NATIONAL DEPARTMENT OF HEALTH STRATEGIC PLAN, 2003/04 TO 2005/06

TABLE OF CONTENTS

Foreword by the Minister of Health …………………………………………… 3

Statement from the Director-General …………………………………………. 4

List of tables ……………………………………………………………………….. 5

Glossary of terms ………………………………………………………………..... 6

Chapter One: Introduction, vision, mission and situation analysis ……… 7

Chapter Two: Measurable Objectives, indictors, targets and budgets ….. 33

Chapter Three: Conclusions …………………………………………………….. 51

FOREWORD BY THE MINISTER OF HEALTH
The White Paper on the Transformation of the National Health System commits the national Department to "provide leadership and guidance to the National Health System in its efforts to promote and monitor the health of all people in South Africa, and to provide caring and effective services through a primary health care approach". In addition, the White Paper outlines the functions of the national Department of Health which include, inter alia, providing leadership on a range of planning and service delivery issues, developing appropriate mechanisms to regulate the public and private health sectors, building the capacity of provincial departments and municipalities and liaison with national Departments of Health in other countries and international agencies.

The increased focus on implementation by our Government and my department is key to improving the lives and health status of our people. This strategic plan clearly illustrates how the national Department plans to carry out this mandate during the next three financial years. I am committed to providing the leadership and mobilising the resources to ensure that the national Department of Health delivers on this plan.

Dr Manto Tshabalala-Msimang
Minister of Health, April 2003

STATEMENT FROM THE DIRECTOR-GENERAL

The national Department of Health is committed to fulfilling its mandate as outlined by the Minister in her foreword. This strategic plan reflects the key priorities of the Department of Health for the next three years. However, given that the plan will be updated annually, we will closely monitor delivery on the plan and new priorities that may emerge during this period and refine the plan on the basis of our experiences.

There are multiple determinants of health status. This reality means that we have to work closely with other government departments and non-governmental stakeholders to improve the health status of the people in our country. One key mediating factor in the delivery of health services, given that health is a concurrent national and provincial function, is the need for the national department to work closely with provincial health departments. During this period we are committed to closer collaboration with our provincial counterparts to improve the delivery of public health services. In addition, we acknowledge that the private health sector has a role to play in the delivery of health services and we will seek to find ways of working together to ensure the provision of affordable and good quality health care.

Dr Ayanda Ntsaluaba
Director-General, April 2003

LIST OF TABLES

Table 1: Administration – medium term objectives, indicators and targets

Table 2: Programme 1 – expenditure estimates

Table 3: Strategic Health Programmes – medium term objectives, indicators and targets

Table 4: Programme 2 – expenditure estimates

Table 5: Health Service Delivery – measurable objectives, indicators and targets

Table 6: Programme 3 – expenditure estimates

GLOSSARY OF TERMS

TERM

ABBREVIATION

Acute respiratory infections

ARI

Chief executive officers/senior executive officers

CEOs/SEOs

Case fatality rate

CFR

Continuing professional development

CPD

Choice on Termination of Pregnancy

CTOP

District Health Information System

DHIS

Division of Revenue Act

DORA

Directly observed treatment – short course

DOTS

Expanded programme on immunisation

EPI

Good manufacturing practice

GMP

Hospital rehabilitation and revitalisation

HR&H

Integrated Management of Childhood Illnesses

IMCI

Infant mortality rate

IMR

Meeting of the Minister and 9 MECs

MINMEC

Municipal health services

MHS

Medium term expenditure framework

MTEF

Modernisation of tertiary services

MTS

Primary health care

PHC

Provincial Health Restructuring Committee (heads of health departments and the Director-General)

PHRC

Perinatal problem identification programme

PPIP

Quality assurance and quality control

QA/QC

South African Demographic and Health Survey

SADHS

South African Health Review

SAHR

Social Health Insurance

SHI

Strategic Position Statements

SPSs

Sexually transmitted infections

STI

CHAPTER ONE: INTRODUCTION, VISION, MISSION AND SITUATION ANALYSIS

1.1 INTRODUCTION

In 1999 the Department of Health produced its five-year strategy entitled the Health Sector Strategic Framework, 1999-2004. The framework was adopted by the Health MINMEC and used by provinces to develop their own strategic priorities.

The Health Sector Strategic Framework, 1999-2004 has undergone a midterm evaluation to assess the extent to which the Department has succeeded in meeting the objectives set out in 1999. In addition to the mid term review the Department is committed to conducting a review of the past five years as part of the ten-year review that is being facilitated by the Presidency through the Social Cluster. A new set of priorities will be developed on the basis of this review and contribute to the political priorities of the newly elected government in 2004.

This three year strategic plan however, is based on the current five-year plan. We therefore consider it necessary to list the key priorities in this plan so that the reader may have a complete picture of the priorities of the Department of Health.

The elements of the Health Sector Strategic Framework, 1999-2004 include: reorganisation of certain support services; legislative reform; improving quality of care; revitalization of hospital services; speeding up delivery of an essential package of services through the district health system; decreasing morbidity and mortality rates through strategic interventions; improving resource mobilization and the management of resources without neglecting the attainment of equity in resource allocation; improving health human resource development and management; improving communication and consultation within the health system and between the health system and communities we serve; and strengthening co-operation with our partners internationally.

1.2 VISION

The vision of the national Department of Health is to play a role in securing a caring and humane society in which all South Africans have access to affordable and good quality health care.

1.3 MISSION

The mission of the Department is to build on our achievements since 1994 in improving access to health care for all and to focus on reducing inequities in health care, improving the quality of care provided at all levels of the health care system with increases in the efficiency of service delivery.

1.4 SITUATION ANALYSIS: EPIDEMIOLOGY, HEALTH STATUS AND HEALTH SERVICES

A detailed situation analysis is outside the scope of this document. However, this section will provide some indication of the nature of the issues

1. 4.1 Epidemiology and health status

1.4.1.1 Child Health

The SADHS (1998) suggests that infant and child mortality rates reflect the social, demographic and economic conditions under which people live. Higher infant and child mortality rates were found particularly in non-urban areas, poor provinces and African people.

According to the SADHS infant mortality rate (IMR) is 45, 2 deaths per 1000 live births. This means that one in every 22 children born in the country dies before reaching the first birthday. The current under-5 mortality is 59,4 per 1000.

The IMR of 52/1000 live births in non-urban areas is higher than that found in urban areas. The provinces with IMR higher than 45/1000 live births are the poverty stricken provinces of the Eastern Cape and KwaZulu-Natal. IMR of 8/1000 live infants was found in the Western Cape and 32/1000 in Gauteng. However, we need to recognise that provincial averages do mask intra-provincial variations.

High infant and under-5 mortality rates are found amongst those mothers without formal education background and those whose level of education was restricted to Sub A – Std 3. In comparison, substantially low infant and under-5 mortality rates are found among mothers with Std 10 and higher education. These findings have suggested a correlation between levels of education amongst the mothers and IMR.

Preventable childhood illnesses affect the right to health for many children in South Africa where diseases like pneumonia, diarrhoea, and immunisable childhood infections continue to account for many of the childhood deaths. A quarter of deaths in children aged under-5 are caused by diarrhoea and acute respiratory infections (ARI). The major causes of death in the 5-14 year old children are infections and trauma or injury. Malnutrition also accounts for child deaths. In 1995, a quarter of all 38047 child deaths occurred within the perinatal period, less than one fifth (19%) were a result of unnatural causes, intestinal infections accounted for 14% whilst respiratory infections 7.5%.

