The Budgetary Review and
Recommendations Report of the Portfolio Committee on Health on the performance of the Department of Health
for the 2011/12 financial year, dated
24 October 2012
1. Introduction
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 over 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 2011/12, the Committee consulted
the following reports and/or documents:
1.2.
The Department
of Health (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, through the promotion of healthy lifestyles,
and to consistently improve the health care delivery system by focusing on
access, equity, efficiency, quality and sustainability.
Government adopted
an outcome-based approach to service delivery and the health sector is
responsible for the achievement of outcome two which is a long and healthy life
for all South Africans. The Department has therefore identified four outputs as
follows:
Diseases from tuberculosis; and
In Strengthening
the Health System Effectiveness, the Department focuses on the following
inputs:
8.
Inter-sectoral action for social determinants of
Health
2. Department’s Strategic Priorities and Measurable
Objectives
2.1.
Strategic Plan
of the Department - Ten Point Plan
The Health
sector’s 10 Point Plan for 2009-2014 serves as an important overarching and
macro framework for overhauling the health system, to enhance its capacity to
improve health outcomes, and to harness focused interventions towards the
Millennium Development Goals.
The priorities
comprising the 10 Point Plan are as follows:
·
Provision of strategic leadership and creation of
social compact for better health outcomes;
·
Implementation of the National Health Insurance
(NHI);
·
Improving the quality of health services;
·
Overhauling the healthcare system and improving its
management;
·
Improved human resources planning development and
management;
·
Revitalization of infrastructure;
·
Accelerated implementation of HIV and AIDS, STI and
TB strategic plan;
·
Mass mobilization for better health for the
population;
·
Review the Drug Policy; and
·
Strengthening Research and Development.
2.2.
Measurable
Objectives of the Department
The measurable
objectives and outcomes of the Department are outlined in accordance with its
six programmes. They summarise what the Department intends to achieve in each
programme in order to achieve its overall health care service delivery mandate.
These programmes are as follows:
2.2.1.
Programme 1:
Administration
The aim of
this programme is the overall management of the Department and centralised
support services. In the 2011/12 financial year, the Department’s main goal was
to ensure that it obtains an unqualified audit opinion. Consequently, the
Department of Health received an unqualified audit opinion from the Auditor-General
of
Measurable Objectives
2.2.2.
Programme 2:
Health Planning and Systems Enablement
The objective of
this programme is to improve access and quality of health services through
planning, integration of health systems, reporting, monitoring, evaluation and
research. The allocated budget for the Health Planning and Systems Enablement
programme is R161 million for 2011/2012.
Measurable Objectives
·
Analyse and provide feedback on nine Provincial
Annual Performance Plans.
2.2.3.
Programme 3: HIV
& AIDS, TB and Maternal, Child and Women’s Health
The objective of
this programme is to coordinate, manage and fund HIV and AIDS, Tuberculosis (TB)
and maternal, child and women’s health programmes. Develop and oversee implementation of
policies, systems and norms and standards.
The allocated budget for the HIV & AIDS, TB and Maternal, Child and
Women’s Health programme was R8, 027 million for 2011/2012.
Measurable Objectives
2.2.4.
Programme 4:
Primary Health Care Services (PHC)
The objective of this programme is to develop and implement a uniform
District Heath System. The programme
also develops a policy for district health services (PHC and district
hospitals), identifies and promotes centres of excellence and supports
planning, delivers and monitors these services. The allocated budget for this programme
was R730 million for 2011/2012.
Measurable Objectives
2.2.5.
Programme 5:
Hospitals, Tertiary Services and Workforce Development
The purpose of
this programme is to develop policies, delivery models and clinical protocols
for hospital and emergency medical services.
The programme also ensures that Academic Medical Centres (AMCs) and
health workforce development programmes are aligned. The allocated budget for the Hospital
Tertiary Services and Workforce Development programme was R15, 963 million for
2011/2012.
Measurable Objectives
·
Improve Health Workforce planning, management and
development.
2.2.6.
Programme 6:
Health Regulation and Compliance Management
The purpose of
this programme is to regulate procurement of medicines and pharmaceutical
supplies, including trade in health products and to promote accountability and
compliance by regulatory bodies for effective governance and quality of health
care. The allocated budget for Regulations and Compliance Management programme was
R525 million for 2011/2012.
Measurable Objectives
3. Analysis of the Department’s Prevailing Strategic
and Operational Plan
3.1.
Introduction
The aim of the
Department of Health is to provide leadership and coordination of health services
to promote the health of all people in
The Department
is in the process of restructuring in order to align itself to the Minister of
Health’s 10-Point Plan for improving health outcomes in South Africa. This
change is evident in the restructuring of the Department’s entire budget as new
programmes are created and other programmes reprioritised. The six programmes
in the new structure are: administration; health planning and system
enablement; HIV and AIDS, TB and maternal, child and women’s health; primary
health care services; hospitals, tertiary services and workforce development.
It is important to note that the changes in the Department’s programmes will
impact on the Committee’s ability to track progress on expenditure on last
year’s budget and service delivery performance.
There are some
important changes to be aware of within the health budget during this financial
year (2011/12). These include: the introduction of a family health approach to
primary health care and the establishment of the Office of Standards Compliance
in the 2011/12 financial year.
3.2.
Policy
Priorities for 2011/12
The health
sector was specifically highlighted in the 2011 SONA as one of the five main priority areas of government, which
include creating decent work, education, health, rural development and agrarian
reform and fighting crime. In line with the President’s directive that all
government departments align their programmes with the job creation initiative
and ensure improved access to Human Resources for Health, one of the most
important focus areas for the Department was the appointment of appropriate and
qualified personnel to the right positions.
The 2011 SONA further
emphasised the training of doctors and nurses, as well as the revitalisation 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.
These and other national
priorities such as women’s health (including programmes related to reproductive
health rights and services related to contraception, sexually transmitted
infections (STI), teenage pregnancy and provision of sanitary towels (for the
indigent), and Human Immunodeficiency Virus and Acquired Immune Deficiency
Syndrome (HIV and AIDS) programmes should also be prioritised by the Department
and reflected in the budget.
Below are the
priorities that are in line with the strategic objectives of the Department,
which are:
·
HIV and AIDS and Tuberculosis (TB), with emphasis
on prevention.
·
Improved Primary Health Care and Public Health
Facilities – the re-engineered primary health care system aims to improve
health outcomes and to assist in achieving the National Health Insurance (NHI),
which is an important priority of the department.
·
A more efficient health sector with respect to
financial management, ICT solutions, improving the health sector’s monitoring
and evaluation capacity, and improving the quality and integrity of data on
health indicators.
·
Ensuring that the Department adopts an
outcomes-based approach for service delivery and performance management.
Furthermore, the
2011 budget also emphasised the need to ensure that the Department’s priorities
are aligned to the Millennium Development Goals (MDGs).
3.3.
Performance and
Service Delivery Information
Ten of the
twelve selected performance indicators differ from the indicators that were
reported on in the previous financial year (2010/11). Therefore, only two
performance indicators can be assessed, which are Tuberculosis Cure Rate and
Tuberculosis treatment defaulter rate.
3.4.
Budget Analysis
The Department
received R25.7 billion, which is 5 per cent of the total appropriation to all
budget votes in the 2011/12 financial year. The Department, therefore, received
a higher percentage of the national budget than the previous financial year,
when it received 4.65 percent of the budget. The total budget has also
increased in both nominal (11.24 per cent) and real (6.14 per cent) terms. The
bulk of the budget, about 93 per cent, was transferred to provinces and
municipalities for HIV and AIDS, TB and Maternal, Child and Women’s Health and
the Hospitals, Tertiary Services and Workforce Development Programmes.
Current payments
constituted a total value of R1.2 billion, which represented 4.7 per cent of
the total budget allocation. Most of the expenditure was allocated to Goods and
Services, taking up 64.9 per cent of the total current payments. Expenditure
items that received the largest share of the goods and services budget were
Medical supplies at R150.8 million, consultants and professional services at
R116.2 million and Travel and Subsistence at R114.4 million.
All capital
payments amounting to R32.9 million were allocated to Machinery and Equipment
in the 2011/12 financial year.
The following
additional allocations had been made in the 2011/12 financial year:
·
R60 million for the HIV and AIDS conditional grant
for the rapidly growing treatment programme and to strengthen prevention
programmes, including R60 million per year for male circumcision.
·
R250 million for the national tertiary services
conditional grant to support public hospitals to achieve norms and standards
(partly in preparation for the NHI) and to implement standards and guidelines
of the Office of Standards Compliance and Quality Assurance, as well as to
address differential costs of occupation specific dispensation for doctors.
