1. Purpose of the Presentation

PRESENTATIONOF THE NATIONAL DEPARTMENT OF HEALTH’S ANNUAL REPORT FOR 2009/10 TO THE PORTFOLIO COMMITTEE ON HEALTHNATIONAL DEPARTMENT OF HEALTH 12 OCTOBER 2010

1. Purpose of the Presentation • To highlight key issues from the Annual Report of the National Department of Health for 2009/10. • To reflect both achievements and problem areas. • To reflect strategies for addressing constraints experienced – that are also outlined in the medium-term strategic plan for 2010/11 to 2012/13

2. Vision & Mission Vision “An accessible, caring and high quality health system” (2005/06 to 2009/10) “A long and healthy life for all South Africans” (2010/11 to 2014/15)” 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”.

3. National Health Systems Priorities: the 10 Point Plan • 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

3. National Health Systems Priorities: the 10 Point Plan 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.

4. Highlights of Performance on the Departmental Strategic Plan 2009/10-2011/12 4.1. Programme 1: Administration Achievements • National DoH received an unqualified audit opinion from the Auditor-General for 2009/10 – reflecting improved financial management. • Average turn-around time for queries from the Auditor-General improved to eight working days, which was in line with the 2009/10 target. • 57% of the Department’s SMS members were vetted, against a 2009/10 target of 50%. National DoH is dependent on the National Intelligence Agency (NIA) for this function.

4.1. Programme 1: AdministrationProblem Areas • Due to the moratorium on the filling of posts, the Provincial Support Unit for Finance was not established. • Provincial DoHs had estimated figures on accruals of R3,3 billion; cumulative unauthorised expenditure of R11,6 billion; and bank overdrafts of R8 billion, with an overall over-expenditure amounting to R3,4 billion. • A Financial Management Turnaround Plan has been developed in collaboration with the Technical Assistance Unit (TAU) of National Treasury. • Owing to capacity constraints, competency assessments could not be conducted for all members of Senior Management Services (SMS) as planned.

4.2. Programme 2: Strategic Health ProgrammesAchievements Improving Maternal and Child Health • To improve antenatal care, 164 of the 549 identified maternity facilities implemented the Basic Antenatal Care (BANC) programme, which was in line with the 2009/10 target. • The BANC programme aims to enhance the quality of antenatal care, and requires availability of advanced midwives or experienced medical officers, to impart skills and knowledge to frontline health workers. • 30% of women were reviewed within three days post-partum days, which was in line with the 2009/10 target. • As part of interventions to improve women’s health, cervical cancer screening coverage increased from 22% in 2008/09 to 47,7% in 2009/10. 8

4.2. Programme 2: Strategic Health ProgrammesAchievements Improving Maternal and Child Health • Nationally, 47 of the 52 districts (90%) attained a measles coverage of over 80% for children under-1 year of age. The 2009/10 target was 80% coverage in 80% of the Districts. • Six districts that could not attain the required measles coverage were: • Metsweding (Gauteng Province) • Sisonke (KwaZulu-Natal) • UMgungundlovu (KwaZulu-Natal) • Dr. K.K. Kaunda (North West) • Dr. Pixley kaSeme (Northern Cape) • Interventions implemented by affected Provinces include enhancing social mobilisation; management of the EPI programme (including cold chain & stock management); improving surveillance, and appointment of EPI co-ordinators.

4.2. Programme 2: Strategic Health ProgrammesAchievements Improving Maternal and Child Health • Community Health Workers implemented the Household Community Component (HHCC) of the Integrated Management of Childhood Illness (IMCI) programme in 88% (16/18) of the priority districts. The 2009/10 target was 60% of the priority districts. • The HHCC component of IMCI entails imparting awareness and knowledge and to Families and Community Members about: • Good hygienic practices; • Safe infant feeding practices; • Identification and referral of children at risk; • Prevention of injuries; • Importance of child immunisation, • Oral dehydration for diarrhoea, amongst others 10

4.2. Programme 2: Strategic Health ProgrammesAchievements Improving Maternal and Child Health • About 92,7% of pregnant women were tested for HIV, which exceeded the target of 80%. • 76,9% of HIV-positive pregnant women were put on highly active antiretroviral therapy (HAART), which exceeded the 2009/10 target of 30%. • 91,7% of HIV-exposed infants received Nevirapine, which exceeded the 2009/10 target of 80%. 11

