• Organisational Development whose purpose is to:
• Strengthen management in hospitals including the development of systems (Financial management, Hospital Management Information Systems, Patient Administration systems);
• Development of management systems and structures (appointment of CEO’s/SEO’s and Financial Officers);
• Support the Monitoring and Evaluation capacity of the hospital services at Provincial level;
• Delegate (HR, Financial and Procurement) powers to identified hospitals;
• Improve systems, processes and procedures to support the delegations; and
• Capacity building and improve PFMA implementation at provincial and hospital levels.
• Quality Improvement whose purpose is to introduce the following:
• Patient complaints procedures;
• Patient satisfaction surveys;
• Medical Audits;
• Morbidity and Mortality reviews;
• Hospital accreditation – systems for quality assessment; and
• Implementation of standardised diagnostic and treatment protocols.

From the table below it is evident that there is no significant growth in the hospital management grant.

• Health Professional Training component: Its purpose is to support provinces to fund service costs associated with training of health professionals and enable shifting of teaching activities from central hospitals to regional and district facilities.
• Developmental component: Its purpose is for the development and recruitment of medical specialists in all under-served provinces i.e. Eastern Cape, Limpopo, Mpumalanga, Northern Cape, and North West. The national Department has required that the benefiting provinces on this component submit business plans. The submitted business plans are reviewed and approved.

• Health Professional Training component: The training of health personnel is progressing well in all provinces. However, DORA does not prescribe any submission of business plans on this component.
• Developmental component: This component is not without challenges. There is nevertheless progress in provinces. Progress is being made in reaching agreements with medical institutions regarding the appointment of registrars. A total of 21 registrars from the expected total of 46 have been appointed in 2002/03. In addition, 80 specialists have been appointed from a total target of 95 during the same period.

A number of factors have obstructed us from reaching our objectives. For example, it is difficult to recruit specialists to these under-serviced provinces and it is difficult to recruit doctors to registrar posts in rural areas.

The total budget for HIV/AIDS and TB at the national office for 2003/04 is R665 721 000. The major elements of this budget are:

- Conditional Grants R333 556 000

- Personnel 15 623 000

- SANAC 10 000 000

- SAAVI 10 000 000

- loveLife 25 000 000

- LifeLine 11 000 000

- NGO funding 35 850 000

- Communication campaigns 50 585 000

- Condoms 115 000 000

- Global Funds on AIDS, TB and Malaria 20 000 000

In terms of the allocation to provinces for conditional grants in 2003/04, the amounts are (in R’000):

The Health HIV/AIDS grant is for the following programmatic interventions:

• HBC
• VCT
• PMTCT
• Step-down care
• Provincial management
• Non-occupational post-exposure prophylaxis
• Commercial sex workers
• Training for health workers

The Education Grant is for life skills education, and the Social Development Grant for HBC.

The main problems identified by the provinces in relation to spending against the conditional grant included the following:

1. Existing staff were over-loaded.
2. Hospital infrastructure was unable to take additional burden of HIV/AIDS.
3. New HIV/AIDS structures needed to be established
4. No existing framework existed to guide programme implementation.
5. No provincial and district coordinators trained on new HIV/AIDS programmes.
6. No nurses trained on HIV/AIDS rapid testing.
7. No counsellors trained for pre & post-test counselling.
8. Mushrooming HBC programmes not coordinated or formally supported.

Subsequently, the Department of Health (national) initiated a range of activities to assist provincial implementation. This included: the appointment of coordinators and administrative staff in the key programmes of VCT, HBC and PMTCT (5 posts per provinces). These appointments were made by the national department against the national budget, and seconded to the provinces; training of 18 master trainers for VCT (2 per province), and the subsequent training of 4,800 counsellors; 50 Mentor trainers trained; appropriate VCT guidelines (pre- and post-test counselling, establishing VCT services, and minimum training standards) were developed and distributed; conducted a national assessment of VCT services; 2000 Home-based carers trained nationally, as well as 180 master trainers (20 per province; rapid assessment of existing HBC projects completed; HBC materials (including manuals) developed and distributed; distributed 1500 HBC kits with basic medical equipment e.g. swabs, antiseptic, gloves, bandages, ointment etc.; regular visits to provinces from the National Coordinator to review provincial progress and identify problems; training of 320 health workers in PMTCT, as well as 100 lay counsellors; 51 PMTCT trainers trained; motivation for the conditional grant to be merged into a single grant as from 2003/04.

1. Highlight any areas (by province or focus area) that have experienced underspending in the last financial year and the reasons therefore.

The provinces that have experienced problems with spending against the conditional grant, especially in the early phases (2001/02) were the Eastern Cape, Free State, Limpopo and Mpumalanga.