·
R10 million to forensic chemistry laboratories to
purchase equipment and provide capacity to address backlogs.
·
A once-off payment of R10 million to the South
African Health Products and Regulatory Authority to establish itself and to
deal with the medicine registration backlogs.
·
R10 million to the Office of Standards Compliance
and Quality Assurance to establish itself and to support its inspectorate,
certificate of compliance and ombudsman functions.
·
R30 million to progressively increase the
distribution of condoms.
·
R21 million for infrastructure management and
private public partnerships to build capacity in the Department to oversee the
hospital revitalisation projects, and to support planning and transaction
advisor costs for large private public partnership projects.
·
R5 million for health technology to support
provincial upgrading of engineering workshops and equipment audits and to
develop equipment packages and systems for health technology.
·
R5 million for the NHI to support development work
and projects, including the Ministerial Advisory Committee.
·
R4 million to develop improved hospital tariff
schedules for use by provinces and the Road Accident Fund, including an
improved uniform patient fee structure, Road Accident Fund reimbursements and
tariff structure, and developing a diagnosis related groups system.
·
R9 million to nursing colleges to plan and
coordinate the second phase of upgrading, recapitalising and maintaining
nursing colleges following the infrastructure audit.
·
R5 million for health information systems to
support national workgroup investigations of new patient based IT systems and
to propose next steps in IT infrastructure to support the district health
information system.
·
R3 million for the Health Systems Trust to support
health systems research activities, including the annual health review and
district health barometer.
·
R2 million to publish standardised annual health
statistics in the new annual health statistics publication to facilitate
performance auditing and better inform the public and health service providers.
·
R5 million for the Compensation Commissioner for
Occupational Diseases (CCOD) to address backlogs in compensation, improve
systems and address problems identified in audit reports.
·
R2 million to monitor and support provinces to
stabilise provincial finances and improve audit outcomes.
·
R1.7 billion towards a new infrastructure grant to
provinces.
·
R4.1 billion for the Hospital Revitalisation Grant.
The Department had started with the planning and design phase of five flagship
private public partnership (PPPs): Chris Hani Baragwanath, Garankuwa, King
Edward VII, Polokwane and Eastern Cape academic complex.
4. Programme Analysis
4.1.
Programme 1:
Administration
In the period
under review, the budget for this programme had increased by 15.6 per cent in
nominal terms and 8.32 per cent in real terms due to the significant increases
in the Management and Financial Management sub-programmes. These sub-programmes
increased by 41.05 per cent and 48.16 per cent in real terms respectively in
the financial year under review. The Corporate Services sub-programme receives
47.9 per cent of the programme budget and was the only programme that decreased
slightly in real terms by 1.16 per cent, while Office Accommodation received
16.9 per cent of the Programme budget. A new sub-programme was the Financial
Management sub-programme, which received the third highest portion of the
budget at 13.9 per cent.
In terms economic
classification, 97.5 per cent of the budget was allocated to current payments.
The highest expenditure items under current payments were Compensation of
Employees at 37.1 per cent; lease payments at 17.3 per cent; 7.6 per cent on
external audit costs and 7.5 per cent on Travel and Subsistence.
4.2.
Programme 2:
Health Planning and Systems Enablement
The budget for
this programme increased by 13.25 per cent in real terms from the 2010/11
financial year, mainly due to the budget increase of the NHI sub-programme. The
NHI, however, still received the lowest portion of the budget at 4.9 per cent
to develop and implement policies, legislation and frameworks for expansion of
health insurance to the broader population, amongst other things. The highest
portion of this programme’s budget was allocated to the International Relations
sub-programme, which was responsible for developing and implementing bilateral
and multilateral agreements to strengthen the health systems. The Financial
Planning and Health Economics sub-programme’s budget was reduced by 41.74 per
cent in real terms from the 2010/11 financial year.
This Programme included the following six sub-programmes:
4.3.
Programme 3: HIV
and AIDS, TB and Maternal, Child and Women’s Health
The budget for
the programme also aimed to develop and oversee the implementation of policies,
systems, norms and standards. This programme contained two sub-programmes from
the programme that was previously named Strategic Health Programmes (Programme
2) in 2010/11, and still received the second largest allocation (that is R8.0
billion or 31.2 per cent) of the budget vote. Of the R8 billion, a total of
R7.97 billion (or 99.4 per cent) of that budget was allocated to the HIV and AIDS
and TB sub programme; and the remaining allocation went to the Maternal, Child
and Women’s Health sub-programme (R51.7 million). In terms of economic
classification, most of the allocation, about 98 per cent, was transferred to
provinces.
In 2010/11 voluntary
counselling and testing (VCT), and the prevention of mother to child
transmission of HIV (PMTCT) services were provided in more than 95 per cent of
health facilities at a cost of R 122.6 million.
Payments were
allocated a total of R357.6 million. The highest expenditure items of current
payments were compensation of employees at 15.9 per cent, advertising costs at
17.3 per cent and Inventory: Medical Supplies at 41.9 per cent.
4.4.
Programme 4:
Primary Health Care Services
The programme
was comprised of four sub-programmes, two of which were part of Programme 2
(Strategic Health Programmes) and two from Programme 5 (Health Services) in
2010/11. The bulk of the programme
budget, which was 91.7 per cent or R 669.5 million, went to the Non-communicable
Diseases sub-programme. That sub-programme, amongst others, assisted provinces
in implementing and monitoring chronic diseases, disability, elderly people
oral health, mental health and substance abuse.
In terms of
economic classification, 80.82 per cent of the budget was transferred to
provinces and municipalities. The highest expenditure items of the expenditure
were compensation of employees at 47.3 per cent, consultants and professional
services at 10.6 per cent, and Travel and Subsistence at 11 per cent.
Although the
programme budget increased by 2.5 per cent in nominal terms, that translated
into a decrease of 2.15 per cent in real terms. That was due to the large
decreases in the budgets of the Districts Health Services (51.57 per cent real
decrease) and Communicable Diseases (18.50 per cent real decrease)
sub-programmes.
4.5.
Programme 5:
Hospitals, Tertiary Services and Workforce Development
The programme
received 62 per cent of the total health budget (R15 962.7 million), most of
which was transferred to provinces and municipalities through the National
Tertiary Services Management and Health Facilities Infrastructure Management
sub programmes which received 50.4 per cent and 36.8 per cent respectively.
Transfer payments consumed 99.4 per cent of the total budget. In terms of
current expenditure, the highest allocations were made to compensation of
employees at 37.5 per cent; consultants and professional services at 34.0 per
cent, property payment at 11.2 per cent and outsourced services at 6.5 per
cent.
All the
sub-programmes within the programme increased in both nominal and real terms,
resulting in a nominal increase of 7.7 per cent and real increase of 2.72 per
cent in the programme budget. The Hospital Management sub-programme, which dealt
with national policy on hospital and emergency medical services, reflected the
highest increase of 28.96 per cent in real terms from the 2010/11 financial
year.
4.6.
Programme 6:
Health Regulation and Compliance Management
The budget for
the programme budget had increased by 1 per cent in real terms, as the budget
allocations of four of the six sub-programmes had increased both in nominal and
real terms. Most of the funds in the programme were allocated to the Public
Entities Management sub-programme, which received 69.5 per cent of the budget.
69.7 per cent of the budget would be transferred to departmental agencies and
accounts and non-profit institutions. The highest spending items under current
payments were compensation of employees at 52.4 per cent, consultants and
professional services at 20.6 per cent; and Travel and Subsistence at 8.6 per
cent.
The programme
consisted of six sub-programmes, three of which were in the Human Resources
Management and Development Programme in the 2010/11 financial year. Those were
the Human Resources Policy Research and Planning; Sector Relations and
Planning; and Health Human Resources and Workforce Management, and Development
Programmes. The Hospital Management, Health Facilities Infrastructure
Management and National Tertiary Services Management sub-programmes were
previously located in the Health Management Programme (Programme 5) in 2010/11.
The Health Facilities Infrastructure Management and National Tertiary Services
Management sub-programmes still consumed the largest portion of the
department’s budget at 54.1 per cent.
5. Analysis of Section 32 Expenditure Report
5.1.
Introduction
In 2011/12
financial year, the Department was allocated R25 967 971 billion. Of
the amount, the Department spent R25 712 842 billion, which was
99.25% of the available budget. That amounted to an under-expenditure of R255 129
million, which was 0.75%. The under-expenditure was a significant decrease
compared to the previous financial year. The under-expenditure was largely attributed
to under-expenditure in all the programmes of the Department.