4.2. Programme 2: Strategic Health ProgrammesAchievements Combating HIV and AIDS and Tuberculosis • A total of 550 facilities were accredited to offer antiretroviral therapy (ART), with 900 down referral sites. Additional sites were established before the start of the HCT Campaign which resulted in over a 1000 accredited sites. • A total of 494 775 new adult patients were initiated on ART during 2009/10, which exceeded the target of 215 000. A total of 45 044 new child patients under the age of 15 years were initiated on ART, which exceeded the target of 33 000. • Cumulatively, over 1,1 million people were on treatment at the end of March 2010.

4.2. Programme 2: Strategic Health ProgrammesAchievements Combating HIV and AIDS and Tuberculosis • 445 million male condoms were distributed to enhance the prevention of HIV, Sexually Transmitted Infections (STIs) and unwanted pregnancies. The 2009/10 target was 450 million male condoms. • 9,730 health professionals were trained in the clinical aspects of TB management, while 3,866 non-professionals (community health workers) also received training in DOTS. The 2009/10 targets were to train 2000 professionals and 2500 non-professionals. • 19 of the targeted 21 TB hospitals were accredited as HIV service points.

4.2. Programme 2: Strategic Health ProgrammesAchievements Malaria Control • A 14% reduction in malaria cases was achieved between 2008/09 and 2009/10, which exceeded the 2009/10 target of 5%. The number of malaria cases decreased from 6 415 in 2008/09 to 5 502 cases in 2009/10. • Department continued to share its technical skills in malaria control with neighbouring countries, including Mozambique and Swaziland through the Lubombo Spatial Development Initiative, and with Zimbabwe through the Trans-Limpopo Initiative.

4.2. Programme 2: Strategic Health ProgrammesProblem Areas Improving Maternal and Child Health • 22,8% of children were immunised with the new Pneumococcal vaccine and 34,6% with the Rotavirus vaccine. This was below the 2009/10 target of 40% for immunization coverage for both vaccines respectively. • 54,6% of HIV-exposed infants were diagnosed using DBS-PCR, which was lower than the 2009/10 target of 80%. This process assists in tracking mother-to-child transmission of HIV.

4.2. Programme 2: Strategic Health ProgrammesProblem Areas Improving Maternal and Child Health • The Proportion of Community Health Centres (CHCs) providing CTOP services decreased from 45% in 2008/09 to 25% in 2009/10. • Key constraints included: • High turnover rate among nurses trained to provide first trimester termination of pregnancy; • Conscientious objection to CToP; • Social stigmatisation of CToP; • Inadequate awareness about CToP • Marginalisation of women in need of CToP. • National DoH has developed and disseminated guidelines on conscientious objection.

4.2. Programme 2: Strategic Health ProgrammesProblem Areas Combating HIV and AIDS and Tuberculosis • Only 56% of TB sputa had a turnaround time (TAT) of less than 48 hours against the target of 65% for 2009/10 - mainly due to logistical inadequacies associated with transportation and poor telecommunication infrastructure between laboratories and facilities. • 56,6% of MDR patients and 65,6% of XDR patients were recorded as having been started on ARV treatment, against the target of 100%. • TB registers did not make provision for recording HIV status for MDR and XDR patients at the time, which may have contributed to under-reporting.

4.2. Programme 2: Strategic Health ProgrammesProblem Areas Laboratory Services • Significant delays and backlogs in Forensic Chemistry Laboratories run are a major concern. • All efforts are now being taken to reverse the current situation through engagement with Treasury and the Criminal Justice Cluster.

4.3. Programme 3: Health Planning and Monitoring Achievements Establishing processes for improving Quality of Care • During the reporting period, the Department produced a revised set of organisational standards. • These were approved by the National Health Council in February 2010. • Quality Improvement Projects were developed by 1,112 health facilities, focusing on the six priority areas, namely: patient safety, cleanliness, infection control, staff attitudes, waiting times and drug supply. List of projects is available. • Health facilities will be supported to develop and implement an integrated quality package.

