The
Budgetary Review and Recommendation Report of the Portfolio Committee on Health,
dated 21 October 2011
The Portfolio Committee on Health having assessed the
performance of the Department of Health for 2010/11, reports as follows:
Section 77 (3) of the Constitution of South Africa
provides for an Act of Parliament which will provide for a procedure to amend
the Money Bills before it. The Money Bills Amendment Procedure and Related
Matters Act, 2009 (Act 9 of 2009) thus enables Parliament to amend aspects
related to tabled Money Bills. The objectives of this Bill are twofold:
1.1 The role of the Committee
Parliament conducts its constitutional obligations
through the work of Committees.
Committees of Parliament facilitate the passing of legislation, approve
annual departmental budgets and conduct oversight of departments falling within
their perimeters.
Section 5 (1) of the Money Bills Amendment Procedure
and Related Matters Bill provides for the National Assembly (NA) through its
committees to annually assess the performance of each national department, with
reference to the following:
Section 5 (2) makes provision for the annual
submission of the budgetary review and recommendations report (BRRR) for
tabling in the National Assembly for each department. It is expected of the BRRR to report on the
following:
In order to enable the Committee to take an informed
decision on the performance of the Department of Health for the financial year
2010/11, the Committee consulted the following reports and/or documents:
1.2 The Department
The Department of Health derives its mandate from the
Constitution. Section 27(1)(a) of the Constitution states that “Everyone has
the right to have access to health care services, including reproductive health
care”. Section 27(3) further notes that “no
one may be refused emergency medical treatment.” Section 28(1)(c) further gives
every child the right to “basic nutrition, shelter, basic health care services
and social services”. Finally, schedule 4 of the Constitution makes health care
services both a national and provincial legislative competence and/or
imperative.
In line with its constitutional obligations, the
vision of the Department is ‘a long and healthy life for all South Africans’.
Its mission is to improve health status through prevention of illness and
disease and through the promotion of healthy lifestyles and to consistently
improve the health care delivery system by focusing on access, equity,
efficiency, quality and sustainability.
2. Department’s
Strategic Priorities and Measurable Objectives
2.1
Strategic Plan of the Department – Ten Point Plan
Health priorities have been set for different epochs
in
The
priorities comprising the 10 Point Plan are as follows:
2.2
Measurable Objectives of the Department
The measurable objectives and outcomes of the
Department are stated in accordance with its various programmes. They
encapsulate what the Department intends to achieve in each programme in order
to achieve its overall health care service delivery mandate:
Programme
1: Administration
The objective of this programme is to conduct overall
management of the Department. Activities include policy-making by the offices
of the Minister and Director-General, and the provision of centralized support
services.
Measurable
Objectives
Programme
2: Strategic Health Programmes
The objective is to co-ordinate a range of strategic
national health programmes by developing policies and systems, and manages and
funds key health programmes
Measurable
Objectives
Programme
3: Health Planning and Monitoring
This programme plans and monitors health services and
co-ordinates health research programmes.
Measurable
Objectives
Programme
4: Human Resource Management and Development
The objective of the programme is to plan and
co-oordinate human resources for the health sector.
Measurable
Objectives
Programme
5: Health Services
This programme supports the delivery of health
services in provinces including primary healthcare, hospitals, emergency
medical services and occupational health.
Measurable
Objectives
Programme
6: International Relations, Health Trade and Health Product Regulation
This programme co-ordinates bilateral and multilateral
International health relations including donor support, regulations of procurement
of medicines and pharmaceutical supplies and regulation and oversight of trade
in health products.
Measurable
Objectives
3. Analysis
of the Department’s Prevailing Strategic and Operational Plan
Vote
15: Department of Health
3.1
Introduction
The aim of the Department of Health is to
promote the health of all people in
3.2
Policy Priorities for 2010/11
The Department identified 10 key strategic
priorities for the five-year period 2009-2014. The 10 Point Plan consists of
the following priorities:
·
Provision of Strategic
leadership and creation of a social compact.
·
Implementation of National
Health Insurance (NHI).
·
Improving the Quality of
Health Services.
·
Overhauling the health care
system and improving its management.
·
Improving Human Resources
Management, Planning and Development.
·
Revitalisation of
Infrastructure.
·
Accelerated implementation
of the HIV & AIDS and Sexually Transmitted Infection National. Strategic
Plan (NSP) 2007-11 and increase focus on TB and other communicable diseases.
·
Mass mobilisation for
better health for the population.
·
Review of the Drug Policy.
·
Strengthening Research and
Development.
In 2010, Government adopted a new outcome-based
approach to attaining the objectives outlined in the MTSF 2009- 2014. In line
with this the health department will focus on four key areas:
1)
Increasing life expectancy.
2)
Combating HIV and AIDS.
3)
Decreasing the burden of
diseases from Tuberculosis.
4)
Improving Health Systems
Effectiveness.
To address these four areas, the health sector
must produce twenty deliverables over the next five years, as described in the
Strategic Plan 2010/11- 2012/13:
·
Increased Life Expectancy
at birth
·
Reduced Child Mortality
·
Decreased Maternal
Mortality Ratio
·
Managing HIV Prevalence
·
Reduced HIV Incidence
·
Expanded access to the
Prevention of Mother to Child Transmissions (PMTCT) Programme
·
Improved TB Case Finding
·
Improved TB outcomes
·
Improved access to
Antiretroviral Treatment for HIV-TB co-infected patients
·
Decreased prevalence of
Drug Resistant-TB
·
Revitalisation of Primary
Health Care
·
Improved Patient Care and
Satisfaction
·
Accreditation of health
facilities for quality
·
Enhanced operational
management of Health Facilities
·
Improved access to Human
Resources for Health
·
Improved Health Care
Financing
·
Strengthened Health
Information Systems (HIS)
·
Improved health services
for the Youth
·
Expanded access to Home
Based Care and Community Health Workers.
3.3
Performance and Service Delivery Information
This section briefly highlights performance and
service delivery information on the department.
