PORTFOLIO COMMITTEE ON HEALTH

1. PORTFOLIO COMMITTEE ON HEALTH PRESENTATION ON THE ANNUAL REPORT 2011/2012 OF THE NATIONAL DEPARTMENT OF HEALTH 17 OCTOBER 2012

3. 1. PURPOSE OF THE PRESENTATION • To reflect on key issues (highlights) from the Annual Report of the National Department of Health (DoH) for 2011/12. • To reflect both achievements and problem areas. 3. To reflect strategies for addressing constraints experienced – which are also outlined in the National DoH’s Annual Performance Plan for 2012/13.

4. 2. STRUCTURE OF THE PRESENTATION • National Health Systems Priorities • Review of Programme Performance - across all 6 Budget Programmes • Budget and Expenditure Per Programme • Budget and Expenditure Per Economical Classification • Explanations of Material Variances • Audit Outcomes • Recommendations • Conditional Grant Expenditure • Trading Entities and Public Entities • Conclusion

5. 3. NATIONAL HEALTH SYSTEM’S PRIORITIES (1) • The Negotiated Service Delivery Agreement (NSDA) 2010-2014 guided the work of the National DoH during the financial year 2011/12. • NSDA 2010-2014 is the implementation plan for Outcome 2 namely: “ A long and healthy life for all South Africans” • Four outputs required from the health sector in terms of the NSDA 2010-2014 are: • Increased Life Expectancy; • Reduction in Maternal and Child Mortality Rates • Combating HIV and AIDS and decreasing the burden of diseases from Tuberculosis • Strengthening Health System Effectiveness • These outputs are also consistent with the Health-related Millennium Development Goals (MDGs), which must be achieved by 2015. • The four outputs are also in harmony with the Health Sector’s 10 Point Plan for 2009-2014.

6. 3. NATIONAL HEALTH SYSTEM’S PRIORITIES (2)

7. 4. REVIEW OF PROGRAMME PERFORMANCE4.1. PROGRAMME 1: ADMINISTRATION (1) Achievements to date • National DoH obtained an Unqualified Audit Opinion from the AGSA for 2011/12. • This is the 2nd Unqualified Audit Opinion in three years. • Given that asset management was the basis for a qualified audit opinion for 2011/12, an Asset Management Plan was developed and effectively implemented by the DoH. A key challenge experienced, which was overcome, was the valuation of the asset register. • With respect to financial management amongst the Provincial DoHs, Only 4/9 Provinces overspent their budgets for 2011/12 – EC; GP; KZN &NC). Factors contributing to the projected over-expenditure were: prior year accruals; price increases; inadequate budget control, as well as underfunding of the health sector. • Provincial Financial Management Improvement plans were developed by all 9 Provinces, with technical support from National Treasury (TAU).

8. 4.1.PROGRAMME 1: ADMINISTRATION (2) Challenges & Remedial Action • Implementation of the Provincial Financial Improvement Plans was constrained by inadequate human resource capacity and limited resources. • The National DoH solicited alternative funding from international development partners (donors) to assist Provinces.

9. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (1) Achievements to date • The 2010 National Antenatal (ANC) Sentinel HIV and Syphilis and Prevalence Survey Report was produced, in partnership with key stakeholders, and published. It was launched by the Minister of Health in November 2011. • A 20-year database of HIV prevalence amongst ANC attendees has now been established (1990-2010). • Data from the 2010 National Antenatal Sentinel HIV and Syphilis and Prevalence Survey will play a significant role in informing the programmatic responses of government, civil society and international development partners to HIV&AIDS. • Data collection for the 2011 National Antenatal Sentinel HIV and Syphilis and Prevalence Survey has been completed and data analysis has commenced.

10. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (2) Achievements to date • A successful National Health Research Summit was convened in July 2011, under the auspices of the National Health Research Committee (NHRC) - A Ministerial Advisory Committee - to identify the strengths, weaknesses, opportunities and threats of health research, with a specific focus on the four (4) outputs of the NSDA 2010-2014. • The National Health Research Summit also aimed to identify the key priorities for strengthening health research, innovation and development over the next 3-5 years. • The Summit attracted diverse stakeholders from government departments, NGO’s, industry, research councils, professional organisations, academia and civil society. • A report on the Summit was published in the Lancet Journal in April 2012.

11. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (3) Achievements to date • An important M&E subsystem, the three-tier system for monitoring the provision of Antiretroviral therapy (ART) to people living with HIV and AIDS, first developed by the University of Cape Town and implemented in the Western Cape, was scaled up to other Provinces. • Tier 1 of the strategy consists of paper-based ART registers; Tier 2 entails the use of electronic registers in non-networked computers, while Tier 3 is the most advanced, as it entails development of a networked patient information system. • 133 Master trainers were trained, and by the end of March 2012, a total of 890 sites had started implementing Tier 2 of the system. • The Health Data Advisory and Coordinating Committee (HDACC), established by the DG of Health in October 2010, to establish consensus on key health outcome indicators for RSA, produced its report for 2011/12. • HDACC produced revised estimates for LE; IMR; CMR and MMR.

12. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (4) Achievements to date • 10 pilot sites for National Health Insurance (NHI) were identified and publicly launched. KZN Province identified an additional NHI pilot site. • NHI Conditional Grant Framework was approved by National Treasury. • The NHI grant provides funding for NHI pilot sites over the 2012/13 MTEF pilot sites.

13. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (5) Achievements to date • National DoH successfully facilitated the recruitment of 80 South African students to study medicine in Cuba, and this cohort group commenced with their medical training in Cuba in October 2011. • Medical students were from the following seven Provinces: • Eastern Cape (12); • Gauteng (10); • KwaZulu-Natal (12); • Limpopo (10); • Mpumalanga (12); • North West (12); and • Northern Cape (12).

14. 4.2. PROGRAMME 2: HEALTH PLANNING AND SYSTEMS ENABLEMENT (5) Challenges & Remedial Action • Auditor General of South Africa (AGSA) conducted an audit of performance information reported in the Annual Report of the National DoH for 2011/12. • AGSA expressed satisfaction in all material respects with the presentation and usefulness of the performance information, in accordance with the predetermined criteria. • AGSA acknowledged that leadership was provided for strengthening Health Information Systems as evidenced by the development of national policies for HIS and the production of draft SoPs. • However, AGSA identified major challenges with the reliability of data for 9 indicators for Programme 3 tested in 20 public health facilities in 8 Provinces. • National DoH developed a roadmap for strengthening HIS, which was adopted by the National Health Information Systems Committee of South Africa.

15. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (1) Achievements to date Combating HIV & AIDS • A total of 617,147 new patients were put on Antiretroviral Treatment in 2011/12, compared to 418,677 in 2010/11 • 9,6 million South Africans accepted HIV Testing in 2011/12 • A cumulative total of 20,2 million people have 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 6million.

16. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (2) Achievements to date Improving TB Management • A TB cure rate of 73,1% (for 2010) was achieved, against a target of 75%. This reflects an improving trend compared to the 71,1% cure rate recorded in 2010/11 (for 2009). • The TB defaulter rate has decreased from 7% in 2010/11 to 6,8% in 2011/12.

17. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (3) Achievements to date Improving Child Health • A national immunisation coverage rate (under 1 year) of 95,2% was achieved, against a target of 95%. • 4% of babies tested PCR positive 6 weeks after birth (out of all babies tested), which reflects very good performance when compared to the target of 7,5%. MRC PMTCT survey reflected a transmission rate of 3,5%. • 56,9% of Mothers and 57,8% Babies received post natal care within 6 days after delivery, against a target of 60%.

18. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (4) Achievements to date Improving Maternal and Women’s Health • An antenatal care coverage (ANC) rate of 100.4% was recorded, consistent with the target of 100%. Denominator issues are 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%.

19. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (5) Challenges & Remedial Action • A total of 347,973 MMCs were conducted in 2011/12, against a target of 500,000. Provincial variations occurred, with KZN conducting the highest number of MMCs. While this was lower than the set target of 500,000, it reflected high levels of performance for a newly introduced HIV prevention programme • A total of 397,106,000 male condoms were distributed, against a target of 1 billion male condoms. • Key challenges included service providers being unable to deliver the numbers specified in the tender as a result of a global latex shortage; delays in the registration of approved service providers in Provinces, and legal action initiated against National Treasury. • A measles immunisation coverage rate (second dose) of 85,3% was achieved, against a target of 95%.

20. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (5) Challenges & Remedial Action Nationally • HIV prevalence amongst antenatal attendees increased from 29,4% in 2009 to 30,2% in 2010, though this increase was not statistically significant. Provincially • HIV prevalence rates amongst antenatal attendees increased in 7 Provinces between 2009 and 2010, with the exception of KZN and NW. • In KZN, HIV prevalence rates amongst antenatal attendees remained stable at 39,5% for both 2009 and 2010. For both years, KZN had the highest prevalence rates in the country. • The North West Province experienced a decline in HIV prevalence rates from 30.0% in 2009 to 29,6% in 2010. • The Western Cape Province had the lowest HIV prevalence rate in the country of 18,5%. This reflected an increase from the 16,9% recorded in 2009, but this is attributed to a larger sample size from this province in 2010.

21. 4.3. PROGRAMME 3: HIV & AIDS, TURBERCULOSIS AND MATERNAL, CHILD AND WOMEN’S HEALTH (5) Challenges & Remedial Action District level • The five districts that recorded the highest prevalence rate in the country amongst antenatal attendees, which were above 40%, were located in KZN namely: Umkhanyakude (41,9%); eThekwini (41,1%); uMgungundlovu (42,3%); iLembe (42,3%) and Ugu (41,1%). • The number of district recording HIV prevalence rates of between 30% and 40% increased from 14/52 in 2009 to 21/52 in 2010. • The Central Karoo District in the Western Cape had the lowest HIV prevalence rate of 0,8%.

22. 4.4. PROGRAMME 4: PRIMARY HEALTH CARE SERVICES (PHC) (1) Achievements to date • A PHC utilisation rate of 2,5 visits per person was achieved in 2011/12, against a target of 2,6 visits per person. • Vitamin A supplementation coverage rate among children aged 12-59 months was 43%, which exceeded the target of 40%. • A total of 337 ward-based PHC Teams were established, which exceeded manifold the target of 54 teams.

23. 4.4. PROGRAMME 4: PRIMARY HEALTH CARE SERVICES (PHC) (2) Achievements to date • National DoH commenced with the implementation of the Integrated Chronic Disease Management (ICDM) model in 41 facilities in three districts across three Provinces. • The ICDM aims to ensure the integrated management of chronic diseases, to enhance the quality, effectiveness and efficiency of services provided to people living with these conditions. • The ICDM is being implemented in the West Rand District (Gauteng Province); Ehlanzeni District (Mpumalanga Province) and Dr. Kenneth Kaunda District (North West Province). Facilities in the three districts have commenced with: • Scheduling of chronic care patients • Designating dedicated consulting rooms for chronic patients. • Implementing waiting time surveys

24. 4.4. PROGRAMME 4: PRIMARY HEALTH CARE SERVICES (PHC) (3) Achievements to date • The Department produced a Strategic Framework for the Prevention of Injury in South Africa, which incorporates a plan for response to violence. • The Strategic Framework for the Prevention of Injury in South Africa is an integrated and intersectoral strategy with 12 key objectives. • It was developed in collaboration with other key stakeholders included the Departments of Basic Education; Correctional Services; Justice and Constitutional Development; Social Development; Trade and Industry; Transport; academic and research institutions such as the Medical Research Council (MRC); University of KwaZulu-Natal; as well as civil society.

25. 4.4. PROGRAMME 4: PRIMARY HEALTH CARE SERVICES (PHC) (4) Challenges & Remedial Action • District Hospitals achieved a Usable Bed Utilisation Rate (USBR) of 67,1% against a target of 70%. • Average length of stay in District hospitals was 4,3 days, against a target of 4 days. • A PHC supervision rate of 66,6% was recorded, against a target of 70%. • A review of Hospital Performance indicators was conducted by HST, and feedback was provided to Provincial DoHs.