4.3. Programme 3: Health Planning and Monitoring Achievements Creating a platform for the introduction of National Health Insurance (NHI) • A Ministerial Advisory Committee (MAC) for NHI was Gazetted in September 2009 • A technical support unit for NHI was established in the Department. • A draft NHI policy is under discussion, and will form the basis for public consultation on the NHI.

4.3. Programme 3: Health Planning and Monitoring Problem Areas Sporadic drug stock-outs • The average drug stock-out of the 45 antiretroviral medicines on tender measured in nine provinces stood at 11,5%, against a target of zero (0%). • The average drug stock-out for the 35 TB medicines on tender measured in nine provinces stood at 15,6%, against a target of zero (0%). • Drug stock-outs resulted from multiple factors, both internal and external to the health sector, including financial constraints resulting in delays in the payment of suppliers, drug supply management problems, suppliers’ incapacity to deliver according to demand, and suppliers’ inability to adhere to lead times.

4.3. Programme 3: Health Planning and Monitoring Problem Areas Strengthening Health Information Systems • A new National Indicator Dataset (NIDS) for the District information System (DHIS) was developed, and implementation by Provinces commenced on the 01st April 2010. • The new NIDS provides a truncated set of indicators to relieve the reporting burden on Provinces. • The NIDS also provides a set of uniform indicator definitions and standard nomenclature to be used across the health sector. • Due to lack of funding, commissioning of the South African Demographic Health Survey (SADHS) was delayed.

4.4. Programme 4: Human Resources Management Achievements Review of long-term plans of Provincial HRH Plans • During the reporting period, the Department reviewed, analysed and provided feedback on the Human Resources for Health plans of eight provinces - excluding the Northern Cape which had not yet submitted by the end of the financial year – but has since done so. Improving Hospital Management • 156 hospital managers were enrolled for a hospital management training programme, which exceeded the set target of 150.

4.4. Programme 4: Human Resources Management Achievements Audit of Nursing Colleges and Schools • An audit of 120 Nursing Colleges and Schools was completed. • The audit results pointed to the need to enhance the infrastructure of these institutions, to review the curricula, and to increase the production of nursing educators.

4.4. Programme 4: Human Resource Management Achievements Nursing Strategy • An implementation plan for the Nursing Strategy was developed in consultation with Provincial DoHs. • The implementation plan seeks to enhance the 6 key pillars of the Nursing Strategy namely: • Nursing practice • Education and Training • Nursing leadership • Nursing regulation • Social positioning – social status of nursing as a profession • Resources for nursing 25

4.4. Programme 4: Human Resources Management Achievements Establishment of Emergency Care Technician (ECT) Colleges • Four Emergency Care Technician (ECT) Colleges were accredited by the Health Professionals Council of South Africa during the reporting period, and commenced with the provision of ECT training. • Though this was lower than the 2009/10 target of 8 colleges, the production of this category of mid-level worker will provide additional EMS capacity in the health sector. 26

4.4. Programme 4: Human Resources Management Achievements Managing disputes between organised labour and the state as the employer • Three collective agreements were tabled in the Public Health and Social Development Sectoral Bargaining Council (PHSDSBC). • A total of three disputes that were lodged with the PHSDSBC were managed and finalised. • In keeping with the 2009/10 target, the collective agreements for: (i) a full-time shop steward; (ii) the Constitution of the PHSDSBC; (iii) a uniform allowance; and (iv) a scarce skills allowance were reviewed.

4.4. Programme 4: Human Resources Management Problem Areas Development of a National Human Resources for Health (HRH) Plan • A National Human Resources for Health (HRH) Plan was not produced by March 2010 as planned. Development of a revised planning framework has commenced. Fewer ECT Colleges accredited by the HPCSA than anticipated • As indicated earlier, 4/8 colleges were accredited by the HPCSA. • A total of 180 employees and 387 school leavers entered the emergency care training programme The target for 2009/10 was 300 employees and 250 school leavers.

4.4. Programme 4: Human Resources Management Problem Areas Slow progress with the data Capturer Project • 609 interns were trained as data capturers in the 21-day skills programme, which was co-funded by the Department and an external funder. The target for 2009/10 target was 1,200. So far a total of 3000 has been trained • Funding constraints resulted in lower numbers of interns being trained. • Provincial departments employed only 50% of the 609 interns who completed the programme, against the 2009/10 target of 90%. Funding constraints limited the ability of Provinces to absorb the interns.