The Department had an under-expenditure of 2.6
per cent which amounts to more than R386 million. This was largely due to under
expenditure in Programme 5: Health Services amounting to R344 million or 3.6
per cent of that sub-programme’s budget. The Department attributed this
underspending on withheld Hospital Revitalisation Grant for some of the
provinces (Western Cape’s Mitchell’s Plain Hospital and
Whilst the National Department of Health
addressed issues raised by the Auditor General in the 2007/08 report, the
Department received a qualified audit for 2008/09 due to the following
1)
Lack of a system to
reconcile application forms from pharmaceutical companies to the fees received
by the Medicines Control Council (MCC) (R29.7 million).
2)
Lack of a system to enable
the reconciliation of payments for the use of vehicles under the National Fleet
Public Private Partnership (R23.2 million).
According to SCOPA this Department has had eight
qualifications in the last nine years.
The Department commissioned and completed a
15-year review of the performance of the health sector. This report also
identified key weaknesses in management and leadership across all level of the
health system.
The completion of Annual Performance Plans
(APPs) were affected by the withdrawal and re-issuing of allocation letters.
The Department experienced great challenges with regards to Information and
Technology (ICT). Some of the key challenges were personnel shortages, network
availability and dilapidated ICT infrastructure. In response to this, four senior
positions were created and advertised to deal with ICT capacity.
The Department introduced a competency
assessment system for short-listed senior management services (SMS) candidates
to be assessed on.
Performance management agreements (PMAs) were one
of the biggest challenges. Only 63 out of the 100 SMS members submitted PMAs.
The Department implemented the Public Service Act and its regulations and
ensured that SMS members who did not submit PMAs were not considered for both
the annual package progression nor performance bonuses.
Programme 2: Strategic Health Programmes
reported 88.8 per cent coverage for children under one year of age, up from
85.2 per cent in 2007/08. 44 out of the 52 districts implemented the Reach
Every District (RED) strategy, exceeding the 2008/09 target of 30 of the 52
districts. 38 of the districts achieved full immunisation coverage of 80 per
cent, not meeting the target of 40 out of 52 districts. Whilst no measles
outbreak was reported for the reporting period, the Department identified the
need to strengthen the immunisation of South African children against measles.
A total of 734 409 (target: 500 000) people
living with HIV and AIDS were provided with nutritional supplements.
Only 50 per cent (target: 70per cent) of primary
health care (PHC) facilities implemented youth friendly services.
The department reported a 29.5 per cent decrease
in malaria cases from 8 743 in 2007/08 to 6 167 in 2008/09.
93 per cent of facilities provided voluntary
(HIV) counselling and testing (VCT) services, however the uptake of VCT
services remained a challenge.
95 percent of facilities offered Prevention of
Mother- to- Child Transmission (PMCT) facilities compared to a target of 100
per cent. 781, 465 patients were initiated on Antiretroviral Therapy (ART) by
the end of April 2009, compared to 483, 084 by the end of April 2008- an
increase of 38.2 per cent.
The incidence of tuberculosis (TB) has increased
from 739.6 per 100 000 population (2007) to 948 per 100 00, a rate of 1 in 105
people in
Only 283.4 million male condoms were
distributed, against a target of 450 million. Delays in awarding tenders by
National Treasury were forwarded as the reason for this. TB cure rates in three
of the four TB crisis management districts were significantly lower than the
target of 70 per cent.
The National Antenatal and Syphilis Survey for
2008 reflects stability in HIV prevalence amongst 15- 24 year old age- group,
from 22.4 per cent in 2006 to 22.1 per cent in 2007 to 21.7 per cent in 2008.
This may suggest that health messages are reaching young South Africans.
However the same survey showed a National HIV prevalence rate of 29.3 per cent.
Average waiting period for a wheelchair in the
Provinces was 8 weeks or longer, where the target is 6 weeks or less. Data
collection for the Demographic and Health Survey (2008) did not commence as
planned, due to resources constraints. Tender specifications were developed and
a target to conduct the survey by October 2008 was set.
The Health Planning and Monitoring Programme
produced national norms and standards for health facilities, and 27 facilities
were assessed against these norms and standards and supported to produce
Hospital improvement Plans. A National Infection Prevention and Control Manual
was produced with support from the University of Kwa-Zulu Natal (UKZN).
Technical work for the National Health Insurance (NHI) was completed by a Task
Team located outside the Department, but including officials from the
Department. The Department contributed to the development of the African Union
(AU) Pharmaceutical Manufacturing Plan, with the view that
The Human Resources Programme saw 8 out of the 9
provinces produce Human Resources for Health (HRH) plans. South African Dental
Technicians Council as well as the South African Nursing Council was
inaugurated in 2008 as targeted. A total of 100 Clinical Associate Students
were enrolled at
23 Emergency Care Technicians (ECT) students
graduated from the
Proposals for the Occupation Specific
Dispensation (OSD) for doctors, dentists and pharmacists were developed.
However, delays were experienced in funding the OSD. A dispute was declared by
the Trade Unions on the OSD for nurses, and an interdict was obtained by the
Trade Unions to stop the implementation of OSD for nurses.
In the Special Programmes and Health Entities
Management Programme, 47 out of the 52 districts produced District Health Plans
(with the exception of districts in the
The Medicines and Related Substances Bill and
Tobacco Products Control Amendment Bill were passed. The Medical Schemes
Amendment Bill and the National Health Amendment Bill were tabled in
Parliament. 100 per cent of public institutions were smoke free institutions.
The Department assisted the Congolese Ministry
of Health with the establishment of the Congo Nursing Council.