26. 4.5. PROGRAMME 5: HOSPITALS, TERTIARY SERVICES AND WORKFORCE DEVELOPMENT (1) Achievements to date • The National DoH produced a Health Workforce Strategy responsive to the service delivery platform and begun to mobilise resources for its implementation. • The National Health Workforce Strategy was launched on the 11th October 2011. • A strategy for rural health workforce was incorporated into the National Health Workforce Plan. • The development of Norms and standards for the Health Workforce for Primary Health Care and Secondary Health Care commenced.

27. 4.5. PROGRAMME 5: HOSPITALS, TERTIARY SERVICES AND WORKFORCE DEVELOPMENT (2) Achievements to date • An audit of CHWs was completed, as part of the re-engineering of PHC. An M&E Plan (and tools) for Community-based services was produced in collaboration with the School of Public Health at UWC. • 42 technicians were trained by Tshwane University of Technology to conduct health technology audits, especially on safety performance across Provinces. • An external service provider was appointed in November 2011, for the development of the Integrated Project Management Information System (PMIS). Operational roll-out of the system and training of the users commenced in the new financial year. • The Essential equipment list (EEL) was completed for different levels of health facilities (Clinics and Tertiary Hospitals). This exceeded the target for 2011/12, which was to finalise the EELs for Primary Health Care.

28. 4.6. PROGRAMME 6: HEALTH REGULATION AND COMPLIANCE MANAGEMENT (1) Achievements to Date • National Health Amendment (NHA) Bill was tabled in Parliament following approval by Cabinet in 2011/12. • By March 2012, 90% of facilities (3,780) had undergone a baseline audit conducted by HST. The audit data has been validated. • Establishment of the new Pharmaceutical and Related Products Regulatory Authority (SAHPRA) was approved by Cabinet. • The draft Medicines and Related Substances Amendment Bill was published for comment for three months, expiring in June 2012. The Bill aims to strengthen transitional arrangements, including the regulation of foodstuffs, cosmetics, medical devices and in vitro diagnostics under SAHPRA and to improve the definition of medicines.

29. 4.6. PROGRAMME 6: HEALTH REGULATION AND COMPLIANCE MANAGEMENT (2) Achievements to Date • The newer triple fixed dose combination generic antiretroviral medicines were finalised within 18 to 19 months, discounting the time taken by applicants to respond to questions. This has contributed to the timely access to newer technologies for managing HIV and AIDS, which in turn improves life expectancy.

30. 4.6. PROGRAMME 6: HEALTH REGULATION AND COMPLIANCE MANAGEMENT (3) Challenges & Remedial Action • A key objective of the Department is to improve the registration of medicines, reduce the current backlog of registration and reduce the time to market. • During 2011/12, a total of 386 generics were registered within an average period of 34 months. The target for 2011/12 was 18 months. • A total of 34 Human NCEs were registered with an average period of 37 months. The target for 2011/12 was 18 months. • Challenges experienced by the Department included a lack of evaluators, both in-house and external. Technical experts were appointed for a fixed period of time to assist in fast-tracking the registration of medicines.

31. 4.6. PROGRAMME 6: HEALTH REGULATION AND COMPLIANCE MANAGEMENT (4) Challenges & Remedial Action • Only 40% of complaints from users of public health services were resolved within the set target of 25 days. • National DOH is dependent on Provincial Health Departments and other investigative authorities to investigate and report on the complaints. • A database of complaints has been established, which facilitates more effective monitoring of progress.

32. 5. BUDGET AND EXPENDITURE PER PROGRAMME (1)

33. 5. BUDGET AND EXPENDITURE PER PROGRAMME (2)

34. 6. BUDGET AND EXPENDITURE PER ECONOMICAL CLASSIFICATION

35. 7. EXPLANATIONS OF MATERIAL VARIANCES (1)

36. 7. EXPLANATIONS OF MATERIAL VARIANCES (2)