Programme 1: Administration
The programme
showed expenditure of 95.3%, with under-expenditure of R15 958 million (4.7%)
against a budget of R342 941 million. The under-expenditure on goods and
services was related to the allocated funds for health statistics publications,
the provincial support unit and the hospital tariffs system review, which could
not be fully used. The 4.7% under-spending on capital could be ascribed to the
suppliers not being able to deliver the ordered Information Technology (IT)
equipment before year end.
Programme 2: Health Planning and System Enablement
The programme
showed expenditure amounting to 91.3% with under-expenditure of R15 359 million
(2%) against a budget of R177 313 million. The under-expenditure was attributed
to slow spending on the NHI funding received, as the legislative processes
delayed the consultation processes. The Technical Policy and Planning Unit were
inactive, as the panel of technical experts was only finalised towards the end
of the financial year.
Programme 3: HIV and AIDS, TB and Maternal, Child,
and Women’s Health
From a total
allocation of R8 014 742 billion, the programme had spent 98.9% of its
allocated funds, amounting to R7 927 131 billion, with under-expenditure of R87
611 million. The under-expenditure could be ascribed to the late finalisation
of the national condom tender awarded by National Treasury and failure to
appoint a communication consultant for HIV and AIDS.
Programme 4: Primary Health Care Services
The total
allocation for the programme amounted to R761 703 million. The programme showed
an expenditure outcome of R741 483 million, which was 97.3%, with
under-expenditure of R20 220 million. The under-expenditure was related to the
late delivery of influenza vaccines.
Programme 5: Hospital, Tertiary Services and
Workforce Development
The programme
had spent 99.4% of its R16 149 471 billion allocated funds, amounting to R16
057 420 billion, resulted in under-expenditure of R92 051 million. The
under-expenditure was mainly attributed to the Infrastructure Unit Support
System not being invoiced by the supplier before year end and the slow start of
the nursing college’s project.
Programme 6: Health Regulation and Compliance
Management
The programme
had spent 95.4% of its R521 801 million allocated funds, amounting to R497 871
million, with under-expenditure of R23 930 million. The under-spending could be
attributed to delays in the implementation of planned activities in the Office
of Standards Compliance.
6.
Analysis of the
Annual Report and Financial Statements of the Department
This section of
the report focuses on the analysis of the annual report and financial
statements of the Department in the 2011/12 financial year.
6.1.
Department’s Key
Strategic Objectives
The South
African government adopted an outcome-based approach to service delivery. The
health sector is responsible for the achievement of outcome 2, which is a “Long and Healthy Life for all South
Africans”.
In order for the
health sector to contribute towards achieving a long and healthy life for all
South Africans, the Minister Dr. Aaron Motsoaledi, has committed to the
following Negotiated Service Delivery Agreement (NSDA) 2010-2014 outputs:
(a)
Increased life expectancy;
(b)
Reduction in maternal and child mortality rates;
(c)
Combating Human Immunodeficiency Virus (HIV) and
Acquired Immune Deficiency Syndrome (AIDS) and decreasing the burden of disease
from Tuberculosis (TB); and
(d)
Strengthening health system effectiveness.
The above
mentioned four outputs are aligned to the priorities outlined in the Department’s
10 point plan, as well as the health-related Millennium Development Goals
(MDGs).
6.2.
Programme
Performance by Budget Programme
During the period under review, the Department
received R25 967 971 billion, of which the Department spent
R25 712 842 billion, which was 99.25% of the available budget. The
Department under-spent a total amount of R255 129 million, resulting in
under-expenditure of 0.75%. That showed an improvement compared to 3.4%
under-expenditure during 2010/11 financial year.
The activities of the Department were organised
in six programmes. Those were as follows:
6.2.1.
Programme 1:
Administration
This programme
shows expenditure of 95.3%, with under-expenditure of R15 958 million (4.7%)
against a budget of R342 941 million. The under-expenditure on goods and
services is related to the allocated funds for health statistics publications,
the provincial support unit and the hospital tariffs system review, which could
not be fully used. The 4.7% under-spending on capital can be ascribed to the
suppliers not being able to deliver the ordered Information Technology (IT)
equipment before year end.
The
programme consisted of the following five sub-programmes:
·
Ministry;
·
Management;
·
Financial Management;
·
Corporate services; and
·
Office administration.
In 2010/11
financial year, the Department of Health received a qualified audit opinion
from Auditor-General of South Africa (AGSA) which was an indication of
financial mismanagement. However, the Department of Health received an
unqualified audit opinion from the AGSA for the 2011/12 financial year.
Therefore, the Department managed to achieve its set target for “ensuring
effective financial management and accountability” for 2011/12. That was
attributed to the establishment of an asset management plan during the period
under review. Furthermore, the Department reported that it implemented an asset
management plan in three provincial departments; Eastern Cape, KwaZulu-Natal
and Mpumalanga. It also reported that it funded the Northern Cape to implement
its own asset management project.
However, out
of the nine provincial health departments, six provinces received qualified
audit opinions for 2011/12 financial year and two received disclaimers (Limpopo
and Northern Cape). Only one province received an unqualified audit opinion
(Western Cape) during 2011/12. In 2010/11 financial year, 7 out of 9 provincial
departments received qualified audit opinions (Free State, Mpumalanga, Gauteng,
Northern Cape, KZN, EC and Limpopo), whereas only two received unqualified
audit opinion (Western Cape and North West). According to AGSA report, the
reasons for unqualified audit opinion were based mainly on asset register,
irregular expenditure, accruals, revenue management and contingent liabilities.
6.2.2.
Programme 2:
Health Planning and System Enablement
The programme
showed expenditure amounting to 91.3% with under-expenditure of R15 359 million
(2%) against a budget of R177 313 million. The under-expenditure was attributed
to slow spending on the NHI funding received, as the legislative processes
delayed the consultation processes. The Technical Policy and Planning Unit were
inactive, as the panel of technical experts was only finalised towards the end
of the financial year.
6.2.2.1. Technical Policy and Planning
In terms of
Annual Performance Plans (APPs), 7 out of the set target of 9 provincial APPs
were analysed and feedback was provided to provinces (Eastern Cape, Free State,
KwaZulu-Natal, Limpopo, Mpumalanga, Northern Cape and Northern Cape). The
Department reported that due to capacity constraints two APPs of Gauteng and
Western Cape were not analysed.
6.2.2.2. Health Information Management,
Monitoring and Evaluation
In terms of
the monitoring and evaluation, a monitoring and evaluation plan for NSDA was
produced in March 2011 and that was done with technical support from an
external service provider. Thus, the plan was accepted by the Health Data
Advisory and Co-ordination Committee (HDACC) of the Department of Health. The
department established a new sub-committee of HDACC, which would focus on the
performance and effectiveness of the health system.
Other
related monitoring and evaluation achievement were made in the following areas:
·
A monitoring and evaluation
framework for the National Strategic Plan for HIV and AIDS and TB 2012-2016 was
produced;
·
Targets for the outcome and impact
indicators of the Global Fund Rounds were revised in alignment with NSP
2012-2016.
·
Progress made with the
implementation of a three-tiered monitoring and evaluation subsystem for
Antiretroviral (ART). By the end of 2011/12 there were 582
6.2.2.3. National Health Insurance
The aim of
this sub-programme is to ensure that all South Africans citizens and residents,
irrespective of their socio-economic status, have access to good quality health
services provided by both the public and private sectors. The ultimate goal for
the NHI is to eradicate financial barriers limiting access to health care.
Some of the
achievements made during that period under review included the following:
·
The Department released the Green
Paper on NHI in 12 August 2012 for public comment;
·
The Department evaluated and
reviewed written inputs;
·
Ten pilot district selected in
February 2012 (OR Tambo (EC), Thabo Mofutsanyane (FS), City of Tshwane (GP),
UMgungundlovu (KZN), UMzinyathi (KZN), Vhembe (Limpopo), Gert Sibande
(Mpumalanga) Dr. KK Kaunda (NW), Pixley Ka Seme (NC), and Eden (WC);
·
The NHI Conditional Grant of R1
billion over the MTEF period 2011/12-2012/13/14 was established.
6.2.2.4. International Relations
The aim of
this sub-programme is to provide stewardship and leadership for improving
health outcomes through working with international development partners,
Southern African Development Community (SADC) and African Union (AU).
