KWAZULU NATAL
DR ZL MKHIZE MEC FOR HEALTH
PROFESSOR RW GREEN-THOMPSON SUPERINTENDENT GENERAL
VOTE NO.7
OVERVIEW
1.1 INTRODUCTION
The Department of Health has during 1997 embarked on a major strategic framework for the management of the delivery of health services within the province. In this exercise the Vision and Mission of the Department were determined.
VISION
To achieve the optimal health status for all the persons in the province of Kwazulu-Natal.
MISSION
TO develop a sustainable, coordinated, integrated and comprehensive health system at all levels of care based on the Primary Health Care approach through the District Health System.
1.2 CORE FUNCTIONS
The core functions of the Department of Health are:
· To provide information, education and actions in order to prevent the occurrence of disease; and
· In the event of disease, to provide appropriate and cos-Leffective curative care.
1.3 CORE BUSSINESS AND GOALS
CORE BUSINESS 1:
Continual assessment of health and health service needs and priorities to ensure equitable resource allocation, through community participation
Goal .1
Effective mechanisms to involve communities and individuals in the identification of health and health service needs and priorities, and ways to address these priorities
Goal .2
Service prioritization and consequential resource allocation is based on relevant, accurate and timely information about health needs and effectiveness of interventions.
CORE BUSINESS 2:
Promote and protect the health of the community and work towards the prevention of disease and injury
Goal 2.1
Enrol all health providers into the concepts of Primary Health Care Approach and the District Health System and the Values they seek to represent.
Goal 2.2
Increase the level of understanding of what determines good health
Goal 2.3
Promote wellness and quality of life to specific vulnerable groups Goal 2.4
Ensure that the Services address potential and actual threats to health which may be unseen by the community and individuals
CORE BUSINESS 3:
Ensure access to health services
Goal 3.1
To provide customer-centred care
Goal 3.2
To ensure Health services are appropriate, accessible and effectively managed to achieve the best value
Goal 3.3
The people of KwaZulu Natal have information which enables them to make decisions about their health and health services
CORE BUSINESS 4:
Promote the provision of Comprehensive' Services that are responsive to the needs of individuals and communities
Goal 4.1
To increase individual and community responsibility for health by maximizing the functional integration of health planning and community development
Goal 4.2
To increase individual and community responsibility for health by maximizing the functional integration of health-specific programme development with the District Health Service development
CORE BUSINESS 5:
To deliver high quality, seamless, comprehensive and effective health services in partnership with clients, the public and related agencies in a supportive environment which promotes trust and confidence
Goal 5.1
Increase the trust and confidence of the public in the health care system Goal 5.2
To promote a positive corporate culture, where staff are enrolled into the Transformation I Developmental nature of the health services
1.4 TYPES OF SERVICES/ACTIVITIES
The Department of Health is responsible for the delivery of the following services/activities that are listed in priority order:
1.4.1 Clinics and Mobile Clinic Services
These facilities are the first level of Primary Health Care and provide services mainly to those patients who do not require admission to a more sophisticated facility.
1.4.2 Community Health Centre Services
These facilities provide a 24-hour health care service and have a doctor in attendance. They provide facilities for, inter alia, childbirth and those cases that cannot be treated at the clinic level, but do not necessarily require hospitalisation.
1.4.3 Health Promotion
Through communication, this service/activity encourages the general population to live more healthy lifestyles, thereby playing a preventative rather than a curative role in health management.
1.4.4 District Hospital Services
These facilities cater for patients who require admission to a hospital for treatment at a general practitioner level.
1.4.5 HIV/AIDS
KwaZulu-Natal has the highest incidence of HIVIAIDS in South Africa. This service provides for the special programmes for education in and the prevention of HIVIAIDS.
1.4.6 Training and Education (HRD)
This service/activity provides training for doctors, nursing and ambulance personnel, health workers and personnel in health management, administration and health promotion.
1.4.7 Communicable Disease Control
This service/activity is aimed at improving the awareness and control of communicable diseases and covers immunisation of children for, inter she, polio, measles and HIV.
1.4.8 Regional Hospital Services
These services cater for those patients who need admission to hospital for treatment at specialist level.
1.4.9 Environmental Health
This service ensures that, inter alia, the standards of food, domestic housing, water supplies, sanitation and refuse management are maintained in order to provide a safe environment for the general population. The inspection of ports also falls under this activity.
1.4.10 Ambulance and Emergency Services
This service provides emergency transport and paramedic personnel for victims of, inter alia, trauma and motor vehicle accidents.
