Children are less aggressive and irritable in class.
• General health improvement.

CHALLENGES AND RESOLUTIONS
Since the inception of the PSNP, capacity and other problems have been experienced that are summarized below.

A lack of human and other resources strained full implementation. Despite its comprehensive range of objectives, implementation has generally been restricted to school feeding.
Resolution: Implementation of staff establishments and resource plans for nutrition
Implementation of school nutrition within the INP framework.

Control weaknesses led to fraud and error
Resolution: Implementation of the management information system and financial control system of the INP.

Incorrect procurement procedures and weaknesses in contracts led to vulnerability to abuse.
Resolution: Implementation of correct contract management practices
Compliance with minimum norms and standards
Do a national evaluation of certain aspects of school feeding
Implementation of national evaluation (1997) findings where appropriate

Ambitious targeting has led to problems with coverage and the quality and quantity of food.
Resolution: Implementation of the targeting strategy of the INP.

Limited capacity at project level restricted programme implementation and compliance with control measures. School feeding is known for being administratively and logistically complicated.
Resolution: Implementation of the national training/capacity-building programme of the INP.

In some parts of the country, the coverage of school feeding has been poor and inconsistent.

Resolution: Capacity of suppliers should be an important criterion in awarding contracts.

Most of these challenges were highlighted in the Audit of the programme conducted through out the country. We have responded to these challenges - first by appointing a Project Management Team (PMT) of Ernest & Young in 1996 for 12 months. Their main brief was to:-

- develop appropriate management systems
- ensure skills transfer
- develop systems to ensure adequate reporting.

There was significant improvement as a consequence of this intervention - although more still needs to be done.

The PSNP was also evaluated subsequently by the HST. Their results suggested that the plans underway in the Department were consistent with their recommendations.