The set
target for 2011/12 was to facilitate three cross-border initiatives. According
to the Department, that target was exceeded, as numerous initiatives were
implemented. These include:
·
The SADC HIV and AIDS Cross-Border
Initiative in Zeerust, Ladybrand, Ficksburg and Oshoek border areas;
·
The
Lubombo Spatial Development Initiative (LSDI) for a malaria control
cross-border project in selected sites in South Africa, Mozambique and
Swaziland and MOZIZA cross-border malaria initiative;
·
Facilitated
a technical working group meeting on TB in mines to discuss background
information on issues relevant to TB in mines, with specific focus on migrants
and development of road map on 12 December 2011 and 5 to 8 March 2012. Those
meetings resulted in the Development of the draft SADC Declaration on TB in the
Mines and the draft SADC Code on TB in the Mines.
In addition to the above, during 2011/12 financial
year, the Department also participated in several forums in the SADC region,
continent and globally, with the view to enhancing international collaboration
to improve South African health outcome. Those could be found on page 49 of the
Department’s Annual Report for 2011/12.
6.2.3. Programme 3: HIV and AIDS, TB
and Maternal, Child, and Women’s Health
The aim of
this programme is to coordinate, manage and fund HIV and AIDS, TB and maternal,
child and women’s health programmes.
From a total
allocation of R8 014 742 billion, the programme had spent 98.9% of its
allocated funds, amounting to R7 927 131 billion, with under-expenditure of R87
611 million. The under-expenditure could be ascribed to the late finalisation
of the national condom tender awarded by National Treasury and failure to
appoint a communication consultant for HIV and AIDS.
The
programme consisted of three sub-programmes that relate directly to MDGs 4, 5
and 6. These sub-programmes included the following:
6.2.3.1. HIV and AIDS and STIs
In terms of
HIV prevention initiatives for 2011/12, the Department recorded the following
achievements:
·
The HIV Counselling and Testing
(HCT) campaign was transformed from the campaign mode and incorporated into the
routine services provided in the public sector. As at end March 2012 an HCT
uptake of 91% had been achieved. By the end of March 2012, a total of 9 602 553
million people had undergone counselling. Of these people mentioned,
8 772 423 people accepted HIV testing, which translate to 91% testing
rate. This exceeded the targeted 85% in 2011/12 financial year.
·
In total, 6 353 000
female condoms were distributed in 2011/12. That exceeded the annual target of
6 million. It also exceeded the recorded figure of 4 989 100 female
condoms distributed in 2010/11 financial year.
In terms of
access to antiretroviral treatment, the Department recorded the following
achievements:
·
A total of 617 147 people were
initiated on ART during 2011/12, which translate to 99% of the annual target of
625 000. That figure was higher than the recorded 418 677 patients
initiated on ART in the previous financial year, 2010/11.
Even though
the Department made significant progress in programme 3, there were challenges
that the Department encountered in the 2011/12 financial year.
6.2.3.2. Maternal, Child and Women’s Health
The aim of
this sub-programme was to reduce infant, child and youth morbidity and
mortality. The Department implemented strategic interventions to improve
maternal, child and women’s health and to enhance progress towards the
health-related MDGs 4 and 5. The targeted interventions to improve maternal and
child health care during 2011/12 included:
·
Increasing nutritional support to
children under the age of five years;
·
Increasing health-seeking behaviour
by encouraging woman to make use of the health services early ;
·
Increasing the proportion of
deliveries in formal health establishments; and
·
Increasing access to ART for
HIV-positive pregnant women.
6.2.3.3. Improving Maternal Health
According to a
recent Biomed Central (BMC) Health Services Research, South Africa's maternal
mortality rate (625 deaths/100,000 live births) was high for a middle-income
country, although over 90% of pregnant women utilised maternal health services. In its
efforts in improving maternal health, the Department reported that an average
rate of 100.4% was recorded nationally during 2011/12 financial year, which was
consistent with the annual target of 100% for 2011/12.
Some of the
achievements in improving maternal health during 2011/12 financial year include
the following:
·
A total of 89.3% of deliveries took
place in health facilities, which was consistent with the set national target
of 90% for 2011/12;
·
A total of 56.9% out of targeted
60% for 2011/12 of mothers received post-natal care within six days after
delivery. That was an improvement compared to 40% for 2010/11 financial year;
·
A total of 98.8% out of the
targeted 100% of pregnant women were tested for HIV in the 2011/12 financial
year. Five (5) provinces recorded 100% coverage for the indicator, i.e. KwaZulu
Natal 114.2%, Mpumalanga 110.9%, North West 106.2%, Limpopo 101.6% and Western
Cape 100.4%. However, the following provinces recorded figures below the set
target for 2011/12; Northern Cape 74.7%, Eastern Cape 94.3%, Free State 97.5%
and Gauteng 85.1%.
6.2.3.4. Improving Child Health
According to a report by the
South African Medical Journal, the South Africa’s child health statistics had
deteriorated, with under-5 mortality rising
from 56 per 1 000 live births in 1990, to 67 in 2008 and just over
half of all under-5 deaths occurring outside health facilities.
However, in its response to
improving child health, the South African Department of Health during the
2011/12 financial year implemented a number of interventions. The achievements
that the Department recorded in the 2011/12 financial year included:
·
In 2011/12, the coverage rate for vitamin A supplementation among
children aged 12-59 months was 43% which exceeded the set target of 40% for
2011/12 financial year;
·
In improving support for exclusive breastfeeding, 24 facilities against
a set target of 25 for 2011/12 were
accredited as providing baby-friendly health services;
·
In 2011/12, the full immunisation coverage rate for children under the
age of one (1 year) was 95.2% against the set target of 95%. That exceeded the
set target. For this indicator there were variations that occurred in provinces,
i.e. Eastern
Cape, Free State,
Gauteng, KwaZulu Natal, Limpopo and Northern Cape exceeded the national target.
Whereas, Western Cape, North West and Mpumalanga reported figures below the
national target;
·
The Department had joined with the
Department of Basic Education and Social Development to revise the Schools
Health Policy. The national Integrated School Health Programme (ISHP) would be
implemented for a period of five years beginning in 2012/13 financial year. That
would target all education phases (including Early Childhood Development,
Primary and Secondary Schools). Each province had developed and submitted their
district-specific ISHP plan, which outlined how the provinces would ensure that
all targeted learners were reached during 2012/13.
6.2.3.5.
TB Control and
Management
The aim of this
sub-programme is to combat TB and HIV by reducing co-infection burden. Some of
the achievements made during 2011/12 financial year in this sub-programme
include:
·
The Department reported that the TB defaulter rate
continued to decrease, and now it stood at 6.8%, compared to a target of 6% in
2010/11 financial year;
·
In terms of TB cure rate, a total of 73.1% was
achieved against a set target of 75% for 2011/12 financial year. That was an
improvement compared to the 71.1% achieved in 2010/11 financial year;
·
A total of 94.1% of HIV patients were screened for
TB against a set target of 85% in the 2011/12 financial year. That exceeded the
set target by 9.1%.
·
With regard to the GeneXpert, South Africa led the
way globally. South Africa had procured more than 50% of the global supply of
GeneXpert tests. From March 2011 to February 2012, South Africa conducted
almost 300 000 (of the global total of 592 000) GeneXpert tests. Of these, 17%
of people suspected of having TB infection were found to have TB. That was a
significantly higher yield than the usual yield of between 4% and 9% using old
technology.
6.2.4.
Programme 4:
Primary Health Care Services
The purpose of
this programme is to develop and implement a uniform district health system. It
also develops a policy on for district health services (PHC and district
hospitals). It further identifies and promotes centres of excellence and
supports planning, delivery and monitoring of these services.
The total
allocation for the programme amounted to R761 703 million. The programme showed
an expenditure outcome of R741 483 million, which was 97.3%, with
under-expenditure of R20 220 million. The under-expenditure was related to the
late delivery of influenza vaccines.
The programme
consisted of four sub-programmes:
6.2.4.1.
Communicable
Disease Control
This
sub-programme aimed to eliminate malaria by 2018 by reducing the local
transmission of malaria cases to 0 per 1000 of the population at risk, through
the implementation of the malaria elimination strategy.
The Department
had implemented measures to track confirmed malaria cases of local origin,
malaria of unknown origin, as well as the total burden of disease from all
malaria cases from both sources of origin. According to the Department, malaria
was endemic (widespread) in three provinces; KwaZulu Natal, Limpopo and
Mpumalanga, and was more prevalent (common) in specific districts than others.