Intestinal infectious diseases, influenza and pneumonia and unspecified unnatural were the top three underlying causes of deaths in 1997-2001 among children aged 0 –14 years as compared to perinatal conditions, ill-defined/unknown and intestinal infectious diseases in 1995.

The main leading causes of deaths in period 1997 – 2001 among male and female children aged 0- 14 years are shown below. Among female children HIV related diseases ranked 3rd as the underlying cause of death compared to male children where it ranked as the 4th. Unspecified unnatural causes ranked the 3rd and 5th among males and female children respectively.

Data from the SADHS indicated that the national EPI coverage is 63.4%, with coverage being 64.7% in urban areas and 62.2% in non-urban areas. More recent data from the DHIS suggests a 71% fully immunised coverage rate.

The last significant measles outbreak was in children of school going age in 1992 with no outbreak in the under-5 age group. There has been a drop in the cases of measles notified from 20,6 per 100 000 in 1996 to 2,8 per 100 000 in 1997. Of the 406 suspected measles cases reported in 1998 only 27 were confirmed by laboratory tests and in 2001 the number of confirmed cases were even lower, 8 of 1 166 suspected cases. Clearly the mass campaigns and routine immunisation is having the desired result.

The last case of acute poliomyelitis was reported in 1989 and there have been no cases since. However, there is a need to improve the surveillance of Acute Flaccid Paralysis and exclude polio as a cause. For the period January to August 2002, only 1 case of tetanus neonatorum was reported. During the same period 5 cases of whooping cough were reported compared to 24 cases for the same period in 2001.

All facilities providing maternity services are encouraged to implement the minimum data set to collect relevant data to assess perinatal care. In all provinces there are facilities that are implementing the Perinatal Problem Identification Programme (PPIP), which helps provinces to identify causes of perinatal deaths. In 2000 27 public sector facilities implemented PPIP and this increased to 91 by 2002. Unlike most other provinces many facilities in Limpopo have implemented the PPIP. As the programme is voluntary, implementation is restricted to interest by health workers at facility level.

The Integrated Management of Childhood Illnesses (IMCI) is a key strategy adopted by the Department to reduce infant and child mortality. Since the introduction of the IMCI strategy counselling uptake has increased from 20% to 50% and drug misuse has decreased by 85%. Whilst these are impressive results, the Eastern Cape, KwaZulu-Natal and the Northern Cape are not meeting their targets.

1.4.1.2 Youth and Adolescent Health

The total estimated number of young people aged 15 –24 years was 8.8.million in 2001. This represented 19.7% of the total South African population.

Young people are particularly vulnerable to HIV/AIDS and STDs, sexual and physical abuse, alcohol and substance abuse, early sexual intercourse, unplanned pregnancies and unprotected sexual activities, and other high-risk behaviours. Many youth experience difficulties in accessing health information and services.

Many young people have their first sexual debut during the teenage years. The SADHS found that about 9% of adolescent women aged 15-19 had their first sexual intercourse at age 15. Delayed sexual intercourse or abstinence is practiced as about 54% of young women aged 15 –19 reported never having sex. The median age at first sexual intercourse for young women aged 15 – 29 was 18.1 years. Rural women report earlier first sexual experiences compared to urban women. Young persons who begin sexual activity at a very early age are more susceptible to sexually transmitted infections and unplanned pregnancy.

Reducing HIV prevalence among young people aged 15- 24 year is critical in the fight to eradicate HIV infection. The prevalence of HIV among adolescents aged below 20 years increased from 1.79% in 1991 to 15.4% in 2001. However, prevalence rates declined from 21% in 1998 to 16.5% in 1999, thereafter stabilising to 16.1% in 2000 and 15.4% in 2001.

Although teenage pregnancy is thought to have continued to escalate, recent information about adolescent fertility shows that the birth rate for teenagers of 15 –19 years has decreased from 116 per 1000 women in mid-1988 to 78 births per 1000 women by mid 1996 (SAHR 2000). However, these figures are still considered high and in need of intervention.

Various studies revealed high levels of alcohol related trauma. Over a quarter of general hospital admissions are related either directly or indirectly to alcohol use.

There are approximately 60 health facilities in the country that have been accredited as ‘youth friendly’. However, national targets have not been met because of staff shortages. Peer educators and groundbreakers are utilised to popularise the youth friendly health services. Twenty-four youth centres are being run by the Planned Parenthood Association. At provincial level staff turnover is a major problem. In addition, the lack of appropriate physical infrastructure is a barrier to the effective implementation of youth friendly services.

 

School health services are not functional in many parts of the country. A school health policy has been approved by MINMEC and an implementation strategy is currently being drafted. Part of the implementation strategy will focus on integrating school health into primary health care.

1.4.1.3 Maternal and women’s health

Maternal deaths have been notifiable medical events since December 1997. Since the beginning of the reporting period 3 453 deaths have been reported to the National Department. The reporting of maternal deaths has allowed strategic interventions to be put in place based on the major causes of death, levels of care, contributing factors, substandard care, etc. The first Saving Mothers report was published in 1998. Subsequently 3 Interim Reports have been published on an annual basis. The second Saving Mothers report has been completed and was launched on 8th March 2003.

The coordination of CTOP monitoring is progressing well in all the nine provinces. The number of functioning designated TOP facilities has increased by 17% in 2002 from 109 (approximately 33% of designated facilities in 2000) to 50% (159) out of 315 designated facilities. However, large parts of the country are still without these services. These include the major rural areas of the Karoo and most of the Northern Cape, most of Limpopo, the Drakensberg area in the Eastern Cape and KwaZulu-Natal, and northern and central KwaZulu-Natal. Almost half (48.5%) of TOPs are performed in Gauteng despite the fact that only 19.4% of women in their reproductive years (15-49 years) live there.

Besides the effort to improve a women’s choice with respect to reproductive health (see CTOP initiatives) the Department has been engaged in a series of other activities to improve women’s health. Workshops for the dissemination of the national guidelines on cervical cancer screening were conducted in 8 provinces but number of smears done is still low. Lack of capacity (finance, human resources, access to laboratories) is cited by provinces as the primary reason for this.

1.4.1.4 HIV/AIDS

The 1999, 2000 and 2001 results of the annual HIV sero-prevalence surveys of pregnant women attending public antenatal clinics suggest that prevalence rates among certain cohorts are stabilising. The overall prevalence rate was 22.4% in 1999, 24.5% in 2000 and 24.8% in 2001 (Department of Health 2002). This can be attributed mainly to HIV prevalence in pregnant women under the age of 20 years remaining stable for the last few years and this is a best indicator of the uptake of the prevention messages since it implies that we are able to curb new infections.

 

Results of behavioural studies also suggest increased levels of abstinence. About 70% of women aged 15- 19 years reported having no sexual partner in 2002 compared to 59% in 1998. In 1998, the SADHS found that 17.1% of women aged 20-24 had no sexual partner. Shisana and Simbayi (2002) found that 31% of women reported having no sexual partners. This may be attributed in part to the concerted educational programmes that government and its social partners are implementing.

It is encouraging that HIV prevalence among teenagers has not increased for the fourth consecutive year. However, the increase in HIV prevalence in older women (particularly those in their twenties) might be an indication that infection is simply delayed and not avoided. This calls for prevention to be sustained beyond the youth category that has largely been the target population of prevention programmes to date.

