NATIONAL DEPARTMENT OF HEALTH National Health Insurance Grant

1. NATIONAL DEPARTMENT OF HEALTHNational Health Insurance Grant Select Committee on Appropriations Hearing on 3rd and 4th Quarter Expenditure 4th June 2013

2. Index • Background • Provincial Expenditure Summaries (IYM) • Q3 and Q4 figures (incl. Province specific challenges) • Total Grant Expenditure • Summary of challenges impacting on Expenditure • Monitoring and Evaluation matters • Way Forward Select Committee on Appropriations_4 June 2013

3. Background • R150 million allocated for 2012/13 FY • Each pilot District received R11.5 million • Focus: • To test innovations that are necessary for the implementation of NHI • To undertake health system strengthening initiatives in identified Districts • To provide strategic resources for supporting the pilot Districts in implementing selected health service delivery interventions Select Committee on Appropriations_4 June 2013

4. Eastern CapeQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

5. Eastern Cape: Challenges • Provincial office delayed notification of the availability of funds to the District • District capacity constraints • Lack of key HR in essential categories; • Inadequate technical support • Supply Chain hurdles • Delays in getting approvals Select Committee on Appropriations_4 June 2013

6. Free StateQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

7. Free State: Challenges • Reprioritisation of funds allocated to activities • SCM hurdles Select Committee on Appropriations_4 June 2013

8. GautengQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

9. Gauteng: Challenges • No support/guidance from relevant officials at Provincial Office • Significant hurdles in procurement processes • Delays in getting information on budget codes • Staff shortages in key areas • Lack of ability to employ staff on long term basis using NHI-CG funding e.g. clinical staff, sessional doctors, etc. Select Committee on Appropriations_4 June 2013

10. KZNQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

11. KZN: Challenges • Structural administrative process • Bureaucratic processes that hamper innovation • The process for obtaining signatures needs to be streamlined • Huge delays at Provincial office • Limited delegations to allow for activities to be undertaken • District level delegations very limited • Significant Supply Chain hurdles • Lack of clarity regarding long delays in getting necessary approvals Select Committee on Appropriations_4 June 2013

12. LimpopoQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

13. Limpopo: Challenges • Challenges around budget matters • Inappropriate / incorrect budget coding • SCM hurdles • Significant delays in getting approvals • Challenges in identifying relevant providers to undertake some activities due to limited database • Technical and administrative support from Province inadequate Select Committee on Appropriations_4 June 2013

14. MpumalangaQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

15. Mpumalanga: Challenges • Majority of the DHMT not appointed • Too many vacancies to undertake activities • Non-existent / limited delegations to allow for activities to be undertaken • District level delegations very limited • SCM hurdles impacting on key activities Select Committee on Appropriations_4 June 2013

16. Northern CapeQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

17. Northern Cape: Challenges • Delays in Provincial Treasury providing information regarding availability of funds • SCM hurdles • Significant delays in getting necessary approvals and lack of technical support in key areas • Challenges in identifying relevant providers to undertake some activities due to limited database • Contextual factors also impact on programme: • Majority of key staff complement based in Kimberley • DHMT has limited delegations Select Committee on Appropriations_4 June 2013

18. North WestQ3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

19. North West: Challenges • Incorrect capturing of budget at Provincial level • District submitted an incorrect business plan to Provincial Treasury • Poor prioritisation of allocated funding • Need to reprioritise to other activities • Lack of technical support in key areas • Need Provincial NHI Coordinator • Challenges in identifying relevant providers to undertake some activities due to limited database • Inability to spend on Infrastructure i.e. clinics, motor vehicles, etc Select Committee on Appropriations_4 June 2013

20. Western Cape Q3 and Q4 Expenditure (R’000) Select Committee on Appropriations_4 June 2013

21. Western Cape: Challenges • Delays in finalising business plan impacted on progress • Approval only granted in August 2012 • Encountered some challenges in undertaking work around Governance arrangements at Community level i.e. CHCs • Delays in getting a supporting legal opinion on the exact roles, responsibilities and functioning of Clinic Committees Select Committee on Appropriations_4 June 2013

22. Summary of Quarter 3 Expenditure(R’000) Select Committee on Appropriations_4 June 2013

23. Summary of Quarter 4 Expenditure(R’000) Select Committee on Appropriations_4 June 2013

24. DORA: Implementation Select Committee on Appropriations_4 June 2013

25. Total Expenditure by Province (%) (April 2012 – 31 March 2013) Select Committee on Appropriations_4 June 2013

26. NHI-CG Provincial Commitments/Roll-Overs2012/13 Financial Year

28. Summary Challenges • Weak HR capacity in some Districts • Weak Provincial technical support • Delays in budgets being communicated to some pilot sites • Incorrect budget capturing • Significant Supply Chain management challenges in many Districts • Lack of necessary delegations to perform outlined activities Select Committee on Appropriations_4 June 2013

29. Monitoring and Evaluation Matters • Monitoring and Evaluation undertaken by Grant Management Unit and Directorate: NHI • Financial, Health Economics and Monitoring and Evaluation skills appointed • All Provinces have submitted Month on Month financial data • Used to compile IYM data • Quarterly reports and meetings with all sites • Mutually identified shortfalls and challenges; • Mutually identified “quick win” activities and interventions; • Expedited Expenditure on commitments in approved Business Plans • Assessed progress on operational plans • Prioritisation process • Focus on quality spending • Evidence gathering Select Committee on Appropriations_4 June 2013

30. Way Forward (1) • Inherent underperformance in early part of the 2012/13 cycle: • NHC Intervention resulted in improvement in Q3 and Q4 • DORA framework to adjust the purpose, focus activities and funding allocations to Provinces: • Allows NDOH a stronger and more interventionist approach: • Influences the scope of work to be undertaken at National and pilot site levels: • Changes in allocations across Districts Select Committee on Appropriations_4 June 2013

31. Way Forward (2) • For 2013/14, the grant has been split into 2 components: • Direct: District piloting (Schedule 5) • In-kind: GP contracting and Central Hospitals work (Schedule 6A) • New focus areas: • Strengthening SCM; • Supporting the roll-out of PHC streams and their role within the District referral system; • Strengthening District level Monitoring and Evaluation capacity • Mobilised funding for appointment of Provincial NHI Coordinators: • Majority appointed to post; • Assist in coordination, project management and Monitoring and Evaluation functions Select Committee on Appropriations_4 June 2013

32. THANK YOU Select Committee on Appropriations_4 June 2013