3.4
Budget analysis
Programme |
Budget |
Nominal |
Real |
Nominal %
change |
Real % change |
|||
R million |
2009/10 |
2010/11 |
2011/12 |
2012/13 |
2009/10 -
2010/11 |
2009/10 -
2010/11 |
||
Programme 1: Administration |
260.4 |
264.8 |
299.9 |
330.9 |
4.4 |
- 12.2 |
1.69 per cent |
-4.70 per cent |
Programme 2: Strategic Health Programmes |
5 791.3 |
7 294.9 |
8 774.4 |
10 147.6 |
1 503.6 |
1 045.5 |
25.96 per cent |
18.05 per cent |
Programme 3: Health Planning and Monitoring |
396.4 |
406.9 |
426.1 |
454.2 |
10.5 |
- 15.1 |
2.65 per cent |
-3.80 per cent |
Programme 4: Health Human Resources Management and Development |
1 799.0 |
1 897.1 |
2 011.7 |
2 111.8 |
98.1 |
- 21.0 |
5.45 per cent |
-1.17 per cent |
Programme 5: Health Services |
10 086.1 |
11 528.8 |
12 083.5 |
12 681.7 |
1 442.7 |
718.8 |
14.30 per cent |
7.13 per cent |
Programme 6: International Relations, Health Trade and Health Product
Regulation |
90.2 |
104.5 |
112.4 |
118.5 |
14.3 |
7.7 |
15.85 per cent |
8.58 per cent |
TOTAL |
18 423.4 |
21 497.0 |
23 708.0 |
25 844.7 |
3 073.6 |
1 723.7 |
16.68 per cent |
9.36 per cent |
The Department of Health receives a total budget
of R21.5 billion for the 2010/11 financial year compared to the R18.4 billion
received in 2009/10, which is 4.65 percent of the total national budget. This
represents an increase of 16.68 per cent in nominal terms, which is an increase
of 9.36 per cent in real terms. In terms of economic classification, 94.9
percent of the department’s budget goes to transfers and subsidies, while 4.9
per cent goes to current expenditure and 0.2 per cent goes to Payments for
Capital Assets.
The department carries out its mandate through
six programmes, namely, Administration, Strategic Health Programmes, Health
Planning and Monitoring, Health Human Resources Management and Development,
Health Services and International Relations, Health Trade, and Health Product
Regulation. Three of the programmes,
namely Health Services, Strategic Health Programmes, and International
Relations, Health Trade and Health Product Regulation received increases in
budget allocations, reflecting their importance as strategic priorities. As was the case in the 2009/10 financial
year, the Health Services Programme remains the key priority for the
Department, receiving 54 per cent of the department’s budget in 2010/11.
Government’s increased commitment to impacting
HIV/AIDS is evident in the 25.9 per cent nominal increase in Strategic Health
Programmes budget allocation. This translates to an 18.05 per cent increase in
real terms, most of which is spent through the HIV and AIDS and STIs
Sub-programme.
Departmental receipts for 2010/11 are projected
at R31.4 million derived mainly from fees for the registration of medicines by
the Medicines Control Council. This figure has decreased by 6.82 percent from
the R33.7million received in 2009/10.
3.5
Programme Analysis
Programme
1: Administration
The purpose of the Administration Programme is
overall management of the department and providing centralised support
services. This Programme is allocated
R264.8 million for 2010/11, which is 1.23 per cent of the department’s
budget. This represents a 4.4 per cent
nominal increase which is a 12.2 per cent decline in real terms, compared to
2009/10. Most of the budget is allocated to the Corporate Services Sub-programme,
which receives R181 million or 68.35 per cent of this programme’s budget. This
is down 2.65 per cent from the previous year’s budget allocation of R184.9
million.
The bulk of the allocation for this Programme is
consumed as current expenditure (97.3 per cent), which includes Goods and
Services, which amount to 55.1 per cent of the Programme budget, Compensation
of Employees at 42.18 percent of the Programme budget and Lease Payments, which
take up 17.78 per cent of the programme budget. In addition, 2.6 per cent of
the allocation will be spent as capital expenditure on Machinery and
Equipment.
Programme
2: Strategic Health Services
The Strategic Health Programme aims to
coordinate, manage and fund strategic national health programmes, including
developing policies, systems, norms and standards. The programme receives an increase of 26 per
cent, which is the largest increase across programmes in the Health Department.
This programme is the second largest programme of the Health budget and is
allocated 34 per cent (R7.3 billion) of the department’s overall budget.
Overall expenditure in this programme is dominated by transfers and subsidies
(93.7 per cent). These include:
·
Comprehensive HIV and AIDS
grant to provinces and municipalities: R6.0 billion
·
Forensic Pathology Services
grant to provinces and municipalities: R557.0 million
·
National Health Laboratory
Services: R77.7 million
·
MEDUNSA and
·
Council for the Blind: R600
000
·
HIV and AIDS: NGOs 65.1
million
·
Lifeline: R12.2 million
·
LoveLife: R77.4 million
·
Soul city: R17 million
·
South African AIDS Vaccine
Initiative: R11.7 million
·
Tuberculosis NGOs: R3.9
million
·
Maternal, Child and Women’s
Health NGO: 1.1 million
The HIV and AIDS and Sexually Transmitted
Infections (STIs) sub-programme received R6.5 billion the largest percentage
(89 per cent) of the programme allocation. This represents an increase of 33
per cent compared to the 2009/10 allocation. The allocation to this programme,
given the tough economic climate and the resulting fiscal pressure,
demonstrates Government’s renewed commitment to reduce the impact of HIV and
AIDS in
At first glance, it would seem that the 37.9 per
cent nominal increase, which represents a 29.24 per cent real increase in
funding for the TB Control and Management sub-programme, represents the
recognition by Government of the importance of treating TB, given the 70 per
cent co-infection rate amongst people living with HIV. However, most of the
allocation to this sub-programme is to fund a national TB prevalence survey to
be conducted in 2009/10 and 2010/11.
The allocation to the Communicable Diseases sub-programme
has increased substantially by 74.77 percent in nominal terms. In 2009/10, the
department indicated that the increase in this programme budget was due to the new health
disaster response (cholera) grant, which has been introduced to contain the
cholera outbreak in
The Maternal, Child and Women’s Health and
Nutrition sub-programme receives R57.3 million, representing a 23 per cent
nominal increase and a 15.49 per cent real increase. This is to implement the
Mass Immunisation against Measles Campaign from 2009/10 to 2011/12. This is a
timeous (some would argue it is perhaps just too late) programme, given the
deaths of at least 8 babies from measles early in 2010, and the resultant
establishment of special isolation wards, especially in the Western Cape and
Gauteng. This outbreak of measles also highlights the importance of providing
adequate health care to refugees and migrant workers in
The Non-Communicable Diseases sub-programme
increased in real terms from R636 million in 2009/10 to R665.4 million in
2010/11. This represents a nominal increase of 4.59 per cent and a decline of
1.98 per cent in real terms. The major part of this programme is the Forensic
Pathology Services Grant, which received an allocation of R557 million in
2010/11.