Since the start of this programme in late 2000 VCT services in 691 clinics have been established. Though this service is still only available in less than a quarter of public health facilities, this is increasing steadily. The challenge remains that in some of the facilities where this service is offered the uptake is still very low.

The research programme on the implementation of the prevention of mother-to-child HIV transmission has yielded information that is being fed into the expansion of the programme in all facilities. Provinces have been provided with guidelines for the implementation of the PMTCT package and additional funds have been identified for this. KwaZulu-Natal, Gauteng, North West and Western Cape Provinces have extended coverage to a significant number of health institutions and other provinces are in the process of increasing coverage.

In 2002/3 the Department of Health will purchase and distribute 2,5 million female condoms at a cost of R18,5 million. This is up from the 1,3 million purchased and distributed in the previous financial year. In addition, the number of sites at which female condoms are distributed have increased to 200 from 114 in the previous financial year. The male condom programme is much larger and the Department will purchase and distribute 358 million male condoms at a cost of R104 million in 2002/2003. This is up from the 267 million condoms purchased and distributed in the 2001/02 financial year.

1.4.1.5 Sexually transmitted infections

There has been a dramatic decrease in syphilis rates across all age groups amongst pregnant women attending public sector clinics that points to the success of the STI control programme. The rate dropped from 9% in 1998 to under 3% in 2001. All provinces except the Northern Cape have seen to different extents, significant decreases in levels of infection of syphilis.

 

A process to roll out STI Surveillance to the 8 provinces has commenced. The current system in the 8 provinces provides limited data on STIs i.e. only on Urethral discharge amongst males through the District Health Information System. Other data on STIs is provided by the Antenatal Survey, which gives an indication of syphilis prevalence among pregnant women only.

Gauteng has implemented a surveillance system for STIs. Data from the STD reference centre have confirmed for other STIs the trend seen in syphilis in Gauteng. However, the challenge remains to see to what extent this is true in other provinces and for the private health sector which provides services to most of the STI patients in the country. A second challenge is to improve the quality of STI care offered in the private health sector.

1.4.1.6 Tuberculosis

TB is the 3rd leading cause of death - accounting for 8% of deaths nationally. It was the 2nd and 5th leading cause of death among males and females respectively in the period 1997-2001.

According to the National TB Control Programme, the reported incidence of all TB cases for 2001 was 423 per 100,000 population. In terms of cases notified, this translates to more than 188 000 total TB cases of which more than 83,000 were new smear positives (infectious). The total number of cases is predicted to double in the next 3-5 years due to the impact of the HIV epidemic.

Almost 129,000 patients with pulmonary (lung) TB were reported in 2001. Of these 101,000 patients were infectious and therefore capable of spreading the disease to others.

1.4.1.7 Malaria and cholera control

The malaria cases and deaths for 2002 to 30 November 2002 were 14 468 and 86 respectively. This is a 42% decrease in malaria cases and a 23% decrease in deaths compared to the previous year (malaria cases 24 951, malaria deaths 112 in November 2001).

There has been increased cross border collaboration with the malaria project of the Lubombo Spatial Development Initiative (LSDI), yielding decreased malaria cases in KwaZulu-Natal. Cross border malaria collaboration has been initiated with Zimbabwe. In addition, Zambian malaria control teams have visited South Africa to learn about the South African experiences with implementing effective combination therapies for malaria control.

 

Cholera outbreaks have presented the Department with serious challenges during the last year. When the first epidemic was officially closed on 31 July 2001, the cumulative number of cholera cases in KwaZulu-Natal was 105 389. There were 219 deaths in the province, and case fatality rate (number of deaths over the number cases) was 0.21%, which was less than 0.5%. The total number of cases in the country was 106 389 and there were 229 deaths (CFR = 0.22%). WHO commended South Africa for this achievement and this was considered an indication that there was good quality case management. Countries developed as South Africa are expected to have the case fatality rate below 1% according to international standards.

1.4.1.8 Chronic diseases and disabilities

The following guidelines have been developed and distributed on the management of priority chronic diseases/conditions: hypertension; asthma; diabetes; and obesity (to be implemented 2003); rheumatic fever/rheumatic heart disease; foot health; active ageing; falls; primary eye conditions; otitis media; stroke and TIA; osteoporosis; arthritis; menopause; and palliative care.

A Strategic Vision for Non-Communicable Diseases and a policy framework for Non-Communicable Diseases in Children have been developed to enhance the implementation of these guidelines.

A tool to evaluate the effectiveness of the integration of non-communicable diseases/conditions at PHC facilities has been developed. In addition, 10 nurses have successfully completed a course in geriatric care.

There is overall improvement in chronic care and nurses and pharmacists are really using their initiative to make things work at primary level. A lot of training in chronic care has taken place in most of the provinces and support groups are being initiated in all the provinces. There are definitely pockets of best practice and pockets of poor care. Stroke units (neuro units) are being developed in Gauteng, Eastern Cape, North West and Mpumalanga.

The National Cancer Control Programme was adopted in 1999. The following projects have been implemented: (a) awareness raising regarding specific priority cancers including development of materials for community members and health professionals on early warning signs of childhood cancers and breast cancer; and (b) screening programmes for cervical cancer and prostate cancer.

An annual budget is ring-fenced within the national Department to provide assistive devices. The budget for 2001/02 was R600 000 and R277 000 for 2002/03. Additional funds have been made available to eliminate the backlog by 2004/05.

 

1.4.1.9 Nutrition

Food fortification is a major national priority and regulations were published for comment in October 2002. Educational and promotional aspects have begun in February 2003 with full implementation by the end of 2003. The programme will be formally launched by the Minister on April 1. Vitamin A supplementation for children 3-60 months and lactating women 6 weeks post-partum is ongoing and the programme will be evaluated in 2004. Through the social sector cluster partnerships have been developed with the Department of Agriculture and the CSIR for the development of vitamin A rich indigenous foods.

The Baby friendly Initiative has resulted in 58 out of 480 maternity units being declared as baby friendly. The programme is being implemented slowly in Gauteng, North West and the Western Cape. The training of staff at facilities in Gauteng and the Western Cape are barriers to expansion in these provinces as is access to baby foods. The North West has experienced a high turn over of lactation managers.

The training of health workers on HIV and infant feeding is ongoing. The biggest problem is the challenge posed by the provision of free infant formula to mothers on the PMTCT programme. A draft infant feeding guideline has been developed and will be presented to MINMEC early in 2003.

1.4.2 Health service delivery

1.4.2.1 Delivery of the PHC package through the District Health System

The national Department costed the PHC package and the results were presented and accepted by the MINMEC in May 2000. Efforts are underway to quantify the extent to which the full package is being rendered in every health district. This data will be used to plan the delivery of the outstanding elements of the package to make the 2004 target of full implementation a reality.

In an effort to integrate PHC services provided by provinces and municipalities the Free State, Eastern Cape, Gauteng and the Western Cape have entered into service level agreements with municipalities. This is consistent with the decision by the Health MINMEC of July 2002 and is related to the decision taken to define municipal health services (MHS) narrowly.

1.4.2.2 Revitalisation of hospitals

The first draft of the Integrated Health Planning Framework document was completed in January 2001. This was done using limited information available and it was agreed that it will be reviewed as the quality of information available improves. All provinces used this draft to produce their first draft Strategic Position Statements (SPSs). This is a costed long-term vision (10 years) for the delivery of sustainable health services.