4.5. Programme 5: Special Programmes and Health Entities Management Achievements Improving access to Primary Level Health Facilities • Utilisation of primary health care services, as measured by headcounts at Primary Level Health Facilities, increased from 117,341,256 in 2008/09 to 121,767,724 in 2009/10. • Increases in the utilisation of PHC services could be reflective of increases in the population of the country, unless expressed as a rate. • The PHC utilisation rate marginally increased from 2,4 visits per person per annum in 2008/09 to 2,5 visits per person per annum in 2009/10.

4.5. Programme 5: Special Programmes and Health Entities Management Achievements Improvements in the implementation of accountable operational management of districts • The Department reviewed the District Health Planning guidelines to align them with the Provincial Planning guidelines, and the Health Sector’s 2009–2014 Priorities. • Governance of the health sector was strengthened, with the establishment of 43 District Health Councils. • 47 districts also established functional PHC facility committees.

4.5. Programme 5: Special Programmes and Health Entities Management Achievements Improving Hospital Infrastructure • Planning for the revitalisation of 17 hospitals was initiated. • Construction work started at three revitalisation hospitals during 2009/10, namely Thabazimbi, Khayelitsha and Mitchell’s Plain. • Construction of seven of these hospitals will commence in 2010/11. Improving Service Delivery in Public Sector Hospitals • Hospital improvement plans were implemented in 80 hospitals, which exceeded the set target of 57 hospitals.

4.5. Programme 5: Special Programmes and Health Entities Management Problem Areas Improvements in the implementation of accountable operational management of districts • 31/ 52 districts had district management teams (DMT) with delegations. • 20/52 Districts submitted their District Health Plans (DHPs) by the end of 2009/10.

4.5. Programme 5: Special Programmes and Health Entities Management Hospital Management • Hospital improvement plans were implemented in 80 Hospitals, which exceeded the 2009/10 target of 57. • Only 17% of hospitals had cost centres, an area that requires further strengthening. • Finalisation of generic framework for delegation of authority must be speeded up. This will be further enhanced by the current project of overhauling the health system and assessment of capacity of CEOs Project jointly undertaken with DBSA.

4.6. Programme 6: International Relations, Health Trade and Health Product Regulation Achievements International Health Relations Agreements on health matters between South Africa and Zambia, Lesotho, Malawi and Cuba were developed and signed. 75 students were recruited for medical training in Cuba for the 2009/10 academic year. A total of 252 South African students have completed their studies in Cuba and graduated since 2004, and returned to work in South African hospitals. A total of 320 students are currently at various levels of medical training in Cuba. Post-conflict support was provided to two countries, the Democratic Republic of Congo (DRC) and Burundi. A twinning agreement between the Charlotte Maxeke Johannesburg Academic Hospital and the Clinique Ngaliema Hospital in the DRC was signed in South Africa on 10 December 2009. This will enable the continued referral of patients from the DRC to South Africa to access tertiary services.

4.6. Programme 6: International Relations, Health Trade and Health Product Regulation Achievements International Health Relations Funding agreements were signed with the United States of America, and an agreement of intent was entered into with Sweden. The Department also renewed its bi-ennial agreement with World Health Organization (WHO).

4.6. Programme 6: International Relations, Health Trade and Health Product Regulation Achievements Health Trade and Health Product Regulation In its quest to improve access to good quality, safe and affordable medicines, the Department improved the timelines for the registration of medicines. The timelines for the registration of medicines were reduced to 24 to 30 months for NCE and 15 to 18 months for generics. A total of 1,214 Clinical trials were registered on the Department’s database. Three universities of technology presented nine training courses to 274 environmental health practitioners (EHPs) on the WHO’s 5 Keys to Safer Foods. 37

4.6. Programme 6: International Relations, Health Trade and Health Product Regulation Problem Areas Health Trade and Health Product Regulation A national coverage of 39,9% for Vitamin A in children aged 12–59 months was attained. This performance was lower than the 2009/10 target of 50% coverage. Limited progress was made on the development of an integrated food production strategy in collaboration with the Departments of Agriculture and Education.