For the 2002/03 financial year, provinces stated the following specific problems. Eastern Cape indicated problems with provincial treasury not processing contracts with pharmaceutical companies. Free State indicated difficulties with spending not allocated against the conditional grant codes, especially in the PMTCT programme. Gauteng experienced structural problems and correctly capturing conditional grant expenditure. Limpopo also highlighted the issue of spending not correctly allocated in the financial system. Mpumalanga indicated that the underspending (currently at 38%) is due to human resource and management capacity problems.

Generally, provinces have indicated a problem with the BAS system and capturing of HIV/AIDS spending. Visits to ‘under-spending’ provinces in March 2003 have provided a picture that all provinces now have correct responsibility codes for HIV/AIDS conditional grant spending.

The late transfer of additional funds (R50 million for PEP) to provinces impacted seriously on provinces’ ability to spend their conditional grant budget.

Whilst some provinces e.g. KwaZulu-Natal, Northern Cape and Western Cape were able to continue rolling out their existing programmes, provinces with weaker infrastructure and human resource capacity had difficulty preparing a business plan and spending against it.

 

2. An allocation was made for the provision of step-down facilities, please provide a progress report also indicating how much of the allocation was spent.

A decision was made that this programme should be managed by hospitals. All provinces have identified hospitals that they would provide monetary support to. A per-bed costing has been devised and additional funding provided for bed linen etc.

The budget allocation is decided by the province and per province expenditure to date is as follows:

Eastern Cape: R36 000

Free State: R2 million

Gauteng: R2.6 million

Against the original budget of R30 million, this reflects spending of R7.2 million, with the assumption that KwaZulu-Natal will spend their allocation of R8 million, bringing the projected expenditure to approximately R15 million (50%).

1. EQUITY
1. Inter-provincial inequity remains a major area of concern – how is the Department working with provinces to address this issue?

Inter-provincial inequity remains a major challenge facing the public health system of South Africa. Despite significant strides being made between 1994 and 1997 to address levels on inequity, recent analysis by the Department of Health indicates that the inequities in per capita expenditure on Public health services have deepened. This is illustrated in the figure below.

The current system of Fiscal Federalism offers limited scope for influencing provincial allocations to Health, let alone trying to influence inequity in Public Health Care spending.

Since 2000, the national Department has attempted to influence provincial allocations for health in the following ways:

• Influencing the system of conditional grant allocations, in a manner that ensured that there was greater equity in the allocation of conditional grants, e.g. the restructuring of the Central Hospitals Grant , Health Professionals Training and Research Grant and Redistribution of Tertiary Services grants into the National Tertiary Services Grant and the Health Professionals Training and Development Grant. The impact of this restructuring was to allocate funds in direct relation to services being rendered.
• The HIV/AIDS conditional grant was also restructured, with the aim of more closely relating the scale of the epidemic to the allocations.
• The preparation of budget proposals to implement or strengthen public health priorities have been designed in a manner that allocates resources more equitably between Provinces.
• Closer working relationship with National Treasury, in understanding the complexities caused by inequitable spending patterns.
• Lastly, and most importantly, the national Department has been working with provinces in their preparation of the Provincial Budget for Health. Specific emphasis has been placed in providing provinces with key information for inclusion in their budgets. It is easier to work with provinces receiving per capita allocations below the national average.

A key and important step for the national Department over the next 12-18 months is the development, finalisation and implementation of basic packages of care that encompass the entire public health system (i.e. PHC, Level I, II, and III). Associated with this is the development of norms and standards on expenditure levels required to deliver these basic packages.

1. Similarly, intra-provincial inequity still persists, how is the Department working with Provinces to ensure a more equitable distribution of funds especially at district and sub-district levels

Between 1999 and 2001, the national Department with assistance from research partners (Centre for Health Policy, the Equity Project, the HST and the Health Economics Unit), developed a tool and guidelines for provincial departments to assess sub-provincial inequity, especially around the district health system. This was called District Health Expenditure Reviews. The tool and guidelines were assessed by Provincial Departments in terms of its feasibility and ease of interpretation and use, and found to be an extremely useful management tool. Provincial Health Departments then undertook to roll- out these expenditure reviews in all of the Health Districts. All provinces are in the process of conducting expenditure reviews linked to district health planning which will enable provinces to more closely interrogate levels of inequity between districts.

 

2. Highlight areas of the budget and the budget process where the Department might require assistance/advocacy of the Committee in facilitating the necessary changes.

There are a number of areas where the Portfolio Committee on Health can influence the promotion greater equity in health care spending. These include areas where the National Department has little influence over: working with the portfolio Committee on Finance to understand why greater emphasis is not placed on inter-provincial equity; together with the Portfolio Committee on Finance and the Select Committees of the NCOP to interrogate Provincial Legislatures and Treasuries in their allocation of revenue to Health departments; as the national Department defines basic Packages of Care and associated norms and standards, it is crucial that the Portfolio Committee on Health assist in obtaining buy-in of this process, to the end that there is commitment to deliver these packages and to fund their appropriate delivery.