During 2002 provinces had to review and finalize their Strategic Position Statements (SPS) so as to be able to prioritise hospitals for the Revitalisation Programme. Some provinces might not be able to complete their SPS review by March 2003 as anticipated.

Further, the national Department is currently engaged in a process of developing a long-term plan for the provision of Tertiary and Quaternary services. This process involves a wide stakeholder consultative process involving approximately 450 clinical specialists representing 49 specialty and sub-specialty disciplines.

It is vital that the national and provincial departments, working with local government ensure that all planning and budgeting processes are aligned and that their implementation is closely monitored. Greater effort needs to be paid to improving the quality of data required for planning and monitoring.

During 2001 the national Department, as part of the national long-term plan for the provision of tertiary and quaternary services, commonly referred to as the Modernisation of Tertiary Services (MTS), restructured the Conditional Grant Framework for the Central Hospitals and Redistribution of Tertiary Services Grant. The new grant framework is called the National Tertiary Services Grant and funds each province for the tertiary services that they provide. During 2002, a monitoring framework was introduced which is a reporting system of national tertiary services provided by each province. Thus far in 2002 two quarters of data were required for submission. All provinces have provided returns for the first two quarters. However, a number of difficulties are being experienced in both data collection and analysis. Most provinces (with the exception of the Free State) are struggling to supply data on all elements. This issue is currently receiving attention and is understandable given that the initiative is still new.

The National Health Facilities Audit of 1996 estimated that R8-10 billion would be needed to upgrade or replace a third of all hospitals by value. The Hospital Reconstruction and Rehabilitation (HR&R) programme which started in 1998, was aimed at providing an integrated and affordable network of well-maintained hospitals in all provinces by 2008.

Since December 1998, R1,6 b out of R1,8 b made available has been spent on the design and construction of 966 projects at 240 hospitals. A total of 492 projects at 141 hospitals have been completed.

The transition from Hospital Reconstruction and Rehabilitation to the Revitalization Programme has been agreed upon with the provinces. This programme combines areas of physical infrastructure, management strengthening, organizational development, quality of care, equipment, information and monitoring systems. Implementation of the programme started towards the end of 2001.

The preparation phase for all projects included developing provincial Strategic Positioning Statements. 27 projects have been selected and prioritised and implementation is taking place in each of the provinces. In terms of large projects the following has been achieved: (a) Nelson Mandela Academic Hospital with 460 level 2 & 3 beds has been completed, the first patients are expected to be admitted in September and October and is expected to be fully operational in mid to late 2004; (b) Inkosi Albert Luthuli Academic Complex with 846 level 2, 3 and 4 beds has been completed, has started admitting patients on a phased basis and will be fully operational by August 2003; and (c) the Pretoria Academic Hospital with 777 level 2 & 3 beds is expected to be completed by November 2003 and is expected to be fully operational by April 2004.

Despite these successes, most provinces struggled to develop strategic plans to revitalise all hospitals. Therefore, provinces spent most of the grant money on the rehabilitation of existing hospitals, ignoring to a great extent the reconstruction and reshaping part of the grant. Transition from HR&R to revitalisation that introduced the health technology, organisation development, quality assurance and monitoring and evaluation components brought the following challenges: slow implementation in 2002; lack of appropriate implementation teams/capacity to coordinate and manage the implementation process of projects; lack of Project Implementation Plans (PIP) to integrate all revitalisation components; and poor reporting and communication of project implementation performance to deal with problems and take corrective action at appropriate times. All these have since improved and are being attended to on an ongoing basis.

A set of delegations for hospital managers has now been drafted and is pending discussion and approval by the PHRC in 2003. A considerable amount of training has been provided for hospital general managers, specifically on strategic and business planning, performance management and change management. Standard job descriptions and performance plans for hospital CEOs have been developed in collaboration with the Department of Public Service and Administration, and have been made available to the provinces.

Seven provinces have granted written delegations to hospitals, but no real progress has been made in Mpumalanga and Eastern Cape, where specific interventions will be required. Gauteng, Free State and North West have made particular progress in the appointment of CEO/SEOs and the implementation of management structures.

Financial management systems in hospitals are being strengthened. National support to the cost centre management programme has been significantly improved and the project has been extended from the original 15 to 46 hospitals.

 

1.4.2.3 Quality of care

The National Policy on Quality in Health Care has been adopted and is being operationalised both by national and the provincial departments of health. Most of the provincial departments have appointed quality of care (QA) co-ordinators and either have or are in the process of developing provincial QA policies based on the national policy.

Many provinces (e.g., Eastern Cape, KwaZulu-Natal, North West and Free State) have employed the services of the Council for Health Service Accreditation in Southern Africa (COHSASA) to assist them to improve the quality of care rendered in public hospitals. Other provinces such as Gauteng have decided against external accreditation in favour of internally developed standards and assessment of compliance.

Most health programmes have produced clinical guidelines to assist health workers to better manage their patients. The national Department is in the process of establishing peer review mechanisms to assess clinical care. In addition, mechanisms to report and investigate adverse reactions are currently being explored.

The Patients’ Rights Charter was launched in 1999. The National Department of Health has printed posters, leaflets and booklets in different languages and distributed these to provinces to create awareness of patient’s rights. An audiotape version of the Patients Rights Charter was also reproduced for use by the blind and the illiterate.

A rapid survey was conducted in August 2002 in Mpumalanga, Limpopo, North West and Free State. The survey found that despite various national and provincial campaigns, health workers still did not understand the context within which health rights are being implemented. In an attempt to address some of the concerns raised, a process is in place to train health workers as facilitators of health rights. It is envisaged that the training will occur during March-May 2003.

The National Department of Health does not have a mechanism to get reports from provinces regarding the number and nature of complaints received and processed by them. However, the National Department of Health’s does process complaints received directly. The complaints that are received are referred to the relevant provinces to deal with them. The National Department of Health has recently agreed with provinces on a common complaints profile to enable comparability. The first national report of complaints should be available by the end of March 2003.

Most facilities have established clinic and community health centre committees, ward committees and hospital boards. Most provinces have established provincial level governance structures in the form of Provincial Health Councils (PHCs). The PHCs have been established as a mechanism for involvement of local government in the spirit of co-operative governance.

1.4.2.4 Support services: health information, NHLS, mortuaries and blood transfusion

Routine and non-routine data collection systems are being developed, for example the district information system, the hospital information system and some of the data is being used for decision-making. There have also been significant improvements in the registration of births and deaths. Whilst most hospitals and districts are collecting and forwarding routinely collected data it is still of variable quality which makes it difficult to plan. More and better trained dedicated personnel at hospital and district level together with more use of data by managers should assist in improving the quality of data. Use of data by managers should become part of their performance agreement. Expansion of the number of telemedicine sites from the current 28 to the planned 73 requires additional funding. Improvements in the registration of births and deaths requires greater co-operation from doctors and nurses and managers are encouraged to facilitate this co-operation.

Much progress had been made in the establishment of the National Health Laboratory System: the act establishing the NHLS has been passed; the new entity has been created and is functional. The key priorities are the appointment of an effective CEO and senior management team, the financial success of the entity, expansion of services to previously underserved areas and improvements in service delivery. Also of concern is the fact that there is dissatisfaction about the level of service being provided to the provinces by the National Health Laboratory Service. Improvements in service delivery can only be made if laboratory services are efficiently provided.

