PRESENTATION TO THE PORTFOLIO COMMITTEE ON HEALTH:

1. PRESENTATION TO THE PORTFOLIO COMMITTEE ON HEALTH: NATIONAL DEPARTMENT OF HEALTH THIRD QUARTER PROGRESS REPORT (Q3 OF 2010/11) AGAINST THE STRATEGIC PLAN 2010/11-2012/13 23 FEBRUARY 2011 1

2. 1. Purpose of the Presentation • To highlight key issues from the performance of the National Department of Health against the targets set in the medium-term Strategic Plan 2010/11-2012/13, with a focus on the third quarter (Q3 of 2010/11). • To reflect both the achievements and challenges. • To reflect strategies for addressing constraints experienced. 2

3. 2. Structure of the Presentation • Vision and Mission • National Health Systems Priorities: 10 Point Plan 2009-2014 • Brief outline of the Negotiated Service Delivery Agreement (NSDA) • Highlights of progress towards the Strategic Plan 2010/11-2012/13, focusing on the 6 Budget Programmes, and reflecting: • Progress to date • Key Challenges • Action taken to resolve blockages • Budget and Expenditure Report • Progress Report on Conditional Grants 3

4. 3. Vision & Mission Vision “An accessible, caring and high quality health system” (Strategic Plan 2010/11-2012/13) Mission “To improve health status through prevention of illness & disease and through the promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equity, efficiency, quality and sustainability”. 4

5. 4. National Health Systems Priorities: the 10 Point Plan 2009-2014 • Provision of Strategic Leadership and creation of Social Compact for better Health Outcomes • Implementation of National Health Insurance (NHI) • Improving the Quality of Health Services • Overhauling the Health Care System and Improving its Management • Improved Human Resources Planning Development and Management 5

6. 4. National Health Systems Priorities: the 10 Point Plan 2009-2014 6. Revitalization of Infrastructure 7. Accelerated implementation of the HIV and AIDS Strategic Plan and the increased focus on TB and other Communicable Diseases 8. Mass Mobilisation for Better Health for the Population 9. Review of Drug Policy 10. Strengthening Research and Development. 6

7. 5. Negotiated Service Delivery Agreement (NSDA) 2010-2014 • In May 2010, the Minister of Health entered into a Performance Agreement with the President of the country. • The Performance Agreement focuses on achieving government’s Outcome 2: “A long and healthy life for all South Africans” and has four (4) strategic outputs: • Output 1: Increasing Life Expectancy • Output 2: Decreasing Maternal and Child mortality • Output 3: Combating HIV and AIDS and decreasing the burden of diseases from Tuberculosis • Output 4: Strengthening Health System Effectiveness • In October 2010, the Health Sector’s Negotiated Service Delivery Agreement (NSDA) 2010-2014 was finalised and signed, to ensure achievement of these outputs. • A consultative process was followed in the development of the NSDA, which included Provincial DoHs; other government departments, stakeholders and international development partners. • Strategic and Annual Performance Plans of the National DoH will henceforth be based on the NSDA 2010-2014. • Reporting for 2010/11 is based on the current medium-term Strategic Plan 2010/11-2012/13.

8. 5. Highlights of Performance on the Departmental Strategic Plan 2010/11-2012/13 during Q3 of 2010/11 5.1. Programme 1: Administration Achievements • Key milestones are being recorded in the implementation of the Financial Management Turn Around Plan for the Health sector, developed jointly with the Technical Assistant Unit (TAU) in the National Treasury. • The Financial Management Turn Around Plan was developed in response to assessments conducted by the Integrated Support Teams (IST), and the Auditor General of South Africa (AGSA), which highlighted common challenges in financial management namely: • Inadequate budget processes; • Poor revenue generation and management; • Expenditure management, including monitoring of Compensation of Employees; • Ineffective Supply Chain Management, • Poor Asset Management and Performance Information audit limitations

9. 5.1. Programme 1: Administration Achievements • Province specific plans have been developed to improve financial management in 7/9 Provinces. • Key cost drivers in health care delivery were identified, which include: • Compensation of employees; • High prices for pharmaceutical supplies, which are influenced by a high demand as well as the inflation rate (driven by increased patient numbers); • Medical inflation rate, which is higher than normal inflation; • Increasing patient numbers of due to the increased burden of disease; • Increases in fuel costs resulting from increased demand and high expenditure on Patient Transport and Ambulance services. • Progress with the implementation of the Financial Management Turn Around Plan plans is a standing item on the Agenda of the National Health Council. 9