According to the
Department, the following were achieved in malaria cases:
·
Total confirmed cases of local origin: 2 443
(translated to 0,43). That was inconsistent with the set target of 0.43 per
1000 of the population at risk confirmed local cases for 2011/12
·
Aggregate of cases (local and unknown): 3 715
(translated to 0,73). That was higher than the set target of 0,62 per 1000 of
the population at risk.
·
It should be noted that the local transmission was
higher in April 2011 and January 2012. The Department argued that it could be
due to higher importation of malaria cases and population movement. It further
stated that evidence suggested that between 70% and 90% of imported cases came
from Mozambique. And the cessation of the LSDI could be a contributory factor.
6.2.4.2.
Non-Communicable
Diseases
The aim of this
sub-programme is to prevent and manage the chronic care model and strengthening
the implementation of the long-term care model for diabetes over the Medium
Term Expenditure Framework (MTEF) period.
In the 2011/12
financial year, the Department implemented the following:
·
Three districts were identified to implement the
chronic care model;
·
The Department targeted 48 districts to implement
the long-term model for diabetes and hypertension. However, a total of 46
districts managed to implement the long-term model. Two districts in Northern
Cape could not implement the long-term plan due to resource constraints,
according to the Department;
·
In 2011/12 financial year, the Department produced
a Strategic Framework for the Prevention of Injury in South Africa, which
incorporates a plan for response violence.
6.2.4.3.
District Health
Services
The delivery of
Primary Health Care (PHC) services through the District Health Services (DHS)
was a key priority for the Department and was reflected in the health sector’s
NSDA for 2010-2014.
In 2011/12
financial year, the Department achieved the following:
·
A PHC utilisation rate of 2.5 visits per person was
achieved, which fell below a set target of 2.6 visits per person per annum. Two
provinces (Northern Cape and Western Cape) recorded the highest PHC utilisation
rates of 3.0 and 2.9 visits per person per annum respectively. On the other
hand, Gauteng recorded the lowest PHC utilisation rate of 2.1 visits per
person;
·
A total of 337 PHC outreach teams were established
across provinces, which exceeded the set target of establishing 54 teams. As a
result, around 5000 Community Health Workers (CHWs) were re-trained by December
2011.
6.2.5.
Programme 5:
Hospitals, Tertiary Services and Workforce Development
This programme
deals with development of policies, delivery models and clinical protocols for
hospital and emergency medical services. It also ensures that Academic Medical
Centres (AMCs) and health workforce.
The programme
had spent 99.4% of its R16 149 471 billion allocated funds, amounting to R16
057 420 billion, resulted in under-expenditure of R92 051 million. The
under-expenditure was mainly attributed to the Infrastructure Unit Support
System not being invoiced by the supplier before year end and the slow start of
the nursing college’s project.
Under this
programme, the Department achieved the following during the 2011/12 financial
year:
·
By the end of 2011/12 financial year, all 9
Provincial Department of Health submitted the revised draft of their User Asset
Management Plans (USMPs), that was intended for 2012/13 MTEF period;
·
By the end of 2011/12 financial year, the
Department had made progress in the construction of five tertiary hospitals
through Public Private Partnership (PPP), these include; Limpopo Academic
Hospital, Chris Hani Baragwanath Academic Hospital, Dr. George Mukhari
Hospital, Nelson Mandela Academic and King Edward VIII Hospital;
·
The Department completed and launched the five-year
HRH Strategy for 2012-2016. This strategy would assist the health sector to
improve health workforce planning, development and management.
6.2.6.
Programme 6:
Health Regulation and Compliance Management
The aim of this
programme is to regulate procurement of medicines and pharmaceutical supplies,
including trade in health products, promotes accountability and compliance by
regulatory bodies for effective governance and quality of health care. This
programme consists of six sub-programmes, namely; Food Control and Regulations,
Public Entities Management, Office Standard of Compliance, Compensation
Commissioner for Occupation Diseases, Occupational Health Management, and
Pharmaceutical Trade and Product Regulation.
The programme
had spent 95.4% of its R521 801 million allocated funds, amounting to R497 871
million, with under-expenditure of R23 930 million. The under-spending could be
attributed to delays in the implementation of planned activities in the Office
of Standards Compliance.
Some of the
achievements made by the Department in 2011/12 financial year include the
following:
·
In terms of improving its oversight over the
registration of pharmaceutical and related products, the Department established
a new pharmaceutical and related product regulation and management authority in
2011/12 financial year;
·
In total, 386 generics were registered in an
average period of 34 months. The target for 2011/12 was 18 months. Thirty-four
(34) human NCEs were registered within an average period of 37 months. The
target for 2011/12 was 30 months;
·
A comprehensive baseline audit of quality (together
with other key aspects, including infrastructure and human resources), covering
90% (3 780) of public health facilities by the end of March 2012, using tools
developed by the cluster to assess compliance with six priority core standards,
had been a huge step forward for the Department;
·
During 2011/12 the Department developed the
legislative framework required for the establishment of an OHSC as a national
quality certification body, which would enforce compliance with norms and
standards for quality and investigate complaints relating to a breach of norms
and standards;
·
The Department participated in twelve Codex
activities, and included Codex standards in four sets of regulations. Nine sets
of regulations were also drafted, published for comment and/or final were
regulations published. The target for 2011/12 was exceeded by the publication
of four more sets of regulations.
6.3.
Human Resources
During 2011/12
financial year, the Department had a total of 1 293 posts filled out of
1 819 posts available on its staff establishment. That translated to an
average vacancy rate 28.9% by the end of the financial year. A total of 160
filled were additional to the establishment.
The Department reported that it was in the process of abolishing all the
unfunded posts on the establishment as part of the Persal clean-up.
The highest
vacancy rate were experienced in the Senior Management (level 13-16) permanent
at a vacancy rate of 37.3%, followed by Highly Skilled supervision (level 9-12)
permanent at a vacancy rate of 35.3%, lower Skilled (level 1-2) at 28.4%,
Skilled (level 3-5) at 26.6%, and Highly Skilled Production (level 6-8) at
23.9%.
7. Consideration of Reports of Committee on Public
Accounts
The Department
did not appear before the Committee on Public Accounts for the period under
review.
8. Consideration of other Sources
8.1.
The State of
the Nation Address
The health
sector was specifically highlighted in the 2011 State of the Nation Address as
one of the five 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 would 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. That was
important in order to achieve the Department’s priority of improving patient
care and satisfaction and improve the quality of health facilities. Also, it
was critical for the initial phase of the implementation of NHI.
8.2.
Report of the
Auditor-General of South Africa
8.2.1.
The findings of
the Auditor-General (AG)
According to the
Auditor-General South Africa’s (AG) opinion, the financial statements presented
fairly, in all material aspects, the financial position of the National
Department of Health at 31 March 2012, and its financial performance and cash
flows for the year then ended in accordance with the Departmental Financial
Reporting Framework prescribed by the National Treasury and the requirements of
the Public Finance Management Act (PFMA). Consequently, the Department of
Health received an unqualified opinion with no findings by the AG. However, there are matters raised in the AG’s
report.
8.2.2.
Report on other
legal and regulatory requirements
8.2.2.1.
Predetermined
Objectives
8.2.2.2.
Usefulness of
information
·
There were no material findings on the annual
performance report concerning the usefulness of the information.
8.2.2.3.
Reliability of
information
·
In respect of nine indicators selected for
programme 3, tested at 20 facilities at provincial level, the manual registers
supporting the totals recorded in the information systems of the Department did
not agree to amounts reported. That was due to inadequate control processes
implemented at provincial facilities to ensure that data was properly recorded.
·
In addition, because of the inadequate design of
internal controls, there were no procedures that the AG could perform to
satisfy itself that all information was completely recorded. As a result, the
AG was unable to satisfy itself that actual reported performance is valid,
accurate and complete.
·
For two indicators selected relating to programme
3, the AG was unable to obtain sufficient, appropriate audit evidence to
satisfy itself that actual reported performance was valid, accurate and
complete. That was primarily due to the lack of a properly documented management
system.
8.2.2.4.
Compliance with
laws and regulations
·
Strategic
Planning and Performance Management
The Department
did not have and/or maintained an effective and efficient system of internal
control regarding performance management, which described and represented how
the Department’s processes of performance monitoring, measurement, review and
reporting were conducted, organised and managed, as required by section 38(1)
(a) (i) and (b) of the PFMA. Policies had been developed and approved for
performance information. The standard operating procedures had been drafted but
had not yet been approved.
·
Human Resource
Management and Compensation
(a)
Employees were appointed without following a proper
process to verify the claims made in their applications, in contravention of
Public Service Regulation 1/VII/D.8.