Plans are at an advanced state to transfer mortuaries to the provincial departments of health. An amount of R45m has been made available for this process but because of lack of clarity on how the monies can be accessed by the provinces this has not been used. Most recently the National Treasury has required that MECs for Health agree in writing that they will take over this service before the funding can be accessed by the provinces. Given that the end of the financial year is in sight it is unlikely that these funds will be spent. Most provinces have now agreed to take over this function and the implementation of plans to transfer mortuaries to provincial Departments of Health can now be implemented.

The South African National Blood Service (SANBS) was registered as a Section 21 in October 2000. On 1 April 2001, six of the former seven blood transfusion services were amalgamated in SANBS. Western Province Blood Transfusion Service (WPBTS) is not included in the amalgamation. The National Health Bill makes provision for the creation of a single national blood service. It is hoped that the problems being experienced with the WPBTS will be resolved once the Bill becomes law.

CHAPTER 2: MEASURABLE OBJECTIVES, INDICATORS, TARGETS AND BUDGETS

2.1 Introduction to the Department’s budget structure

The national Department of Health’s budget is divided into three programmes. Programme 1 entitled administration consists of the budgets for the office of the Minister, Deputy Minister and Director-General. In addition, a range of support functions are funded from the programme. These include: administration of the department; communications; legal services; strategic planning; and internal audit.

Programme 2 is entitled strategic health programmes and overall purpose of which is to co-ordinate a range of strategic national health programmes through the development of policy, systems and monitoring, and manage and fund key programmes. Sub-programmes that are funded from this programme include: district development; international health liaison; health monitoring and evaluation; maternal, child and women’s health and nutrition; mental health; HIV/AIDS, STIs and TB; quality of care; pharmaceutical policy and planning and; the medicines regulatory authority. The key high level objectives for this programme are to: continuously strengthen policies and programmes for HIV/Aids prevention and care, including those for sexually transmitted diseases and tuberculosis, child health, reproductive and women’s health, occupational and environmental health, and nutrition; ensure that all medicines used are safe and affordable, and that 90 per cent of essential medicines are available at all times in the public health sector; and monitor and evaluate health trends, through relevant research and epidemiological surveillance, to ensure that national health policies and programmatic interventions are having their desired impact.

The main purpose of programme 3 - Health Service Delivery is to support the delivery of services, primarily in the provincial and local spheres of Government. Sub-programmes that are funded from this programme include: disease prevention and control; hospital services and emergency medical services; human resource development and management; non-personnel health services; and the health and Welfare Bargaining Council and Industrial Relations. Two key measurable objectives for this programme are to: co-ordinate and support the development of a sustainable network of hospitals – completely upgrading or replacing 27 hospitals over the MTEF – to provide appropriate health care; and develop and assist provinces to implement a comprehensive national health human resources plan that will ensure an equitable distribution of health professionals.

    1. Programme 1: Administration
      1. Measurable objectives, indicators and targets
      2. The table below summarises the key measurable objectives, indicators and three-year targets for the various sub-programmes funded from programme 1.

        Table 1: Administration - medium-term objectives, indicators and targets

        Sub-programme

        Measurable objective

        Indicator

        Target (03/04)

        Target

        (04/05)

        Target

        (06/07)

        Legal

        Key pieces of legislation finalised for debate in and passage by Parliament

        National Health Bill

        Bill submitted

        Traditional Healers Bill

        Bill Submitted

        Other legislation (13 bills)

        % of Bills submitted

        % of Bill submitted

        Communication

        Development of a communications strategy

        Strategy adopted by the Heads of Health (PHRC) & MINMEC

        Dec

        Quarterly progress reports on implementation made to PHRC

        Quarterly reports

        Quarterly reports

        Quarterly reports

        Number of proactive communication events

        9

        15

        18

        Strategic planning

        Finalisation of an integrated strategic planning framework

        Adoption of the framework by the Heads of Health (PHRC)

        October

           

        SPS framework updated to support provincial biannual reviews

        Oct

        Oct

        No. of provinces that’ submit SPSs that comply with the framework

        5

        9

        PSP framework updated to support provincial PSPs

        June

        June

        June

        No. of provinces that submit PSPs that comply with framework

        5

        7

        9

        Revision of national strategic plans annually

        April

        April

        April

        Health Finance

        Equitable allocation of resources

        Development of costed packages and associated norms and standards required to deliver care for all levels of care

        March

        Annual report on inter-provincial equity

        Feb

        Feb

        Feb

        Mechanisms for increasing revenue generation developed

        No. of provinces with revenue retention agreements with Treasuries

        3

        6

        9

        Develop policy and implement SHI

        Adoption of SHI proposal by Cabinet

        SHI implemented

        Dec

         

        March 2006

         

      3. COMMENTARY ON PLANS AND BUDGETS

It is anticipated that the next few years will continue to see many new pieces of legislation introduced by the Minister of Health. Besides the National Health Bill which was published for public comment in November 2001 and revised on the basis of comments received and the Traditional Healers Bill a range of other legislation will be tabled in the next two financial years. These include: Nursing Amendment Bill; Tobacco Products Control Amendment Bill; Health Professions Amendment Bill; Dental Technicians Amendment Bill; Pharmacy Amendment Bill; South African Medical Research Council Amendment Bill; Medicines and Related Substances Control Amendment Bill; Red Cross Bill; Circumcision Bill; and Foodstuffs, Cosmetics and Disinfectants Amendment Bill.

The table below provides a detailed description of the expenditure for the 1999/00 to 2001/02 financial years and the budget for the next three financial years. The exceptionally high expenditure in 2001/02 is explained by once-off capital expenditures, related in particular to the National Health Laboratory Service. When one excludes this exceptional expenditure, there has been steady growth between 1999/00 and 2002/03, which continues over the medium term. This growth is explained primarily by increased allocations to Corporate Services, which also sees expenditure on personnel grow strongly. Personnel expenditure growth is partly due to growing average remuneration per employee, and partly to the filling of posts to meet additional governance and administration requirements. These follow from the implementation of the Public Finance Management Act (PFMA) (1 of 1999); the Skills Development Act (97 of 1998), and the Employment Equity Act (55 of 1998), among others.

Units such as Internal Audit have been considerably strengthened. During 2002/03 a Deputy Minister was appointed, and this is now accommodated in the budget.

Table 2: Programme 1 - Expenditure estimates

Sub-programme

Expenditure outcome

Medium-term expenditure estimate

Audited

Audited

Prelimi-nary outcome

Adjusted appropria-tion

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

Minister 1

577

525

630

691

746

791

835

Deputy Minister 2

607

643

679

Management

8 408

3 382

4 850

5 708

7 426

9 165

9 677

Corporate Services

61 703

66 536

105 529

91 802

98 148

98 304

121 016

Total

70 688

70 443

111 009

98 201

106 927

108 903

132 207

Change to 2002 Budget Estimate

11 001

20 776

17 094

1 Payable as from 1 April 2002. Salary: R552 984. Car allowance: R138 246.

2 Payable as from 1 April 2002. Salary: R449 460. Car allowance: R112 365.

Expenditure outcome

Medium-term expenditure estimate

Audited

Audited

Prelimi-nary outcome

Adjusted appropria-tion

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

Economic classification

Current

68 076

67 508

74 124

87 415

103 540

106 491

128 656

Personnel

30 565

31 814

38 788

45 634

56 190

59 561

62 908

Transfer payments

-

-

-

-

-

-

-

Other current

37 511

35 694

35 336

41 781

47 350

46 930

65 748

Capital

2 612

2 935

36 886

10 786

3 387

2 412

3 551

Transfer payments

384

-

-

-

-

-

-

Acquisition of capital assets

2 228

2 935

36 886

10 786

3 387

2 412

3 551

Total

70 688

70 443

111 010

98 201

106 927

108 903

132 207

Standard items of expenditure

Personnel

30 565

31 814

38 788

45 634

56 190

59 561

62 908

Administrative

10 889

19 634

18 100

18 116

28 409

30 414

34 592

Inventories

1 702

2 563

2 380

2 932

3 252

3 349

2 635

Equipment

5 222

4 666

4 967

7 418

8 493

7 555

8 650

Land and buildings

177

616

35 640

7 841

-

-

-

Professional and special services

21 315

10 678

10 792

16 260

10 583

8 024

23 422

Transfer payments

384

-

-

-

-

-

-

Miscellaneous

434

472

343

-

-

-

-

Total

70 688

70 443

111 010

98 201

106 927

108 903

132 207

Transfer payments per sub-programme

Corporate Services

Policy Analysis

384

0

0

0

0

0

0

Total

384

0

0

0

0

0

0

 