10. 5.1. Programme 1: Administration 5.1. Programme 1: Administration Achievements • In keeping with the target for 2010/11, progress has been made with revision of the National DoH organogram, to enhance the Department’s capacity to deliver on national health priorities. • An extensive organisational assessment process was undertaken in 2010, with external expertise provided by McKinsey Company. • A revised top level structure of the National DoH has been prepared. • Six Task Teams have been established to develop proposals about other levels of the organogram. • The Department of Public Service and Administration has also been consulted. 10

11. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health • Key interventions for enhancing child health outlined in the Strategic Plan include: • implementing mass immunisation campaigns to protect South African children against preventable diseases; • providing early and quality antenatal services; • ensuring the early diagnosis of HIV exposed infants; • strengthening the Prevention of Mother-to-Child Transmission (PMTCT) of HIV programme; and • increasing the percentage of mothers and babies who receive post-natal care within 6 days of delivery. 11 11

12. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Achievements • Mass immunisation campaigns against preventable diseases including polio and measles have been markedly successful. • During a mass immunization campaign against polio conducted in 2010, an Oral Polio Vaccine (OPV) coverage of 101.6% was achieved in the first round, which exceeded the target of 90%. • A mass immunization campaign against measles was also conducted during 2010. The target was to reach 95% of children in the following age categories: 6-59 months and 60-179 months. 12 12

13. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Achievements • Numerically, it was planned that 4, 345, 722 children aged 6-59 months, and 10,395,789 children aged 60-179 months would be immunised. • A total of 5,325,764 children aged 6-59 months were immunised against measles, which represented coverage of 117%. Far more children were reached than the original target. • A total of 9, 266, 957 children aged 60-179 months were also immunised against measles, which represented coverage of 89%. This was lower than the set target of 95%. • Overall, a national measles coverage of 98% was recorded.

14. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Achievements • Early diagnosis of HIV exposed infants has also been improved. By December 2010, 73.7% of HIV exposed infants had been initiated on Cotrimoxazole prophylaxis from the age of 6 weeks. • A system of perinatal reviews was set up to monitor and evaluate causes of perinatal deaths and illness at 72% of maternity facilities country wide. • The Prevention of Mother to Child Transmission of HIV (PMTCT) reflects significant increases in the number of babies tested between 2008-2010, and declines in transmission rates in all 9 Provinces. 14

15. 5.2. Programme 2: Strategic Health Programmes TABLE: TRENDS IN PCR TESTS AND POSITIVITY RATES 15 Data Source: National Health Laboratory Services, January 2011

16. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Achievements • 81% of mothers and newborn babies were reviewed within 6 days post-natally in the first two quarters of 2010/11. • Up to December 2010, 40% of designated health facilities provided the Choice on Termination of Pregnancy (CToP) services, in keeping with the target for the period under review. • This has contributed to reducing the number of women dying from unsafe, induced terminations. 16

17. 5.2 Programme 2: Strategic Health Programmes Improving Maternal and Child Health Challenges • A shortage exists of health personnel (doctors and nurses) experienced in newborn care. • It is also imperative to ensure that perinatal reviews established in maternity facilities yield the required actions necessary to reverse the trend in maternal and child deaths in the system. • Diverse estimates of Maternal, Child and Infant Mortality Rates have been produced by different data sources. 17

18. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Action taken to resolve blockages • Interventions to address the shortage of medical personnel experienced in newborn care are also addressed, including collaboration with training institutions. • Technical Support Teams consisting of specialists in Paediatrics, and Obstetrics and Gynaecology will be deployed in the Districts. • Improvement of health worker skills and capacity in managing women, mothers and children is a key feature of interventions going forward. • Discussions have been conducted with nursing professionals and training providers, to solicit their contribution to this critical area of need. 18

19. 5.2. Programme 2: Strategic Health Programmes Improving Maternal and Child Health Action taken to resolve blockages • In April 2011, a national Nursing Summit will be convened with a variety of professionals and students; academics; retired and active professionals, to focus on practical solutions for challenges in the health system. • National Treasury has provided resources for the filling of vacant medical registrar posts during the 2011/12-2013/14 planning cycle. • Community involvement in securing and promoting the health of mothers and babies is essential.

