1 DEPARTMENT OF HEALTH BUDGET HEARING MAY 2002 MPUMALANGA PROVINCE

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DEPARTMENT OF HEALTH

BUDGET HEARING MAY 2002

MPUMALANGA PROVINCE

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VISION:

Is a caring and humane society in which all the inhabitants of Mpumalanga have access to

affordable, good quality health services.

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MISSION

To provide and improve access to health care for all, and reduce

inequity and to focus on working in partnership with other stakeholders to improve the quality of care on all

levels of the health system especially preventive and promotive

health and to improve the overall efficiency of the health care delivery

system.

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The following priorities were set for improving Health in Mpumalanga,

and were confirmed by the MEC in her policy and budget speech.

Tackling HIV and AIDS

Improving Child Health

Improving Adolescent Health

Improving Women`s Health

Managing Rehabilitations Services

Improving Mental Health

Reducing Infectious and Parasitic Diseases

Tackling Trauma and Violence

Improving the Management Chronic Conditions

Improving Primary Health Care

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Improving Hospital Services

Improving Pharmaceutical Management System

Develop a Quality Framework

Develop the Workforce

Develop and maintain our Facilities

Poverty Alleviation/PNSI

Improve Information and Communication

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Achievements against priorities:

Much has been achieved against the priorities, such as:

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Tackling HIV and AIDS

Health Promotion Practitioners were trained as master trainers on Voluntary Counseling and Training (VCT) and they in turn are training Health Workers on VCT.

Life Skills programmes were introduced and implemented in Primary and Secondary Schools.

Awareness and Education Campaigns were conducted in all the districts.

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The Provincial Aids Council was launched as well as the District Councils in all the districts.

Home Based Care Projects were initiated in the Province and the pilot sites for Prevention of Mother to Child Transmission were established at Shongwe and Evander.

Our pilot sites for Neviarpine are continuing to provide the drug to pregnant women.

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We have invested considerable time and energy preparing the research sites for the prevention of mother to child transmission of HIV programme.

In addition,more Health Workers need to be trained in Voluntary Counseling and testing.

The launching of the Provincial Aids Council as well as the District Aids Council marked the culmination of the collaboration of efforts between government and the stakeholders to strengthen the partnership against the spread of HIV/AIDS. Local Aids Council are in the process of being established.

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However there are many challenges and constraints which still need to be addressed in this priority.

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Improving Child Health

The Province conducted a successful Immunization campaign in which all districts reached an access of 90% coverage. Minmec has however imposed a challenge for the Province to reach over 90% to 100% coverage.

An enhanced measles surveillance system was initiated and implemented.

There is a nil return of polio cases since 1990.

IMCI is implemented in focus areas, covering all our district.

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Three of our hospitals received Baby Friendly Awards. (Themba, Barberton and Bethal)

Mpumalanga still experiences a high rate of infant mortality which is attributed to factors such as HIV/AIDS, Malnutrition etc.

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Improving Women's Health

Guidelines on Management of main causes of maternal deaths were developed, launched and distributed throughout the Province.

Community awareness on the major causes of maternal deaths were addressed during the pregnancy education week on radio Ligwalagwala and Ikwekwezi.

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The management protocols for labour and hypertensive disorders in pregnancy had been completed and distributed to all facilities. These are used in all facilities and in particular those hospitals without a resident obstetrician.

Mpumalanga has been identified as one of the pilot sites for the Cervical Cancer Screening and Coloscopy Clinic Project. The following sites have been identified:

Philadelpia Hospital

Themba Hospital

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However there is still poor reporting of Maternal Deaths and their causes.

Abortion Care Programme: Only 6 hospitals in the Province are currently implementing TOP. The demand for TOP services has however increased.

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However the culture and the religious beliefs of the Health Workers imposed a constraint on the effective provision of TOP services.

In terms of maternal mortality most of the deaths are attributed to HIV and AIDS, hypertension during pregnancy, etc.

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Managing Rehabilitation Services

During this period the Department issued a lot of assistive devices to people with disability such as electric wheelchairs, hearing aids, walking aids and prosthesis.