1.4.11 Integrated Nutrition Services
This service/activity supports a number of feeding schemes for the poor providing supplementary nutrition in order to prevent diseases that accompany inadequate nutrition.
1.4.12 TB Hospitalisation
This activity provides hospitalisation for patients suffering from resistant strains of tuberculosis as well as those who become TB infected as a result of HIVIAIDS.
1.4.13 Patient Transport Services
This service/activity provides transport to indigent patients who have no other means of transport.
1.4.14 Maintenance of Buildings and Equipment
This activity ensures the maintenance of existing buildings and equipment in order to avoid the necessity for major works and replacements at a later stage.
1.4.15 Malaria Control
Malaria is endemic in pans of the Province of KwaZulu-Natal and its incidence is monitored and controlled by means of this service.
1.4.16 Central Hospital Services
This service provides the facilities and expertise needed for sophisticated medical procedures as well as a platform for training health workers;
1.4.17 Mental Health Hospitalisation
This activity provides facilities for those patients requiring psychiatric care and management.
1.4.18 Oncology Services
This service provides facilities for the treatment of cancer, including chemotherapy and radiotherapy.
1.4.19 Convalescent Hospitalisation
This service/activity provides facilities for those patients who require nursing care with minimal supervision by doctors. It is becoming increasingly important because of the increased HlV/AIDS incidence necessitating care for the terminally ill.
1.4.20 Forensic Medicine and Pathology
This activity provides information and support for any case that pertains to a health problem that borders on the line of the law. It includes a medico-legal support service for cases managed by the South African Police Service and covers cases concerning doctors' and patients' rights as well as rulings on medical ethics.
1.4.21 Renal Services
This service/activity provides both a hospital and home-based programme for those patients suffering from chronic renal disease.
1.5 MANAGEMENT OF THE BUDGET
The budget allocation to responsibilities is managed according to four principles:
1.5.1 Prioritisation of activities
The Department, through strategic planning exercises and wide participation of the Health Managers, has determined its main activities in priority order and these are set out in paragraph 1.4 above.
1.5.2 Pre-allocation for Central Provincial Services
Before the budget is allocated to the regions, funding for those services which are provided province wide or are peculiar to an area, are deducted These include Central Hospitals and Conditional grants, capital works and maintenance, management, education and training and Ambulance and Emergency Services.
1.5.3 Regional Equity Formula
The following formula is used in order to progress towards equity between the regions:
Weighted population of Region
% Allocation ------------------------------------------- x100
Total weighted population
Where nominal weighted population equals
Provincial per capita income
Act pop + (0.25 x act pop x -----------------------------------------)
Income per capita in region
Note: With the pending new demarcation on district boundaries the present division of funds will have to be revisited.
1.5.4 Balancing of the Levels of Services
The balancing of the levels of services is regarded as important in providing an optimal health service within financial constraints. The Department in consultation with its stakeholders has
defined the undermentioned broad targets. These targets are expressed in a percentage of to total allocation.
Percentage
Administration - 2
Central Hospital Services - 11
Regional Hospital Services - 18
Specialised Hospital Services - 6
District Hospital Care - 22
Primary Health Care - 26
Ambulance and Patient Transport - 4 Health Sciences - 3
Capital and maintenance - 8
2 REVIEW OF CURRENT BUDGET YEAR -1999/2000
There are two main areas which will be discussed, namely the review of the Financial Information and a review of service delivery.
2.1 FINANCIAL INFORMATION
2.1.1 Bottomline requirement for 1999/2000 = 1998/99 expenditure + uncontrollable items
EXPENDITURE 1998/99 R4,869 bil
Plus Salary increase (3 months 98/99): 38 mil
Rank promotions : 63 mil
Inflation: 74 mil
Nutrition (old): 18 mil
IALCH extra Conditional Grant: 46 mil
Maintenance Conditional Grant: 25 mil
Y2K: 49 mil
Dist Health, Clinics & Com H Workers: 25 mil
TOTAL MINIMUM REQUIRED 1999/2000: R5,207 bil
INDICATIVE ALLOCATION: R4,894 bil
ANTICIPATED SHORTFALL AS AT 1 APRIL 1999: R 313mil
This excludes any increases in salaries, medical aid and housing subsidies in 1999/2000
2.1.2 To place the department's dilemma in perspective, the actual final budget for 1998/99 including an amount of R141, 520mil for improvement to conditions of service was R4, 804 billion. The provision for 1999/2000 is R4, 894 billion, an increase of R90 million. Two additional items were added to the budget - R46 mil on for the Durban Academic Hospital and R25 million for maintenance. If this R71 million is deducted from the R90 million, there is only a R19 million effective increase. The cost of three months improvement to conditions of service, alone is R88 million.