37. 8. AUDIT OUTCOMES • Unqualified Audit Opinion for 2011/12. • Matters to be attended to: • Employees were appointed without following a proper process to verify the claims made in their applications, in contravention of Public Service Regulation; • Not all senior managers signed performance agreements as required by Public Service Regulation; • A human resource plan was not in place as required by Public Service Regulation; • NGO funding monitoring not adequate to ensure transfers made was applied for intended purpose; • Conditional Grants monitoring of expenditure and non-financial information was not adequate for HIG, HPTDG and NTSG as required by DORA; • Requirements and responsibilities for HIG not adhered to; • Transfer payments for HIV/Aids not made in accordance with approved payment schedule; • Arrangements for HRG, FPG and HIV/Aids grant not adequately adhered to; • Business plans for FPG and HIV/Aids grant not approved prior to start of the financial year

38. 9. RECOMMENDATIONS • Further improve coordination and communication with the AG (Continue with audit protocols and regular steering committee meetings to manage the audit process); • Implement strategy to address audit findings (especially HR, NGOs and Conditional Grants). For those that can be implemented immediately the Department needs to determine whether they require processes and policies; • Address future audit risks e.g. Inventory

39. 10. CONDITIONAL GRANT EXPENDITURE (1)

40. 10. CONDITIONAL GRANT EXPENDITURE (2)

41. 10. CONDITIONAL GRANT EXPENDITURE (3)

42. 13. CONDITIONAL GRANT EXPENDITURE (4)

43. 10. CONDITIONAL GRANT EXPENDITURE (5)

44. 10. CONDITIONAL GRANT EXPENDITURE (6)

45. 11. TRADING ENTITIES AND PUBLIC ENTITIES (1) Medical Research Council : • The Medical Research Council (MRC) undertakes scientific research on clinical and health systems issues; • Funding from the Department’s vote amounted to R 271,2 million in 2011/12; • There is close co-operation with the Department of Health in setting research priorities.

46. 11. TRADING ENTITIES AND PUBLIC ENTITIES (2) National Health Laboratory Services • The National Health Laboratory Service Act, Act No 37 of 2000 came into operation in May 2001; • The National Health Laboratory Service’s major source of funding will be the sale of analytical laboratory services to users such as Provincial Departments of Health, but it continues to receive a transfer from the National Department, which amounted to R82,1 million in 2011/12.

47. 11. TRADING ENTITIES AND PUBLIC ENTITIES (3) Medical Schemes Council • The Medical Schemes Council regulates the Private Medical scheme industry in terms of the Medical Schemes Act (131 of 1998), and is funded mainly through levies on the industry in terms of the Council for Medical Schemes Levies Act (58 of 2000); • During 2011/12 the Department transferred R4,194 million to the Council.

48. 11. TRADING ENTITIES AND PUBLIC ENTITIES (4) South African National Aids Council Trust (SANACT) • During the period under review the SANAT was dormant. SANAC itself operated as planned with its activities funded by the HIV and AIDS Cluster within the National Department of Health.

49. 11. TRADING ENTITIES AND PUBLIC ENTITIES (5) Mines and Works Compensation Fund • The Compensation Commissioner for Occupational Diseases is responsible for the payment of benefits to miners and ex-miners who have been certified to be suffering from lung-related diseases because of working conditions. • The Mines and Works Compensation Fund derives funding from levies (Mine Account, Works Account, Research Account, State Account) collected from controlled mines and works, as well as appropriations from Parliament. • Payments to beneficiaries are made in terms of the Occupational Diseases in Mines and Works Act (78 of 1973). The value of the fund for the CCOD amounts to R1,1 billion while the Department’s transfer payment amounting to R2,777 million for the year under review. • The entire financial system of the Compensation Commissioner for Occupational Diseases is being re-engineered.

50. 12. CONCLUSION • Key milestones were achieved during the financial year 2011/12, in relation to the objectives and targets set in the National DoH Annual Performance Plan for this period. • The highlight of these is the improvement of financial management and the unqualified audit opinion for 2011/12. • Key challenges were also experienced, which affected some areas of service delivery. • Going forward the department will enhance the implementation of interventions to achieve the four outputs of the NSDA 2010-2014 namely: • Increased Life Expectancy • Decreasing maternal and child mortality • Combating HIV and AIDS and Decreasing the burden of diseases from Tuberculosis • Strengthening Health System Effectiveness.