983 Wheelchairs were distributed throughout the Province.

468 Hearing Aids were issued.

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A community based Rehabilitation Peer Counseling Programme established under the auspices of Disabled People South Africa, Mpumalanga is continuing. This programme has been extended and services are rendered in all 17 Municipalities

5963 Individuals have benefited from this programme.

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An integrated disability service programme for the Department has been developed as an input to the Provincial Plan of Action on Disability facilitated by the Office on the Status of Disabled Persons in the Office of the Premier.

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Improving Mental Health Services

PHC Nurses were trained in Mental Health Care.

Medical Officers attended workshops on Mental Health Care and they were trained in Mental Health Care, Assessment, Diagnosis and Treatment.

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However the Province does not have facilities for chronic patients. Patients are referred to facilities outside the Province in particular Gauteng and this imposes transport and accommodation problems in such Provinces. Therefore the need to develop community based facilities and a chronic care facility in the Province.

The Othandweni Violence Referral Centre is progressing well and is counseling and supporting on an average 80 clients per month. Clients seen presented with rape, other sexual offences and domestic violence.

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Victim Empowerment Rooms have been established in hospitals such as Ermelo, Lydenburg, Middleburg and Witbank.

A database of all mentally ill patients has been initiated and has provided information in terms of the magnitude of mental health problems, types, length of treatment, patterns of diagnosis and prescription. This information will form a basis for resource planning in mental health.

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Reducing Infectious and Parasitic Diseases

Tuberculosis.

The TB programme was successfully conducted.

The availability of TB Drugs was secured.

The laboratory turn around time for sputum smears remains below 48 hours average, with most of the clinics receiving their results within 24 hours.

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TB is treated according to the Direct Observed Treatment Strategy (DOTS). Executed in PHC Clinics the DOTS Programme has been effectively implemented in the Province.

Patients who can not be treated on an ambulatory basis are admitted in one of the Santa Hospitals or the Provincial TB Hospital. TB registers are maintained in each of the hospitals for all patients admitted.

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However the doubling of the mortality ratio within 2 years a finding reflected in the National TB Statistics does indicate the maturing of HIV Epidemic and the urgent need for adequate palliative care provision and dedicated TB facilities.

TB Management has been identified as a National Priority and to that regard a Medium Term Strategy was launched at Standerton to cover 2002 to 2005.

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Malaria:

Malaria Programme received an award for their successes.

A field based evaluation of local mosquito plant repellents demonstrated that fever tea plant (Lippia javanica) provides effective protection against malaria mosquito bites.

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Cholera:

The Cholera Control effort continued into the new financial year. Radio slots were obtained for health promotion. Health Promotion Material, water sanitizing materials were distributed.

Training of personnel in cholera control.

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Managing Chronic Conditions

Standard Treatment Guidelines were developed in line with International Best Practice and National Guidelines.

An essential Drug List at both Primary and Secondary Levels of care developed and implemented

23 Community Service Dentist were appointed, the Continuing Professional Development Programme is on-going.

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The Dentists are given the opportunity to rotate to more specialised services at Witbank and Rob Ferreira, to enable them to practice their newly acquired skills.

In respect of Ophthalmology Services, eye care awareness was conducted in the Province.

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A primary eye care network has been established in all hospitals and several clinics in the Ehlanzeni district, at Embhuleni, Piet Retief and Bethal Hospitals in the Eastvaal, and Witbank Middelburg and Philladelpia in Ekangala.

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Improving Primary Health Care Services.

PHC was adopted by the Province as the main strategy for developing and promoting the health of the communities, our goal was to bring health care closer to our communities, ensuring an equitable distribution of resources and encourage individuals to fully participate in decision making and responsibility of their own health care.

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It was the objective of the Department to develop the capacity of local communities, clinics and health centres to provide high quality health Promotion and comprehensive PHC Services.

However patients bypass clinics and go directly to hospitals where it is perceived that they would receive a better quality of service.

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Much still needs to be done on the provision of an Essential PHC Package.

The availability of drugs and staff at clinics are some of the challenges facing the Provision of PHC.

The availability of drugs has however improved.

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Develop a Quality Assurance Framework

The Quality Assurance Unit conducted various workshops in all three districts on improving the quality in the provisioning of our health services.

In service training on Batho Pele and the Patient`s Charter was conducted by the Quality Assurance Unit.

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However the question posed is are we adhering to these principles and the Patient Charter.