2.1.8 As at the end of January 2000, the anticipated shortfall has been reduced to R67 mil through further savings and curtailment of services.
2.2 SERVICE DELIVERY
To enable the Department to assess its performance, targets have been set to measure progress. The statistics of the Department are used for this purpose. Statistics for 1997/98 are compared with those of 1998/99 in order to establish a trend.
2.2.1 TARGET ONE: Improved access to Community Health Services
One of the main policies of the Department of Health is to provide basic health care services to as many indigent people as possible. The target in this regard is to provide an average of 21 million visits to lower level services per annum. This represents an average of approximately 2.8 visits per person per year. In order to achieve this the number of personnel as well as clinics have been increased. According to the statistics the Department is achieving this target as is borne out by the following figures:
1998/97 10,00Cm clinic/community health centre visits
1997/98 13,641m clinic/community health centre visits (36% increase)
1998/99 17,94Cm clinic/community health centre visits (31% increase)
2.2.2 TARGET TWO: Reduction in Stillbirths
Stillbirths at clinics and CHC's have been reduced from 1Q80 in 1996/97 to approximately 288 in 1993/99 (73% reduction)
2.2.3 TARGET THREE: Increased Ante-natal Visits
It is the aim of the Department to improve the number of antenatal visits at the clinics/Community Health Centres, with the aim of reducing infant morbidity. Antenatal visits have increased from 709
in 1 996/97 to 892 in 1998/99. (25.8% increase)
2.2.4 TARGET FOUR: In creased attendance's for children under 6 years
It is the intention of this Department to provide facilities for approximately 3,6 million attendance's by children under the age of six, per annum with the aim of reducing the child morbidity rate. A projection on the available figures for 1998/99 shows that these visits have increased to 3,2 million from approximately 2,2 million in 1996/97. (45% increase)
2.2.5 TARGET FIVE: Improved immunisation
To fulfil its core function to prevent disease the Department set out to increase the immunisation rate and a number of campaigns have been held in this regard. The monthly average from 1997/98 to 1998/99 has increased from 157,866 vaccinations to 196,926, (24%increase)
2.2.6 TARGET SIX: Reduction in the utilisation of higher level services
It is a policy of this Department to shift services from higher level services to lower level services by reducing funding for the former and increasing funds for the latter. The success of this policy is borne out by the following figures based on King Edward and Wentworth's monthly 1997/98 averages compared with those of 1998/99 (extrapolated):
Outpatient visits from 118,570 to 109,528 (8% decrease)
Deliveries from 869 to 663 (24% decrease)
Operations from 2,863 to 2,801 (2.5% decrease)
Bed Occupancy from 67% to 62% (7.5% decrease)
2.2.7 CONCLUSION
The above statistics indicate that a shift in service from the higher levels to the lower levels of health care is in fact taking place and that the Department is achieving its targets despite some severe cuts in funding.
2.3 PROBLEMS EXPERIENCED WITH THE FINANCIAL AND SERVICE DELIVERY ASPECTS OF THE BUDGET
2.3.1 Maintaining the Momentum
One of the difficulties experienced at present is maintaining the current momentum, which is evident in the above statistics. The severe pressure on the personnel and medicine budgets results in the quality of the service deteriorating. The clinics and the hospitals are running out of medicines and this has resulted In negative reports in the press.
2.3.2 Freezing of Posts
There is a clear indication that the professional staff is being overburdened and although at this point in time there is no major labour unrest, the freezing of posts places further pressure on personnel and this may change the situation.
2.8.3 Underfunding relative to other Provinces with Central Hospital Services
This Province has been underfunded relative to other Provinces with Central Hospital Services and the cuts made to the higher level services are causing an imbalance in the health service delivery chain. This state of affairs can be managed for a limited period. However, if the situation 5 not resolved the stopping of elective surgery will ultimately result in the need for emergency surgery.
2.8.4 Reduced Stock Levels
Another worrying factor is that the cushioning effect of higher levels of stock no longer exists as hospital stores are running at the barest minimum. This will create enormous pressure on the stores and livestock budget, especially medicines
2.4 OVERALL COMMENT ON THE CURRENT BUDGET YEAR - 1999/2000
2.4.1 Taking the above factors into consideration as well as the rate of inflation, should the current expenditure trend continue, it will not be possible to remain within the budget allocation provided. If health services are to be maintained at the 1998/1999 level, over-expenditure of 5pproxmately R313 million was anticipated at the start of the financial year. In order to remain within budget, will be necessary to reduce service levels and to possibly retrench personnel. The same strict control put in place during 1998/99, will be mantained to ensure that the projected over expenditure is kept to an absolute minimum.