5. Background to the National DoH Budget and Expenditure The final appropriation for the National Department of Health for the year 2009/10 was R18,4 billion. Of the R18,4 billion appropriated, an amount of R16,7 billion was a provision for Conditional Grants. The conditional grants form 91% of the total allocation for Vote 14. Actual total expenditure amounted to R17,9 billion which is 97.5% of the appropriated amount. Under expenditure amounted to R457 million which is 2.5% of the total appropriated. The Conditional grants account for 84% of the total under expenditure. 39

6. National DoH Appropriation including Conditional Grants 40

7. Summarised reasons for underspending including Conditional Grants Programme 1: Administration The programme shows an under expenditure of R4,738 million (1.7%) against a budget of R244, 9 million. The under spending was due to under payment of capital assets ascribed to the delays experienced in relocation to upgraded CIVITAS Building. The delay was due to incomplete processes between the contractors and the Department of Public Works. The Department has now moved to Civitas building 41

7. Summarised reasons for underspending including Conditional Grants Programme 2: Strategic Health Programmes • The programme shows an under expenditure of R 24,3 million (0,4%) against a budget of R5,777 billion. • The under spending can mainly be ascribed to two factors: • the delayed portion of the H1N1 vaccines supply • pending court case for the construction of a mortuary using the Forensic Pathology Services Conditional grant at Northern Cape provincial level. 42

7. Summarised reasons for underspending including Conditional Grants Programme 3: Health Planning And Monitoring • The programme shows an under spending of R 10,9 million (2.6%) against a budget of R414,2 million • The under spending was due to initial slow spending for the new cluster of Office of Standard Compliance • Capital Funds also shows under spending due to the delays related to CIVITAS Building planned IT equipment costs. The equipment has subsequently been procured in the current financial year 43

7. Summarised reasons for underspending including Conditional Grants Programme 4: Human Resources and Management Development • The programme shows an under spend of R 7,348 million (0.4%) against a budget of R1,801 billion. • The under spending can mainly be ascribed to the delay in finalizing a tender for an audit of the Nursing Colleges project. The project was finalised in March and payment made in April 2010. 44

7. Summarised reasons for underspending including Conditional Grants Programme 5: Health Services • The programme has spent 96% of its allocated funds amounting to R10,074 billion which resulted in an under expenditure of 4% amounting to R402 million. • The under expenditure can be attributed to withheld Hospital Revitalization conditional grant to Mpumalanga due to delays under spending on current allocation and condition by National Treasury on Roll-over that Audit need to be conducted before releasing the funds. • Another reasons for under spending related to other provinces with construction processes of approved projects as well as invoices which could not be paid before year end due to cash flow limitations. 45

7. Summarised reasons for underspending including Conditional Grants Programme 6: International Relations, Health Trade And HealthProducts Regulation. • The programme has spent 91% of its allocated funds amounting to R83 million with an under spending of R7,572 million (9%). • Under spending was due to outstanding accounts to be claimed by the Department of International Corporations and Relations. The claims were subsequently paid in April 2010. 46

8. Appropriation per Economic Classification

9. Expenditure per Economic Classification Compensation of Employees: • Out of a final appropriation of R333,682 million, the department spent R333,023 million which resulted in 99.8% expenditure. Goods and Services: • Actual expenditure amounted to R756,701 million out of an allocation of R811,701million resulting in 93.2% expenditure. The reasons for the under expenditure are as indicated under programmes 2 to 6 in previous slides. 48

9. Expenditure Per Economic Classification (Cont.) Transfers and Subisdies: • The final overall appropriation for all categories of transfers and subsidies, including grants, amounted to R 17,248 billion. • The total expenditure amounted to R 16,863 billion, which resulted in a 97,8% expenditure. • The under expenditure was mainly for the Revitalization grant transfers. 49

9. Expenditure per Economic Classification (Cont.) Payments for Capital Assets: • The final appropriation was R29,741 million and the expenditure amounted to R13,046 million, resulting to 43.9%. • Reasons for the under expenditure are related to delays related to the CIVITAS Building upgrade and renovation costs. 50

1. Purpose of the Presentation