(b)
Not all senior managers signed performance
agreements as required by Public Service Regulation 4/ III/B.1.
(c)
A human resource plan was not in place as required
by Public Service Regulation 1/III/B.2 (d).
8.2.2.5.
Transfer of
funds to Non-Profit Institutions and Conditional Grants
·
The Accounting Officer did not maintain appropriate
monitoring and review measures to ensure that transfers to non-profit
institutions were applied for their intended purposes, as required by Treasury
Regulation 8.4.1.
·
The expenditure and non-financial information was
not adequately monitored for the programmes funded by the Health Infrastructure
Grant, the Health Professions Training and Development Grant and the National
Tertiary Services Grant in accordance with the framework for the allocation, as
required by section 9(1) (b) of the Division of Revenue Act.
·
The requirements and responsibilities for the
Health Infrastructure Grant were not adhered to, in contravention of section
9(1) (c) of the Division of Revenue Act.
·
Transfer payments for the Comprehensive HIV and
Aids Grant were not made in accordance with the payment schedule approved by
the National Treasury, as required by sections 10(1)(c) of the Division of
Revenue Act.
·
The arrangements and requirements for the Hospital
Revitalisation Grant, Forensic Pathology Grant and the Comprehensive HIV and
Aids Grant, as defined in the framework for the allocation, were not adequately
adhered to, in contravention of section 10(1)(e) of the Division of Revenue
Act.
·
Business plans for the utilisation of the Forensic
Pathology Grant and the Comprehensive HIV and Aids Grant allocations made to
all provinces were not approved prior to the start of the financial year, as
required by section 10(1)(a)(iii) of the Division of Revenue Act.
8.2.2.6.
Internal
Controls
·
Leadership
The accounting
officer had developed and approved policies for reporting performance
information. Standard operating procedures had been drafted but had not yet
been approved and formally implemented.
·
Financial and Performance Management
Management did
not adequately implement internal controls designed to monitor compliance with
laws and regulations relating to human resource management, transfer payments
and conditional grants.
·
Donor Funding
(a)
An audit was performed on the donor funds received
by the Department in respect of the Global Funds Grant: Strengthening National
and Provincial Capacity for Prevention, Treatment, Care and Support Related to
HIV and Tuberculosis for the year ended 31 March 2011. The audit was in the
process of being finalised.
(b)
An audit was performed on the donor funds received
by the Department in respect of the Global Funds Grant: Expanding Services and
Strengthening Systems for the Implementation of the Comprehensive Plan for HIV
and Aids in South Africa for the year ended 31 March 2011. The audit was in the
process of being finalised.
8.2.2.7.
Investigations
The Department
and National Treasury were currently investigating the awarding of tenders for
HIV testing kits which did not comply with the standards set by the World
Health Organisation (WHO). The investigation commenced in July 2012. The
National Treasury was in the process of investigating fraudulent payments that
were made on the Basic Accounting System during the 2009-10 financial years.
8.3.
Fact-finding
visit and meetings held with provincial departments
The following
findings were drawn from most of the health institutions the Committee visited
and on meetings the committee held with provincial departments:
9.
Report on
Entities
9.1.
National
Laboratory Services
9.1.1.
Introduction
The National
Health Laboratory Service (NHLS) provided laboratory and diagnostic services to
public health facilities in South Africa. Created by the National Health
Laboratory Act (No. 37 of 2000), the NHLS also provided health science training
and education and supported health research. As the largest provider of
diagnostic pathology services in South Africa, the NHLS services over 80 per
cent of the population through its 265 laboratories countrywide.
Cash flow
remained a significant challenge for the National Health Laboratory Service, as
it was in the previous financial year. The Gauteng and KwaZulu-Natal Provincial
Departments of Health remained significantly in debt to the NHLS. The KZN
Department of Health continued paying a flat fee of R45 million per month
(against a consumption of R90 million) and the NHLS was awaiting a decision of
an arbitrator, appointed by the Minister of Health to resolve the dispute.
The NHLS
increased overall test costs by 0.1 per cent; priority tests prices were
reduced by 5 per cent and for all other tests there was an increase of 3 per
cent.
Turnaround times
(TAT) continue to be met; except for cytology as there was a shortage of
cytotechnologists. There was growth in test volumes of 11 per cent, processing
over 80 million tests. The increase was due mainly to several gate-keeping
initiatives implemented in pilot hospitals in all provinces.
The surplus was
R614 million. However, cash flow remained a significant challenge.
Research output equalled 448 peer publications for the year. 218 pathologists,
201 medical scientists, 1388 technologists and 639 technicians are in training.
The NHLS reported
Key Performance Indicators in terms of four perspectives (comparable to
programmes), namely:
·
Customer Perspective (previously Customer Value);
·
Financial Perspective (previously Financial
Efficiency and Sustainability);
·
Employee Perspective (previously People Value); and
·
Internal Perspective (previously Operational
Efficiency).
9.1.3.1. Perspective 1: Customer Perspective
The performance of the Perspective was as follows:
In terms of C1 which is to Improve Customer Satisfaction:
A total of 70% of Customer satisfaction index – Service was achieved
against a set target of 69%. The percentage exceeded the set target. A total of
94.4% of turnaround time for TB Microscopy was achieved against a set target of
90%. That also exceeded the set target. A total of 84.8% for TAT CD4 was
achieved against a set target of 80%. That exceeded the set target of 80%. However,
it should be noted that in the previous financial year 86% was achieved against
a target of 95%).
In terms of C2 which was to improve total TAT:
A total of 57% for TAT Target for cervical smear was achieved against a
set target of 60%. The NHLS did not achieve its set target.
In terms of C3 which was to improve quality of tests:
The two indicators reported on appear identical (Proficiency testing –
Excluding Parasitological + Mycology), yet the targets (90 % and 70 %
respectively) and actual performance (93,3% and 87,5%) differ.
9.1.3.2. Financial Perspective
Only 3 out of
the 6 targets were met. These included:
·
Turnover (Rm): R3 947 (target R3 460)
·
Spend overheads as per budget: R2 503 (target
R2 519)
·
Spend materials as per budget: 25.6% (target 26.6%)
The targets not
achieved related to late or non-payment by debtors included:
·
Minimum cash collection (Rm): R3 547 (target
R4 536)
·
Improve payment to creditors: 108 days (target 30)
·
Improve collections from debtors: 160 days (target
45)
The NHLS reports
had achieved all set targets, except an employee satisfaction survey which it
said was not done due to cash constraints. Those measures achieved included:
·
Maintain low staff turnover: 9.8% (target 10%)
·
Maintain low vacancy rate: 6.8% (target 10%)
·
Maintain high registrar pass rate: 94% (target 64%)
·
Improve BEE procurement: 56% (target 42%)
Performance
measures (except Regional labs’ SANAS accreditation) were largely achieved:
·
Achieve lab accreditation:
o
SANAS accreditation – Academic institutions: 83%
(target 70%)
o
SANAS accreditation – Regional laboratories: 24%
(target 30%) not achieved
·
Improve translation of research:
o
Research report submitted to influence policy: 23
(target 2)
o
Research report translated into service: 35 (target
2)
The 2011/12 year
was described as “annus horribilis”,
which in English means “horrible year.” That was due to the cash flow crisis
which “threatened the viability and continued sustainability of the entity”.
The cash flow crisis was caused largely by poor payment patterns by certain
Provincial Departments of Health. Two Provincial Departments of Health, in
particular, were highlighted, namely Gauteng and KwaZulu-Natal (KZN) as these
departments’ collective debts accounted for 80 per cent of the total debt,
amounting to R1.69 billion of the R2.1 billion debt. As a result of this,
services were reduced, capital projects put on hold and key critical vacancies
were not filled.
·
The independent auditor gave the NHLS an
unqualified audit opinion with additional matters.
·
The auditor reported that at the date of writing,
the annual report had not been made available for audit inspection.
·
There were no material findings on the usefulness
and reliability of the information presented.
·
Achievement of targets: only 19 of the 25 targets
were achieved, meaning 24% (6) of the targets were not achieved. This was
largely attributed to cash flow problems.
·
Compliance with laws and regulations: 6 properties were still not in the name of
the NHLS.
·
Investigations: 3 employees were dismissed
following disciplinary proceedings regarding travel, subsistence and
procurement non-compliance.
9.2.
Council for
Medical Schemes
9.2.1.
Introduction
The Council for
Medical Schemes (CMS), under the Medical Schemes Act (No. 131 of 1998),
oversees the medical schemes industry in South Africa. The report looked at
some of the performance indicators, and financial issues raised in the Annual
Report as well as highlight key issues for consideration.