Programme
3: Health Planning and Monitoring
The aim of Health Planning and Monitoring
Programme is to plan and monitor health services and coordinate health research
programmes. The Programme is divided
into four sub-programmes and its allocation increased from R396.4 million in
2009/10 to R406.9 million in 2010/11. This represents a 2.6 per cent nominal
increase, in which is a real decrease of 3.8 per cent. 68.27 per cent of the
programme budget goes to transfer payments, while 31 per cent goes to current
expenditure.
The Health Information Research and Evaluation
Sub-programme, which receives 74.71 per cent of the programme allocation aims
to maintain health information systems, conduct research and training on
disease surveillance and outbreaks and monitors and evaluates health
programmes. The allocation for this sub-programme increased from R278.1 million
(2009/10) to R304 million (2010/11), which represents a real increase of only
2.45 per cent. Funding for the Medical Research Council is channelled through
this sub-programme (R270 million).
The Financial Planning and Health Economics
Sub-programme is responsible for conducting health economic research,
developing policy for medical schemes, social health insurance and public
private partnerships. It also oversees funds for the Council for Medical
Schemes. The budget allocation for this sub-programme decreased by 41.67 per
cent in nominal terms (45 per cent in real terms) from R62.4 million in 2009/10
to R36.4 million in 2010/11. This decrease in budget is because the 2009/10
budget contained R30 million which was used by provinces in preparation for the
2010 FIFA World Cup, mainly to procure medical equipment for stadiums and
Emergency Medical Services. Whilst one
would assume that this particular sub-programme would receive increased funds
in preparation for the proposed National Health Insurance (NHI) it receives
less funds going forward (R36.4 million in 2010/11, R 24.4 million in 2011/12,
and R25.3 million in 2012/13).
The Pharmaceutical Policy and Planning
Sub-programme aims to monitor the procurement and supply of drugs, and ensure
that there are no stock-outs of all essential drugs, especially paediatrics, TB
and antiretroviral (ARV) medicines in accredited sites. This sub-programme
received a nominal increase of 4.3 per cent, which represents a real decrease
of 2.51 per cent. The real decrease in this sub-programme might have serious
implications when viewed against the backdrop of stock-outs of ARVs in the
The Office of Standards Compliance Sub-programme
aims to deal with quality assurance, licensing and the certificates of need
required in terms of the National Health Act, No. 61 of 2003. It also deals with radiation control. This
sub-programme receives 12.56 per cent of the programme budget, which will be
used to inspect hospitals countrywide. Funding for this sub-programme will
increase at an average annual rate of 22.7 per cent over the medium term to
build up all aspects of the functioning of the Office of Standards Compliance.
Increasing from R41.1 million (2009/10) to R51.0 million (2010/11) the
sub-programme experienced nominal increase of 24.09 per cent, which is 16.3 per
cent in real terms. Over the MTEF, the sub-programme aims to increase the
number of hospitals audited.
Programme
4: Human Resource Management and Development
The Human Resources Management and Development
Programme aims to plan and coordinate human resources for the Department of
Health. This Programme receives R1.9
billion in 2010/11, 98.3 per cent of which will be spent through transfers and
subsidies.
The Human Resources Policy, Research and
Planning Sub-programme aims to plan for the medium to long term human resources
needs in the national health system, and received an allocation of R8.9 million
in 2010/11. This is a 57.87 per cent decrease compared to the 2009/10
allocation of R19.8 million. In the 2009/10 financial year, the sub-programme
received a large increase in expenditure in order to conduct an audit of
nursing colleges to inform the recapitalisation process for proposals on the
upgrading of colleges, equipment and teaching facilities.
The Sector Labour Relations and Planning
Sub-programme aims to provide the resources and expertise for bargaining in the
national Public Health and Social Development Sectoral Bargaining Council. It is allocated R3.5 million, 41.6 per cent
less than its 2009/10 allocation of R6.0 million.
By far the highest share of the Programme budget
goes to the Human Resources Development and Management Sub-programme, which
receives R1.9 billion, which is 99.35 percent of the programme budget. This sub-programme
is responsible for developing human resource policies, norms and standards, and
for the efficient management of employees of the national Department of
Health. It funds the Health Professions
Training and Development Conditional Grant, which is transferred to provinces,
to the amount of R1. 86 billion and represents 98.32 percent of the programme
budget.
Programme
5: Health Services
The Health Services programme aims to support
health services in provinces including hospitals, emergency medical services
and occupational health. This programme receives the largest share (53.6 per
cent) of the national Department of Health budget. Its objectives include.
·
Strengthening primary
health care through an audit of primary health care services and facilities in
all provinces by December 2010.
·
Expanding access to health
infrastructure by developing a plan to add 18 hospitals to the hospital
revitalisation project, to be delivered through public private partnerships.
·
Improve the delivery of
health services in the 18 priority districts through a detailed set of
interventions in maternal and child health and other areas by March 2012.
By far the largest portion of this programme’s
budget (99.24 per cent) goes to the Hospitals and Health Facilities Management
Sub-Programme. This Sub-programme is responsible for national policy on
hospitals and emergency medical services (
Over the MTEF period, the department will
continue to develop a comprehensive national infrastructure plan. One of the
key aspects of this plan is to collect information on the remaining facilities
that are not part of the hospital revitalisation and infrastructure grants that
need major upgrades and minor repairs. Another key aspect is that the health
facilities maintenance budget per health facility will be monitored in each
province and a strategy will be
developed to progressively increase the maintenance target to 3- 5 per cent of
capital value by March 2011.
The aim of the District Health Services
Sub-programme is to promote and coordinate the district health system, monitor
primary healthcare and activities related to the Integrated Sustainable Rural
Development Programme and the Urban Renewal Programme, as well as deal with
policy and monitoring for health promotion and environmental health. This
sub-programme received an increase of R4.4 million to total R34.7 million in
2010/11, which is a real increase of 7.33 per cent from the 2009/10 allocation.