2.4.2 The latest projected over expenditure based on January expenditure is P67 million, indicating that the anticipated over expenditure may be substantially reduced if the current expenditure trends are maintained.
OUTLOOK FOR THE COMING BUDGET YEAR 2000/2001
3.1 OVERVIEW OF THE FINANCIAL POSITION
3.1.1 To place the allocation for 2000/Olin perspective it is again necessary to clearly understand that the apparent 11.5% increase on Budget to Budget is misleading. It is therefore important that the various items which where not on the previous Budgets be identified clearly. The following table indicates these changes.
Revised Budget 199912000 R4,979 bil
PLUS items not on previous Budget and uncontrollable expenditure
Salary increase Full year: 171 mil
Rank promotions: 63 mil
Inflation: 75 mil
Nutrition (old): 21 mil
IALCH extra Conditional Grant: 27 mil
Maintenance Conditional Grant (Ex Works): 15 mil
Dist Health, Clinics & Com H Workers: 19 mil
Hospital Rehabilitation: 69 mil
HIV Vaccine: 20 mil
Additional AIDS Challenge 2000: 20 mil
Community Pharmacists: 5 mil
R 505 mil
MINIMUM Budget to break even 2000/2001: R5,484 bil
INDICATIVE ALLOCATION: R5,556 bil
ACTUAL INCREASE: R 72mil
REAL PERCENTAGE INCREASE: 1,31%
Taken into account that no, non-Y2k, medical equipment was purchased for more than two and a half years, the increase will not cover more than 30% of the replacement requirements of hospitals.
3.1.2 In order to maintain service delivery at the same level as that of 1999/2000, a minimum amount of R5,825 billion, excluding new salary increases, will be required. In terms of the guideline amount of R5,556 billion, there will be a shortfall of some P269 million. If the anticipated over-expenditure of R176 mil is carried through from 1999/2000, this could result in an estimated shortfall of P445 million. The following table illustrates the funding dilemma of the Department.
Bottomline requirement for 200012001 = 199912000 expenditure +
uncontrollableladditional items
ESTIMATED EXPENDITURE 1999/2000 R5,276 bil
PLUS items not in previous Expenditure and uncontrollable expenditure
Salary increase ( 3 Months): 33 mil
Rank promotions: 63 mil
Inflation: 75 mil
Nutrition (old): 21 mil
IALCH extra Conditional Grant: 27 mil
Maintenance Conditional Grant (Ex Works): 15 mil
Dist Health, Clinics & Com H Workers: 19 mil
Capital programme & Hospital Rehabilitation: 149 mil
HIV Vaccine: 20 mil
Additional AIDS Challenge 2000: 20 mil
Community Pharmacists: 5 mil
Equipment replacement Programme: 102 mil
R549 mil
TOTAL MINIMUM REQUIRED 2000/2001: R5,825 bil
INDICATIVE ALLOCATION : R5,556 bil
ANTICIPATED SHORTFALL REQUIRED FOR 2000/2001: R 269 mil
This excludes any increases in salaries, medical aid and housing subsidies in 1999/2000
3.2 SERVICE DELIVERY OUTCOMES
The main service delivery outcomes will be:
a. The continued development and upgrading of basic services in the under-served areas through the primary health care approach.
The main aim is to provide quality service at clinics and community health centres at a rate 0 2,8 visits per non-medical aid members of the population per annum. Based on the existing weighted population this would extrapolate to approximately 21,6 million visits per annum. The figure for 1998/99 is estimated to be approximately 17,94Cm visits and it is anticipated that the number will increase in the new financial year by some 10% or 1 ,8mil;
b. To ensure that quality services are provided at clinics.
All clinics have been allocated sufficient funds to provide the necessary medicines and a special task force has been put in place to ensure this. The effect of this policy should eventually result in a reduction of patients seen as outpatients at hospitals. This should result in a saving as outpatient facilities are generally more costly to run than clinics. Initially this will result in major pressure on the medicine budget. However, the Department is of the opinion that the positive results will be seen in the latter part of 2000/2001 and the outer years.
c. A shift towards equity within the regions
This drive will aim at the upgrading of services within the historically underserved areas and should take place via the equity formula.
d. Maintaining the present services at lower cost.
The aim remains to do more at our major hospitals with less funding through cost effective service delivery.
