Mpumalanga Department of Health Report of the Integrated ... · Mpumalanga Department of Health: Report of the Integrated Support Team Strictly Private & Confidential Page 7 Not for

Mpumalanga Department of Health

Report of the Integrated Support Team

Strictly Private & Confidential May 2009

Mpumalanga Department of Health: Report of the Integrated Support Team

Strictly Private & Confidential Page 2 Not for quotation

Contents

Contributors and Editorial Support ......................................................... 4

Acknowledgements................................................................................ 5

Abbreviations ......................................................................................... 6

Foreword ............................................................................................... 9

Executive Summary ............................................................................. 10

Introduction .......................................................................................... 16

1. BACKGROUND ................................................................................................. 16

2. AIMS OF THE EXERCISE ................................................................................. 16

3. SPECIFIC OBJECTIVES ................................................................................... 17

4. METHODOLOGY .............................................................................................. 17

5. OUTLINE OF THE REPORT ............................................................................. 18

Financial Review ................................................................................. 20

1. INTRODUCTION ............................................................................................... 20

2. UNDER-FUNDING OF THE PUBLIC HEALTH SYSTEM IN SOUTH AFRICA ... 21

3. PROVINCIAL BUDGET ALLOCATION .............................................................. 21

4. NATIONAL CONDITIONAL GRANT ALLOCATION ........................................... 25

5. TOTAL BUDGET PER CAPITA ......................................................................... 26

6. TRENDS IN HEALTH EXPENDITURE .............................................................. 28

7. UNFUNDED MANDATES DURING 2008/09 ..................................................... 33

8. BUDGETING PROCESS ................................................................................... 34

9. FINANCIAL MANAGEMENT PROCESSES ...................................................... 35

10. COST ALLOCATION ......................................................................................... 36

11. QUARTERLY PERFORMANCE REPORTS ...................................................... 36

12. FINANCIAL REPORTING .................................................................................. 37

13. MONITORING STRUCTURES .......................................................................... 37

14. RECOMMENDATIONS ..................................................................................... 38

Leadership, Governance and Service Delivery .................................... 41

1. INTRODUCTION ............................................................................................... 41

2. GENERAL ISSUES OF GOVERNANCE AND LEADERSHIP ............................ 42

3. PLANNING ........................................................................................................ 43

4. GOVERNANCE ................................................................................................. 47

5. SERVICE DELIVERY (HIV, TB AND MCH) ....................................................... 47


Human Resources ............................................................................... 57

1. INTRODUCTION ............................................................................................... 57

2. DELEGATIONS, ACCOUNTABILITY AND RESPONSIBILITY .......................... 58

3. INTEGRATION AND CO-ORDINATION ............................................................ 58

4. HUMAN RESOURCE PLANNING ..................................................................... 58

5. ORGANISATIONAL DESIGN AND ESTABLISHMENT ..................................... 59



6. RECRUITMENT ................................................................................................ 60

7. PERFORMANCE MANAGEMENT .................................................................... 60

8. RETENTION ...................................................................................................... 61

9. REWARDS ........................................................................................................ 62

10. LEARNING AND DEVELOPMENT .................................................................... 63

11. HR INFORMATION SYSTEMS ......................................................................... 63


Information Management ..................................................................... 68

1. INTRODUCTION ............................................................................................... 68

2. USE OF INFORMATION FOR DECISION MAKING .......................................... 71

3. DISTRICT HEALTH INFORMATION SYSTEM (DHIS) ...................................... 72


Medical Products ................................................................................. 76

1. INTRODUCTION ............................................................................................... 76

2. MEDICAL PRODUCTS ...................................................................................... 76


Technology and Infrastructure ............................................................. 79

1. OVERVIEW ....................................................................................................... 79


Security ............................................................................................... 82

1. OVERVIEW ....................................................................................................... 82


Taking Forward the Recommendations ............................................... 85

Appendices ........................................................................................ 108

1. APPENDIX 1: TERMS OF REFERENCE ........................................................ 108

2. APPENDIX 2: LIST OF DOCUMENTS REVIEWED......................................... 121

3. APPENDIX 3: SCHEDULE OF INTERVIEWS ................................................. 126

4. APPENDIX 4: FINANCIAL TABLES REFERENCES ....................................... 128



Contributors and Editorial Support

Peter Barron

Annalize Fourie

Hanno Gouws

Bertie Loots

Gerrit Muller

Laetitia Rispel

Annie Snyman

Malcolm Wallis



Acknowledgements

We wish to thank the Acting Head of Department, Dr Sibongile Zungu, for facilitating the review

and for access to information. Special thanks go to Ms Milani Wolmarans, Director: Strategic

Planning, for providing additional information. Thanks also to all the managers from the

Mpumalanga Department of Health for the time spent in interviews and the valuable insights

provided.

We thank Gitesh Mistry, Frank Groenewald, Thuli Mashinini, Pontsho Makgabo and Ruqayya

Dawood for project management and administrative assistance.

This review has been conducted with funding from the UK Government‟s Department for

International Development Rapid Response Health Fund.

The views presented in this report are those of the authors and are based on inputs received

during the interview process and documentation analysed. It does not necessarily represent the

decisions, policies or views of the national Ministry of Health, the Mpumalanga Department of

Health or DFID.



Abbreviations

AFS Annual Financial Statements

AIDS Acquired Immunodeficiency Syndrome

APP Annual Performance Plan

ART Anti-retroviral Therapy

ARV Anti-retroviral

BAS Basic Accounting System

BBR Bushbuckridge

CEO Chief Executive Officer

CFO Chief Financial Officer

CHC Community Health Centre

CSIR Council for Scientific and Industrial Research

DFID UK Government‟s Department for International Development

DHIS District Health Information System

DHS District Health System

DMT District Management Team

DOH Department of Health

DOPW Department of Public Works

DOTS Directly Observed Therapy Short-Course

DPSA Department of Public Service and Administration

EU European Union

HAS HIV, AIDS and STI

HIS Health Information System

HIV Human Immunodeficiency Virus

HOD Head of Department

HR Human Resources

HSS Health Systems Strengthening

HST Health Systems Trust

ICT Information and Communication Technology

IDP Integrated Development Plan(ning)

IST Integrated Support Teams



IT Information Technology

IYM In Year Monitoring

LOGIS Logistical Information System

LPDOH Limpopo Province Department of Health

M&E Monitoring and Evaluation

M&OD Management & Organisational Development

MACH Ministerial Advisory Committee on Health

MCH Maternal and Child Health

MEC Member of the Executive Council

MP Mpumalanga Province

MPDOH Mpumalanga Provincial Department of Health

MPDOPW Mpumalanga Department of Public Works

MPDOSS Mpumalanga Department of Safety and Security

MTEF Medium Term Expenditure Framework

N/A Not available/ not applicable

NDOH National Department of Health

NSP National Strategic Plan

NTSG National Tertiary Services Grant

OSD Occupational Specific Dispensation

PALAMA Public Administration Leadership and Management Academy

PDE Patient Day Equivalent

PERSAL Personnel and Salary Administration System

PFMA Public Finance Management Act

PHC Primary Health Care

PMDS Performance Management Development System

PMTCT Prevention of Mother-To-Child-Transmission

RFH Rob Ferreira Hospital

RRHF Rapid Response Health Fund

SAMDI South African Management Development Institute

SCOA Standard Chart of Accounts

STI Sexually Transmitted Infection

STP Service Transformation Plan



TB Tuberculosis

TR Team Representative

WHO World Health Organization



Foreword

As South Africa is entering its fourth period of democratic government, together with the

appointment of a new Cabinet on 10th May 2009, this presents a window of opportunity to

revitalise the public health system for improved health outcomes.

This report contains the findings and recommendations of the IST Review in Mpumalanga

Province (MP) on the Mpumalanga Provincial Department of Health (MPDOH). There are many

senior managers who are working hard to maintain and improve the foundations of a functional

public health system. However, the report also identifies many shortcomings that are critically

affecting and undermining optimal service delivery to the almost four million people in MP that

depend on the public system for comprehensive health service delivery.

The causes of these shortcomings are complex and different government departments such as

the National Treasury, and the Provincial Treasury, the Department of Public Service &

Administration and Department of Public Works will be required to work together with the

National and Provincial Departments of Health towards their solution. However, many solutions

fall within the ambit of the MPDOH and the new political leadership and senior MPDOH

managers are urged to become champions for the changes proposed in this report. The

concluding section of the report contains a detailed set of recommendations proposed to

address the many pressing challenges that the IST has identified in MPDOH.

The IST dedicates this report to the custodians of public health in MP with the following quote

from the 2008 World Health Report:1

“In order to bring about such reforms in the extraordinarily complex

environment of the health sector, it will be necessary to reinvest in

public leadership in a way that pursues collaborative models of policy

dialogue with multiple stakeholders – because this is what people

expect, and because this is what works best”.

1 World Health Organization (2008). World Health Report 2008: Primary health care: now more

than ever. Geneva, Switzerland: WHO, 2009



Executive Summary

The accompanying report contains the background, methods, results and recommendations of

the review conducted by the Integrated Support Team (IST) of the Mpumalanga Province

Department of Health (MPDOH). The IST was established in February 2009 at the initiative of

the former honourable Minister of Health, Ms Barbara Hogan. The review was prompted by the

projected overspending in certain of the provinces during the 2008/09 financial year, because

overspending has the potential to undermine the capacity of the national health system to

improve health outcomes, in particular the health sector‟s response to the HIV epidemic.

The aims of the IST review were to:

Recommend prioritised and practical actions to improve the functioning of the public health

care system in South Africa on a sustainable basis.

Integrate the recommended actions into a health systems approach that includes

perspectives on governance, leadership, finances, human resources, information,

infrastructure and technology and that will result in improved service delivery that is

effective and equitable.

Achieve maximum possible consensus on the recommended actions with the existing

public health delivery structures in South Africa.

The full terms of reference are attached as Appendix 1.

The IST review was a broad-based, rapid appraisal that focused on the health system as a

whole. The review was conducted by a team of financial, public health, and management and

organisational development specialists. The work of the finance, health systems and

management experts was integrated into a holistic framework, adapted from the World Health

Organization (WHO). This WHO framework suggests that the key building blocks of a health

system are: Service Delivery, Leadership and Governance; Human Resources (Health

workforce); Finances; Information management; Medical products; and Technology and

Infrastructure.



Selected key findings from the IST review

1. The per capita budget for health in Mpumalanga (based on the total uninsured

population) is lower than the average provincial uninsured per capita budget for

South Africa by a large margin.

2. Overspending has led to stringency measures with associated negative

consequences for service delivery, managerial performance and staff morale.

Unfunded mandates (e.g. policy decisions such as functional integration,

occupational specific dispensation, introduction of dual-therapy PMTCT) exacerbate

spending pressures.

3. Financial management is in crisis, as many managers are in acting positions and

almost half of financial posts are vacant. Budgeting and financial management

processes (including cost allocations and proper cost centre accounting; financial

monitoring and evaluation) are sub-optimal. The reported underspending is

misleading since it does not include the effect of accruals and if no radical measures

are taken to remedy the situation there are likely to be further cuts in service delivery

in the 2009/10 financial year.

4. The full budgetary impact of the cost of treatment required by patients on ART needs

to be better quantified.

5. The lack of stable political and administrative leadership and political interference in

key management processes over a relatively long period of time has led to an erosion

of good management practices. This has been exacerbated by many managers

serving in acting positions.

6. Key planning documents of the MPDOH show the lack of an overall vision for the

public health system in the province. It is often difficult to reconcile strategies, targets

and planned activities with stated priorities and budgets.