9.2.2.
Key Performance
Indicators
The CMS reported
Key Performance Indicators for the ten programmes it administered, namely:
1.
Administration
2.
Accreditation
3.
Research and Monitoring
4.
Stakeholder
5.
Compliance
6.
Complaints Adjudication
7.
Benefit Management
8.
Legal Services
9.
Strategic Projects
10.
Financial Supervision
9.2.2.1. Administration
Three of the nine performance indicators were not achieved. Those related
to revenue, procurement, and asset management. Some of the key successes and
challenges included:
·
Accurate Financial statements: 1 out of 1(target 1)
·
Number of tenders adjudicated on: 2 out of 1(target
1) exceeded the set target
·
Number of Audit and Risk Committee meetings held: 4
out of 4 (target 4)
·
Number of Helpdesk incidents handled per year: 744
out of 800 (target) less than set target
·
Number of major network-related incidents per year:
3 out of 4(target 4) less than set target
·
Number of software “bugs” reported per year: 173
out of 600 (target 600) exceeds the target.
·
Number of days of interrupted access per year: 1
out of 4 (target 4) exceed the target.
·
Staff turnover rate: 1.1% out of 8% (target 8%) less than set target
·
Percentage of budgeted income collected: 99.9% out
of 100% (target 100%) less than set target
·
Number of staff trained per year: 31 out of 50
(target 50) less than set target
·
Accurate asset register maintained : 98% out of 100% (target 100%) less than
set target
Whilst the
number of applications had increased across all categories, the percentage of
actual accreditations appeared to be low. That could indicate, amongst other
things, a lack of adequate application preparations or ineffective
communication on the requirements.
·
Number of new individual broker applications: 918
out of 617 (target) exceeded the set target
·
Number of new individual brokers accredited: 326
out of 415 (target 415) less than set target
·
Number of individual broker renewals applications:
4 298 out of 3 372 (target 3 372) exceeded the set target
·
Number of individual broker renewals accredited: 3 722 out of 2 920 (target 2 920)
exceeded the set target
·
Number of new broker organisation applications: 145
out of 122 (target 122) exceeded the set target
·
Number of new broker organisations accredited: 83
out of 90 (target 90) exceeded the set target
·
Number of Managed Care Organisation (MCO)
applications: 26 out of 21 (target 21) exceeded the set target
·
Number of MCOs accredited: 15 out of 20 (target 20)
less than the target. target
9.2.2.3. Research and Monitoring
·
Number of clinical support cases completed: 827 out
of 750 (target 750) exceeded the set target
·
Number of research projects finalised: 5 out of 4 (target 4) exceeded the set
target
·
Number of support projects completed: 3 out of 4
(target 4) less than set target
·
Number of medical schemes complying with ICD-10:
359 out of 380 (target 380) less than set target
9.2.2.4. Stakeholder
Three out of the
five targets for the Education and training sub-programme were not met. A
planned trustee training session for KwaZulu –Natal (KZN) was not held due to
low participation. One of three planned annual return workshops was also
cancelled due to low attendance. Over 40 000 beneficiaries attended
consumer education training (target 30 000). In the communication
Five of the
eight targets were not met. Inspection of regulated entities performed poorly
achieving none of the set targets. A high number of directives were issued due
to non-compliance by medical schemes. Exemption applications did poorly in
communicating Council decisions after receiving them.
·
Number of directives issued : 23 out of 20 (target 20)
exceeded the set target
·
Number of schemes requiring inspection actually
inspected: 10 out of 12 (target 12) less than set target
·
Number of completed individual inspections: 9 out
of 12 (target 12) less than set target
·
Number of units utilising inspection reports: 3 out
of 20 (target 20) less than set target
·
Number of days it takes to communicate Council’s
decisions: 29 out of 8 (target not met)
Four of the six
targets were met. However, 5 of the measures deal with the time taken to
resolve complaints and it appears that most complaints take longer than 60 days
to be resolved.
·
Number of complaints received: 6 138 out
of 5 645 (target 5 645) less
than set target
·
Number of complaints resolved within 30 days: 1 490
out of 1 649 (target 1 649) less than set target
·
Number of complaints resolved within 60 days: 1 505
out of 2 258 (target 2 258) less than set target
·
Number of complaints resolved within 90 days: 1 278
out of 1 016 (target 1 016) exceeded the set target
·
Number of complaints resolved 120+ days: 1 075
out of 169 (target 169) exceeded the set target
All the targets
appear to have been achieved.
·
Number of schemes’ marketing material reviewed per
year: 45 out of 45 (target 45)
·
Number of amalgamations: 1 out of 2 (target 2) less
than set target
A number of
legal opinions (61) were provided and there were 20 court cases where court
papers were filed.
One of the
strategic projects was to provide recommendations to the Department of Health
on amendments to the prescribed minimum benefits (PMB)
The
sub-programme dealt with, amongst other things, improving statutory returns as
well as medical schemes’ reporting, and providing financial oversight of
medical schemes.
·
The Auditor General of South Africa (AGSA) gave the
CMS an unqualified audit opinion with additional matters. That was the CMS’ 12th
unqualified audit in a row.
·
The AGSA reported that “material misstatements in
the annual performance report were identified during the audit, all of which
were corrected by management.”
10.
Report on
Millennium Development Goal
10.1.
Background
In September
2000, South Africa with other world leaders made commitments to the Millennium
Declaration. The leaders committed themselves to a series of eight time-bound
goals with a target date of 2015 that respond to the world’s main development
challenges. According to a recent assessment of achievements made by various
countries, human rights had not yet played a significant role in supporting and
influencing MDG-related activities. The content of the MDGs partly resembled
some aspect of human rights, but systematic human rights based approach to
understanding and achieving the MDGs remained an unmet challenge.
However, three
of the MDGs related directly to health care, thus underlying the importance of
the status of the health of a nation on the path to development. A number of laudable
development targets for health had been agreed to at the Millennium Summit and
in other UN conferences and international forums. These included reducing
mortality rate for children under five by two-thirds, and reducing the maternal
mortality rate (MMR) by three-quarters by 2015; by 2010, reducing HIV
prevalence in all young people (aged 15-24 years) by 25%, and the proportion of
infants infected with HIV by 50%; as well as reducing TB related deaths and
prevalence, and the burden of disease associated with malaria by 50%, also by
2010. South Africa has pledged to meet the eight MDG goals by 2015.
According to a
report of the Medical Research Council (MRC), the South African government had
made much better progress in improving life expectancy and reducing deaths
among young children than it had expected. It was argued that that was largely
due to the rapid expansion of the Department of Health’s HIV-treatment
programme. The report further stated that by 2011, life expectancy had risen to
60 and the childhood mortality rate had fallen to 42 per 1000 live births.
There had also been marked improvement in the infant mortality rate, which was
30 per 1000 per live births in 2011, that was well ahead of the 2014 set target
of 36 per 1000 live births.
However, it
should be noted that the maternal mortality ratio (goal 5) had worsened to an
estimated level of 333 per 100 000 live births in 2009 and the neonatal
(babies under-1 month of age) mortality rate had shown no signs of improvement
by 2009.
10.2.
Goal 4: Reduce
Child Mortality
The improvement
of child health remained one of the Department of Health’s key performance
areas. In that regard, the Department strived to “reduce infant, child and
youth morbidity and mortality. The target for MDG 4 was to reduce by two thirds
the mortality rate among children under five. The indicators for goal 4 included
the following:
4.1. Under-five
mortality rate (U5MR);
4.2.
Infant-mortality rate (IMR); and
4.3. Proportion
of one-year old children immunised against measles.
10.2.1.
Progress to Date
10.2.1.1.
Strategic
Interventions
The Department
of Health’s key strategic interventions identified for the 2011/12-2013/14
period include the following:
·
Maintaining a set target of 95% rate of full
immunisation for children under the age of 1 year;
·
Maintaining a set target of 95% measles
immunisation coverage rate;
·
Increasing the number of sub-districts implementing
school health services from 100 to 150 in 2011/12, 200 in 2012/13 and 232 by
2013/14
10.2.1.2.
Achievements
During 2011/12,
the Department of Health hade made the following achievements in reducing child
mortality:
·
A national immunisation coverage rate (under 1
year) of 95,2% was achieved, against a target of 95%.
·
A total of 4% of babies tested PCR positive 6 weeks
after birth (out of all babies tested), which reflected very good performance
when compared to the target of 7,5%. The Medical Research Council Prevention of
Mother-to-Child Transmission survey reflected a transmission rate of 3,5%.
