Presentation to the Portfolio Committee on Health 24 April 2013 Strategic Plan (2013 – 2015) &

1. Presentation to the Portfolio Committee on Health 24 April 2013 Strategic Plan (2013 – 2015) & Annual Performance Plan (2013/14) Medical Bureau for Occupational Diseases & Compensation Commissioner for Occupational Diseases Barry Kistnasamy, MuzimkhuluZungu & Sam Molautsi

2. Overview • History • Diagnostics of Issues • Strategic Plan • Annual Performance Plan • Budget • Way forward • Conclusion

3. In History… Barrier Miner (Broken Hill, NSW : 1888 - 1954), Monday 13 November 1922, page 1 National Library of Australia http://nla.gov.au/nla.news-article45589068 MINERS' PHTHISIS IN AFRICA Tile South African Union legislature's select committee on public accounts reports that the compensation fund out of which compensation has to be paid to miners' phthisis victims on the Rand has still to face a liability estimated at £l4,000,000. As the exhausted mines close down it falls with cumulative effect on the surviving mines. The committee considers that no time should be lost in laying down measures to ensure the adequacy of the fund. Miners’ Phthisis Act 19 of 1912

4. In Summary… • Problem – governance, claims management, service delivery, infrastructure, sustainability • Paradox – lots of data… • Pressure – multiple fronts (1867 – diamonds; 1886 - gold) • Potential for change, Auditor General’s report • Promise ….

5. Interventions • Unified management structure (Medical Bureau, Compensation Commissioner) • All activities now in one building • Support from National Department of Health • Development of the strategic plan and annual performance plan

6. Strategic Plan (2013-2015) • Combines the Compensation Commissioner and Medical Bureau (Occupational Diseases in Mines & Works Act (1973) • Vision: • An accessible and effective occupational health system and services that ensure …..compensation for workers and their beneficiaries • Mission: • Enhancement of the health system to prevent occupational diseases and provide services • Values:

7. Policy Initiatives • Amendments to the Occupational Diseases in Mines & Works Act (1973) • Expanding the coverage of controlled mines & works • Decentralised services for workers & ex-workers • Explore models for service delivery (within & outside South Africa) • Alignment of compensation (Department of Labour & Treasury)

8. Past Performance (Financial Year 12/13) • Poor performance (annual reports; compliance; management) • Administration covered by Department of Health (R34.4m) – 1.4% of Fund • Compensation Fund (R2.4b) • Mines account, Works account, State account & Research account • R336m revenue & R149m expenditure • Compensation for occupational diseases (workers & ex-workers in controlled mines & works) (R140m) • Pensions (R2.9m) (188 pensioners) • Eastern Cape project (R54 000 to 20 claimants) • Actuarial valuation problems

9. Eastern Cape Project • R54m was available & R38m paid • 18 569 ex-mine workers were identified • R2 700 per beneficiary • 14 114 ex-workers or beneficiaries paid to date • R16m available for a further 4 455 possible claimants (close on 31 Mar 2014) • Inter-departmental committee (Deputy President)

10. Past Performance (Financial Year 12/13) • Medical Bureau for Occupational Diseases • No annual reports since 2000 • Medical examinations of workers and ex-workers • 183 service providers (private & public) • Review and certification • Training and outreach (provincial hospitals) • Risk Committee non-functional since 1998 (controlled mines & works)

11. Strategic Plan: Goals • Make policy and legislative changes • Improve governance • Optimise management • Enhance service delivery • Ensure sustainability of the Compensation Fund

12. Strategic Objectives • Policy & legislative changes • Implement the strategic plan • Improve corporate governance (various committees) • Reorganise claims administration • Consolidate outreach activities • Ensure financial sustainability • Develop a surveillance system • Conduct appropriate research • Assess the human resource, technical and infrastructural needs

13. Policy & Legislation • Externalised health, social & environmental consequences • Internal cohesion (Medical Bureau & Compensation Commissioner) • Alignment of compensation systems (Department of Labour) • Alignment with Department of Mineral Resources • Inspectorate • Risk Committee • Administrative provisions • Transport, Accommodation, Intermediaries • Local services & outside South Africa (medical examinations, claims and payments)

14. Governance • Advisory, Adjudication and Audit & Risk Committees (CCOD) • Certification, Review and Joint Committees (MBOD) • Risk Committee • Internal • Health & Safety • Equity & Skills • Internal Audit & Risk • Service providers

15. Claims Administration & Service Delivery • Registry • Quantify files • Make one file • Verify data • Sort files (year, mines or works, claim type etc) • Tender (filing & process) • Verification (database of 246 controlled mines & works;The Employment Bureau of Africa (TEBA), Home Affairs & South African Revenue Service) • Link IT systems (Registry, Mineworkers System & Accounting System) • Reconciliations

16. Infrastructure

17. Claims Administration & Service Delivery • Front office • Conduct feasibility study of call centre • Customer relations training • Feedback (claimants & stakeholders) • Benefit medical examinations • Decentralised pilot (Eastern Cape, Swaziland) • Back office • Completed forms • Training of service providers • Fraud & corruption

18. Outreach & Awareness • Update communication materials; improve marketing • Involvement in various forums (Health, Labour, Mineral Resources; Development Partners; conferences & workshops) • Meetings with trade unions and employers • Inspections of controlled mines & works • Continuing professional development of health professionals & service providers • Links to provincial health departments and district health facilities • Links to parliament, portfolio committee & their outreach activities