7. HIV&AIDS, TB and MCH are being designated as high priority areas in the APP and

relatively ambitious targets are set. However, reported progress towards achieving

these targets does not appear to support a sense of urgency in improving access to



or outcomes of services provided. Slow progress with the accreditation of ARV

treatment sites and inadequate costing of the treatment plan are likely to restrain the

scaling up of access to treatment to the levels targeted.

8. The financial feasibility of key interventions such as the new STP and the new

organogram needs more thorough assessment to ensure cost effectiveness.

9. A highly centralised HR model exists, with an unwillingness to delegate authority to

lower levels and reportedly low morale throughout the organisation.

10. Although the number of unfilled posts is high, the new organogram amounts to an

approximate 50% increase in the total number of posts of which the cost implications

have not been considered.

11. Selection processes are reportedly politically determined rather than based on the

merit of the applicants. Performance management has not been fully implemented.

12. The implementation of OSD for nurses and the agreement reached with the unions in

2007 has created funding pressures which the province cannot meet financially.

13. M&E is not assigned sufficient significance in the organisational structure, levels of

resourcing (including HR, finances and ICT), planning processes and accountability

mechanisms in MPDOH.

14. There are many different information management systems for “service delivery”

(DHIS and programmes) and “resource” systems (e.g. BAS, LOGIS, PERSAL) that

are poorly integrated.

15. Drug budgets are insufficiently prioritised. Stock-outs of medicine and medical

products have become widespread and common in all facilities across the province

during the 2008/09 financial year, affecting many aspects of service delivery,

exacerbated by failure to pay drug suppliers on a timely basis and inefficient supply

chain management processes.



Key recommendations are listed below:

FINANCES

1. The Provincial Treasury should allocate an amount to the MPDOH, which is

substantially in line with the equitable share from the National Treasury.

2. Allocations of conditional grants by the NDOH should be based on clear, objective

criteria that are linked to grant specific indicators.

3. The operational impact of national policy decisions (e.g. OSD, new vaccine

programme) should be determined and must be agreed with the MPDOH prior to

implementation. There should be alignment between political decisions and

operational implementation and agreement reached for any proposals on increases

of service levels prior to their announcement. The availability of funding should also

be confirmed.

4. The staffing crisis of the financial unit needs to be resolved as a matter of urgency,

both through permanent appointment of staff and appropriate training.

5. The budgeting process needs to be seen and used as an extension of the annual

performance plan, and needs to follow an iterative process.

6. The current model of monitoring and delivering ARVs needs review to ensure that it is

sustainable, affordable, and equitable and addresses issues of access.

SERVICE DELIVERY, LEADERSHIP AND GOVERNANCE

1. There should be a clear separation of roles between the political and administrative

heads of health, and all efforts should be made to stabilise the management of the

MPDOH.



2. The NDOH needs to play a far greater and more structured role in ensuring

stewardship and assistance to the province which faces intractable problems linked

to finances.

3. Service delivery and budgets need to be linked to each other so that managers are

not faced on a regular basis with the making of ad hoc financial cuts.

4. A clear vision and strategic direction for MPDOH should be developed through

dynamic leadership and clear national guidelines and targets for the next MPDOH

strategic planning process.

5. The STP should be revived, finalised, costed, amended if necessary and then

endorsed politically and communicated to all relevant stakeholders. This should be

the foundation on which all other plans rest. As a priority, the STP should inform

finalisation of the referral policy and organogram and should provide the foundation

on which other plans rest.

6. The practice of planning and reporting mainly for purposes of compliance should be

strongly discouraged.

7. The NDOH should produce comprehensive, integrated guidelines covering all

aspects of service delivery in relation to HIV, TB and MCH. These guidelines should

be in line with the aim of integrated service delivery in a DHS-based system. They

must contain affordable norms and standards (including human resources,

equipment, drugs, M&E) and should be clear and specific with regard to

responsibilities and accountability.

8. Drug budgets should be prioritised and the alleged practice of conscious under-

budgeting for drugs has to be terminated.

HUMAN RESOURCES

1. A policy on decentralisation should be developed and more delegation needs to be

given to managers.



2. The responsibility level of CEOs of institutions and district managers and their district

management teams (DMTs) should be reviewed and addressed. This should include

a review of financial management responsibilities.

3. Planning should be aligned with strategic priorities, service transformation and HR

staffing needs (short, medium and long term) at the various service delivery levels.

4. Restructuring, with a view to establishing minimum staffing levels, should be

undertaken based on a number of factors including objectively agreed benchmarks,

the provincial disease burden profile, optimal application of scarce skills and service

delivery priorities as well as on available resources.

5. Norms and standards from NDOH should exist to guide provinces to determine

correct structures and establishments. This should include guidance on management

levels, ratios and grading of positions.

MONITORING AND EVALUATION

1. M&E needs to become a central component of all managerial activity with the use of

objective information being the basis for decision making. This applies to all aspects

of management, including financial and HR matters, and not only service related

data. There needs to be an iterative link between planning, implementation and

monitoring.

2. Regular, formal monitoring of key indicators needs to take place with analysis and

questioning of variances (in much the same way as financial management variance

analysis should take place). Managers should be held accountable for variances.

3. All planning processes in the MPDOH should be simplified and aligned with each

other and well communicated. There should be a limited number of key targets for

each area of operation for which managers are responsible and accountable.



Introduction

1. BACKGROUND

1.1. During the course of the 2008/09 financial year it became apparent that there was a

negative difference between the allocated health budget and projected health

expenditure. This projected overspending in most of the provinces has the potential

to undermine the capacity of the Health Ministry and the National and Provincial

Departments of Health to revitalise and reorient South Africa‟s response to the HIV

pandemic and to support health systems strengthening to improve health outcomes.

In response to this threat to the overall functioning of the health system, the former

Minister of Health, honourable Ms Barbara Hogan, requested an in-depth review of

the underlying causes of the overspending and its impact on health service delivery.

This led to the establishment of the Integrated Support Teams (ISTs) in February

2009. The teams comprised financial, public health, and management and

organisational development specialists.

1.2. The purpose of this specific IST consultancy was to provide the Ministerial Advisory

Committee on Health (MACH) with a thorough and holistic understanding of the

underlying factors behind the overspending trends, to review health service delivery

priorities and programmes and to make recommendations on where and how cost

savings can be made into the future through improved cost management. The full

terms of reference are attached as Appendix 1.

2. AIMS OF THE EXERCISE

2.1. THE AIMS OF THE ISTS WERE TO:

2.1.1. Recommend prioritised and practical actions (flowing from reviews at national,

provincial and district levels) by which the functioning of the public health care system

in South Africa can be improved on a sustainable basis.

2.1.2. Integrate the recommended actions into a health systems approach that includes

perspectives on governance, leadership, finances, human resources, information,



infrastructure and technology that result in improved service delivery that is effective

and equitable.

2.1.3. Achieve maximum possible consensus on the recommended actions with the existing

public health delivery structures in South Africa.

3. SPECIFIC OBJECTIVES

3.1. THE SPECIFIC OBJECTIVES OF THE ISTS WERE TO:

3.1.1. Assess the current and projected expenditure trends at the National Department of

Health (NDOH) and the 9 Provincial Departments of Health.

3.1.2. Examine the alignment between:

3.1.2.1. Stated objectives in the Strategic Plans and the Budget Statements.

3.1.2.2. Budget Statements, the resources used/available and the actual results achieved.

3.1.3. Identify the key cost drivers underpinning expenditure and to establish the extent of

overspending.

3.1.4. Review the management and financial processes in operation with a view to

suggesting possible improvements.

4. METHODOLOGY

4.1. The review was a broad-based, rapid appraisal that focused on the health system as

a whole, but with an emphasis on finances and financial decision-making. The work

of the finance, health systems and management experts was integrated into a holistic

framework, adapted from the World Health Organization (WHO). This WHO

framework suggests that the key building blocks of a heath system are: Service

Delivery, Leadership and Governance; Human Resources (Health work force);

Finances; Information management; Medical products; and Technology and



Infrastructure.2 Due to time constraints, the HIV & AIDS, tuberculosis (TB) and

maternal and child health (MCH) programmes were used as tracer programmes,

both to add depth and to complement the health system building block reviews. The

rationale for selecting these programmes include: contribution to the disease burden;

ministerial priorities; important Millennium Development Goals indicators; facilitates

analysis of conditional grant and the equitable share expenditure; and their relative

contribution to component expenditure (e.g. pharmaceuticals).

4.2. The rapid review of MPDOH had two main components: a desk top review and key

informant interviews. The desk top review commenced before the provincial

interviews and continued throughout as additional documentation became available.

A list of these documents is shown in Appendix 2. The second component was in-

depth interviews and discussions with key informants at the provincial offices of

MPDOH, as well as the offices of Ehlanzeni Health District. Two managers from the

Bushbuckridge Sub-District were also interviewed at the Ehlanzeni District Health

Offices. The interviews commenced on 30th March 2009 and ended on 8th April

2009. A list of people interviewed is shown in Appendix 3. Because of circumstances

around the suspension of the MPDOH CFO, an interview was also conducted with a

MP Provincial Treasury Task Team that was investigating issues of financial

management in MPDOH at the time of the IST review. Despite the circumstances and

understandable anxiety about the review, the team was well received and interviews

were generally comprehensive, frank and informative.

5. OUTLINE OF THE REPORT

5.1. This document reports on the IST review done in the MPDOH. Because the current

overspending by provincial health departments was the catalyst of the IST review, the

first section (Financial Review) focuses on findings and recommendations pertaining

to the MPDOH budget and financial management. A selection of broader systemic

and organisational issues that either contribute to and/or are affected by funding and

financial management constraints are dealt with in subsequent sections of the report.

Leadership, Governance and Service Delivery focuses on an assessment of

2 WHO. Everybody’s Business. Strengthening health systems to improve health outcomes. World Health Organization, Geneva, 2007.



leadership, governance and service delivery; Human Resources deals with human

resources; Information Management focuses on Information Management; Medical

Products, Technology and Infrastructure and Security provide an overview of findings

and recommendations pertaining to medical products, technology & infrastructure

and security, respectively. Taking forward the Recommendations integrates the

recommendations from the various sections, and indicates responsibilities for their

implementation.



Financial Review

1. INTRODUCTION

1.1. The financial review derives from an in-depth assessment of the MPDOH budget and

expenditure reports, National Treasury reports and interviews with MPDOH

management. The key findings are summarised in Box 1, and elaborated on below.

Box 1: Key findings from the financial review

1. About one fifth of the total MP provincial revenue is allocated to health. This has

been fairly constant over the past four years, although there is a slight increase in

the 2009/10 allocation.

2. The per capita budget for health in Mpumalanga (based on the total uninsured

population) is lower than the average provincial uninsured per capita budget for

South Africa by a large margin.

3. Key informants indicated that there is underfunding of the MPDOH in particular

and the South African public health system in general.

4. Unfunded mandates (e.g. policy decisions such as functional integration,

occupational specific dispensation, introduction of dual-therapy PMTCT)

exacerbate spending pressures.

5. Budgeting and financial management processes (including cost allocations and

proper cost centre accounting; financial monitoring and evaluation) are sub-

optimal.

6. There is lack of alignment between annual plans and the budget.

7. Management accountability for finances needs improvement.

8. The financial system is not integrated with the quarterly performance reporting

system.

9. The lack of an integrated health information system contributes to a deficient

budgeting process.

10. The full budgetary impact of the cost of treatment required by patients on ART

needs to be better quantified.