20. 5.2. Programme 2: Strategic Health Programmes Combating HIV and AIDS and Tuberculosis Achievements • The HIV Counselling and Testing (HCT) campaign was launched in April 2010. • Through the HCT campaign, government succeeded in reaching 6,021,330 South Africans by December 2010, who were counselled for HIV. • A total of 5,843,937 people agreed to be tested for HIV. Of these 5,474,505 people tested in the public sector, and 369,432 in the private sector. • A total of 936,168 (18%) people tested positive. • Without this campaign 5,8 million people would not have known their HIV status. 20

21. 5.2. Programme 2: Strategic Health Programmes Combating HIV and AIDS and Tuberculosis Achievements • A total of 1,3 million people living with AIDS have been placed on Antiretroviral therapy (ART). • Prevention has remained the cornerstone of efforts to combat HIV and AIDS. • By the end Q3, a total of 403,839,460 male condoms and 4,637,185 female condoms (cumulative) had been distributed. • A number of provinces have embarked on medical male circumcision. By December 2010, Over 49,803 male circumcisions had been conducted.

22. 5.2. Programme 2: Strategic Health Programmes Combating HIV and AIDS and Tuberculosis Achievements • The Department launched the National Antenatal Sentinel HIV and Syphilis Prevalence Survey in November 2010. • Results of the National Antenatal Sentinel HIV and Syphilis Prevalence Survey also indicate that HIV prevalence amongst pregnant women in the country has remained stable at 29.4% in 2009.

23. 5.2. Programme 2: Strategic Health Programmes Combating HIV and AIDS and Tuberculosis Achievements • Efforts to combat TB have been strengthened. • During the HCT Campaign, 2,717,376 people were also screened for TB, and 441,485 were referred for further assessment for TB. • The TB cure has increased from 68% in 2008 to 70.4% in 2009. • Through effective defaulter tracing and support, the proportion of people who default TB treatment has decreased from 7,9% in 2009 to 6.4% in 2010. • 17 public sector facilities are now diagnosing and initiating treatment for drug resistant TB patients.

24. 5.2. Programme 2: Strategic Health Programmes Combating HIV and AIDS and Tuberculosis Challenges • Only 48% of TB/HIV co-infected patients were started on Antiretroviral Treatment (ART), against a 2010/11 target of 70%. • The TB cure rate must be further improved. WHO has set a target of 85%.

25. 5.1. Programme 2: Strategic Health Programmes Combating HIV, AIDS and Tuberculosis Further action needed to resolve blockages • Additional resources have also been provided in the 2011-2014 MTEF period for increasing access to ART for people living with HIV&AIDS, particularly initiating TB/HIV co-infected and Drug Resistant TB patients on ART. • Government will enhance TB case finding, as well as strengthening laboratory services for diagnosis and management. • Improvement in TB case identification will also be achieved through expanding the outreach programmes to households through Community Health Workers.

26. 5.1. Programme 2: Strategic Health Programmes Combating other Communicable Diseases and Non Communicable Diseases (NCDs) Achievements • Evidence points to the increasing contribution of NCDs to the burden of disease in South Africa. • Work on reducing the impact of Non-Communicable Diseases) or ‘lifestyle-related health conditions” resulted in the hosting of The Diabetes Leadership Forum Africa 2010 held in South Africa in September 2010. • An Implementation Plan for the Diabetes Declaration has been produced and disseminated. • A chronic diseases management register was introduced in all Provinces in the first half 2010, and will continue to be used going forward. 26

27. 5.1. Programme 2: Strategic Health Programmes Combating other Communicable Diseases and Non Communicable Diseases (NCDs) Challenges • Although the objectives of the HCT campaign include screening people for chronic conditions such as diabetes and hypertension, this has not taken off as planned. • This aspect of the HCT Campaign is being strengthened. • The chronic diseases management register will contribute to enhancing the identification of chronic conditions, and ensure their appropriate management and control. 27

28. 5.1. Programme 3: Health Planning and Monitoring Strengthening Monitoring and Evaluation of Health Sector Performance Achievements • Lack of availability of good quality and reliable data on the health status indicators of South Africans has been a key impediment. There has also been a lack of consensus between local data sources and international agencies about the health outcome indicators. • In October 2010, the National Department of Health established a Health Data Advisory and Coordination Committee, which will improve the quality and integrity of data on health indicators.