These principles and the Patient Charter are still very relevant, if we are to improve the quality of our services.

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Our Province received a number of Awards to reward good Performance namely:

Tonga received a Certificate for best practices as a rural area with external support.

Lydenburg as a rural area without external support.

Middelburg received a certificate for participation as a urban area without external support.

Lydenburg received a trophy for the Best Managed HIV/AIDS Programme nationally.

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Ehlanzeni District awards for best managed HIV/AIDS & TB Programme nationally.

Piet Retief certificate for best practice in Quality Assurance

Three prizes were received in the Cecilia Makiwane Awards.

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Improving Emergency Medical Services

The management of EMS services was decentralized to the Hospitals. This however posed many challenges in the provision of EMS and the management there of.

Work-study eventually approved the establishment of EMS directorate in the Provincial Office which will attend to all issues affecting the provisioning and management of EMS.

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The Director EMS has been appointed.

30 Ambulances were purchased, as well as 30 patient transporters.

However our drivers will be subjected to extensive training so as to ensure that these vehicles are not lost due to reckless and irresponsible driving.

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In service training is provided at the training college in Barberton.

Training facilities are not adequate and most personnel are still sent outside the Province to do training.

We will be looking however to the possibility of developing a Training Centre in the Province.

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Developing the Workforce.

The objectives set for achieving this priority:

The developing a Workforce Plan for the Mpumalanga Health Department.

Developing a training and education plan in support of the Workforce Plan. Establishing a Personnel Management System.

The training and education plan was finally put in place during 2001 and training programmes conducted.

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A workforce Plan is being finalized.

Performance Management System is in the process of being finalized.

A major constraint was the lack of an approved organisational structure.

This resulted in understaffing in some areas and a skewed distribution of personnel.

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Improving hospital services

The objective was to develop the capacity of district hospitals, regional and referral hospital complexes and where appropriate provide a range of secondary and tertiary care services in the Province.

Due to an inadequate referral system our Level 1 services experience an influx of patients and inappropriate admissions.

Aim is reduce referral outside the Province.

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PHC centres and clinics are passed.

This imposes an increasing burden on our hospitals.

At present Level 2 services are provided at Witbank Hospital.

A programme has been developed to Redistribute specialist services to the 3 regions in the Province, namely Rob Ferreira-Themba Hospital complex in Ehlanzeni and outreach services at Ermelo in the Eastvaal.

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Improving Pharmaceutical Services

Because of the cash flow constraints experienced during the year 2000, the early parts of 2001 initially saw the inadequate supply of pharmaceuticals in our facilities. However by June 2001 all accounts for drugs were paid and the supply of drugs improved dramatically reaching a level of 95%.

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However because of inadequately trained staff especially in the clinics a short supply of drugs was experienced in some clinics.

The theft of drugs also poses a major problem on our resources, thus one cannot over emphasize the stamping out of corrupt officials. There is a need for the training of pharmacists to monitor the supply of essential drugs and needless to say the revision of the Essential Drug List is important.

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Improvement and Maintenance of our Health Facilities:

There was an on going process of upgrade our health facilities and clinics in the Province.

New Piet Retief Hospital:(main building) The building work has commenced.

Upgrading of hospitals:

Themba Hospital,

Witbank Hospital

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New Clinics built:

Mmamethlake, Nonkaneng, Seabe and Moloto Clinics.

The following upgrades are planned for 2002/2003

Kwamhlanga Hospital,

Rob Ferreira Hospital,

Philadelphia Hospital,

Witbank Hospital,

Embhuleni Hospital,

Themba Hospital,

Ermelo Hospital and

Mmamethlake Hospital

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Pharmaceutical Depot

Clinics:

Amsterdam

Moutse

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BUDGET 2002/2003

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BUDGET BUDGET MTEF MTEF2001/ 02 2002/ 03 2003/ 04 2004/ 05

R'000 R'000 R'000 R'000

Personnel expenditure 812,412 879,185 941,332 990,158 Administrative expenditure 72,670 90,965 145,892 151,710 Inventories 242,658 266,243 329,649 342,562 Equipment 48,584 57,983 67,229 99,850 Lands and Buildings 4,493 2,622 4,151 6,554 Professional and Special Services 283,561 299,927 337,331 379,686 Transfer Payments 51,241 56,790 58,317 61,816 Conditional Grants Specified items General TransfersMiscellaneous 1,397 2,851 4,069 4,312 Total 1,517,016 1,656,566 1,887,970 2,036,648