2. UNDER-FUNDING OF THE PUBLIC HEALTH SYSTEM IN

SOUTH AFRICA

2.1. The IST team has consistently been confronted by the assertion that the main cause

of the difficulties being experienced by the public health system in Mpumalanga

Province (MP) and nationally is due to the under-funding of the system, which is

exacerbated by “unfunded mandates”.

2.2. A separate component of the IST review is focusing on the adequacy of public health

funding and the findings of the rapid investigation will be included in the consolidated

IST report.

3. PROVINCIAL BUDGET ALLOCATION

3.1. The allocation of the Mpumalanga Province‟s budget to the MPDOH is shown in

Table 1. The allocation includes the equitable share, conditional grants and provincial

revenue. Slightly more than one fifth of the total provincial revenue is allocated to

health. The allocation was fairly consistent in the past, but is projected to increase

over the MTEF period.



Table 1 Allocation of Provincial budget to Health (including conditional grants)

Financial year

R m

Provincial Budget

Year on year increase

R m

Health Budget


% Allocation to Health

R m

Adjustment Provincial Budget

R m

Adjustment Health Budget


2005/06 11 295 N/A 2 472 N/A 21.9% 12 027 2 653 22.1%

2006/07 12 805 13.4% 2 912 17.8% 22.7% 12 832 3 032 23.6%

2007/08 16 211 26.6% 3 595 23.5% 22.2% 16 846 3 718 22.1%

2008/09 18 740 15.6% 4 242 18.0% 22.6% 20 390 4 656 22.8%

2009/10 22 545 20.3% 5 429 28.0% 24.1% N/A N/A N/A

2010/11 24 633 9.3% 5 874 8.2% 23.8% N/A N/A N/A



3.2. MPDOH management pointed out that only 22% of the provincial budget is allocated

to health. This is well below the national average of around 26% for health. Although

the Mpumalanga Treasury has indicated that it is their intention to increase the

allocation to 24%, which is still below average, this has not yet materialised.

3.3. Although the year on year growth in the MPDOH health budget excluding conditional

grants from 2005/06 financial year up to 20010/11 is well above inflation, the

provincial equitable share allocation to health remains at around 22% (Table 2).



Table 2 Allocation of Provincial budget to health (excluding conditional Grants)

Financial year

R m

Adjustment Provincial Budget (incl Grants)

R m

Adjustment Conditional Grants

R m

Adjustment Provincial Budget (excl Grants)

R m

Adjustment Health Budget (incl Grants)

R m

Adjustment Health Grants

% year on year increase in health Grants

R m

Adjustment Health Budget (excl Grants)

% allocation to Health

2005/06 12 027 1 010 11 017 2 653 300 N/A 2 352 21.3%

2006/07 12 832 1 208 11 624 3 032 345 15.0% 2 688 23.1%

2007/08 16 846 1 908 14 939 3 718 485 40.6% 3 233 21.6%

2008/09 20 390 2 368 18 022 4 656 669 37.9% 3 987 22.1%

2009/10 22 545 3 101 19 444 5 429 817 22.1% 4 612 23.7%

2010/11 24 633 3 385 21 247 5 874 1 000 22.4% 4 874 22.9%



4. NATIONAL CONDITIONAL GRANT ALLOCATION

4.1. The comprehensive HIV & AIDS and National Tertiary Services Grants (NTSG) were

used as two tracers to assess trends in the allocation of conditional grants to the

MPDOH (Table 3). There has been a decline from around 7% to 6% in the proportion

of the HIV and AIDS grant allocated to the MPDOH from 2005/06 to 2010/11. The

criteria for the allocation of the HIV & AIDS Conditional Grant are not clear. For

example, in 2009/10, the proportion of the HIV & AIDS grant allocated to MPDOH is

5.76%, which is not commensurate with the province‟s share of the South African

population (7.4%). The HIV&AIDS conditional grant allocation stays in the 5-6%

range between 2006/07 and 2010/11 despite the fact that Mpumalanga has the third

highest antenatal HIV sero-prevalence of 32%. MPDOH has identified a funding

deficit of R44 million for 2009/10 in order to fund an HIV&AIDS response in the

province in line with the goals and targets of the National Strategic Plan (NSP).

Table 3 National conditional Grants to Provinces Adjustment Budgets

Grant Financial year

R 000

Total Conditional Grant to Provinces

R 000

Mpumalanga Provincial Allocation

% Allocation of Grants

Comprehensive HIV/AIDS Grant 2005/06 1 150 108 81 392 7.08%

2006/07 1 616 214 107 479 6.65%

2007/08 2 006 223 121 190 6.04%

2008/09 2 885 400 151 849 5.26%

2009/10 3 476 200 200 226 5.76%

2010/11 4 311 800 261 544 6.07%

National Tertiary Services 2005/06 4 709 386 42 224 0.90%

2006/07 4 981 149 44 757 0.90%

2007/08 5 321 206 54 995 1.03%

2008/09 6 134 100 66 621 1.09%

2009/10 6 614 400 81 410 1.23%

2010/11 7 398 000 91 879 1.24%

Total Conditional grants to Provinces 2005/06 8 907 346 260 452 2.92%

2006/07 10 206 542 300 383 2.94%

2007/08 11 736 678 412 073 3.51%

2008/09 14 362 800 643 004 4.48%

2009/10 15 578 400 702 149 4.51%

2010/11 18 012 800 811 336 4.50%



4.2. The NTSG grant to the MPDOH has been fairly constant at around one percent of the

total national grant. Mpumalanga does not have a fully developed tertiary facility. In

two facilities some tertiary work is done but the allocation is not large enough to

facilitate the development of a fully-fledged tertiary facility.

5. TOTAL BUDGET PER CAPITA

5.1. The budget per capital for the MPDOH was calculated using Statistics South Africa

mid-year estimates and reduced with the insured population according to the STATS

SA General Household Survey (Table 4).

5.2. The nominal budget per capita has increased, and is expected to increase at a rate in

excess of inflation over the MTEF. This per capita budget is well below the national

average.



Table 4 Comparing National and MPDOH trends in per Capita health budget

Financial year

Uninsured National Population

R m

Total of Provincial Health Budgets

R

Uninsured Total Provincial Health Budget per capita

% Increase year on year

Uninsured Mpumalanga Population

R m

Mpumalanga Health Budget

R

Un-insured Mpumalanga Health Budget per capita

R Increase year on year

2005/06 40 323 852 47 147 1 169 N/A 2 881 811 2 653 920 N/A

2006/07 40 898 347 53 175 1 300 11.2% 3 115 104 3 032 973 5.8%

2007/08 41 007 279 60 812 1 483 14.1% 3 115 480 3 718 1 193 22.6%

2008/09 41 725 016 73 581 1 763 18.9% 3 162 790 4 656 1 472 23.4%

2009/10 41 725 016 82 359 1 974 11.9% 3 162 790 5 429 1 717 16.6%

2010/11 41 725 016 91 999 2 205 11.7% 3 162 790 5 874 1 857 8.2% Source: Population numbers per STATS SA mid-year estimates (P0302) adjusted with the insured population from the STATS SA general household survey.



5.3. There are reportedly large numbers of people from the two neighbouring countries

(Swaziland and Mozambique), who make use of health services in Mpumalanga, thus

putting further pressure on the budget and aggravating inter-provincial inequities.

6. TRENDS IN HEALTH EXPENDITURE

6.1. MPDOH has underspent its overall budget for the past three years (Table 5). This

underspending is due mainly to underspending of capital expenditure of projects

funded by conditional grants, thus masking the over-expenditure in the operational

budgets. Since 2006/07 MPDOH has consistently, and by a growing amount,

overspent their operational budgets. The surplus/(deficit) according to the

Appropriation Statements has been adjusted to take into account the increase in the

accruals outstanding at year-end (i.e. accounts payable). This has been done to

better align the operational activity with actual payments of expenses made (e.g.

medication utilised prior to year end and only paid after year end). It should be noted

that the numbers for the 2008/09 financial year have been prepared on a different

basis from those for the other years (i.e. the numbers for 2008/09 are unaudited and

have been affected by a change in the funding policy from the Provincial Treasury).

Comparable figures will only be available once the 2008/09 annual financial

statements have been audited. Any conclusion on trends up to 2008/09 should

therefore be reserved until the financial statements have been finalised.



Table 5 Trends in MPDOH expenditure

R000 2005/06 AFS

R000 2006/07 AFS

R000 2007/08 AFS

R000 2008/09 Estimate

Surplus/(deficit) per Appropriation Statement

(11 468) 18 989 60 438 111 388

Less underspent capital expenditure

9 241 25 834 165 576 121 249

Operational surplus/(deficit) adjusted for underspent capital expenditure

(20 709) (6 845) (105 138) (9 861)

(Increase)/decrease in accruals payable

(420) (16 025) (219 200)

Operational surplus/(deficit)adjusted for movement in accruals and under-

spent capital expenditure

(20 709) (7 265) (121 163) (229 061)

Balance of accruals at year end 44 355 44 775 60 800 280 000

6.2. The underspending as reported in the appropriation statements of the MPDOH does

not reflect the effect of surrendering the underspent portion on capital expenditure on

conditional grants, as well as the increase in accruals (Table 5).

6.3. When adjusted for the items mentioned in the previous paragraphs, the MPDOH has

overspent since 2006/07. The main contributors to the overspending in the 2007/08

and 2008/09 financial years are listed below:

6.3.1. Compensation of employees, in particular the effect of implementation of the OSD for

nurses and higher salary increases than budgeted for.

6.3.2. Increase in operational service levels e.g. higher numbers of patients on anti-

retrovirals (ARVs) than the forecast numbers.

6.3.3. The incorporation of BBR (Bushbuckridge) into MP. The budget for direct costs in

BBR was shifted from Limpopo to Mpumalanga. However, some services were

provided in Limpopo from a central budget and these funds were not shifted.

6.3.4. MPDOH refers some level 2 patients to private hospitals and in some cases to

Gauteng. This is a very expensive practice.



6.4. It was raised as a concern that additional funding without fundamental improvements

in the health delivery system (focus, effectiveness and efficiency) will only result in

more usage and spending. Additional funding alone, without these improvements,

may therefore only resolve the current overspending, but the pattern of overspending

will continue as soon as the additional funding is exhausted.



Table 6: Trends in health programme budget and expenditure, 2005-08

2005/06 2006/07 2007/08

R 000 R 000 R 000 R 000 R 000 R 000 R 000 R 000 R 000

Programme Final Appro-priation

Actual Expenditure Variance

Final Appro-priation




Administration 134 413 133 721 692 179 569 179 619 ( 50) 186 069 186 074 ( 5)

District Health Services 1 323 496 1 358 797 (35 301) 1 562 735 1 554 782 7 953 1 929 133 2 016 415 ( 87 282)

Emergency Medical Services

105 989 105 783 206 109 416 109 407 9 146 200 136 595 9 605

Provincial Hospital Services

399 506 399 450 56 440 847 440 791 56 534 887 533 452 1 435

Central Hospital Services

383 538 382 724 814 443 134 443 068 66 445 213 444 659 554

Health Sciences and Training

71 242 71 107 135 83 993 82 225 1 768 99 448 99 369 79

Health Care Support 25 761 25 633 128 35 666 24 868 10 798 105 344 66 944 38 400

Health Facilities Management

207 531 185 708 21 823 176 132 177 732 ( 1 600) 270 592 173 079 97 513

Special functions

Internal charges 750 771 ( 21) 750 761 ( 11) 750 611 139

Total 2 652 226 2 663 694 (11 468) 3 032 242 3 013 253 18 989 3 717 636 3 657 198 60 438

Economic classification

Compensation of employees

1 378 726 1 449 633 (70 907) 1 672 884 1 627 813 45 071 2 031 153 2 039 918 ( 8 765)

Goods and services 930 617 869 144 61 473 999 992 1 062 437 (62 445) 1 197 776 1 288 297 ( 90 521)

Financial transactions in assets and liabilities

151 ( 151) 18 ( 18)

Transfers and subsidies 77 531 88 806 (11 275) 88 655 77 975 10 680 99 459 105 293 ( 5 834)



Table 6: Trends in health programme budget and expenditure, 2005-08

2005/06 2006/07 2007/08

R 000 R 000 R 000 R 000 R 000 R 000 R 000 R 000 R 000

Programme Final Appro-priation






Buildings and other fixed structures

150 244 156 264 ( 6 020) 134 350 155 638 (21 288) 218 157 143 943 74 214

Machinery and equipment

115 108 99 847 15 261 136 361 89 239 47 122 171 091 79 729 91 362

Total 2 652 226 2 663 694 (11 468) 3 032 242 3 013 253 18 989 3 717 636 3 657 198 60 438 Source: Annual reports of various financial years



7. UNFUNDED MANDATES DURING 2008/09

7.1. Unfunded mandates are changes in policies or operational requirements resulting

in additional expenditure for which provision has not been made in the approved

provincial budget.