3.3 POLICY INITIATIVES IN 2000/2001
3.3.1 Four new policy initiatives are funded in the allocation for 2000/01:
a. During 1999/2000 a National policy directive was issued to immunise all new borns with the HIV vaccine. The National Department funded the initial drive and the provinces are to make provision in their budgets from 2000/01. The estimated cost involved is P22 mil per year.
b. The first Community Pharmacists will be appointed in January 2000 and will have an affect on the Personnel budget for 2000/01. The expenditure involved is estimated at R5,4 mil.
c. HIV/AIDS remain a high priority for the Department. It initiated a special Campaign for the new millennium involving the whole Provincial Government. A special allocation to the value of R214 mil has been made available for this purpose. This allocation is in addition to the R14,5 mil already provided for the AIDS awareness campaign.
d. As part of the Department's drive to improve health information and to reach as many in the population as possible, a special allocation will be made for the recruitment of additional Community Health Workers. R19 mil has been provided for this programme.
3.3.2 Various declared policies, initiated since 1995, are still priority areas and will be pursued in the 200012001 and the outer years. These initiatives include the following:
The promotion of Mother and Child Health.
Health promotion through Community Health Workers.
Immunisation campaigns.
Replacement and Upgrading of Clinics.
Re-introduction of an affordable capital works and maintenance programme.
Implementation of Primary Health Care through the District Health System.
Provision of an integrated Nutrition Scheme.
4. BUDGET STATEMENT NO 3- CAPITAL WORKS
4.1 INTRODUCTION
4.1.1 The Department has revised its Multi Year Capital end Maintenance Programme thereof is. The basis of the Programme is the Health Facilities Audit done in 1996 end updated during 1998/99 and 1999/2000.
41 2 Preliminary estimates of the requirements for 2000/2001 are R126,080 million of which some R69 million will be funded from the Hospital Reconstruction and Rehabilitation Programme via National Health as a conditional grant.
4.2 STRATEGIC DECISIONS
4.2.1 All the strategic decisions are indicated in the Business Plan for the Multi Year Capital and Maintenance Programme. These refer mainly to the provision of Clinics, Community Health Centres, the rehabilitation of existing hospitals, as well as to the downgrading of certain hospitals As indicated in the plan, identified hospitals will be upgraded to provide an efficient and acceptable regional hospital for each region.
4.2.2 New facilities will only be undertaken in cases where no facilities exist, for example Clinics and Community Health Centres, as well as in instances where it is uneconomical to repair or refurbish an existing hospital, for example king George and king Edward Hospitals. Plans are being developed to replace these hospitals with smaller hospitals on the same sites. During 2000/2001 a start will be made with the first phases of redevelopment.
4.2.3 From the Multi Year Capital and Maintenance Programme the following information is offered:
a. Over the next five to eight years the Department will undertake, in consultation with the Department of Works some 643 projects estimated to cost some R2 bil.
b. Three projects are estimated to cost in excess of R100 mil each. They are:
i) Finalisation of Nkosi Albert Luthuli Central Hospital - R273 mil (R375 mil)
ii) Redevelopment of King George V Hospital - R20 mil (R252 mil)
iii) Redevelopment of King Edward VIII Hospital - R15 mil (R480 mil)
c. It contains some 130 projects estimated to cost between R2 mil and R100 mil.
d. It contains some 510 projects estimated to cost less than R2 ml.
5.3 IMPLICATIONS
Some of the implications that will result because of inadequate funding are:
· the inability to maintain the hard won improvements evident in the provision of Primary Health Care facilities and services
· the inability to fill posts will result in an additional workload on an already overloaded personnel component increasing the possibility of strikes and labour unrest;
· the dissatisfaction of the general population;
· delay in the implementation of the District Health System which is a national priority;
· deterioration in the standards of environmental health;
· an increase in the need for emergency surgery because elective surgery will have to be curtailed further; and
· the further reduction of certain higher level services.
NATIONAL ASSEMBLY PORTFOLIO COMMITTEE ON HEALTH
REQUESTED WRITTEN INPUTS FOR THE 2000/2001BUDGET HEARINGS
B. PROVINCIAL DEPARTMENT OF HEALTH B.I BUDGET INFORMATION
B. 1. 1. General
Question (a)
Budget and actual expenditure by programme and standard item for 1999/2000. If final expenditure figures are not yet available for 1999/2000 provide an estimate of expected final expenditure.
Answer (a)
See Annexure A and B
Question (b)
Please provide the Provincial Health Budget for 1999/2000 by programme and standard item. In addition provide an estimate of actual expenditure for the year, especially if expected to differ from budget expenditure.