2.3 Programme 2: Strategic Health Programmes

2.3.1 Measurable objectives, indicators and targets

The table below summarises the key measurable objectives, indicators and three-year targets for the various sub-programmes funded from programme 2.

Table 3: Strategic Health Programmes - medium-term objectives, indicators and targets

Sub-programme

Measurable objectives

Indicator

Target (03/04)

Target (04/05)

Target (05/06)

Districts and Development

Development of functional health districts nationally

Number of provinces that use the national checklist to assess functional integration

9

9

9

Number of provinces that use the national guidelines to develop & sign province specific service level agreements with local government

9

   

Assessment of % of health districts that render the full PHC package

Annual reports by Feb

Annual reports by Feb

Annual reports by Feb

Implementation of the workplans to improve service delivery in rural and urban nodes

% of budget spent according to targets

100%

   

IHL

To expand bi-lateral and multilateral relations with key partners

No. of agreements signed

13

6

 

 

No. of agreements implemented

5

5

5

No. of NEPAD projects implemented

1

2

2

Health Monitoring and Evaluation

Strengthen health information systems and use of data for planning and management

Proportion of health districts (including hospitals) use minimum data for management and planning

40%

60%

70%

Report on SADHS

Interim Dec

Final April

 

Ante-natal survey (HIV) results released

April

April

April

Coordination of research & surveys

Plan by Dec

Implementation from April

 

Maternal, Child and Women’s Health & Nutrition

Reduction in childhood and youth morbidity & mortality

No. of districts with immunisation coverage of less than under 80%

40%

25%

15%

Number of districts implementing Integrated Management of Child Illnesses (IMCI)

30%

40%

60%

Number of health districts implementing Integrated Nutrition Programme (including youth nutrition)

100%

100%

100%

% of partners implementing the NPA at national, provincial and local levels

50%

80%

100%

% of baby friendly maternity facilities

15%

20%

25%

Reduce maternal morbidity and mortality

Reports from the Confidential Enquiry into maternal deaths & plans for intervention

Interim report & plan by Dec

Interim report & plan by Dec

Triennial report & assessment of implementation of recommendations of previous Triennial Report

Percentage of health facilities authorised to provide termination of pregnancy services which provide them

45%

60%

65%

Mental Health

Increase integration of mental health services into health care

% of districts that have integrated services

20%

40%

60%

Reduce advertising and include health warning labels on alcoholic beverages (as per policy which is still to be adopted)

Percentage of alcoholic beverage bottles with a health warning

80%

100%

100%

Percentage reduction in advertising of alcohol on TV

70%

100%

100%

HIV/AIDS, STIs and Tuberculosis

Improved strategies to deal with the HIV/Aids epidemic

Percentage of public health facilities offering voluntary counselling and testing (VCT)

80%

90%

100%

Number of male condoms distributed

400m

425m

450m

Proportion of health facilities that offer PMTCT services

60%

80%

100%

Reports and plan interventions on cohort studies on PMTCT programme

June

June

June

STI course is mandatory component of CPD

May

Effective use and management of conditional grants

Percentage of business cases or service level agreements approved using objective criteria before funds transferred

100%

100%

100%

Percentage of reports received in compliance with DORA requirements

100%

100%

100%

Percentage of funds spent

100%

100%

100%

Strengthen the tuberculosis programme

Percentage of new smear-positive tuberculosis cases cured at the first attempt

65%

75%

85%

Smear conversion rate (sputum test change from positive to negative)

70%

75%

85%

Percentage of health districts with DOTS programme

100%

100%

100%

Proportion of health districts with turn around time of 48hrs or less

100%

   

Quality of care

Strengthen and expand mechanisms to improve quality of care

National Patient Complaints Systems fully functional

Sept

Number of provinces that require all facilities to undertake client satisfaction surveys

9

9

9

Number of provinces implementing the national system for clinical audits

9

9

9

Pharmaceutical Policy and Planning

Strategies to improve pharmaceutical procurement and management

Revision of PHC, adult and paediatric EDLs & align to procurement

PHC - July

Adults & Paeds - Oct

 

Functional Pricing Committee

Dec 2003

   

Proportion of pharmacies licensed

80%

90%

100%

Medicines Regulatory Authority

Improved mechanisms for safety of medicines

% of compliance with target for registration

80%

90%

100%

Membership of the International Pharmaceutical Inspection Scheme & inspection

Member

Inspection

 

Centre for excellence for GMP and quality systems for SADC and NEPAD developed

   

Status achieved if inspection passed

 

2.3.2 COMMENTARY ON PLANS AND BUDGETS

Allocations to Strategic Health Programmes grow rapidly over the medium term, with a notably large upward adjustment of 33,8 per cent in 2003/04. The main reasons for this strong growth are:

The HIV/AIDS, STI and TB cluster allocates much of the conditional grant to provinces and non-governmental organisations. In order to ensure good financial management these transfers are closely monitored. Besides requiring business plans, regular expenditure reports are required. Similarly, the Hospital Services cluster also provides funds from the conditional grants to provinces. These are also monitored in a similar fashion. The indicators by which control over expenditure will take place during this three-year period have been included in the table above.

The Primary School Nutrition Programme (PSNP) will be transferred to the Department of Education in the 2004/05 financial year. The Department of Health will work closely with the Department of Education to ensure a smooth transition during the 2003/04. Every effort will be made to ensure that the targets set, in terms of number of beneficiaries and number of feeding days will be maintained during and post the transition.

After doubling between 1999/00 and 2002/03, the allocation to the Medical Research Council grows more slowly over the next three years. A range of prioritised activities also see significant growth in allocations, namely to the Health Monitoring and Evaluation sub-programme to strengthen the Department’s evaluation of the national health system, and for support to and regulation of the pharmaceutical industry in order to supply the South African public with cheaper and safer medicines.