7.2. Examples of unfunded mandates in the case of the MPDOH include:

7.2.1. Occupational Specific Dispensation (OSD) – the implementation and costing of

this policy resulted in higher expenditure than the amount provided for in the

budget. The additional amount allocated for OSD by the National Treasury was

based on an equitable share calculation, and not on actual human resource (HR)

figures from the PERSAL system. The underfunding for this OSD was estimated

to be R100 million for the 2008/09 financial year.

7.2.2. Nationally negotiated salary increases for 2008/09 came to 10.5%, although the

budgeted increases provided for by the MPDOH only amounted to 7.1%. The

impact of this was R85 million during the 2008/09 financial year.

7.2.3. HIV/AIDS. The MPDOH did a comprehensive study on HIV treatment and

concluded that the province has a funding gap of R44 million.

7.2.4. Functional integration. The budget did not cater for the movement of operations,

e.g. in respect of Emergency Medical Services and municipal clinics from local

government to the MPDOH. The deficit to fund the remuneration of local authority

employees amounts to R108 million per annum.

7.2.5. District shift The incorporation of BBR into Mpumalanga had a negative effect,

particularly on the funding inequity between districts in the province.

7.2.6. Activity levels increased. Activity levels increased at PHC. Utilisation in PHC

facilities, increased from 5,953,138 in 2003/04 to an estimated 7,260,000 in

2007/08. But even more significantly – and more telling of the challenges with the

referral system in MPDOH and associated cost pressures - is an increase in the



PHC utilisation in hospitals from 175 789 in 2003/04 to 598 765 in 2006/07. At the

same time, the numbers of patients registered for ARTs increased from a reported

2 041 in 2005/06 to 23 691 in 2007/08; 35 698 in 2008/09 to a projected 44 000 in

2009/10 (which is slightly above the target of 42 431).

7.2.7. New facilities. The opening of a clinic during a financial year without funding being

provided in the budget. The opening of this clinic was based on political promises

being made without ascertainment of whether the concomitant running costs had

been provided for.

7.2.8. Higher medical inflation than budgeted inflation increases. The exact effect of this

cannot be accurately quantified with the summarised information available.

8. BUDGETING PROCESS

8.1. The budgeting process was identified as a major contributor to the current funding

challenges in the MPDOH. Line managers are totally disillusioned with the budget

process with the result that the call for budget bids and/or zero based budgets are

ignored. This in turn weakens the bids submitted to Provincial Treasury.

8.2. Currently, the budgeting process is a top down process. Although basic inputs are

compiled from operational levels, an indicative figure is obtained from the national

budgetary process. This indicative amount is then allocated to the operational

budgets (various institutions/levels). The plans drafted have in most cases no

relevance to the budgets.

8.3. There is also no clear alignment between the annual performance plans and the

financial budgets. Annual performance plans are also not updated subsequent to

the allocation of funding. A good example of this non-alignment is the difference

between the forecasted numbers of patients on ART and the budget allocated.



9. FINANCIAL MANAGEMENT PROCESSES

9.1. Cost centre accounting is only done down to a sub-district level, and not down to

clinic level. Efficiency and effectiveness indicators needed for good financial

management are therefore not available.

9.2. Variance analysis of differences between actual and budgeted expenditure can be

a very useful management tool. Currently, whenever variances are identified, the

practice appears to be to reallocate budgeted amounts in order to reduce the

variance amounts for the different over and under-expenditure items. On the

evidence available to the IST, very little follow-up is done to identify any possible

or necessary operational corrective actions flowing from variances.

9.3. Management responsibility and accountability are limited at all levels of the

hierarchy, making it more difficult to maintain effectiveness and efficiency

standards. Supporting evidence for this contention is provided under Human

Resources, paragraph 2.

9.4. The financial units are under-capacitated so that separation of duties for proper

internal financial control cannot be achieved.

9.5. Besides the lack of staff in the financial units, the posts are generally at lower

salary levels than their counterparts in other departments. This results in a rapid

turnover of financial staff.

9.6. The lack of capacity was further exacerbated by the suspension of the CFO in

response to a Provincial Treasury Task Team Report, which found that both

financial management and internal controls were inadequate. All the senior

officials in the finance section are now acting in more senior positions. In addition,

there is 45% under-staffing, thus posing a serious risk to already fragile systems.



9.7. A further aggravating aspect is that the unauthorised spending of the last two

financial years has not been condoned. This puts an immediate cash restraint of

approximately R400 million on the MPDOH.

10. COST ALLOCATION

10.1. In some cases, costs for doctors and dentists are allocated to district hospitals, but

the personnel in question are deployed in PHC facilities. As a result, the cost per

patient day equivalent (PDE) indicator becomes inaccurate and loses its relevance

and usefulness. Hence, there is need to improve the personnel cost allocation.

10.2. Distribution of medication is not always done through the medical depot. The

various pharmacy personnel developed a manual system to redistribute

medication and medical supplies to the different facilities themselves. As a result

of this non-integrated, manual system, accurate cost allocation of medication to

institutions/cost centres is not done. Again, the cost per PDE indicator loses

effectiveness and cannot be used to identify areas that require investigation and

possible corrective action. In Mpumalanga the situation is aggravated due to the

fact that MPHOD staff was not properly trained to implement the SCOA which

leads to wrong allocations to cost centres.

11. QUARTERLY PERFORMANCE REPORTS

11.1. Quarterly performance reports on service related indicators are compiled and

submitted to the Provincial Treasury. There is no alignment between the quarterly

performance reports and financial performance. In addition, there are too many

non-financial indicators, with doubtful value and usefulness. Currently, variances

are identified, but there is no follow-up of these variances.

11.2. This reporting often forms a major part of the agenda of the Operations Committee

which brings together all managerial staff and not just those at a senior level. It

meets regularly (at least every quarter) as evidenced by the minutes obtained. It

does not purely concentrate on the financial picture but reviews all operational

matters. However, it is beginning to make an impact in the financial realm. As far



as finance is concerned, effectiveness depends in part on the role played by the

Chief Financial Officer. The current instability around this position is problematic

from this perspective.

12. FINANCIAL REPORTING

12.1. The principal financial reporting mechanisms are the Annual Financial Statements

and the monthly In Year Monitoring (IYM) reports.

12.2. Although the IYM report can be an effective tool to identify possible budget over-

runs, these are compiled on a cash basis and not on an accrual basis. The result

is that any unpaid expenditure is carried forward to future financial periods and the

reported results do not accurately reflect the actual operational cost of the current

year‟s operations. Reported overspending is also limited by the withholding of

invoices for payment. The effect of this deficiency where unpaid amounts show an

abnormal increasing trend is highlighted in Table 5. (The PFMA implications of this

practice have not been considered for purposes of this report).

12.3. The annual financial statements (AFS) are drafted on a cash basis. Expenditure

not paid (accruals) is not matched with the operational activities of the MPDOH.

Material amounts payable are accumulated, but the reporting does not take this

into consideration.

13. MONITORING STRUCTURES

13.1. The Audit Committee is functioning well, - however, the committee meets only 3

times per year. This is not sufficient to turn governance around in the MPDOH.

The effectiveness of essential monitoring structures requires improvement.

13.2. Issues reported by the Auditor-General in the 2007/08 annual report include:

13.3. External audit – prior year‟s external audit recommendations have substantially not

been implemented.



14. RECOMMENDATIONS

14.1. PROVINCIAL HEALTH BUDGET ALLOCATION

14.1.1. The Provincial Treasury should allocate an amount to the MPDOH, which is

substantially in line with the equitable share from the National Treasury.

14.1.2. Allocations of conditional grants by the NDOH should be based on clear, objective

criteria that are linked to grant specific indicators and not on the equitable share

formula.

14.2. UNFUNDED MANDATES

14.2.1. The operational impact of national policy decisions (e.g. OSD, new vaccine

programme) should be determined and must be agreed with the provincial health

department prior to implementation.

14.2.2. There should be alignment between political decisions and operational

implementation and agreement reached for any proposals on increases of service

levels prior to their announcement. The availability of funding should also be

confirmed.

14.3. BUDGETING PROCESS

14.3.1. The budgeting process needs to be seen and used as an extension of the annual

performance plan, and needs to follow an iterative process.

14.3.2. All operational units (cost centres) need to have a realistic budget that can be used

as a guideline for the financial year‟s activities. Operational plans need to be

aligned with available funding to deliver the services.

14.3.3. Budget virements need to be linked to changes in operational activity, not merely

to balance the number of over and under-expenditure items.



14.3.4. The practice of continuous budget reallocations needs to be discontinued.

Virement movements which are effected to minimise unauthorised expenditure

(over-spending) should not hinder the application of the principles of proper

financial management and variance analysis during the course of a financial year.

14.4. FINANCIAL MANAGEMENT

14.4.1. The staffing crisis of the financial unit needs to be resolved as a matter of urgency,

both through permanent appointment of staff and appropriate training.

14.4.2. Cost centre accounting needs to be done at the lowest possible practical level (i.e.

facility/clinic level).

14.4.3. Variance analysis needs to be used as a management tool to identify areas that

require attention.

14.4.4. The required monitoring structures need to be improved.

14.4.5. Managers should be held accountable for the performance of their operating units

and this must be built into the performance management system.

14.5. QUARTERLY PERFORMANCE REPORTS

14.5.1. The accuracy and use of essential performance indicators needs to be improved.

The necessary steps must be taken in conjunction with the NDOH to improve the

quality of information available in this regard.

14.5.2. Variances in specific indicators need to be followed up with actions, and not

merely identified.

14.5.3. There needs to be a link between performance and financial reports. A financial

report reflecting actual expenditure compared to budget should also be provided

where performance indicators reflect a deviation in operational performance.



14.6. FINANCIAL REPORTING IYM (IN YEAR MONITORING)

14.6.1. The IYM report needs to be expanded to include accruals. The report needs to be

compiled on an accrual basis and not only on a cash basis to create a link

between operational activity and costs.

14.6.2. The IYM report must differentiate between operational budgets and expenditure,

and capital budgets and expenditure. In the case of capital budgets and

expenditure a further distinction needs to be made between funding from

conditional grants and own funding.

14.6.3. The IYM report needs to serve as an accurate forecast of expected expenditure

and cost. It has limited use as a monitoring tool when it only reflects actual and

expected cash flow, which is not linked to operational activity (expenditure).