Answer (b)
See Annexure A and B.
Question (c)
In relation to both (a) and (b) those provinces which have a Health and Welfare Budget combined, should provide details of the Health Budget only.
Answer (c)
This question is not applicable to this Province.
Question (d)
Where budgeted and actual expenditure deviated during the 1999/2000 financial years, indicate:
· Where a deficit occurred, how this was funded;
· The reasons for the surplus/deficit;
· Providing the above by sub-programme according to table.
Answer (d)
See Annexures A and B.
· it is anticipated that there will be a total over-expenditure of approximately R101,5 million when all the Programmes are taken into consideration. This deficit will be funded through a debit against the budget allocation received for the 2000/2001 financial year. The Department is confident that the expected over expenditure can still be reduced by the end of the Financial Year.
Reasons for the surplus/Deficit
Programme 2: District Health Services.
The main reasons for the anticipated over-expenditure are the increase in the treatment of AIDS related diseases, tuberculosis and malaria, as well as rank promotions, salary increase and inflation.
Programme 3: Provincial Hospital Services
The projected over-expenditure is mainly due to inadequate funding of Health Services as well as inflation and rank promotions and salary increases.
Programme 4: Central Hospital Services
The projected over-expenditure is mainly due to inflation and rank promotions and salary increases.
Question (e)
Please note that, in total, 8 tables are being requested.
Answer (e)
Only two are requested
B1. 2. Budgets and expenditure in relation to specific policy issues
The Portfolio Committee would like to receive financial information on the following specific policy areas:
Question:
a) Anticipated revenue raised from private patients using public hospitals for the 1999/2000 financial year:
Answer a):
Revenue raised for Patient Fees:
1999/2000: R78, 708m (projected)
The separate figures for private patients using public hospitals are not maintained. It is however estimated that 2% of patients are private and that these contribute approximately 40-50% of total fees revenue.
Question:
b) HIV/AIDS budget for the years, 1999/2000 and 2000/01
Answer b):
Please note that the AIDS budget is in respect of awareness and prevention.
1999/2000: R15,800m
2000/01: R35,800m
Question
c) HIV/AIDS allocation for NGO'S for 1999/2000
Answer c)
1999/2000 Local Authorities: R3,265m
NGOs: R7,173m
Question
d) TB Programme allocation for the yearsl999/2000 and 2000/01.
Answer d)
1999/2000 R1114, mil. Tuberculosis is also managed at the clinics and within hospitals. This expenditure is not monitored separately.
2000/0001: R119,7 mil (estimate)
Question:
e) Planned expenditure on Information Systems.
Answer e)
R15 mil
Questions:
f) Planned new capital expenditure on Hospital Services 1999/00 and 2000/01 and
g) Planned new capital expenditure on District hospitals, 1999/00 and 2000/01.
h) Planned new capital expenditure on community health centres and clinics, 1999/2000 and 2000/01.
Answer f), g) and h)
4.2.2. The capital planning is done in a comprehensive plan and not separated as above. From the Multi Year Capital and Maintenance Programme the following information is offered:
a. Over the next five to eight years the Department will undertake, in consultation with the Department of Works some 643 projects estimated to cost some R2 bil.
b. Three projects are estimated to cost in excess ofPl00 mil each. 'They are
i) Finalisation of Inkosi Albert Luthuli Central Hospital - R273 mil (R375 mil)
ii) Redevelopment of King George V Hospital - R20 mil (R252 mil)
iii) Redevelopment of King Edward VIII Hospital – R15 mil (R480 mil)
c. It contains some 130 projects estimated to cost between R2 mil and R10O mil.
d. It contains some 510 projects estimated to cost less than R2 mil
B. 1.3. Narrative Report
The Portfolio Committee would like a written comment on the following specific issues:
Question:
(a) Key problems experienced in relation to the budgeting process:
Answer (a).
i. Insufficient capacity to meet deadlines required by the Provincial Treasury & National Department of Health
ii. Lack of trained staff in the field to enable implementation of the principles of the budgeting process.
Question:
(b) Ability to realise national policy objectives generally
Answer (b):
1. Lack of funding and increased demand on the Health Services have seriously hampered the implementation of the various policies. However, we have been able to improve primary health care by opening more clinics.
Question:
(c) Implementation of revenue retention policy:
· has a policy been decided on?
· is there agreement from the Provincial Treasury?
· implementation process?
Answer (c)
1. This matter has not been finalised, but discussions have taken place between Provinces and between this Department and Treasury.
ii. The Department has an incentive scheme in place to enhance revenue collection.