Table 4: Programme 2 - expenditure estimates

Sub-programme

Expenditure outcome

Adjusted appropria-tion

Medium-term expenditure estimate

Audited

Audited

Prelimina-ry outcome

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

District Health Systems

5 846

3 589

2 487

2 555

3 233

2 820

2 958

International Health Liaison

20 705

20 531

35 759

36 092

41 840

41 662

48 133

SADC

1 281

1 751

1 977

2 079

–

–

–

Health Monitoring and Evaluation

99 484

121 464

145 373

164 213

183 130

185 019

197 365

Maternal, Child and Women's Health

732 195

654 706

616 227

631 241

843 921

973 741

1 066 220

Medicines Regulatory Affairs

11 509

15 105

15 843

19 967

23 012

23 691

25 112

Mental Health and Substance Abuse

4 563

4 649

6 033

6 060

6 221

6 989

7 408

HIV/Aids and Tuberculosis

74 480

181 148

265 839

458 628

665 721

850 968

903 344

Pharmaceutical Policy and Planning

10 220

10 630

49 180

16 704

23 937

23 246

25 521

Medical Schemes

2 313

9 217

2 585

2 673

2 673

2 833

3 003

Total

962 596

1 022 790

1 141 303

1 340 212

1 793 688

2 110 969

2 279 064

Change to 2002 Budget Estimate

73 489

374 490

513 409

 

 

Expenditure outcome

Adjusted appropriation

Medium-term expenditure estimate

Audited

Audited

Preliminary outcome

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

Economic classification

Current

953 095

1 021 863

1 137 143

1 338 240

1 791 483

2 108 790

2 276 608

Personnel

39 565

45 692

49 218

57 369

71 774

79 931

84 451

Transfer payments

806 189

746 640

838 198

1 063 378

1 422 151

1 707 055

1 869 650

Other current

107 341

229 531

249 727

217 493

297 558

321 804

322 507

Capital

9 501

927

4 159

1 972

2 205

2 179

2 456

Transfer payments

–

–

–

–

–

–

–

Acquisition of capital assets

9 501

927

4 159

1 972

2 205

2 179

2 456

Total

962 596

1 022 790

1 141 302

1 340 212

1 793 688

2 110 969

2 279 064

Standard items of expenditure

Personnel

39 565

45 692

49 218

57 369

71 774

79 931

84 451

Administrative

26 277

24 605

59 062

56 286

88 049

90 323

96 143

Inventories

31 430

110 794

57 872

75 573

123 837

133 638

140 891

Equipment

10 906

2 632

5 664

3 592

4 160

5 242

4 691

Land and buildings

–

–

–

–

–

–

–

Professional and special services

47 615

92 067

131 288

84 014

83 717

94 780

83 238

Transfer payments

806 189

746 640

838 198

1 063 378

1 422 151

1 707 055

1 869 650

Miscellaneous

614

360

–

–

–

–

–

Total

962 596

1 022 790

1 141 302

1 340 212

1 793 688

2 110 969

2 279 064

Transfer payments per sub-programme

Health Monitoring and Evaluation

Medical Research Council

79 566

108 661

127 221

145 498

156 695

163 388

173 304

Health Systems Trust

1 500

2 000

2 970

2 000

2 000

2 120

2 247

South African Institute for Medical Research

287

287

287

287

287

304

322

Maternal, Child and Women's Health

Primary School Nutrition

710 923

582 411

582 411

592 411

808 660

950 418

1 041 543

Poverty Relief

3 784

3 316

3 487

18 513

15 000

–

–

South African Vaccine Producers

2 439

4 000

4 052

–

–

–

–

Financial Assistance to NGO's

60

150

–

310

350

370

392

Mental Health and Substance Abuse

Financial Assistance to NGOs

722

1 152

978

1 377

1 080

960

1 018

HIV/AIDS and Tuberculosis

South African Tuberculosis Association

25

–

–

–

–

–

–

HIV/AIDS (NGOs)

2 070

5 000

5 001

47 600

43 250

40 250

49 745

Government AIDS Action Plan

4 813

14 013

29 808

–

–

–

–

South African National AIDS Council

–

–

–

10 000

10 000

15 000

10 000

HIV/AIDS Conditional Grant

–

16 819

54 398

210 209

333 556

481 612

535 108

Love Life

–

–

25 000

25 000

25 000

25 000

25 000

Tuberculosis: Financial Assistance to NGOs

–

–

–

2 500

2 600

2 800

2 968

South African AIDS Vaccine Initiative

–

–

–

5 000

10 000

10 000

10 000

Life Line

–

–

–

–

11 000

12 000

15 000

Medical Schemes

Medical Schemes Council

–

8 831

2 585

2 673

2 673

2 833

3 003

Total

806 189

746 640

838 198

1 063 378

1 422 151

1 707 055

1 869 650

 

2.4 Programme 3 - Health Service Delivery

2.4.1 Measurable objectives, indicators and targets

The table below summarises the key measurable objectives, indicators and three-year targets for the various sub-programmes funded from programme 2.

Table 5: Health Service Delivery – measurable objectives, indicators and targets

Sub-programme

Measurable objectives

Indicator

Target (03/04)

Target (04/05)

Target (05/06)

Disease Prevention and Control

Expand measures to combat the spread of malaria and cholera

Preparation and monitor annual malaria control provincial plans (including plans for Lubombo Spatial Development Initiative)

Feb

Feb

Feb

Number of provinces with plans to prevent and contain cholera outbreaks

9

9

9

Expand the cataract surgery project

Increase cataract surgery rate to 1 per 1000 people by 2005

32000 operations

32000 operations

 

Eliminate backlog in assistive devices

Number of wheelchairs and hearing aids purchased

3621 wheelchairs; 3637 hearing aids

3621 wheelchairs; 3638 hearing aids

 

Expand services in NCD chronic diseases

Proportion of national guidelines on NCD chronic diseases implemented by provinces

60%

80%

100%

Improve and expand key support services

Creation of single Blood Transfusion Service

June

Number of provinces in which SAPS mortuaries have been transferred

1

4

9

Proportion of laboratories with a QC system

70%

80%

100%

Expansion of water fluoridation

Number of front runners who supply fluoridated water

2

4

6

Hospital Services & EMS

Revitalisation of the public hospital system

Proportion of hospitals in the revitalisation programme

6%

8%

11%

Number of provinces with development and maintenance programmes for facilities not in the revitalisation programme

3

6

9

Percentage of hospitals in the revitalisation programme implementing hospital management and health technology components

50%

80%

100%

Number of provinces with effective management delegations at hospital level

3

6

9

Number of provinces implementing hospital asset management systems

3

6

Number of hospital departments for which hospital design and commissioning guides issued

20%

60%

100%

Develop and implement national EMS plan

Adopted by MINMEC by Dec

Implemented in 5 provinces

Implemented in 9 provinces

Effective use and management of conditional grants

Percentage of business cases or service level agreements approved using objective criteria before funds transferred

100%

100%

100%

Percentage of reports received in compliance with DORA requirements

100%

100%

100%

Percentage of funds spent

98%

100%

100%

Human Resources

Develop rolling human resource plan linked to recommendations of the Pick Report

National HR plan (implementation of the Pick Report) adopted by MINMEC

Sept

Number of provinces with a HR plan based on the national HR plan

4

6

9

Proportion of training institutions implementing the need & employment equity quotas set nationally

25%

50%

75%

Health Professional Councils transformed

Legislation prepared for debate and adoption by Parliament

April

Develop OD plan for the NDOH

Plan developed & monitored annually

Plan by Dec

Progress report by March

Progress report by March

Non-personal health services

Improving environmental health services

Number of provinces implementing the National Health Care Waste Management Strategy

5

9

Devolution of environmental health services to district municipalities

All

All

All

Expanding occupation health services

Number of provinces implementing the national strategy for occupational health

9

9

Proportion of DOH facilities that are safe and risk free

30%

50%

Percent reduction in CCOD backlogs

20%

70%

90%

Number of provinces that have assessed health risks on mines with specific reference to TB