·
A total of 56,9% of Mothers and 57,8% Babies received
post natal care within 6 days after delivery, against a target of 60%.
·
The mortality rate of children under 5 years of age
fell from 73 per 1000 live births to 42 per 1000 live births.
10.3.
Goal 5: Improve
Maternal Mortality
Maternal health
remained a core strategic focus for the Department of Health. In that regard,
the Department strived to reduce by three quarters the maternal mortality
ratio. Goal 5 has two set targets, namely; Target 5 (a) Reduce by three
quarters the maternal mortality ratio and 5 (b) achieve, by 2015, universal
access to reproductive health. The indicators for goal 5 (a) and 5 (b) included
the following:
·
Maternal mortality ratio;
·
Proportion of births attended by a skilled health
personnel;
·
Contraceptive prevalence rate;
·
Adolescent birth rate;
·
Antenatal care coverage (at least one visit and at
least four visits); and
·
Unmet need for family planning.
10.3.1.
Strategic
Interventions and Achievements
10.3.1.1.
Strategic
Interventions
The Department’s
key strategic interventions for 2011/12 aimed at reducing maternal mortality
included the following:
·
Maintaining ante-natal coverage at 100%;
·
Increasing the proportion of deliveries in health
facilities;
·
Increasing the proportion of designated health
facilities providing Choice on Termination of Pregnancy (CTOP), thereby
reducing the demand for back-street abortions;
·
Increasing the percentage of mothers and babies
receiving post-natal care from 40% to 80%;
·
Implementing programmes in secondary
schools to address youth risk behaviour with a focus on
life skill based HIV and AIDS education in 60 Sub-Districts during 2011/12 and
100 Sub-Districts during 2012/13;
·
Increasing cervical cancer screening and extending
screening to include breast cancer;
·
Testing 100% of pregnant woman for
HIV;
·
Increasing the rate of antenatal
clients initiated on Highly Active Antiretroviral Therapy (HAART) from 87% in
2011/12 to 100% in 2013/14;
·
Decreasing the proportion of babies
testing polymerase chain reaction (PCR) positive 6 weeks after birth from 10%
in 2011/12 to 6.5% in 2013/14; and
·
Increasing the uptake rate of HIV
positive antenatal clients on AZT for any period before labour from 86% in
2011/12 to 100% in 2013/14.
10.3.1.2.
Achievements
During 2011/12,
the Department of Health reported that it had made the following achievements
in reducing maternal mortality:
·
An antenatal care coverage (ANC) rate of 100.4% was
recorded, consistent with the target of 100%.
Denominator issues were being discussed with StatsSA.
·
40,2% of pregnant women presented to the health
services before 20 weeks of pregnancy, which exceeded the 2011/12 target of
40%.
·
100,7% of pregnant women were tested for HIV, which
was consistent with the set target.
·
89,3% of deliveries took place in health
facilities, under the supervision of qualified health personnel. The target for
2011/12 was 90%.
·
A cervical cancer screening coverage rate of 55% was achieved, which exceeded the target
of 52%
10.4.
Goal 6: Combat
HIV and AIDS, Malaria and Other Diseases
Combating HIV
and AIDS remained one of the core Department’s key performance areas. In that
regard, the Department strived to combat HIV and AIDS, Malaria and other
Diseases. Goals 6 had three set targets, namely; 6 (a) Halted and began to
reverse the spread of HIV and AIDS, 6 (b) achieved by 2010, universal access to
treatment for HIV and AIDS for all those who need it, and 6 (c) Halted and began
to reverse the incidence of malaria and other major diseases. The indicators
for goal 6 included the following:
10.4.1. Progress to Date
10.4.1.1.
Strategic Interventions
The Department’s
key strategic interventions for 2011/12 aimed at reducing new HIV infections
included the following:
·
1 billion male condoms to be distributed in
2011/12;
·
6 million female condoms to be distributed in
2011/12;
·
Perform 500 000 Medical Male Circumcisions in
2011/12;
·
To achieve a total of 85% HCT (HIV and AIDS
counselling and treatment) uptake in 2011/12;
·
Initiate 625 000 new patients on ART in 2011/12;
·
Achieve a total of 100% pregnant women tested for
HIV;
·
Achieve a total of 100% antenatal clients initiated
on HAART;
·
Achieve a total of 100% HIV positive antenatal
clients on AZT for any period before labour;
·
Increasing the number of new patients initiated on
anti-retroviral therapy (ART) to between 625 000 and 675 000 annually;
·
Increasing the number of primary health care facilities
(PHC); and
·
Implementing nutritional intervention for people
with HIV and AIDS and TB from 77% to 88%.
10.4.1.2.
Achievements
·
A total of 617,147 new patients were put on Antiretroviral Treatment in
2011/12, compared to 418,677 in 2010/11;
·
A total of 9,6 million South Africans accepted HIV Testing in 2011/12;
·
A cumulative total of 20,2 million people had undergone HIV Testing since
the launch of the HCT campaign by the President of RSA in April 2010;
·
A total of 6,353,000 female condoms were distributed, which exceeded the
target of 6 million;
·
A TB cure rate of 73,1% (for 2010) was achieved, against a set target of
75%. That reflected an improving trend compared to the 71,1% cure rate recorded
in 2010/11 (for 2009); and
·
The TB defaulter rate had decreased from 7% in 2010/11 to 6, 8% in
2011/12.
The Department
of Health made progress in improving the health status of the South African
citizens. The life expectancy started to increase from a low of 54 in 2005 to
60 in 2011. That showed that there had been sustained improvements in mortality
of young adults and child mortality. It was argued that that was largely due to
the roll-out of ART treatment and prevention of mother-to-child transmission of
HIV. However, as mentioned earlier neonatal mortality rate had not improved,
and by the year 2009, maternal mortality was said to be increasing.
11. Recommendations made by the Committee and not implemented
by the Department
Programme 1
Programme 2
Programme 3
Programme 4
Programme 5
12.
Committee’s
Observations
13. Committee’s observations on Programme by Programme
Programme 1
Programme 2
Programme 3
Programme 4
·
The Department continues to concentrate more on hospitals
(curative intervention) rather than preventative or Primary Health Care. This is illustrated by the greater proportion
of the budget which went to hospitals rather than programme dealing with
Primary Health Care and clinics.
·
Primary Health Care supervision rate of 66,6% was
recorded, against the target of 70%.
Programme 6
13. Recommendations
The Minister of
Health should ensure that:
·
Traditional leaders and communities are better
educated about the importance of medical male circumcision and continuously
ensure that sterile equipment and consumables are made available.
·
The Department increases its focus on the Primary
Health Care programme by increasing funding and human resources in order to
reduce hospital overcrowding and move away from hospital centralism.
·
The Department of Health prioritises rural health
and ensures that rural health institutions are supported with the necessary
resources.
·
The Department allocates additional funds for
hospital revitalization and monitor spending, in preparation for the Office of
Health Standard Compliance. This will
assist health institutions when they are assessed on the prescribed norms and
standards.
·
The Department of Health regulates the functioning
of the private healthcare industry, including collecting health data, and also
play an oversight role.
·
The National Department of Health provides support
to the Eastern Cape and Limpopo Provincial Departments of Health especially
with regards to upgrading of infrastructure and improvement and strengthening
of health services.
·
People who manage hospitals or health institutions
are skilled professionals with medical backgrounds.
·
Academic and tertiary hospitals are run by the National
Department of Health. This will
alleviate budget constraints provinces are faced with.
·
The cancer registry is updated.
·
Consideration is given to amending the National
Health Laboratory Services Act so as to ensure that the entity is able to
deliver on its mandate.
·
The Department of Health increases its budget
allocation to the Medical Research Council (MRC) to enable it to do more
research in assisting the country in the fight against the high burden of
diseases.
14. Conclusion
The report
provided an assessment of the performance of the Department of Health on its
programme, budget and administration. The overall assessment and production of
this report enables the committee to fulfil its obligations in relation to the
amendment of Money Bills by Parliament in relation to the Department of Health.
During 2011/12,
The Department of health received an unqualified audit opinion from the
Auditor-General of South Africa. However, the Department experienced financially
driven challenges during this period of reporting.
Key milestones
were achieved during the reporting period. The highlight of this is the
improvement of financial management and the unqualified audit opinion.
The Department
of Health is committed to fulfilling its constitutional obligations to deliver
socio-economic rights within the context of Millennium Development Goals (MDGs)
4, 5 and 6.
Report to be
considered.