19. Sustainability of the Compensation Fund • Ensure a functioning Risk Committee • Dusts • Vapours, gases, any other factor affecting risk • Expansion of controlled mines and works • Revenue • Collection of levies / penalties / interest • Investments • Re-insurance • Inspections • Verification of data (risk shifts, contractors) • Prevention interventions • Correct the base for actuarial valuation

20. Actuarial Valuation ??? Ex-workers Mines ? 500k • Depends on base (CCOD, MBOD, outside system – not diagnosed, do not know their rights) • Depends on disease process (latency, more than 1 disease)

21. Occupational Injuries • Abrupt break in … AGENT – HOST – ENVIRONMENT balance • Cause established

22. Occupational Diseases • Not diagnosed / mis-diagnosed • Lack of knowledge • Masked by other diseases • Long lag time • Need special investigations • Difficult to find cause

23. Need Special Investigations

24. Diseases caused by Silica Dust Normal

25. Surveillance “data for action” (Giesecke, 1999) “ongoing, systematic collection, analysis & interpretation of data for planning, implementation & evaluation” (CDC, 1988)

26. Surveillance Data • MHSC / DMR / CoM • DoL, DoH • Pathaut • Special surveys • TB incidence • Dust surveys

29. Research • Risks in mines and works • Scientific approach to valuation • Quantification of numbers of workers / ex-workers at risk + modelling studies • Operational research (models for delivery of services)

30. Human Resource, Technical & Infrastructural Needs • Based on Strategic Plan • Need for legal, accounting, economic, actuarial, health & social sciences, logistics • Technical – Information Systems & Technology; digital X-rays, GeneXpert, lung function; financial models • Infrastructural – buildings, vehicles & equipment, decentralised services • Training & capacity building

31. Annual Performance Plan (2013/14) • Policy & legislative changes • Implementation of strategic plan • Governance & management • Service delivery • Re-organisation of claims administration • Outreach activities • Human resource, technical & infrastructural needs • Surveillance system • Appropriate research • Sustainability of the Compensation Fund • Levies • Inspections

32. Objectives & Targets

33. Objectives & Targets

34. Budget Medium Term Expenditure Framework (2013 – 2015)

35. Budget • Occupational Health (Department of Health) • The Compensation Fund (Trading Entity in Department of Health)

36. Occupational Health (Budget) • 2% of Compensation Fund Value

37. Staff Establishment (Feb 13)

38. The Compensation Fund Cash Value (31 March 2013): R2.38b

39. Workers’ Compensation Phase 1 • Effective and efficient compensation system for miners / ex-miners • Clear backlogs • Improve Turn-Around-Times (benefit examinations, certification, claims processing & payments) • Ensure financial sustainability of the Fund • Awareness

40. Promoting Occupational Health Public Health Approach • Action beyond workplace • All health determinants • All workers (contract) • All stakeholders • Overall policy / legal framework Traditional Occupational Health • Only at workplace • Only work-related • Permanent employees • Employer’s responsibility • Workers & employers

41. Occupational Health Services: Core Functions • Preventive • Risk identification, assessment & management • Recognise high risk groups & priorities • Health Promotion • Optimal physical & mental health • Healthy lifestyles • Curative services • General practice level • Referral to specialists • First aid • Rehabilitation & Compensation

42. Conceptual Model – Delivery of Services

43. Occupational Health Service Model PHC Nurse / CHW SUPPORT REFERRAL Family Medicine / OHN / Occ Hyg Occ Med Spec + Academic / Reference Units

44. Delivery of Services • Links to Primary Health Care • 1 nurse at each facility trained to recognise work related injuries & diseases • 1 doctor, 1 nurse and 1 occupational hygienist at district hospital trained to manage work related injuries & diseases • Links to social services & Community Health Workers • Links to private providers

45. Delivery of Services • Occupational health unit at specialist hospital to manage workers with ill-health • Occupational health academic units • Links to National Health Insurance • Ensure collection systems in pilot districts get revenue from compensation system for work related diseases and injuries

46. Delivery of Services (outside South Africa) • Links with relevant government departments in those countries dealing with migrant workers • Link with Ministries of Health for delivery of services (benefit examinations) • Harmonisation of interventions • Appropriate referral systems as per South Africa (ex-workers can access higher levels of system in South Africa) • New models for compensation payments

48. Occupational Health System Phase 2 • Innovative models for occupational health services • Support the development of an integrated social security system for workers • Development of infrastructure and human resources for occupational health • Ensure appropriate funding for the occupational health system (prevention, treatment & care, rehabilitation & compensation) • Work with the Departments of Mineral Resources, Labour and Public Service & Administration in achieving a better health system for worker's health

49. Service Delivery Challenges • Human resources (occ. health practitioners; nurses; occ. hygiene, etc) • Curative focus (non-renewable human capital) • Fragmented service delivery • Little or no quality assurance (radiology, audiology, spirometry, occ. hygiene, laboratory) • Dumping syndrome / Referral system

50. Occupational Health Human Resources • 4.1 / 100 000 doctors (712) – 4300* • 0.77 / 100 000 hygienists (100 or 450) - 1340* • 15.4 / 100 000 nurses (2000) – 8670* • 0.6 / 100 000 ergonomists (80) • Safety practitioners, ventilation etc • ? Education and training inputs * need D. Rees, NIOH. 2012