14.7. ANNUAL FINANCIAL STATEMENTS

14.7.1. The annual financial statements, while meeting Constitutional and Government

Accounting requirements, should be expanded beyond the cash basis of reporting

and include accruals as part of reported, aggregated expenditure numbers.



Leadership, Governance and Service Delivery

1. INTRODUCTION

Box 2: Key review findings on leadership, governance and service delivery

1. The lack of stable political and administrative leadership and political

interference in key management processes over a relatively long period of

time has led to an erosion of good management practices. This has been

exacerbated by many managers being appointed in an acting capacity.

2. There have been problematic relationships between successive heads of the

MPDOH and members of the executive council responsible for health, with a

negative impact on performance management in the MPDOH and general

problems of accountability.

3. There are major gaps in the implementation of the National Health Act,

including the failure to establish provincial and district health councils.

4. Managers appear to spend excessive time in meetings, displacing other

priorities.

5. Key planning documents of the MPDOH show the lack of an overall vision for

the public health system in the province. It is often difficult to reconcile

strategies, targets and planned activities with stated priorities and budgets.

6. Plans and priorities are not informed by or based on contextual realities or a

critical analysis of performance in implementation of previous plans.

7. Reporting against targets is done mechanistically and often only for purposes

of compliance; accountability is eroded because there is “no consequence” if

targets are not achieved and plans not delivered.

8. The large population size in all three districts is well in excess of the WHO

benchmark of 500 000. This, together with the lack of established sub-district

management structures, makes it difficult to render equitable, quality

comprehensive health care to people living in these areas.

9. The referral system in MP is not working as intended. Level 2 and 3 hospitals

reportedly provide a lot of PHC and Level 1 Hospital services.

10. HIV&AIDS, TB and MCH are designated as high priority areas in the APP and

relatively ambitious targets are set which illustrate this. However, reported



Box 2: Key review findings on leadership, governance and service delivery

progress towards achieving these targets does not appear to support a sense

of urgency in improving access to or outcomes of services provided.

11. Slow progress with the accreditation of ARV treatment sites and inadequate

costing of the treatment plan are likely to restrain the scaling up of access to

treatment to the levels targeted.

12. Clinic supervision is inadequate, which impacts negatively on the quality of

service delivery.

2. GENERAL ISSUES OF GOVERNANCE AND LEADERSHIP

2.1. By and large, the review found many able and committed people, but managers

are often confronted with impossible choices, including finite resources, an ever

growing demand for services and managing “unfunded mandates” (e.g. the

decision to implement dual-therapy PMTCT, as well as the introduction of two new

childhood vaccines).

2.2. A number of interviewees pointed to difficulties of the political and administrative/

managerial interface and historical, vexed relationships between the MEC and the

HOD. In MPDOH there is a history of MECs‟ involvement in recruitment, supply

chain management, grievance and disciplinary procedures, service delivery and

planning e.g. the Service Transformation Plan. It was also pointed out that the

implementation of the National Health Act has not been effective. Provincial and

District Health Councils as required in the Act (see chapters 4 and 5 of the Act) do

not exist. A Provincial Health Council was created but is not functioning. At district

level, there have never been any Councils established. This is detrimental to

community participation in the governance framework for Health.

2.3. Respondents pointed to accountability problems, for example, unauthorized

expenditure is often tolerated and discipline is largely absent. Officials whose

positions derive from political considerations or nepotism reportedly have less

accountability. This is exacerbated by weak or a lack of control systems, making it

difficult to detect non-compliance. Management spend inordinate time in



meetings, (reportedly in excess of 50% of the available time), leaving insufficient

time for the remainder of their functions, including field visits.

2.4. Many respondents pointed to the „unstable‟ nature of management, evidenced by

a high rate of turnover, many vacancies and numerous positions filled in an acting

capacity. Currently the HOD and the CFO are acting, there is no Chief Director for

Corporate Services, and the Chief Director for Hospital Services has only recently

started. That only leaves the Chief Director for Primary Health Care who has been

in the position for a while. At the political level, the turnover of MECs has been as

rapid as that of HODs. There have been seven MECs and eight HODs in the last

five years. This has resulted in lack of continuity in providing leadership;

insufficient time for leaders to adequately acquaint themselves with the MPDOH

and the requirements of the job; poor institutional memory; and difficulties in the

exercise of authority especially from those in acting positions. Many chief

executive officers of hospitals are also in acting positions, although these are

being filled.

3. PLANNING

“It is difficult to have a vision and a clear sense of direction

if leadership keeps on changing”

3.1. A common vision and focus on “big picture” priorities for service delivery in

MPDOH are largely absent. High senior management turnover, together with the

large numbers of senior managers in an acting capacity for prolonged periods of

time, makes it difficult to plan and manage a highly complex service with the

required focus and continuity. Often, processes aimed at addressing critical

challenges or constraints are far progressed, or at a point where they may begin to

have an impact, when leadership changes. Support and momentum for the

initiative is lost and new priorities and directives begin to dominate.



3.2. STRATEGIC TRANSFORMATION PLAN

3.2.1. A service transformation plan (STP) was completed in October 2008. The purpose

of the STP is to create a “leaner”, more efficient and sustainable service delivery

system. It recommends, for example, that the number of district hospitals be

reduced from 23 to 16, while seven of the current 23 district hospitals should

become Community Health Centres (CHCs). Savings from this were to be used to

increase clinics from 129 to 340 and CHCs from 37 to 61.

3.2.2. Implementation of the preferred service delivery platform as outlined in the STP

would not only serve to render the service configuration in the province more

sensible and sustainable; it would also inform a pragmatic referral policy and

provide a framework around which to construct a functional district health system

in MP. However, the STP has not been approved and both the referral policy and

the recently revised organogram are going ahead. This means that both the

referral policy and organogram are based on a service platform that is in need of

fundamental restructuring and rationalisation.

3.3. ANNUAL PERFORMANCE PLAN

“Good things tend to happen by accident, not by

design”.

3.3.1. Annual Performance Plans (APPs) and Annual Reports are viewed by MPDOH as

being done for purposes of compliance according to national requirements,

resulting in poor ownership of plans, exacerbated by the lack of feedback from

NDOH following their submission or publication. It was pointed out that even at a

provincial level there is “no consequence for non-delivery”.

3.3.2. Senior MPDOH managers noted that the “right” questions about APPs and Annual

Reports are not being asked in the Provincial Legislature and that APPs‟

resourcing and implementation are not sufficiently interrogated at this level.



3.3.3. The APPs for 2007/08 – 2009/10 and 2008/09 – 2010/11 show a disjuncture

between the situation/contextual analysis and eventual plans or planning priorities.

Plans and targets appear to be unrealistic; the APPs show a lack of an overall

sense of direction, are not driven by a clear vision and the lack of clarity with

regard to priorities is evident. For example, the APP 2007/08 – 2009/10 refers in

different sections to three different sets of priorities which the plan claims to be

premised on e.g. the NDOH Guidelines/10-Point Plan; the Five Strategic Goals of

MPDOH and the Eight “Key/Focal areas” of the MPDOH.

3.3.4. There is little noticeable variation in planning priorities from year to year and no

evidence that the targets in new plans had been informed by a critical review of

implementation of previous plans. The same challenges are repeated from one

plan to the next, while the planning priorities, targets and activities remain largely

static. Attempts are being made by the Planning Directorate to institute a more

rational planning cycle, but it may be too early to see their impact yet.

3.3.5. There is no real sense that national or provincial priorities receive special attention

in the provincial plans. For example, in the APPs and Annual Reports, problems

around TB management and low cure rates compared with other provinces are

mentioned and the need identified to “strengthen the TB control programme”.

However, there is no evidence that any special attempts are made to address it; or

that additional resources are allocated to it. TB cure rate targets are set at a

“standard” 5% year-on-year increase (starting from a relatively low baseline of

52% in 2005/06); without any reference to, or apparent consideration of, the

resources that would be required to achieve this.

3.3.6. The “national compliance” requirement of the APP is borne out by the fact MPDOH

develops a “Year Plan”, which is a detailed operational plan that apparently

“enjoys a higher status than the APP”. The “Year Plan” is regarded as touchstone

against which MPDOH measures its performance, and not the APP. The format of

the Year Plan has until now been different from Part C of the APP, but from 2009 it

will comply with Part C of the APP. Several programme and district plans have to

be incorporated into the APP and the “Year Plan”. The quality of these plans varies

greatly. Senior MPDOH managers are of the opinion that this is because planning



capacity (especially financial planning capacity) at programme and district level is

often inadequate.

3.3.7. Even though MPDOH claims to be measuring its performance against the “Year

Plan”, accountability measures based on the “Year Plan” are not in place. APP and

“Year Plan” targets are not incorporated into the Performance Management

Development System (PMDS), which means that plans and priorities are not

translated into responsibilities and responsible managers cannot be held

accountable for their delivery. Reviews of delivery on Year Plan priorities appear to

be an academic exercise, as poor performance and unmet targets are not

interrogated, or followed up nor sanctioned. It was described in several interviews

as a “culture of no consequences”.

3.4. ALIGNMENT OF PLANS

3.4.1. Important planning processes in MPDOH are not aligned. Most critically, the

budget process is not driven by service delivery plans. Strategic Planning and

Programmes prepare plans and budgets, but the budgeting process runs in

parallel and is managed by the Finance Section. The strategic planning process

also runs on a different time line than the budget process.

3.4.2. Although financial resources enable the implementation of plans, money allocated

to programmes is not based on the plans or budgets prepared by programmes.

This leads to a perpetual cycle of blaming that financial resources for service

delivery are inadequate; and counter blaming that plans are unrealistic and

idealistic because they do not take account of the budget. This is a very serious

challenge, as it defeats the purpose of bottom-up planning and budgeting process.

The result is that planning processes in MPDOH are essentially viewed as

“meaningless”, since the financial resources required for the implementation of

plans are hardly ever forthcoming. It also fundamentally erodes accountability as it

would be unreasonable to hold managers accountable for the delivery of plans that

are not adequately funded or otherwise resourced.

3.4.3. Furthermore, the following challenges also undermine the alignment of plans:



3.4.3.1. Vertical programmes have their own plans, budgets and management structures,

which complicate their integration into district plans.

3.4.3.2. “Joined-up” government and joint planning by different line departments are not

working well and it is mainly “reactionary” in response to crises (e.g. a recent

outbreak of cholera). This is in contrast to the situation in BBR prior to the transfer

from Limpopo. On the positive side, district managers are beginning to participate

in Integrated Development Planning (IDP) forums and, for the first time in 2008,

Municipal IDP managers were involved in the development of district health plans.

Synergies are beginning to emerge at this level, but it will require ongoing

leadership and high-level support to be sustained.

4. GOVERNANCE

4.1. The Provincial Health Council was established in 2005, but due to high turnover of

MECs and lack of political leadership it ceased to exist after having met only twice.

District Health Councils have never been formally established. In 2006/07, only

12% of fixed PHC facilities in MP had a Clinic Committee or Hospital Board. Even

where these structures exist, they are reportedly ineffective and their roles in

governance and accountability seem to be poorly understood and perhaps not

taken seriously.

5. SERVICE DELIVERY (HIV, TB AND MCH)

5.1. Resource constraints and management failures at a high level appear to affect

service delivery throughout MPDOH facilities. A low funding base, together with

inadequate HR management and inefficient supply chain management, leave the

providers of health services with insufficient supplies and equipment in often poorly

maintained, sometimes structurally inadequate, facilities where they have to render

a service without the necessary “tools of their trade”.