29. 5.1. Programme 3: Health Planning and Monitoring Strengthening Monitoring and Evaluation of Health Sector Performance Achievements • The Health Data Advisory and Coordination Committee consists of researchers from diverse academic and research institutions, statisticians; and demographers. • This committee will release its report in March 2011.

30. 5.1. Programme 3: Health Planning and Monitoring Strengthening Monitoring and Evaluation of Health Sector Performance Achievements • Data quality assessments were conducted in 80 facilities across 17 of the 18 priority districts, with the aid of the SA Statistical Quality Assurance Framework (SAQAF) tool developed by National Treasury. • These assessments assist in enhance the quality of data from the routine information system – the DHIS. 30

31. 5.1. Programme 3: Health Planning and Monitoring Strengthening Monitoring and Evaluation of Health Sector Performance Challenges • The South African Demographic and Health (SADHS) Survey 2010 was not conducted. • However, research questions were incorporated into a national nutrition survey (SANHANES) to be conducted by the Human Science Research Council (HSRC) in 2011. 31

32. 5.1. Programme 3: Health Planning and Monitoring Improving Quality of Care Achievements • A set of Core Standards have been developed and approved, and will be used as the basis for strengthening quality of health care provision locally, provincially and nationally, and holding managers accountable. • The National Health Amendment Bill was gazetted on the 24th January 2011, to give effect to the Core Standards and enforce them in our health system. • The Bill also provides for the establishment of an independent Office of Standards Compliance, which will enforce compliance with national standards and conduct independent investigation of complaints. • A national Health Facility Audit is underway in 2011, which will further provide a status of various aspects of quality in the public health sector.

33. 5.1. Programme 3: Health Planning and Monitoring Implementing National Health Insurance Achievements • A solid foundation for the introduction of Insurance (NHI) has been laid. • A policy document, the White Paper on NHI, will soon be published for public comment. • Legislation for the establishment of the NHI Fund will also be produced, and submitted to Cabinet by December 2011.

34. 5.3. Programme 3: Health Planning and Monitoring Improving the availability of safe and affordable medicines Achievements • The Department of Health awarded a tender to the value of R4,2 billion over two years for procurement of ARVs. • The department amended the usual procurement strategies which has resulted in a saving of 53%. • This will allow the department of Health to place more patients on Antiretroviral treatment with the same resource envelope. 34

35. 5.4. Strengthening Human Resource Planning, Development and Management in the Public Health Sector Strengthening Human Resource Planning and Development Achievements • A comprehensive audit of Nursing Colleges has been completed . • A business plan for the revitalization of 105 of the 126 public sector nursing colleges was developed. • A total of 183 Clinical Associates were enrolled within the degree programme, which exceeded the 2010/11 target of enrolling 125 clinical associates. • 17 Clinical Associates graduated at the end of 2010, from Walter Sisulu University. • This cadre of health workers will enhance the availability of medical support in Public Health Facilities.

36. 5.4. Strengthening Human Resource Planning, Development and Management in the Public Health Sector Strengthening Labour Relations in the Health Sector Progress to date • In October 2010, the State as the Employer tabled the final offer Occupation specific Dispensation (OSD) for Allied health Professionals in the Medical, Diagnostic and Therapeutic Services. • This OSD agreement for diagnostic, therapeutic and related allied health professionals was signed in November 2011.

37. 5.5. Programme 5: Special Projects and Public Entities Implementing a revitalised Primary Health Care (PHC) approach Progress to date • A new re-engineered Primary Health Care (PHC) model for South Africa has been produced, which emphasizes: • a population oriented service delivery model (rather than a health facility-based one); • deployment of multidisciplinary PHC Teams across well defined geographic areas; • effective utilization of the skills of community-based resources such as Community Health Workers, and • greater community involvement in securing and promoting health. • Funding has been obtained from the national fiscus for the establishment of the PHC Teams during the 2011/12-2013/14 planning and implementation cycle.