The Environmental Health Promotion and Nutrition
Sub-programme aims to provide technical support and monitor the delivery of
municipal health services by local government, provide port health services and
support poison information centres. This
Sub-programme received a 6.32 per cent nominal increase (a real decrease of
-0.36 percent) from R19 million in 2009/10 to R20.2 million in 2010/11. The
sufficiency of this amount is debatable, given the extra burden the 2010 FIFA
World Cup poses with the thousands of tourists expected to enter the country’s
ports.
Programme
6: International Relations, Health Trade and Health Product Regulation
Programme
The International Relations, Health Trade and
Health Product Regulations Programme aims to coordinate bilateral and
multilateral international health relations, including donor support, regulate
procurement of medicines and pharmaceutical supplies, and regulation and
oversight of trade in health products. . The budget allocation for this
programme increased from R90.2 million in 2009/10 to R104.5 million in 2010/11,
which is a real increase of 8.5 per cent.
The purpose of Multilateral Relations
sub-programme is to:
·
Develop and implement
bilateral and multilateral agreements to strengthen the health system.
·
Conclude agreements on the
recruitment of health workers from other countries.
·
Provide technical capacity
to
·
Mobilise international
resources for priority health programmes.
The major portion of this Sub-programme’s budget
goes to paying membership fees to international agencies such as the World
Health Organisation (WHO) and for activities of health attachés. This
sub-programme received a 12.42 per cent nominal increase from R45.1 million in
2009/10 to R50.7 million in 2010/11.
The Food Control and Non-medical Health Product
Regulation Sub-programme aims to ensure food safety by developing and
implementing food control policies, norms and standards, and regulations. . Its
budget allocation increased from R6.5 million in 2009/10 to R 7.2 million in
2010/11, which represents a nominal increase of 10.77 per cent and a real
increase of 3.81 per cent.
The aim of the Pharmaceutical and Related
Product Regulation and Management Sub-programme is to regulate the trade in
medicines and pharmaceutical products through the Medicines Control Council
(MCC). Expenditure on this Sub-programme
is expected to grow by an average of 10.2 per cent over the MTEF to support the
new Medicines Regulatory Agency, develop Information Technology (IT) systems
and reduce backlogs. In 2010/11 the
department aims to:
·
Improve patient safety
through a pharmaco-vigilance plan for monitoring extreme resistant drug
tuberculosis (XDR-TB) medicines.
·
Improve the regulation of
medicines and health products through a functional electronic document
management system.
·
Improve medicine
registration timelines from 36 months for new chemical entities and 24 months
for generics to 24 to 18 months
·
Develop legislation in
2010/11 to establish the functioning of the South African Health Products
Regulatory Authority.
This sub-programme increased by R7.9 million
from the 2009/10 allocation to receive R46.6 million in 2010/11, a 20.4 per
cent nominal increase and a 12.8 percent real increase from 2009/10.
4. Analysis of Section 32 Expenditure Report
Introduction
In 2010/11, the Department was allocated R21.6 billion
which included the adjustment of R164.05 million made by the Department during
the period under review. Of this amount,
the Department spent R20.9 billion at the end of March 2011. This amounted to an under-expenditure of
R742.9 million. This was mainly due to
notable under-expenditure in Programme 2 and Programme 5 which amount to R645
million accounting for approximately 86% of the total under-expenditure.
Programme
1: Administration
The administration programme was allocated a total
budget of R264.8 million, adjusted to R282.1 million. At the end of the reporting period, the
Administration programme had spent R260.0 million, under-spending its budget by
7.75%. This was attributed to no funds
being spent on Service Sector Education and Training Authority.
Programme
2: Strategic Health Programmes
The Strategic Health Programme received R7.29 billion
which subsequently increased by R106 million to R7.4 billion during the
adjustment period. By the end of the
financia year 97.7% (R7.232 million) of budget allocation had been spent. The 2.3% under-expenditure was mainly due to
funds not being transferred to Love Life non-governmental organization (NGO)
and other NGO’s due to non-compliance with the Public Finance Management Act
(PFMA) (No.1 of 1999) regulations.
Programme
3: Health Planning and Monitoring
Programme 3 was allocated a total budget of R406.9
million in 2010/11 financial year before the adjustment period. During the adjustment period, an amount of
R7.7 million was added to its budget, totaling R414.6 million. At the end of the reporting period, the
Health Planning and Monitoring Programme had spent 94.38% of its budget. The reasons given for the under spending were
the late commencement of the project for the audit of health facilities in all
provinces due to a new approach of a comprehensive, integrated approach from a
central point, as well as delays in filling of critical posts.
Programme
4: Human Resource Management and Development
The budget for this programme totaled R1. 897 billion,
being adjusted by an additional R500 000.
The programme’s actual expenditure totaled R1. 883 billion (99.25%),
recording an under-expenditure of R14.6 million or 0.75%. The under-expenditure is related to
commitments made in March which will be paid in April for the next financial
year, as well as delays in the recruitment process for critical posts.
Programme
5: Health Services
The main appropriation of the Health Services
Programme (R11. 528 billion) was adjusted with an additional R28.3 million,
giving an available budget totaling R11.557 billion. R11. 072 billion (95.81%) of this amount was
spent by the end of the financial year, translating into a 4.19%(R485 million)
under-expenditure. The under-expenditure
was mainly due to hospital revitalization conditional grants being withheld for
certain provinces (the
Programme
6: International Relations, Health Trade and Health Product Regulation
During the period under review, the budget for the
Programme (R104.5 million) was increased by R4 million in the adjustment
process. At the end of the financial
year, the programme had spent 72.23% (R78. 378 million) of its R108.5 million
budget. The 27.77% under-expenditure was
mainly related to Goods and Services items and outstanding accounts to be
claimed from the Department of International Relations and Co-operation.
5.