5.2. One of the most notable characteristics of the public health system in MP is that

the referral system as envisaged by the DHS is essentially non-functional. Very



few facilities render the full package of services at levels commensurate with their

position in the referral system. Because of poor maintenance and lack of

resources to replace units that are not fit for service, mobile clinics are battling to

remain operational. Many 8-hour PHC clinics are under-staffed; stock-outs of

essential drugs have become common, especially during the past financial year,

and some clinics experience problems with water and electricity supply.

5.3. Many CHCs do not have trained advanced midwives or visiting doctors, while

some are structurally unsuitable to function as CHCs. Many CHCs do not provide

a 24 hour service. District hospitals deal with large numbers of patients that could

be managed at PHC facilities, but they often lack the resources (doctors,

equipment) to provide level 1 hospital services. Regional hospitals also deal with

large numbers of PHC and level 1 patients and often do not have the facilities,

equipment or staff to render level 2 services. The same applies to the two

hospitals in MP that provide limited level 3 services. This is substantiated by the

high percentage of district health services expenditure on district hospitals. For

example, in Gert Sibande district in 2006/07, 66.2% of district health services

expenditure was spent on eight district hospitals. This is the second highest of all

health districts in SA and well above the national average of 43.6%.Referrals to

private providers/facilities or to public facilities in Gauteng are common, but this is

an expensive stop-gap measure that places additional pressure on the MPDOH

budget.

A dysfunctional referral system

Case study: Bushbuckridge

Mapulaneng Hospital has 279 active beds (it is registered for 252 beds). The

hospital is supposed to render mainly Level 2 services.

Because of a non-functional referral system and under-resourced PHC

facilities, it is providing mainly Level 1 (PHC) services. The number of level 1

patients seen at the hospital has increased substantially since mid-2008.

Currently, of the ±200 patients seen at Mapulaneng Hospital per day, between

70% and 80% are uncomplicated level 1 patients that could have been seen by

a nurse at a PHC facility.



Between 70% and 80% of deliveries done at this hospital are uncomplicated

deliveries resulting from pregnancies that had been monitored throughout and

that could therefore be handled at CHCs – if these had only been adequately

equipped; had trained midwives; and could provide a 24 hour service.

5.4. Service delivery in all three “tracer” programmes (HIV & AIDS, TB and MCH) in

MP is likely to come under severe pressure as a result of a combination of factors,

including:

5.4.1. The shortage of nurses, partly because MPDOH is failing to implement rural

allowances that are competitive compared to other provinces (especially

neighbouring LP) and current moratoria on staff appointments;

5.4.2. Programmes “competing” for available resources. There is a lack of integration of

directives from programme managers at the provincial (and national) levels, while

accountability mechanisms do not promote integration of services at a district

level. Specific mention was made here of the role of NDOH; namely that many

directives and demands come from NDOH, but there is little understanding or

appreciation of the challenges, and the obstacles that have to be overcome, to

implement these demands at provincial and district levels.

5.5. Delayed and deferred payment of suppliers and generally inadequate supply chain

management are resulting in stock-outs, insufficient maintenance of available

equipment, inability to replace essential equipment and generally deterioration in

the levels of supplies and equipment needed to render quality services. Because

MPDOH has a particularly poor payment record – also with regard to suppliers

under national contracts, these suppliers tend to favour other provinces at the

expense of MPDOH when it comes to delivering orders. This interferes with the

ability of facilities to provide services and it has a demoralising effect on service

providers. At the same time, it erodes public confidence in the public health

system.

5.6. Clinic supervision is a serious challenge which impacts negatively on the quality of

care. The current organogram does not make provision for clinic supervisors.

Funding was secured from the European Commission PHC Support Programme



for six PHC supervisors‟ posts. However, the EU programme is ending in 2011 and

the sustainability of these appointments is entirely contingent on the

implementation of the new organogram. A target was set in 2006/07 that each

PHC facility3 should receive at least two supervisory visits by a trained supervisor

every month. This is an unrealistic target that is unlikely to be resourced to the

levels required.

5.7. HIV & AIDS

5.7.1. TB has been separated from the HIV/AIDS and STIs (HAS) Programme. These

highly inter-related conditions are therefore dealt with through vertical

programmes, which complicate the provision of integrated PHC services at a

district level. In MPDOH, HAS is one of the programmes for which service delivery

has been decentralised to a district level. However, planning, as well as funding,

remain at a provincial level and service providers report directly to the HAS

provincial programme manager, even though the district director is responsible for

integrated service delivery at a district level. It is anticipated that the introduction of

the new organogram will provide new impetus to the integration of service delivery

at a district level and should address these apparently illogical accountability

arrangements.

5.7.2. Because of the budget structure, funding for HIV & AIDS is shown against

“Programme 2” (district health services). This creates the impression that

Programme 2 is relatively well funded. However, a large proportion of this budget

is specifically “ring fenced” for HIV & AIDS and managed at a provincial level. It is

therefore not generally available for integrated PHC services at a district level.

While HIV & AIDS impacts on health services and contributes significantly to the

burden of disease - and therefore on the demand for service delivery across the

board - service delivery in general does not benefit from the relatively generous

resourcing of HIV & AIDS, but the budget structure conceals this.

3 There are 231 PHC clinics in MP.



5.7.3. There is a perception that the priority attached to and preferential resourcing of

HIV & AIDS are “crowding out” other equally important services. There is even a

perception among some managers that HIV & AIDS is “over-funded”. Others

maintain that, because of the implementation of dual-therapy PMTCT and rapid

expansion of the ARV treatment programme, it is under-funded.

5.7.3.1. Although there is very high priority attached to HIV & AIDS and funding appears to

be available, HAS did not spend its entire budget in 2006/074. In 2006/07, 27

hospitals and 279 PHC facilities (from a targeted 344) were offering PMTCT and

only one new ARV treatment site was accredited between 2005/06 and 2006/07,

which brought the number of ARV treatment sites in MP to 19. Long waiting

periods for treatment initiation is reported as a major challenge. It would appear

that the current model of physician-initiated treatment at a limited number of

accredited sites is not compatible with making this service accessible to the large

numbers of people who are currently infected.

5.8. TB

5.8.1. TB is the main cause of mortality in MP. The TB cure rate in MP in 2006/07 was

50.9%, which is well below the WHO target of 85% and somewhat lower than the

SA national average of 57.6%. The smear conversion rate was 48.5%, which is

also much lower than the national target of 70% and the SA national average of

55.8%. Set in a context of a dramatic increase in the number of reported TB cases

(a 20% increase between 2005/06 and 2006/07) and a 15% increase in the

number of smear positive cases during the same period, MPDOH has

nevertheless set itself the target to cure 75% of all newly detected, smear positive

cases; to detect 70% of all TB cases and to reduce treatment interruption to under

5% (from the current 10.8%). This is yet another example of extremely ambitious

target-setting that does not take account of realities on the ground, and the serious

systemic and structural challenges described so far. It further seems to confirm the

notion that targets are set mechanistically, without apparent concern for possible

consequences if they are not met.

4 It reportedly spent 95% of its budget in this year.



5.8.2. One of the main reasons for the low TB cure rate is the high defaulter rate, which

is largely being ascribed to challenges with the implementation of DOTS. One of

the consequences is a relatively high prevalence of MDR TB in MP. (75 new cases

of MDR TB were detected in MP in 2006/07.) Yet, there is only one TB hospital in

MP, namely Witbank, where MDR TB patients can be admitted and it has only 36

beds suitable for the admission of such patients. It therefore has to be deduced

that relatively large numbers of people with MDR TB are not institutionalised,

which should be a reason for concern from a public health perspective.

5.9. MCH

5.9.1. MP is not doing well on maternal mortality indicators. Maternal deaths have

increased from 89 to 105 between 2005/06 and 2006/07. One of the main reasons

for this is the lack of trained professionals to provide obstetric care – i.e. advanced

midwives in CHCs and Gynaecologists and Obstetricians in hospitals.

6. RECOMMENDATIONS

6.1. GENERAL LEADERSHIP

6.1.1. There should be a clear separation of roles between the political and

administrative heads of health, and all efforts should be made to stabilise the

management of the MPDOH.

6.1.2. There should be explicit and open discussion around the budget and the level of

services that can be rendered for that budget. The areas of rationing and

prioritisation should be made clear and communicated effectively to all relevant

stakeholders.

6.1.3. There should be an iterative process to national policies where provincial realities

are considered and feedback is given so that either policies can be amended to fit

the realities or else additional resources made available so that the level of service

delivery can be elevated, consistent with policies.



6.1.4. The NDOH needs to play a far greater and more structured role in ensuring

stewardship and assistance to the province which faces intractable problems

linked to finances.

6.1.5. Service delivery and budgets need to be linked to each other so that managers are

not faced on a regular basis with the making of ad hoc financial cuts.

6.1.6. Diaries of all managers need to be respected through better time management and

discipline.

6.1.7. Management of over-expenditure is a core senior management function together

with its effects on service delivery and needs to be explicitly on the agenda of

senior management.

6.1.8. Short term rationing of important areas (e.g. maintenance of facilities) can

influence long term strategies (e.g. run down of facilities) and should be guarded

against by ring-fencing these critical components of the budget.

6.2. PLANNING

6.2.1. A clear vision and strategic direction for MPDOH should be re-introduced through

dynamic leadership and clear national guidelines and targets for the next MPDOH

strategic planning process.

6.2.2. Align planning and budgeting processes and strengthen capacity and systems for

evidence-based planning and decision-making. Clear guidelines and parameters

should be provided for planning at all levels.

6.2.3. New planning processes should not be embarked on before performance and

delivery on previous plans have been reviewed. This should inform priorities and

targets for the next planning cycle and should be reflected in activities and the

allocation of resources.



6.2.4. Plans have to be realistic and informed by availability of resources (including

Human and Financial resources). However, they also have to be resourced to

levels that would enable optimal implementation. (This applies to planning

throughout the system: facilities, districts and provincial.) There needs to be

iteration between plans and resources available.

6.2.5. Clear targets for each area of operation should be identified for which managers

are held responsible and accountable.

6.2.6. Regular monitoring of plans should be supported by a coherent M&E process

embedded in a formal review cycle with a clearly stated purpose and outcomes.

6.2.7. The STP should be revived, finalised, costed, amended if necessary and then

endorsed politically and communicated to all relevant stakeholders. This should be

the foundation on which all other plans rest. As a priority, the STP should inform

finalisation of the referral policy and organogram and should provide the

foundation on which other plans rest.

6.2.8. The practice of planning and reporting for purposes of compliance should be

strongly discouraged.

6.3. GOVERNANCE

6.3.1. There should be clear written guidelines delineating the areas of responsibility for

the MEC and the HOD.

6.3.2. All senior management appointments should take merit and ability into

consideration.

6.3.3. The NDOH should provide provinces with clear written guidelines regarding the

delegation of authority, responsibility and accountability to facility and district

managers. Provinces should implement these delegations whilst ensuring that

there is sufficient and adequate oversight and monitoring.



6.3.4. Provincial legislation should be passed and enforced to ensure that the provisions

of the Health Act in relation to the district health system, hospital boards and clinic

committees are put into effective operation.

6.4. SERVICE DELIVERY (HIV, TB AND MCH)

6.4.1. Management constraints to service delivery in MPDOH should be addressed as a

matter of priority. Drastic and innovative measures will be required to address the

lack of senior management capacity in MPDOH, including the permanent filling of

a large number of posts with appropriately qualified and committed managers

through recruitment processes free of undue political influence.

6.4.2. A referral system should be established whereby facilities could focus on the

packages and levels of care they are supposed to provide. This has to be

supported by the requisite resources and management.