Question:
(d) Medium term expenditure framework
1. Comment on current process
ii. Is the MTEF a fair reflection of envisaged health policy?
iii. Is effective medium-term planning occurring? If not, comment on requirements to achieve an appropriate process.
Answer (d):
i) The Medium Term Framework is in principle a good planning and budgeting tool but this Department is experiencing problems with:
(a) financial constraints;
(b) a lack of human resource capacity, which is being addressed.
(c) The system is labour intensive and time consuming especially) in the Department of Health where the matter needs to be dealt with at institutional level.
ii) At this stage it bears no relation to the Health Policy owing to disparity in health funding between the Provinces.
iii) Yes, but it is being seriously hampered by an inadequate budget.
B.2 POLICY ISSUES
B.2.1 GENERAL
Each Department should provide a written evaluation which should accompany their presentation.
The reports should include the following:
1. Any over- and under-expenditure by Department must be explicitly indicated. All explanation should accompany this information indicating:
· Why the deviation from the budget occurred?
· What policy consequences resulted?
· What is to be done to deal with the surplus/deficit? Any disciplinary actions resulting.
Answer:
The over expenditure was due to die under allocation of funds to Health Services. In the 1999/2000 financial year; the policy of using Community Doctors was implemented without additional funding been provided.
The commissioning of new clinics and increased demand at clinical level. This has resulted in referral to higher level services, thereby increasing expenditure at hospital level.
With regard to policy changes which had to take place were the reduction in higher level services and limiting elective surgery and prescriptions to three items only.
· The latest projected deficit is R101,5 million reduced from a potential deficit at die beginning of the financial year of R313 million. Indications are that the Department will probably have to reduce its expenditure during 2000/2001 by this amount.
· No disciplinary action is contemplated at present as the Department is of the opinion that everyone
involved made considerable contributions under difficult circumstances, to reduce the total expenditure
2. How the Department fared in relation to specific benchmarks and performance targets in 1999/2000:
· List each Departments specific performance targets asset for the 1999/2000 fiscal year:
· Indicate actual performance by specifying whether target as set for the year was:
(a) achieved (with explanation)
(b) not achieved -
* state clearly what stage in relation to the target the policy reached.
* state reasons why target was not achieved.
(c) priority of the performance target (very high, high, medium, low)
Answer 2
TO FOLLOW LATER IN THE FORM OF AN ANNEXURE
3. Provide the performance targets, by chief directorate and directorate for 1999/2000 financial year indicating:
· Priority of the target (very high, high, medium, low)
· Where a particular target was set but not achieved in the 1999/2000 fiscal year.
· The process by which particular performance objectives are to be achieved (include time-scales)
· Whether legislation is involved
· Anticipated bottlenecks, constraints and difficulties in achieving targets, as well as the actions taken to limit their affects
· How any constraints and limitations which prevented key targets from being achieved in the 1999/2000
· financial year are being or have been dealt with.
Answer 3
TO FOLLOW LATER IN THE FORM OF AN ANNEXURE
B.2.2 SPECIFIC POLICY AREAS
1. HIV/AIDS
Provide a general report on the progress made in implementing the National AIDS strategy in your Province. Comment specifically on the following:
a) Please indicate what targets your province has set in relation to the epidemic. These should include:
· Output targets: e.g. number of condoms distributed.
· Performance targets: e.g. specific reduction in new infections within specified age groups.
If no targets exist, provide reasons why no targets exist and whether the province intends setting targets.
b) To what extent are NGO'S used as part of your provincial strategy?
c) What process has been introduced to deal with inter-departmental co-operation and co-ordination?
d) What access is available to hospices for AIDS patients in your province? And, is there a policy to improve access.
e) Is there a strategy to provide home care for AIDS patients? Provide details of policy decisions, existing or envisaged process and time-scales.
f) Provide a detailed report on the implementation of the HIVIAIDS education programme in your province. Include information on the process, as well as the number of schools and pupils reached.
g) Indicate your province's strategy to deal with discrimination against HIV positive people in the following
settings:
· Public sector employees;
· Public hospitals and clinics; and
· In the community.
h) Provide specific details, time-scales and performance targets associated with any advertising campaign;
i) Provide specific policy and targets in relation to providing counselling and testing services;
j) Provide details indicating how your province's STD services are to be used to provide an integrated prevention strategy for HIV/AIDS.