MPUMALANGA DEPARTMENT OF HEALTH

STANDARD ITEMS 2002 - 2005

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BUDGET ADJUSTMENT TOTAL ACTUAL BUDGET BUDGET EXPENDITURE BALANCE

2001/ 2002 2001/ 2002 2001/ 2002 2001/ 2002 2001/ 2002R'000 R'000 R'000 R'000 R'000

Personnel expenditure 799,864 12,548 812,412 811,435 977 Administrative expenditure 49,329 23,341 72,670 67,031 5,639 Inventories 215,103 27,555 242,658 253,852 -11,194 Equipment 31,044 17,540 48,584 66,656 -18,072 Lands and Buildings 6,046 -1,553 4,493 3,642 851 Professional and Special Services 285,937 -2,376 283,561 201,605 81,956 Transfer Payments 23,678 27,562 51,241 50,623 617 Conditional Grants - Specified Items General TransfersMiscellaneous 1,397 1,397 1,717 -320 Total 1,411,001 106,014 1,517,016 1,456,561 60,454

MPUMALANAGA DEPARTMENT OF HEALTH

ALLOCATION AND EXPENDITURE PER STANDARD ITEM

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Budget Budget MTEF MTEF2001/ 2002 2002/ 2003 2003/ 2004 2004/ 2005

R'000 R'000 R'000 R'000

Programme1: AdministrationMember of the Execurtive 6,992 1,811 2,495 2,646 Corporate Services 94,022 128,476 162,365 177,907 Management

Total: Programme 1 101,014 130,287 164,860 180,553

Programme 2:District Health ServicesTechnical Services 6,501 3,000 3,255 3,371 Malaria Control Programme 12,143 12,217 12,950 13,727 Emergency Medical Services 33,239 22,852 24,223 26,275 Pharmaceutical Services 32,362 District Health Services 975,433 1,100,641 1,245,945 1,345,274 Total: Programme 2 1,059,678 1,138,710 1,286,373 1,388,647

BUDGET 2002 - 2005

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Programme 3:Regional & Specialised ServicesRegional Hospital 78,444 97,663 102,595 101,220 Specialised Hospital 4,141 6,973 7,392 7,835 Total: Programme 3 82,585 104,636 109,987 109,055 Programme 4:Human Resource DevelopmentNursing College 25,302 28,533 30,125 31,811 Ambulance Training College 1,333 1,333 1,413 1,498 Bursaries 8,973 11,025 11,687 12,388 Total: Programme 4 35,608 40,891 43,225 45,697


R'000 R'000 R'000 R'000

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Programme 5:Health Care Support ServicesProvincial Motor Transport 10,801 21,548 22,841 24,211 Pharmaceutical Services 3,703 3,822 4,051 4,294 Total: Programme 5 14,504 25,370 26,892 28,505

Programme 6:Healt Facilities & Capital StockNew Facilities 10,300 9,923 13,496 12,288 Clinics RehabilitationUpgrading ( Rehablitation ) 1,125 Total: Programme 6 10,300 9,923 14,621 12,288


R'000 R'000 R'000 R'000

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ACTUAL BUDGET TOTAL ACTUAL2001/ 2002 BUDGET EXPENDITURE ACTUAL BUDGET

2000/ 2001 MARCH 2001 2001/ 2002 2002/ 01/ 312001/ 2002 2002/ 2003R'000 R'000 R'000 R'000 R'000 R'000

EQUITABLE SHARE 990,469 1,252,385 1,303,689 1,294,772 1,449,817 CONDITIONAL GRANTS 126,899 158,616 213,327 161,747 206,749 Sub-Total 1,117,368 1,411,001 1,517,016 - 1,456,519 1,656,566 OWN REVENUE 12,160 25,270 24,069 33,501 TOTAL BUDGET 1,129,528 1,411,001 1,542,286 - 1,480,588 1,690,067