6.4.3. The NDOH should produce comprehensive, integrated guidelines covering all

aspects of service delivery in relation to HIV, TB and MCH. These guidelines

should be in line with the aim of integrated service delivery in a DHS-based

system. They must contain affordable norms and standards (including human

resources, equipment, drugs, M&E) and should be clear and specific with regard to

responsibilities and accountability.

6.4.4. Plans and budgets need to be arranged so that priority is given to integrated

primary care and within that, priority should be given to the three health challenges

which give rise to the largest burden of disease.

6.4.5. Programme managers need to remain mindful of the broader institutional vision

and the contextual realities within which special programmes are delivered and

their roles and performance expectations have to reflect this. Clear communication

between programme managers and line service delivery managers at all levels

has to be maintained.



6.4.6. Planning must be based on current realities and targets should be set that

continuously ensure significant improvement in health outcomes in agreed upon

priority areas.

6.4.7. The clinic supervision programme needs to be strengthened.

6.4.8. The current model for rolling out ARV treatment needs review to ensure that it is

sustainable, affordable, equitable and addresses issues of access.

6.4.9. An investigation should seek to identify the reasons for poor outcomes in

MPDOH‟s TB programme and how to address this.

6.4.10. The model of treating MDR TB needs review to cope with the increasing patient

load.



Human Resources

1. INTRODUCTION

Box 3: Human resource review key findings

1. A highly centralised model exists, with an unwillingness to delegate authority

to lower levels.

2. The leadership of the HR function has been compromised by the Director

being given additional responsibility for Corporate Services.

3. Morale in the MPDOH appears to be very low.

4. There continues to be a high number of unfilled posts, with slow progress

being made towards filling these. Within top management, three posts are

either vacant or filled by acting managers. The post of Chief Director for

Hospital Services was filled in 2008 after a two year hiatus.

5. The new organogram which was recently submitted to the DPSA has major

cost implications. It will cause an approximate 50% increase in the total

number of posts. In addition, it is not based on the STP, nor have the costs of

implementing the new organogram been given sufficient attention. Meanwhile,

there are high expectations and a perception that the new organogram will

result in the “salvation” of the MPDOH.

6. Selection processes are often politically influenced rather than based on the

merit of the applicants.

7. Staff retention is a serious constraint, especially in the case of doctors and

nurses.

8. MPDOH lacks facilities to be self sufficient in training. For managers, most of

the training received has been generic rather than health specific.

9. Performance management was introduced five years ago but has not been

fully implemented. Bonuses have been paid inconsistently. Reporting in this

regard has been superficial and sometimes cannot be traced. The system is

not being used as a developmental tool.

10. The implementation of OSD for nurses and the agreement reached with the

unions in 2007 has created funding pressures which the province cannot meet

financially.



2. DELEGATIONS, ACCOUNTABILITY AND RESPONSIBILITY

2.1. A highly centralised model exists in MPDOH, ostensibly in the face of the financial

crisis. No policy for decentralisation exists. Hospital managers consider the cut off

point for HR delegations at level 6 to be too restrictive. BBR sub-district managers

indicated that there was more decentralization when this area fell under the

Limpopo DOH.

3. INTEGRATION AND CO-ORDINATION

3.1. Health programmes tend to operate in silos with their own systems, training and

reporting procedures which are not always aligned to those of managers of health

facilities such as the Rob Ferreira Hospital in Nelspruit.

3.2. The medical depot and pharmaco-vigilance staff responsible for overall drug

management in the province, are in different clusters and the lines of

communication between them are not clear.

3.3. There is inadequate communication and co-ordination between health

programmes and DHIS to ensure a single system of data flow. This is aggravated

by the fact that strategic health programmes and DHIS fall under different clusters.

4. HUMAN RESOURCE PLANNING

4.1. HR policy documents and frameworks exist, but are mostly incomplete. Progress

is being made with the finalisation of some policies during the last year, for

example a policy on overtime. However, the execution of these policies is sub-

optimal with a number of factors contributing to this. These include:

4.1.1. The alignment between the HR planning and feedback loops to planning and

budgeting seems to be generally problematic.



4.1.2. Key HR statistics and indicators were not always consistent in the various

document sets. This has potentially serious consequences for planning if the

wrong base data is used for planning and reporting.

4.1.3. Although a HR plan is being prepared, financial constraints and the uncertain

status of both the organogram and the STP, make its finalization problematic.

4.1.4. HR planning has not been directly related to disease burden and policy decisions

(e.g. additional services have to be rendered, but structures are not adjusted to

address service delivery requirements).

5. ORGANISATIONAL DESIGN AND ESTABLISHMENT

5.1. PERSAL data indicated that there are currently 27 000 posts of which 16 670

posts are filled. A large number of the unfilled positions are long standing,

unbudgeted vacancies.

5.2. The current organogram dates back to 2003. A new organogram has been

developed and sent to the DPSA for approval. The exercise was conducted with

the advice of consultants but with little input from DPSA or NDOH. Respondents

expressed an opinion that this new organogram is a fait accompli in that it is

assumed that all that remains is a “rubber stamp” by DPSA for its approval.

However, much depends on a lengthy assessment process by the DPSA

5.3. There is a belief that the new organogram will be the salvation of the MPDOH and

its early implementation is anticipated. However, the difficulty is that substantial

cost pressures will be put on MPDOH should it be implemented because ultimately

it will effectively double staffing figures

5.4. It is a matter of concern that the financial implications of the new structure has not

been given full consideration, neither has the availability of, and challenges in

attracting and retaining, suitably qualified people in MP.



6. RECRUITMENT

6.1. Respondents indicated that the recruitment processes are sub-optimal and some

of the main reasons include lengthy recruitment processes, political and labour

union interference leading to appointments of staff that do not always have

appropriate skills and experience, as well as difficulty in attracting staff because of

inadequate reward structures, lack of accommodation and unsatisfactory working

conditions and a lack of basic medical equipment.

6.2. There is a history of a large number of unfilled posts (8000), many of which are not

budgeted for. In 2007, the province had only filled about half the nurses‟ positions

on the establishment. Following labour action in 2007, it was agreed to fill these

posts notwithstanding the financial implications of doing so. As a result an

unmanageable number of applications were received. A service provider was hired

to assist with the recruitment process but it did not yield the desired results as the

service provider lacked the capacity to deal with the size and scope of the

recruitment exercise.

6.3. Respondents indicated that the selection processes are often of interest to the

MEC who can overrule short lists and the final recommendation. This has

happened from time to time and views exist that appointments are not always

based on merit, but sometimes on political connections.

6.4. Respondents also indicated the high level of influence labour unions have in

selection processes and this is seen as further undermining the capacity of

managers to select the appropriate staff needed.

7. PERFORMANCE MANAGEMENT

7.1. A performance management system was introduced in compliance with DPSA

directives in 2004. However, the execution is poor and there have been several

problems with its implementation:



7.1.1. HR does not have the capacity to manage it properly.

7.1.2. Bonuses have been paid, but in a haphazard way which has caused confusion and

resentment.

7.1.3. Senior managers do not always take the system seriously by, for example, not

preparing their personal documentation and ignoring the need to review the

performance of their subordinates properly.

7.1.4. There is little understanding that performance management is a developmental

tool. As such the one-on-one interview between line manager and subordinate is

crucial as a way of identifying strategies for the development of individuals. This

rarely happens and, if it does, is unlikely to create any real impact.

7.1.5. The process is flawed e.g. documentation disappears and respondents indicated

that the possible reasons include the lack of efficiency in managing documents

and in some cases, a deliberate undermining of the system.

7.2. However, the current Acting HOD and Premier‟s Office (which is answerable to the

DPSA on this matter) are strongly supportive of the system. This may augur well

for its better management in the future but will depend on stabilizing the

management of the MPDOH.

8. RETENTION

8.1. Staff retention was raised as a serious concern; however, there is not a specific

policy available to deal with staff retention. It was stated that a significant number

of staff appointed stay less than a year and on a yearly basis and taking into

account exits, there is no net annual gain from appointing new staff.

8.2. Some of the constraining factors mentioned include salary levels, as MPDOH

practice has been to appoint new staff at the bottom of the scale, accommodation

difficulties (particularly affecting nurses), and poor working conditions at some

facilities.



8.3. An indication of the seriousness of these problems is that when BBR was

transferred from the neighbouring Limpopo, two thirds of doctors (22 out of 33)

chose not to come over as it would have led to a worsening of their conditions of

service.

9. REWARDS

9.1. OSD implementation and labour union agreement with the MPDOH resulted in

numerous problems and also contributed to overspending. The OSD agreement

arrived at with the unions in 2007 specifies the staff members who are to benefit

but leaves out much detail including the specifics of salary adjustments. The DPSA

appears to have arrived at this way out of the dispute without considering what

would be financially feasible for provinces like Mpumalanga. Further confusion has

arisen because of what appears to be lack of agreement between the DPSA and

the NDOH. A joint team of the two departments visited Mpumalanga but „agreed to

disagree‟ on implementation issues.

9.2. It is important to note that, if thorough costing of any change in the reward system

is not done in collaboration with the affected parties and is well linked to the

performance management system, accountability is blurred, money is wasted and

there are unintended effects. In addition, if only a certain category of staff are seen

to benefit, the perceived disparities and inequalities in the reward system could

lead to dissatisfaction, people leaving and possible manipulation within the reward

system.

9.3. There is a perception that rewards are not linked to performance. A suggestion

received was that this could be corrected by linking performance reviews to clearly

defined objective indicators and to reduce the general eligibility to salary increases

to a lower number than is presently applied.



10. LEARNING AND DEVELOPMENT

10.1. There is not a clear training plan in MPDOH and only a limited skills audit to

support human resource development. Although training is undertaken, it is

haphazard and with no clear link to planned staff development or service delivery

requirements.

10.2. Documents analysed indicate that a large number of staff have been trained at the

South African Management Training Institute (SAMDI) which is now the Public

Administration Leadership and Management Academy (PALAMA). This training

does not appear to be particularly health specific. This reflects a problem in

management training in the health sector. A generic form of training, divorced from

the context of that which it is to be delivered in, has been the dominant mode; but

this is probably insufficient for health managers.

10.3. The province also has limited education and training capacity since there are few

institutions of higher education and training in the province; there are no

universities, for example. There is substantial dependence on the Gauteng

Department of Health (particularly for the training of nurses) and Pretoria

University. However, this does not meet the needs. The facility for training nurses

at Rob Ferreira Hospital is quite limited and lack of accommodation is a major

constraint. The difficulty is compounded by the closure of nursing colleges.

11. HR INFORMATION SYSTEMS

11.1. The PERSAL system is established but not fully used and it was reported that the

unit responsible for its maintenance is short-staffed. PERSAL data indicated that

there are currently 27 000 posts of which 16 670 posts are filled. However, a large

number of the unfilled positions are long-standing, unbudgeted vacancies and

PERSAL should be corrected to ensure that it can be used for planning purposes.



11.2. PERSAL data does not appear to be factored into planning and part of the problem

is that some of the information is not reliable and forms a weak basis for decision

making on staff matters.

12. RECOMMENDATIONS

12.1. DELEGATIONS, ACCOUNTABILITY AND RESPONSIBILITY

12.1.1. A policy on decentralisation should be developed and more delegation needs to be

given to managers where it is appropriate to do so.

12.1.2. The responsibility level of CEOs of institutions and district managers and their

district management teams (DMTs) should be reviewed and addressed. This

should include a review of financial management responsibilities.

12.2. HUMAN RESOURCE PLANNING

12.2.1. Planning should be aligned with strategic priorities, service transformation and HR

staffing needs (short, medium and long term) at the various service delivery levels.

12.2.2. Clear and consistent key HR statistics and indicators should be developed and

reported on.