Analysis of the Annual Report and Financial Statements of the Department
The strategic framework used to guide the
department is the 10 Point Plan for 2009-14, and the Negotiated Service
Delivery Agreement (NSDA) 2010- 2014, which was signed in October 2010. The
Department is responsible for Outcome 2: “A long and healthy life for all South
Africans.” Four outputs have been identified to achieve Outcome 2, viz.:
1. Increasing life expectancy.
2. Decreasing maternal and child mortality rates.
3. Combating HIV and AIDS and TB.
4. Strengthening health systems effectiveness.
These outputs are broadly in line with the
health-related United Nations (UN) Millennium Development Goals (MDGs) 4, 5 and
6 which seek to reduce child and maternal mortality and reduce the spread of
HIV and AIDS and TB.
Under-spending of Budget
The Department spent R20.9 billion of the adjusted appropriation budget
of R 21.6 billion, recording a 3.4% under expenditure of R 742 million. This
represents an increase of approximately 62% from the previous year’s under
expenditure of R457 million or 2.5%.
Under expenditure
Under expenditure occurred in several programmes. Two programmes account
for R645 million of the under expenditure. The most significant in terms
of actual variance was R484 million (up from R402 million or 4% in the previous
financial year), which was under-spent in Programme 5: Health Services due to
the withholding of Hospital Revitalisation Conditional Grant funds for some
provinces. This amount is 4.2% below the allocated funds of R11, 557
billion. The reasons forwarded for the under spending were delays in
construction and poor monitoring of projects, as well as delays in commencing
the national facilities audit.
The second amount is R160 million (2.2%) which was underspent in the
Strategic Health Programmes. The reasons given for the under spending were the
delayed finalisation of the condom tender by National Treasury, delayed
transfers to certain NGOs due to non-compliance with the Public Finance
Management Act, as well as late commitment for capital expenditure for Forensic
Chemistry Laboratories equipment.
Three of the six programmes recorded under spending of more than 7%,
namely Programme 1: Administration (7.8%), Programme 3: Health Planning and
Monitoring (7.4%) and Programme 6: International Relations, Health Trade and
Health Product Regulation (27.8%).
The Department of Health consists of six main
programmes that include various sub-programmes. These programmes will now be
reviewed.
5.2.1
Programme 1: Administration
The Administration programme aims to conduct
overall management of the department. The programme had an under expenditure of
7.8% (R21.8 million) of its budget of R282.1 million.
The Administration programme consists of the
following sub-programmes:
·
Strategic Planning.
·
Financial Services and
Deputy Chief Financial Officer (CFO).
·
Legal Services.
·
Communication.
·
Human Resource Management.
·
Information and
Communication Technology (ICT) Services.
·
Gender Focal Point.
The Strategic
Planning sub-programme achieved its target, amongst others, of producing an
Annual National Health Plan (ANHP), supporting all 9 provinces with the
development of their respective Annual Performance Plans (APPs). However, the
goal of producing 9 provincial and 1 national Service Transformation Plans
(STPs) for 2010- 2020, was not achieved (2 provincial and 1 national STPs are
outstanding). The production of STPs is important for the delivery of effective
healthcare services over the long term, and for shaping short- and medium- term
plans. Also, 3 of the 18 District Health Plans (DHPs) were not reviewed as
these were submitted late to the Department.
Whilst the Department in 2009/10 received an
unqualified audit opinion from the Auditor-General for the first time in seven
years, it was unable to repeat the achievement this year. Two of the 9
provinces (
Legal Services reports
a comprehensive review of health legislation as the reason for the Health Laws
Amendment Bill not being drafted.
The Communication
policy and five-year communication strategy has not been published to date. The
reason given was that these had to be aligned to the government policy produced
by Government Communication and Information Services (GCIS).
The ICT Services of
the department reports 30% downtime in July and August 2010 in network
availability and 40% downtime in accessing transversal systems, due to the
relocation of data lines to the
The Human Resources
Management reports that the revised organisational structure was approved by
the Minister and submitted to the Department of Public Service and
Administration (DPSA).
The Gender Focal
Point sub-programme did not produce the 4 quarterly gender audit reports, nor
the 9 provincial gender audit reports it aimed to achieve. However, interviews
with senior management and focus groups with officials were conducted.
The Strategic Health Programmes co-ordinates a
range of strategic national health programmes by developing policies and
systems, and by managing and funding key health programmes. These
sub-programmes relate directly to the health MDGs 4, 5, and 6 which address
child and maternal mortality and HIV and AIDS and Tuberculosis. Programme 2
consists of the following sub-programmes:
The programme achieved a 97.8% expenditure of its budget of R7,393
billion, with 2.2% under-expenditure. This under-expenditure, which amounts to
approximately R160 million, was largely attributed to the delayed finalisation
of the condom tender by National Treasury, delayed transfers to some NGOs due
to non-compliance with the PFMA and departmental priorities, as well as late
commitment of capital expenditure for Forensic Chemical Laboratories equipment.
Some of the significant achievements with regards to the maternal and
child health programmes, which relate to the child and maternal MDGs, include:
·
69.1% from a set target of
60% of HIV-exposed infants were initiated on Cotrimoxazole prophylaxis therapy
(CPT) from 6 weeks. CPT is important to reduce opportunistic infections.
·
More than 72.8% of children
were immunised, an increase of 12.8% from the set target of 60%.
·
Measles immunisation campaigns
were conducted in all 9 provinces.
·
72% (target 60%) of primary
health care facilities provided basic antenatal care (BANC).
·
79.4% (target 70%) of
pregnant women who are HIV positive were initiated on Highly Active
Antiretroviral Treatment (HAART).
However challenges were experienced in a number of areas, including:
The sub-programme: HIV and STI management encompasses government’s
response to the HIV and AIDS pandemic, and addresses its efforts to achieving
MDG 6. As noted above, significant changes to the government’s HIV and AIDS
policy, announced in the President’s National AIDS Day speech on the 1st
of December 2009, were implemented as from the 1st of April 2010.
The HIV Counselling and Testing (HCT) aimed to increase the number of people
testing for TB, diabetes hypertension and HIV and AIDS. At the end of the
financial year, 11.4 million people had been counselled with 9.7 million agreed
to be tested. Other significant achievements include:
·
42 756 community care
givers (target 36 106) received stipends- all programmes which have community
based projects and were funded from the Expanded Public Works Programme (EPWP)
and conditional grants were included.