38. 5.5. Programme 5: Special Projects and Public Entities Health Facility Improvement Progress to date • Health facilities are being enhanced, to provide a conducive environment for delivering quality services. • Of the existing 4,333 public health facilities in South Africa, 41% were built in the post-1994 period. • In 2010, there were 2,299 infrastructure related projects at health facilities across the country. These included the construction of 167 clinics and 25 Community Health Centres (CHCs) nationally. A total of 272 hospitals projects are being implemented across Provinces.

39. 5.5. Programme 5: Special Projects and Public Entities Health Facility Improvement Progress to date • Progress is being made with the planning and design phase for five (5) flagship tertiary hospital projects to be implemented through PPPs namely: • Nelson Mandela Hospital in the Eastern Cape • Dr. George Mukhari Hospital in Gauteng Province • Chris Hani Baragwanath Hospital in Gauteng Province • King Edward VIII Hospital in KwaZulu-Natal • Limpopo Academic Hospital in Limpopo Province

40. 5.5. Programme 5: Special Projects and Public Entities Health Facility Improvement Progress to date • Refurbishment of other hospitals through the Hospital Revitalisation Programme also continued during Q3 of 2010/11. • Cecilia Makiwane hospital (EC) is in the tender stage. • Initial Project Implementation Plans for Trompsburg and Ladybrand Hospitals (FS) have been approved. • Design of Dr. Pixley kaSeme (KZN) has been evaluated, and the Province is in the process of amending the business case. • The project brief for Edendale Hospital (KZN) has been evaluated. • Planning processes for Musina Hospital (LP) have progressed much slower than anticipated. • Review of the business plan for De Aar Hospital (NC) has been completed. • Tender documentation for Bophelong Hospital (NW) is being prepared. • Project brief for the Valkenburg Hospital (WC) has been resubmitted by the Province to the National DoH.

41. 5.5. Programme 5: Special Projects and Public Entities Health Facility Improvement Challenges • Underspending of the health infrastructure budget has been noted in several Provinces, despite the need for the rehabilitation of health infrastructure.

42. 5.5. Programme 5: Special Projects and Public Entities Health Facility Improvement Action taken to resolve blockages • An infrastructure support model has been implemented - a component of which includes the appointment of qualified engineers in each province to provide consistent technical expertise for managing active projects in the health sector. • Four provinces have finalized their appointments and other appointments are in process. A much improved provincial resource planning and allocation model is being implemented– enabling a reduction in unspent funding on infrastructure projects country-wide. • Assistance of Infrastructure development resource persons and built environment specialists from the DBSA and CSIR has been secured to strengthen implementation, monitoring and evaluation in all provinces. • Measures for better financial management and planning will ensure a decline in the amounts of rollovers and unspent funds for infrastructure development in our country.

43. 5.5. Programme 5: Special Projects and Public Entities Improving Hospital Management • With the Development Bank of Southern Africa (DBSA), a diagnostic assessment of the competencies of CEOs and district managers has been completed. • This is aimed at assisting in designing interventions at facility level intended to support the improvements in service delivery, and in enhancing health outcomes.

44. 5.6. Programme 6: Enhancing Health Care Delivery through International Relations • 80 South African students were recruited into the SA-Cuba programme. The last group departed for Cuba on 25 October 2010. • 45 Cuban health professionals were recruited to work in Rwanda under the trilateral arrangement. The 2010/11 target was to recruit 10 Cuban Health professionals to work in Rwanda and Sierra Leone under the trilateral arrangement. • Implementation of the Malaria Lubombo Spatial Development Initiatives involving RSA, Mozambique and Swaziland has continued effectively.

45. Summary expenditure per programme by end of December 2010, Target:75%

46. Summary expenditure per Economic Classification by end of December 2010, Target: 75%

47. 8. Progress Report on Conditional Grants, December 2010. Target : 75%

48. 8. Progress Report on Conditional Grants, December 2010, Target : 75% (cont.)

49. 9. Progress Report on Conditional Grants – Third Quarter Report

50. 10. Summary of expenditure per programme by end of January 2011, Target: 83.3%