ANSWER QUESTION 1
TO FOLLOW IN THE FORM OF AN ANNEXURE
2. PRIMARY CARE SERVICES
2.1 District Health System
Provide a report on progress made in implementing the District Health System in your province indicating the following:
a) District Management Structure
b) Process for achieving equity in the allocation of Primary Health Care services;
c) Relationship with local government structures;
d) Indicate all new fixed clinics constructed from the 1995/96 financial year to the present. Also indicate which are operational.
2.2 Primary Care Core Package
Indicate the process and time-scales for implementing the Primary Care Core Package in your province.
2.3 Management of Drugs
Please provide information on any policy to improve drug distribution and procurement within your province. This should include an evaluation of hospital and clinic-level issues.
ANSWER QUESTION 2
TO FOLLOW IN THE FORM OF AN ANNEXURE
3. HOSPITAL SERVICES
3.1 Central Hospitals
Provide a report on any intended restructuring of central hospitals in your province focusing on the following:
a) Future strategic directions
b) Impact of conditional grants for central hospitals
c) Retention of revenue policy
d) Inter-provincial arrangements for the use of specialist services
e) Improved management
f) Service reprioritisation
g) Movement of services from central to regional hospitals
h) Rationalisation of staff
i) Future of academic functions
j) Serious problems encountered during 1999/2000
3.2 Regional Hospitals
Provide a report on any intended restructuring of regional hospitals in your province focusing on the following:
a) Future strategic directions
b) Improved management
c) Service reprioritisation
d) Retention of revenue policy
e) Rationalisation of staff; and
f) Serious problems encountered during 1999/2000
ANSWER QUESTION 3
TO FOLLOW IN THE FORM OF AN ANNEXURE
4. TUBERCULOSIS
Provided a general report on the achievements of the tuberculosis programme in your province. The following information is requested:
a) Specific performance targets of the programme for 1997/98, 1998/99, 1999/2000 and 2000/01:
b) Achievements in relation to targets
ANSWER QUESTION 4
TO FOLLOW IN THE FORM OF AN ANNEXURE
HUMAN RESOURCE ISSUES
5.1 General
a) indicate all human resource restructuring that has occurred since 1996/97 to the present;
b) provide an overview of your intended medium-term (i.e. next three years) human resource strategy.
5.2 Students and Trainees
Please provide a list of all students currently on your hospital staff establishments in the following:
a) Final year medical students (not on staff establishment)
b) Medical interns
c) Dental interns
d) Nurse students by type of student; and
e) Allied staff by type of student. e.g. physiotherapy, occupational therapy, etc.
ANSWER OUESTION 5
TO FOLLOW IN THE FORM OF AN ANNEXURE
6. INFORMATION SYSTEMS
Provide an update on your provinces strategy in relation to information systems. The following should be indicated:
a) Indicate your minimum reporting requirements for hospitals and clinics
b) Hospital performance indicators
c) Clinic performance indicators
d) Health status indicators
e) Computer systems and their utilisation
ANSWER QUESTION 6
TO FOLLOW IN THE FORM OF AN ANNEXURE
7. WOMEN'S HEALTH ISSUES
The committee would like to outline your province's strategy in relation to women's health issues. In addition it would like specific comment on:
a) Termination of pregnancy
b) Maternity services
c) The province's policy and activities related to cervical cancer screening and treatment; and
d) The province's policy and activities related to breast cancer screening
ANSWER QUESTION 7
TO FOLLOW IN THE FORM OF AN ANNEXURE
8. SPECIFIC PROBLEM AREAS AND CONSTRAINTS
Briefly provide an overview of specific difficulties experienced during the 1999/2000 financial year. The following areas should be discussed:
a) Financial
b) Control, management and administration
c) Institutional.
Answer:
a) Financial
Once again the Department was not funded sufficiently to deliver an effective health service. 0ther factors that had to be taken into account was funding of Y2K. The Department had to concentrate on specific financial control measures which on many occasions were directly in conflict with the service provision policies.
b) Control, management and administration
In general control, management and administration has improved dramatically regarding financial management. Lack of capacity in this area is still evident, especially in those hospitals where the financial systems were highly centralised. A lot of training in computer literacy and basic financial management is still required.
c) Institutional
All our institutions have responded positively to the challenge and the main difficulties experienced were mainly of a technical nature, such as unavailability of data lines and on line systems.
QUESTION B 1.1(a).(b),(e) ANNEXTURE A
ADJUSTED BUDGET ALLOCATION FOR THE 1999/2000 FINANCIAL YEAR ACCORDING TO STANDARD ITEMS
[TABLE NOT INCLUDED]
QUESTION B.1.1(d),(e)
1999/2000 : ANTICIPATED EXPENDITURE AND VARIANCE
[TABLE NOT INCLUDED]