·
99 % of TB/HIV co-infected
patients were provided with Cotrimoxazole prophylaxis therapy (CPT).
However, despite some improvements compared to the previous financial
year, a number of targets were not achieved:
The FIFA 2010 Strategic Plan for Communicable Disease Control was
implemented and achieved. Malaria incidence reduced to 0.66 per 1000 population
local incidence, but was 1.65 per 1000 population when so-called “imported”
cases were included. 90% coverage of indoor residual structure spraying (target
80%) was one of the key interventions against malaria.
Non-communicable diseases, including hypertension, diabetes and obesity
are part of the quadruple burden of diseases that confronts
TB control and management recorded a limited number of successes:
The following targets were not achieved:
The Health Planning and Monitoring Programme supports the delivery of
health services primarily in the provincial and local spheres. It consists of
the following four sub-programmes:
·
Health Information,
Epidemiology, Research and Evaluation.
·
Office of Standard
Compliance.
·
Health Financial Planning
and Economics.
·
Pharmaceutical Policy and
Planning.
This programme spent R391 million (92.6%) of its total budget of R422
million, with an under-expenditure of R31 million or 7.4%. The under expenditure
was related to vacancies due to recruitment processes which could not be
completed before the end of the financial year.
Health Information, research and evaluation experienced a number of
challenges:
The Office of Standards Compliance was not established and therefore
failed to meet a number of its targets. These include:
However, the Department did report that 60% (target 40%) of complaints
were resolved within 25 days.
The Health Financial Planning and Economics sub-programme reported
successes include:
The Pharmaceutical Policy and Planning sub-programme reported that
stock-outs of ARVs was at 2.6% on average, which was an improvement on the
<5% threshold targeted. However, the
stock-outs for TB medication averaged 5% (target <5%), with the
The Human Resources Management and Development
programme plans and co-ordinates human resources for the health sector. The
programme consists of the following sub-programmes:
·
Human Resources (HR) Policy
Research & Planning.
·
Human Resource Development
and Management.
·
Sector Labour Relations and
Planning.
The following challenges were experienced during
the period under review:
The Department reports a number of successes in
this programme, including:
The purpose of the Health Services programme is
to support the delivery of health services in provinces including primary
healthcare, hospitals, emergency medical services and occupational health. The
programme consists of the following sub-programmes:
District Health Services recorded a limited
number of successes which were concentrated in the area of implementing
appropriately decentralised and accountable operational management model. In
particular, these successes were:
·
Revised the Primary Health
Care (PHC) package.
·
Developed the PHC
multi-disciplinary team outreach strategy.
·
Developed the PHC service
delivery model.
However, a number of challenges were experienced
in this sub-programme:
·
PHC audit was not
conducted.
·
PHC utilisation: 2.4
(target 2.6) visits per person per capita to a PHC facility. This is also below
the 2.5 visits achieved in the previous year.
·
40 (target 52) districts
with a full complement of District Management Teams.
·
46 (target 52) districts
with district health plans (DHPs) received from provinces. This was due to one
province (
·
32 (target 52) district
health councils (DHCs) were established and are functioning.
·
68.4% (target 80%) of PHC
facilities were visited by a supervisor once a month. Some districts lack PHC
supervisors and/or vehicles.
In terms of the Hospital Services sub-programme,
a number of targets were not achieved:
·
A number of delays were
experienced with the revitalisation of hospitals.
·
Plans on preventative
maintenance were not implemented and “all provinces are far away from the set
target”.
·
None of the provinces
(target 3) implemented disaster management plans.
·
None of the provinces
(target 4) implemented a standardised data management system, due to the FIFA
2010 World Cup.
·
Only 1 out of 9 provinces’
health technology acquisition systems was analysed due to a lack of asset
management systems as well as insufficient data provided by hospitals.
·
55.5% (target 80%) of
hospital boards have been trained. The appointment of some of the hospital
boards was delayed and, therefore, training was postponed.
·
67% (target 100%) of
hospital CEOs have signed delegations of authority – some provinces, such as
This programme co-ordinates bilateral and
multilateral international health relation, including donor support and provide
oversight over health trade and the development of health products. This
programme consists of the following sub-programmes:
The Department achieved most of its targets in
the Multilateral Relations sub-programme including:
·
80 (target 80) South
African students recruited and retained in the SA-Cuba programme.
·
6 (target 2) cross border
initiatives facilitated to manage communicable disease along border areas.
·
6 (target 6) initiatives
were facilitated to strengthen health systems South African Development
Community? (SADC)
·
Signed and implemented 7
(target 7) agreements to mobilise financial and technical resources for the
implementation of the 10 Point Plan.
The Department was unable to achieve any of the
targets it set for the Pharmaceutical and Related Product Regulation and
Management sub-programme:
·
Average time for
registration of new chemical entities (NCE) was 32 months (target 24 months)
and 30 months (target 12 months) for generics.
Electronic document
management system (EDMS) could not be implemented due to the move to the
Civitas building.
During the period under review, the Department
had a total of 1 277 posts filled out of the 1 912 posts available on
its staff establishment and 95 posts filled, were additional to the
establishment. This translates to an average vacancy rate of 33.2% by the end
of the financial year. The highest vacancy rates were experienced in the
Contracts (levels 3-5) Permanent which had a vacancy rate of 68.5%. This was
followed by highly skilled supervision at 37.9% and highly skilled production
at 32.1%. It is noted that from Contract
(levels 6-8), Contract (levels 9- 12) and Contract (levels 13 -16) reported
only 1 vacancy at (Contract level 9-12). The Department is experiencing its
highest turnover rate in the Contract (levels 1 -2) 93.75 %, Contract (levels3
-4) 50%, and Contract (levels 6-8) 36.36%.
6.
Consideration of Reports of Committee on Public Accounts
The Department did not appear before the Committee on
Public Accounts for the period under review.