4

7

9

Number of medical benefit examinations done

25 000

28 000

30 000

Expanding health promotion services

Percent of schools implementing the Health Promoting Schools initiative

25%

35%

50%

Number of provinces that implement the 5 priority health promotion campaigns (nutrition; substance abuse; tobacco use; healthy environment; risks)

4

6

9

Health and Welfare Bargaining Council & Industrial Relations

Improved management of employee relations

Proportion of grievances resolved internally (within NDOH)

60%

70%

90%

Improved working conditions of employees

Number of resolutions passed by the PHWSBC & the PSCBC that improve the working conditions of employees

5

5

5

 

2.4.2 COMMENTARY ON PLANS AND BUDGETS

After annual average growth of 8,8 per cent between 1999/000 and 2002/03, growth on this programme slows to an annual average 6,4 per cent over the medium term. However, average growth rates underestimate the extent of growth in key programmes because of large once-off payments in 2002/03 (specifically the refund to KwaZulu-Natal of malaria-related expense), the transfer in 2002/03 of the National Institute of Virology to the National Health Laboratory Services, and the completion of funding for a number of large hospital capital projects between 2001/02 and 2003/04.

In particular over the MTEF, there is strong growth in allocations to medico-legal mortuaries and hospital rehabilitation, both of which are conditional grants to provinces. The allocation to hospital rehabilitation increases to more than R1 billion in 2005/06. Funding for the Lubombo malaria initiative has been allocated for a further three years (R5 million per year) given the great successes in reducing malaria in South Africa, Swaziland, and southern Mozambique.

R50 million has been allocated to update and transform the equipment stock of the health sector to decrease the average age of the equipment, and this includes allocations for health technology audits, technology systems and management tools.

The large conditional grants have been reconfigured with the introduction of the new National Tertiary Services Grant and Health Professions Training and Development Grant. In the design of the new grant framework, funds have been shifted from the training grant to the services grant, since the costing methodology for the new National Tertiary Services Grant included a significant proportion of training costs within tertiary cost centres.

Radiation control is an important function of the Department of Health. In the 2003/04 financial year the Department has provided additional funds to the Unit responsible for radiation control to enable it to employ additional personnel to reduce the backlog of inspections.

Table 6: Programme 3 - expenditure estimates

Sub-programme

Expenditure outcome

Adjusted appropriation

Medium-term expenditure estimate

Audited

Audited

Preliminary outcome

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

Disease Prevention and Control

100 152

51 273

58 333

261 098

125 013

160 175

169 005

Hospital Services

4 664 518

5 455 550

5 360 623

5 884 943

6 291 730

6 781 638

7 245 173

Human Resources

11 304

8 419

9 988

6 532

6 651

7 328

7 768

Non-Personal Health Services

49 563

57 937

53 204

60 605

60 741

68 432

68 705

Health and Welfare Bargaining Sector Negotiations

–

1 014

1 981

2 406

1 770

2 699

2 861

Total

4 825 537

5 574 193

5 484 129

6 215 584

6 485 905

7 020 272

7 493 512

Change to 2002 Budget Estimate

384 377

334 746

523 619

Economic classification

Current

4 431 383

4 699 461

4 822 910

5 487 076

5 661 203

6 093 679

6 451 362

Personnel

61 790

63 611

68 500

71 118

63 580

67 395

71 875

Transfer payments

4 258 605

4 578 277

4 705 034

5 370 453

5 552 336

5 975 085

6 333 827

Other current

110 988

57 573

49 376

45 505

45 287

51 199

45 660

Capital

394 154

874 732

661 219

728 508

824 702

926 593

1 042 150

Transfer payments

383 172

866 191

653 800

719 000

809 984

911 856

1 027 427

Acquisition of capital assets

10 982

8 541

7 419

9 508

14 718

14 737

14 723

Total

4 825 537

5 574 193

5 484 129

6 215 584

6 485 905

7 020 272

7 493 512

Standard items of expenditure

Personnel

61 790

63 611

68 500

71 118

63 580

67 395

71 875

Administrative

8 228

13 351

12 557

19 980

19 172

18 710

18 520

Inventories

60 329

14 275

12 921

11 007

8 323

10 662

10 963

Equipment

12 966

10 507

10 305

11 121

17 504

17 550

17 474

Land and buildings

–

–

–

–

–

–

–

Professional and special services

39 469

27 482

21 012

12 905

15 006

19 014

13 426

Transfer payments

4 641 777

5 444 468

5 358 834

6 089 453

6 362 320

6 886 941

7 361 254

Miscellaneous

978

499

–

–

–

–

–

Total

4 825 537

5 574 193

5 484 129

6 215 584

6 485 905

7 020 272

7 493 512

Expenditure outcome

Adjusted appropriation

Medium-term expenditure estimate

Audited

Audited

Preliminary outcome

R thousand

1999/00

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

Transfer payments per sub-programme

Disease Prevention and Control

Council for the Blind

250

350

350

400

510

424

449

National Health Laboratory Services

–

–

–

8 294

23 704

24 336

30 796

Medical Legal

–

–

–

45 000

52 000

86 600

91 796

Malaria LSDI

–

–

–

5 000

5 000

5 000

–

Cholera Epidemic - KwaZulu-Natal (conditional grant)

–

–

–

147 000

–

–

–

Hospital Services

Hospital Revitalisation

153 455

423 139

500 000

649 000

717 628

911 856

1 027 427

Hospital Construction: Durban Academic Hospital

188 776

331 200

103 800

–

–

–

–

Hospital Construction: Umtata Hospital

40 941

111 852

–

–

–

–

–

Hospital Construction: Pretoria Academic Hospital

–

–

50 000

70 000

92 356

–

–

National Tertiary Services

3 130 055

3 391 041

3 459 594

3 727 077

3 994 774

4 273 005

4 529 386

Health Professionals Training and Development

1 118 000

1 174 000

1 234 090

1 299 248

1 333 499

1 434 132

1 520 180

Hospital Management and Quality Improvement

–

–

–

126 000

133 404

141 832

150 342

Non-Personal Health Services

Compensation Fund

9 000

12 000

11 000

11 434

8 805

9 000

10 000

Health Promotion

1 300

886

–

1 000

600

700

800

Environmental Health NGO

–

–

–

–

40

56

78

Total

4 641 777

5 444 468

5 358 834

6 089 453

6 362 320

6 886 941

7 361 254

 

 

CHAPTER THREE: CONCLUSION

 

Much progress have been made in achieving the goals set out in the White Paper for the Transformation of the Health System in South Africa. In addition, significant progress has been made towards achieving some of the targets set out in the Health Sector Strategic Framework, 1999-2004. However, given the enormity of the task at hand much more remains to be done. In this strategic plan the Department commits itself to accelerating progress towards its vision and mission as set out in this document.

This plan clearly lays out the key objectives, indicators and targets that the Department will seek to achieve in the next three years. Whilst only the key objectives are listed in the tables above, much more will be done. The many operational activities of the Department will be reflected in the operational plans of each of the clusters.

One of the key features of the budget of the national Department of Health is the large conditional grants for which it is accountable. Besides the activities listed in the tables above viz., releasing funds only after proper business plans or service level agreements have been presented and requiring regular reports, the Department will also undertake site visits to ensure that what is contained in the business plans and other agreements is actually delivered.

While it is the provincial Departments of Health and municipalities that actually delivery most public health services, the national Department is committed to providing leadership and to supporting both provinces and municipalities to achieve national targets.