BULK ALLOCATIONS

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R'000 R'000 R'000 R'000

Total: Equitable Share 1,303,689 1,449,817 1,645,958 1,764,745

Conditional grants:Integrated Nutrition Programme 44,723 39,728 39,728 42,112 Redistribution of Health Services 75,158 National Tertiary Grant 38,413 39,237 40,249 Health Professional Training and Research 24,377 30,347 34,456 45,277 Hospital R & R 45,987 45,000 47,025 49,847 Health Management 4,000 3,000 7,000 7,420 Hospital Management Improvement 8,000 12,000 12,720 Provincial Infrastructure 8,573 16,655 24,944 30,879 HIV/ AIDS 5,058 15,606 25,621 34,852 Flood Reconstruction 5,451 10,000 2,000 Supplementary Treasury Grant 10,000 8,547

Total: Conditional grants 213,327 206,749 242,011 271,903

Total: Provincial Department of Health 1,517,016 1,656,566 1,887,969 2,036,648

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Budget Supplem. Total Actual *Adj. Bud. Budget Expenditure Balance

2001/ 2002 2001/ 2002 2001/ 2002 2001/ 2002 2001/ 2002R'000 R'000 R'000 R'000 R'000

Programme1: Administration 99,300 29,760 129,060 110,220 18,840

Programme2: District Health Services 1,048,552 34,389 1,082,941 1,076,260 6,681

Programme3: Regional & Specialised Services 151,164 38,879 190,043 160,221 29,822

Programme4: Human Resource Development 35,608 2,987 38,595 32,638 5,957

Programme5: Health Care Support 14,504 14,504 12,664 1,840

Programme6: Health Facilities & Capital Stock 61,873 61,873 63,763 -1,890

Theft and Losses 754 -754

Total: Programmes 1,411,001 106,015 1,517,016 1,456,520 60,496


EXPENDITURE PER PROGRAMME

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2001/ 20022001/ 20022001/ 20022001/ 20022001/ 2002Allocation Roll-over Total Actual Balance

R'000 R'000 R'000 R'000 R'000Conditional grants:

Intergrated Nutrition Programme 39,728 4,995 44,723 35,950 8,773Redistribution of specialised Hospital Services 37,588 37,570 75,158 49,574 25,584National Tertiary Services 0 0Health Professional Training and Research 24,377 24,377 22,275 2,102Hospital R & R 43,000 2,987 45,987 43,419 2,568Health Management 2,000 2,000 4,000 0 4,000Hospital Management Improvement 0 0Provincial Infrastructure 8,573 8,573 4,550 4,023HIV/ AIDS 3,350 1,708 5,058 1,528 3,530Flood Reconstruction 1,000 1,787 767 1,020Malaria 4,451 4,451

Total: Conditional grants 158,616 54,711 213,327 161,747 51,600


CONDITIONAL GRANTS

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Explanatory Notes:

Programme 1; Administration:

The Department was able to control Cell phone and Telephone expenditure. Savings effected were needed to cover over expenditure in inventories (i.e. medicine and equipment urgently need in the hospitals and clinics).

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Programme 2; District Health Services

Savings effected by rationalising renting of various former district offices and utilisation of government buildings in terms of Cabinet Resolution.

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Programme 3; Regional and Specialised Services.

Payment for Specialised equipment ordered during 2001/2002 will be effected during the first quarter of 2002/2003.

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Programme 4; Human Resource Development

Adjusted budget of R2,987 million was wrongly Gazetted by Provincial Treasury to Programme 4 instead of Programme 6. Used to cover over-expenditure in programme 6.

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Programme 5; Health Care Support.

Savings due to scaling down of activities in the packaging deport in Middleburg to the main depot at Ekandustria.

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Programme 6; Health Facilities and Capital Stock.

The programme is overspent due to the error as mentioned above.

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Conditional Grant:

Integrated Nutrition Programme:

Payment to contractors and helpers for services rendered in March, effected during April 2002.

Health Professional Training and Research

Payment to both University of Pretoria and Medunsa for joint appointees effected in April 2002, for March services.

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Redistribution of specialised hospital services.

Specialised equipment ordered in late 2001/2002 payments to be effected during first quarter of 2002.

HR & R

For planning briefs, as a result of appointment of consultants delayed due to tender processes and repriotitization of projects.