7. Consideration
of other Sources
7.1
The State of the Nation Address
The health sector was specifically highlighted in the
2011 State of the Nation Address as one of the four main priority areas of
government. In line with the President’s
directive that all government departments should align their programmes with
the job creation initiative and to ensure improved access to Human Resources
for Health, one of the most important focus areas for the Department of Health
will be the appointment of appropriate and qualified personnel to the right
positions.
The State of the Nation Address further emphasized the
training of doctors and nurses, as well as the revitalization of 105 nursing
colleges and refurbishment and renovations of hospitals and clinics. This is important in order to achieve the
Department’s priority of improving patient care and satisfaction and improve
the quality of health facilities.
7.2
Report of the Auditor-General of
The Auditor-General having considered different
sources of information on the Health Sector made the following findings:
Findings
from audit of human resource management
Findings
on supply chain management/procurement
Findings
on the audit of infrastructure
Findings
on Financial Statements
7.2.1
Comments from the National Department of Health
The
following remedial action has been put in place and is underway to address the
challenges related to the management and planning for health infrastructure:
7.3
Report of the Financial and Fiscal Commission (FFC)
ü Movable tangible capital assets
The asset register used to
account for assets was not properly maintained.
ü Matters of emphasis
Irregular expenditure to
the amount of R43.3 million was incurred due to non-compliance with the supply
chain management procedures.
ü Conditional Grants
The Transferring Officer
did not adequately monitor expenditure and non-financial performance
information as required by the DORA.
7.3.1 Provincial Health Expenditure outcomes
7.3.2 Health Conditional Grants Expenditure Outcomes
·
Provinces are struggling to spend on Forensic
Pathology Services and Hospital Revitalisation grants.
·
Only the Health Professions Training and
Development Grant and National Treasury are spending at 41%.
·
HIV and AIDS, infrastructure and Revitalisation
Grants reported slow expenditure.
7.3.3 FFC Recommendations
·
The government must develop norms and standards
for the public hospital system.
·
The government must develop norms and standards
that should address issues in relation to the public health system.
7.4
Fact-finding visit
The following findings are drawn from most of the
health institutions the Committee visited:
The United Nations (UN) Millennium Development Goals (MDGs) are a series
of eight time-bound goals with a target of 2015 that respond to the world’s
main development challenges. The three goals relevant to the Department aim to:
(4) reduce child mortality, (5) improve maternal health, and (6) combat HIV and
AIDS, malaria and other diseases. The Department of Health plays a critical
role in achieving these MDGs.
The “Under-5
Mortality Rate” (U5MR) refers to the chance of a newborn baby dying before the
age of five, and is represented out of every 1000 live births. In 2008, 69 out
of every 1000 newborn babies died in
Infant Mortality is defined as the probability of a
child born in a particular year dying before reaching the age of one year. The infant mortality rate has declined from 54
death per 1 000 live births in 2001, to 53 in 2007.
The maternal
mortality ratio is defined as the number of women who die as a result of
childbearing, during pregnancy or within 6 weeks of delivery or termination of
pregnancy in one year.
The proportion
of births attended by skilled health personnel is defined as the percentage of
women whose live birth occurred in a health facility. This figure has increased
from 76.6% in 2001, to 94.3% in 2009. Therefore, achieving the target of
approximately 100% births attended by skilled health personnel by 2015, is
regarded as possible.
The antenatal
care coverage refers to the between one and four visits to a health facility
during pregnancy. In 2001, the antenatal care coverage was calculated at 76.6%
against a target of 100%. This number has significantly increased since, and it
is reported that in 2009
The use of
modern contraceptive methods by sexually active women increased from 61.2% in
1998, to 64.6% in 2003. which is below the 70% target set. Achieving this
target is deemed unlikely. No data and no target were reported by
It is suggested
that non-pregnancy related infections, mainly HIV and AIDS, Tuberculosis (TB)
and pneumonia accounts for 38% of all maternal deaths in
The HIV
prevalence rate amongst persons 2 years and older has
not changed significantly since 2002, suggesting that the epidemic may be stabilising in
Research indicates that condom use is lowest in
stable relationships (married or persons living together) and highest among
persons with less stable relationships. About 74-83% of men and 56-66% of women
reported condom use at their last high-risk sexual encounter. On average,
condom use at last high-risk sexual encounter is about 62.4%, compared to 100%
target set for 2015. Based on current
statistics, it is unlikely that
Awareness and knowledge of HIV prevention methods
are generally high, with an 87% on average knowledge level for condoms across
all age groups. However, knowledge on prevention methods such as faithfulness,
partner reduction and abstinence is lower (thought it had increased significantly
since 2006).
The proportion of the population with advanced HIV
infection with access to antiretroviral drugs increased significantly from
13.9% in 2005 to 41.6% in 2009. However,
The ratio of school attendance of orphans to school
attendance of non-orphans aged 10-14 years is almost 1:1. This suggests that
school attendance of orphaned children is on par with non-orphaned children.
Malaria is not endemic in
9.
Prior BRRR’s Recommendations that were made by the Committee and were not
implemented by the Department
Programme
1
Programme
2
Programme
3
Programme
4
Programme
5
10. Committee’s Observations
11.
Committee’s observations on Programme by Programme
Programme
1
Programme
2
Programme
3
Programme 4
Programme
5
Programme
6
12.
Conclusion
The Department of Health received a qualified opinion.
The overall performance of the Department in the reporting year has been
unsatisfactory in most programmes.
The Department experienced financially driven
challenges during this period of reporting, especially in the delay of some
projects. It also continues to face challenges in terms of under spending especially
on the hospital revitalisation programme. However, a notable success is the
Department’s implementation of the HCT campaign in which over 11 million people
were counselled and over 9.7 million people have been tested for HIV and AIDS.
In addition the PMTCT programme continues to be run successfully.
In addressing some of the challenges that were raised
in the Auditor-General’s report, the Department is going to conduct a workshop
with the AG on the 26 October 2011.
The Committee, however, was impressed with the Kopano
MDR unit and the MDR unit at the Dr J.S Moroka Hospital in the
The Committee adopted the BRR Report without getting
outstanding responses to the questions that were raised by the Committee from
the Department.
13.
Recommendations
Report to be considered