Another good example of where the portfolio committee could be significantly influential is the area of influencing budget allocations is interrogating how provinces have budgeted for certain policy priorities, e.g. in the budget for the coming MTEF, after lobbying from the NDoH, the National Treasury has allocated additional funds for HIV/AIDS and human resources.

To amend the Tobacco Products Control Act, No 83 of 1993 so as to clearly create certain offences and to increase penalties applicable to certain offences.

The draft Bill will be submitted to Cabinet in April 2003.

Note: Amendment Bill to be revisited in the light of latest developments relating to the Framework Convention on Tobacco Control. The last round of negotiations took place in February 2003. Advocate Patricia Lambert of the Minister’s office led the negotiations on behalf of the South African Ministry of Health. This Bill is a priority for 2003.

The issue of the designation of facilities to perform terminations of pregnancy needs to be addressed. The thinking is that all facilities equipped to deliver babies should be able to perform TOP.

Amendment to be submitted to Cabinet by or before September 2003.

8. Medicines and Related Substances Control Amendment Bill, 2003

There is a need to regulate complementary medicines, to make provision for the creation of new categories of medicines and certain powers of the Medicines Control Council and to make further provision for the control by the Council of certain kinds of medical devices and various other matters of a technical nature. Bill to be submitted to Cabinet for approval in September 2003.

Note: This entails some fairly complex amendments in view of the fact that most complementary medicines have not been formally regulated before and that they are, in scientific terms, quite different to allopathic medicines. The Medicines Regulatory Authority is working with the Legal Unit of the Department on the proposed amendments.

9. Red Cross Bill, 2003

There is a need for a legislative framework for a formal relationship between the South African Red Cross and the government to ensure that health efforts in rescue and disaster management are properly co-ordinated so as to avoid duplication of efforts of government and the South African Red Cross and a waste of scarce resources. Bill to be sent to Cabinet in September 2003

10. Sterilisation Amendment Bill

There is a need to clarify certain provisions of the Sterilisation Act No 44 of 1998 so that they will be interpreted in a manner which supports the constitutional rights of persons affected by the Act. Currently the Act is not being interpreted correctly within the provinces by the panels established to decide whether or not a sterilisation operation should be performed - especially with regard to the question of whether mentally disabled children under the age of 18 years should be sterilized when this is in their best interests. The Bill also needs to be aligned with the principles expressed in draft Children’s Bill that the Department of Social Development is busy with.

Amendment to be submitted to Cabinet in September 2003.

Note: This is a relatively short amendment and is in process within the Legal Unit at present

 

11. Foodstuffs,Cosmetics and Disinfectants Amendment Act, 2003

 

To amend the Foodstuffs, Cosmetics and Disinfectants Act, 1973 (Act No 54 of 1973) so as to provide for stricter control of the spread of foodborne diseases and other matters relating to the control of foodstuffs; to regulate food premises and the medical examination of food handlers and the importation and exportation of foodstuffs .

Bill to be submitted to Cabinet in September 2003.

12. National Health Bill 2003

To provide for a legislative and regulatory framework for a structured national health system within the Republic of South Africa.

The National Health Bill was submitted to Cabinet in 2002. It must be certified by the State Law Advisors and tabled in Parliament in 2003.

Note: The State Law Advisors and the Department are liaising concerning some of the issues raised by the State Law Advisors in their commentary on the Bill. The Department is hoping to be able to respond to the State Law Advisors within the next two weeks on the legal technical changes they have proposed. This Bill is a priority for 2003.

13. South African Medical Research Council Amendment Bill 2003

It is necessary to redefine a number of issues, including the role of the Medical Research Council, in the light of changes in current thinking relating to public health. The amendments will bring the activities and role of the MRC into line with Departmental public health initiatives and enable it to assist in meeting Departmental needs in this regard.

Bill to be submitted to Cabinet for approval in July 2003.

5. OTHER ISSUES
8. The Department has been reviewing the distribution of health personnel, remuneration of health workers, incentive schemes (monetary and non-monetary) for more than a year, please provide targets and dates for implementation of this review.

The announcement on the provision of additional funds for the recruitment and retention policy was made in October 2002. The date for implementation is 1 July 2003. The Minister will provide details in her budget speech.

9. What is the overall allocation for the rural incentive scheme and are funds allocated as a conditional grant?

R500m was allocated for the retention and recruitment policy and the breakdown will be provided in the Minister’s budget speech. The funds will be included in the equitable share to provinces.

10. Provide a breakdown of which health professionals are included in the rural health incentive scheme.

Currently doctors, dentists and specialists are included in the scheme. The Minister will announce an extension to other categories in her budget speech.

11. How has the absence of the National Health Bill impacted on policy and service?