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Health Management:

Under expenditure due to unavailability of organogram which was urgently undertaken, for appointment of CEO`s and Senior Managers at designated hospitals.

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PROVINCIAL INFRASTRUCTURE:

Orders for greater capital equipment have been issued, awaiting delivery to effect payment.

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HIV/AIDS:

Investigation conducted since officials in this Unit were discovered to be trustees of an NGO called MPSA. Investigations were to establish whether any government funds were transferred to the NGO and investigations revealed that none were transferred. The Head of Unit, has since resigned. This had effect of delaying the projects. New Director HIV/AIDS has since been appointed and Business Plans are in place. There will be monthly and quarterly reporting on transfer to National.

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HIV/AIDS:

Social Awareness Campaigns have been conducted and Business Plans are in place for VCT, Home Based Care and PMTCT.

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Flood Reconstruction:

Transfer of R1 million was effected after the Malaria season was over. Business Plan for this financial year is available and full allocation will be used for the coming Malaria season, for radio slots, medicine, mosquito nets and spraying equipment.

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Mechanisms to improve Capacity:

Monthly and Quarterly Financial Reports submitted to Treasury

Certificate signed by Accounting Officer at the end of the financial year.

Liaison and Technical support to be received from the National Department.

Programme Managers submit business plans on conditional grants

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Service agreement signed with National for provision of Tertiary Services, in terms of National Tertiary Services Grant.

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Quarterly reporting on tertiary service level, and posts filled in terms of agreement.

Province to supply information on the training of medical personnel in terms of the Health Professional Training and Development Grant.

Compliance with Provincial Priorities.

Reports on Projects implementation to be submitted.

Quarterly and monthly financial reporting on transfers and expenditure.

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Comment on budgetary allocation, MTEF, process and any shortcomings and addressing of Equity.

The Mpumalanga Province had a budget of R1,350 billion for the 2001/2 financial year. For 2002/3 budget is R1,656 billion.

However demands on the budget exceed the resources available.

Problems of cross border influx: Patients from neighboring Provinces and countries accessing our health care e.g.. Northern Province, Kwazulu Natal, Gauteng, Swaziland and Mozambique.

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Need for expansion of Primary Health Care Services.

The impact of HIV/AIDS.The 200 HIV Survey showed that 29,7% of Women attending ante-natal clinics in the Province were HIV positive.

This would mean that in the short term opportunistic diseases need to be treated, resulting in increased costs of interventions, i.e. bed occupancy, medication and laboratory tests.

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Training of caregivers in Home Based Care and community based care needs to receive attention to prevent prolonged institutionalization of HIV infected patients. The Department plans to expand testing counseling and voluntary care and support services.

Timeous business plans need to be prepared in this regard.

Youth behavioral change will be targeted through intensifying life-skills programmes and social awareness campaigns.

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Training of personnel to manage HIV/AIDS are challenges to the budget, as well as ensuring that there is adequate infrastructure.

Further distribution of specialised services.

Mpumalanga Province is poorly supplied with level 2 services. Patients are referred constantly outside the Province. It is the aim of the Province to move specialist services nearer to the population. At present Level 2 services are pounded at Witbank Hospital and to a certain extent at Rob Ferreira.Mpumalanga has virtually no Level 3 services.

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Consideration is given to the phasing in of the provision of highly specialised services.

Human Resources: Mpumalanga is rural Province. Retention of Professional staff is a challenge.

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Budgetary Allocation – Progress towards Equity.There is inequity in budgetary allocation.

According to the FFC Formula, 85:15 ratio should be applicable, in favor of Social Services.

Provincially however we are at ± 82%.

Health is allocated, 17.1% of the Provincial Budget, as opposed to its other Provincial Counterparts e.g. Gauteng.

Mpumalanga Province, is below the National average per capita spending as opposed to Gauteng and Western Cape. (R600 as opposed to R1 600 – Inter-Provincial)

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Provincial Discretion on allocation of funds between sectors.

Conditional grants mechanism to overcome.

Provincial discretion, however late transfers are problematic.

All provinces are moving upwards in spending pattern, but only ±2,2% growth in budget.

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Department of Health

Mpumalanga

Documents

1 DEPARTMENT OF HEALTH BUDGET HEARING MAY 2002 MPUMALANGA PROVINCE