12.2.3. Feedback loops should be established to update plans and define cost and service

delivery impacts should new priorities arise.

12.2.4. Clear decisions and direction at various levels (national, provincial and district

levels) in terms of service delivery should be communicated – if fewer HR

resources and decreased funds are available, priorities need to be adjusted and

communicated accordingly.



12.3. STAFF ESTABLISHMENT

12.3.1. Restructuring, with a view to establishing minimum staffing levels, should be

undertaken based on a number of factors, including objectively agreed

benchmarks, the provincial disease burden profile, optimal application of scarce

skills and service delivery priorities as well as on available resources. Special

consideration should be given to:

12.3.1.1. Structuring to allow for the optimal use of scarce skills.

12.3.1.2. Appropriate management ratios and levels should be reviewed.

12.3.2. Job titles and job grades should be consistent across various areas.

12.3.3. PERSAL should be corrected to accurately reflect personnel positions and staffing

numbers as reported in the Budget Estimate and Annual Report statements.

12.3.4. Norms and standards from NDOH should exist to guide provinces to determine

correct structures and establishments. This should include guidance on

management levels, ratios and grading of positions.

12.3.5. DPSA should provide more support and assistance to NDOH and provinces to

support changes to structures in a more efficient manner.

12.4. RECRUITMENT

12.4.1. A thorough review and improvement of recruitment procedures and processes

should be urgently conducted with a goal to shorten appointment time and prevent

undue political influence in the process.



12.5. PERFORMANCE MANAGEMENT

12.5.1. Performance contracts at job level 13 and above should be clearly linked to

organisational priorities and key indicators that drive organisational performance.

12.5.2. The performance management system should be utilised as intended and

incorporate:

12.5.2.1. Efficient documentation and recording of processes and recommendations;

12.5.2.2. Organisational performance;

12.5.2.3. Staff development and involvement;

12.5.2.4. Reward based on clear performance goals and determined consistently.

12.5.3. Team performance should form part of performance standards and evaluation.

12.6. RETENTION

12.6.1. A national health professional and scarce skills retention strategy should be

developed by the NDOH.

12.6.2. The provincial retention needs should be analysed with a view to attracting

qualified staff more readily, and a policy on this developed.

12.7. REWARDS

12.7.1. A total reward strategy (monetary and non-monetary) review should be undertaken

at national level to address issues of employee compensation, overspend, skills

scarcity and staff retention – including highlighting the importance of:



12.7.1.1. A thorough costing of any change in the reward system which must be done in

collaboration with the affected parties and include an assessment of affordability at

various levels.

12.7.1.2. Rewards should be linked to organisational, employee and team performance.

12.7.1.3. Lessons learned from the current OSD implementation review for nurses should

be captured to inform future implementation of other improvement initiatives.

12.8. LEARNING AND DEVELOPMENT

12.8.1. Training needs should be properly and objectively determined.

12.8.2. Well considered and prioritised commitments to relevant training should be

maintained even during times of cost containment. Training and development

programmes should be clearly defined and aligned to the service delivery priorities

of the province.

12.8.3. The possibility of more effective involvement of PALAMA and tertiary educational

institutions should be explored. In such an exercise, a key need is to link

management education and training within the context of Health.

12.9. HR INFORMATION SYSTEMS

12.9.1. An assessment should be undertaken to establish reasons for under utilisation of

systems and improved measures should be implemented, including the full use of

PERSAL as a HR management tool.



Information Management

1. INTRODUCTION

Box 4: Information management review key findings

1. Although efforts have been made to institutionalise M&E through quarterly and

annual reviews of the MPDOH “Year Plan” at district level, a culture of

evidence-based planning and decision-making has not been established.

2. M&E is not assigned sufficient significance in the organisational structure,

levels of resourcing (including HR, finances and ICT), planning processes and

accountability mechanisms in MPDOH.

3. There are many different management information systems that are poorly

integrated. Importantly, management information systems for “service delivery”

(DHIS and programmes) are not compatible with “resource” systems (e.g. BAS,

LOGIS, PERSAL).

4. The DHIS is relatively well established and DHIS 1.4 is currently used. Data on

a large number of indicators are collected and a substantial body of data is

generated in the process. However, quality control of data is not always

adequate; capacity for data analysis and interpretation is often lacking; and

available information is not used optimally for decision-making.

5. DHIS is seen as being located and driven from outside NDOH, which raises

questions about NDOH ownership, endorsement and support of DHIS.

6. Data reported through various levels are not sufficiently validated and

interrogated. Inaccurate data are reported throughout the system and often

finds its way into official reports, which results in conflicting official information.

Obvious inaccuracies are not followed up or corrected.

7. Information management and M&E are not seen in relation to accountability.

There is a lack of managerial accountability for the attainment of service-related

targets and M&E does not appear to be part of managerial performance

assessment processes.

8. Information management and M&E are constrained by inadequate ICT and lack

of capacity.



1.1. Institutionally, information management and M&E are not afforded sufficient

importance in MPDOH, as evidenced by the following:

1.1.1. There are no permanent posts for information officers at a sub-district level,

because there are no established sub-district management structures in MPDOH5.

1.1.2. Information officer posts in hospitals are at too low a level, which makes it difficult

to attract appropriately qualified, experienced people.

1.2. Key elements of a health information system are absent in MPDOH. These

include:

1.2.1. The forms and indicators to be reported on are not always well understood by

those in the data chain, especially where information originates.

1.2.2. Nurses don‟t see data collection as part of their duty and do not in general

appreciate the importance of keeping accurate records.

1.2.3. Managers at all levels (facility, district, provincial and national) do not always have

the capacity or interest to focus on the significance of key indicators in their sphere

of management and therefore fail to apply it to plan, “trouble shoot”, to query data

or decisions; or take corrective actions.

1.2.4. Information reported is not sufficiently analysed or interpreted by managers at

higher levels; they do not hold those who report the data accountable on the basis

of data reported and do not provide adequate feedback on the data reported.

1.2.5. At all levels, it is not always clear to see how data collected is used to inform

planning and decision-making, which does not motivate those who collect or

capture the data to perform these tasks with the necessary accuracy.

5 The new organogram makes provision for such posts and, as with other programmes in MPDOH, high

hopes are pinned on the implementation of the new organogram to address this particular challenge.

Unfortunately, this also means that hopes and expectations will be disappointed if the implementation of

the new organogram proves to be unfeasible.



1.3. Lack of M&E capacity has an adverse impact on planning and management in

MPDOH. Although major improvements were reported with regard to both the use

and quality of data during the past five years, a culture of evidence-based planning

and decision-making has not yet been established.

1.4. District and provincial quarterly and annual reviews (based on the MPDOH “Year

Plan”) were instituted in 2006 and have been instrumental in improving the quality

and use of information. These reviews focus on key indicators for PHC and service

delivery that are used for sub-district “benchmarking” and responsible managers

are held accountable for the findings. It has also provided a useful way of getting a

common understanding and shared view of what the priorities and challenges are

that need to be managed at a district level.

1.5. The Strategic Planning Directorate has drafted a discussion document in an

attempt to strengthen institutionalisation of quarterly reviews across districts and at

a provincial level.

1.6. Some of the specific challenges pertaining to the quality of data are:

1.6.1. The importance of accurate record-keeping and data capturing is not fully

appreciated at a facility level. Service providers who collect data at this level do not

necessarily understand how these fit into the “bigger picture”.

1.6.2. A large proportion of district information officers‟ time (in Ehlanzeni, the district

information officer estimated it to be about 80%) is devoted to providing inputs to

various reports and plans (including the APP). This aspect of her work is therefore

about providing data to managers for purposes of their planning and reporting.

This leaves very little time for essential work, such as monitoring of trends,

validation and quality assurance of data coming in from the sub-districts.

1.6.3. It is challenging for an information clerk at level 1 to address issues around data

quality if the collector of the data is at level 9 or higher.



1.7. Information management is hampered by inadequate ICT:

1.7.1. There are serious challenges and backlogs in repairing and replacement of IT

equipment.

1.7.2. ICT maintenance and support is inadequate. For example, in Ehlanzeni District,

which is one of the largest health districts in South Africa, there are only three

people in the entire district who cover work on servers, hardware, software and

DHIS.

1.7.3. E-mail connectivity between the different centres is not reliable.

2. USE OF INFORMATION FOR DECISION MAKING

2.1. One of the main constraints to using information for decision-making is the lack of

integration between “service delivery” and “resource” data. This implies that

planning for service delivery takes place without due consideration of available

resources (e.g. funding, human resources, equipment), while budgets are

compiled without due consideration of service delivery data. The structure of the

health information system and how it relates to the organisational structure of

MPDOH obstructs this required integration of data. Various systems, e.g.

PERSAL, BAS, PAAB and DHIS, are not compatible, with the result that composite

indicators cannot be used for planning and decision-making. This issue is

frequently raised at information meetings at district, provincial and national levels,

but the response so far has not been satisfactory.

2.2. Managers do not have access to a sufficiently integrated set of data that would

enable them to plan or make decisions about service delivery on the basis of

resources, and vice versa.

2.3. There is currently a strong drive to revive the system that links DHIS to finances

(District Health Expenditure Review). A meeting to start addressing this will take

place in May 2009. The current health information system in MPDOH does not

meet managers‟ information or reporting requirements.



2.4. The use of integrated information for planning and decision-making would require

high levels of M&E and information management capacity (including for data

analysis, collation and interpretation) at all levels, as well as appropriate ICT

equipment and IT support. It is doubtful that this would be achievable over the

short to medium term in MPDOH. (The HST scoping exercise of 2007 found that

8% of HIS staff did not have computers; only 35% of computers in district offices

and 8% of computers in provincial offices had sufficient memory to run DHIS 1.4;

and only 25% of computers in district offices and 50% of computers in provincial

offices had sufficient hard drive capacity.)

2.5. At Rob Ferreira Hospital (RFH), the structure of management meetings was

changed in December 2008 specifically to improve information management.

2.6. Attendance of management/operational meetings has been extended to include

clinical managers. Standard indicators (e.g. average length of stay, bed utilisation

rates, caesarean section rates, patient day equivalent, causes of mortality,

maternal mortality) are compared with national norms and interrogated and

discussed from a clinical point of view. One of the main shortcomings of current

patient information systems relate to the inability to track patients between

facilities.

3. DISTRICT HEALTH INFORMATION SYSTEM (DHIS)

3.1. The DHIS is well established. The quality of the DHIS is regarded as good,

considering capacity in the districts. (MPDOH has even received a national award

for the best data collection system in the country.)

3.2. About a year ago, MPDOH changed from using DHIS 1.3 to DHIS 1.4. The benefit

was supposed to be the consolidation of data in an integrated database that would

enable easier calculation of composite indicators. However, because of

implementation problems - mainly around software - data accuracy has reduced

from 70-80% to about 50%. Once technical glitches have been addressed,

accuracy levels should again improve to original levels.



3.3. The role of the district information office(r) is to receive and collate routine data

from sub-districts, to validate it and to support district management with reporting

(monthly, quarterly and annually) and planning. The flow of data from facility level

to the office of the district information officer is as follows:

3.4. In Ehlanzeni, where the team focused its investigation, this system has been well

established over the past ten years.

3.5. There appears to be insufficient high-level support from NDOH for DHIS (attention

and funding). The implementation of DHIS 1.4 went ahead without adequate

national guidelines or support. The question was raised whether this is because

the DHIS is developed and “driven” from an independent unit, situated outside

NDOH.



4. RECOMMENDATIONS

4.1. OVERALL M&E

4.1.1. Establishment of a comprehensive MPDOH HIS, within an overall national

framework, should be a priority supported by the necessary political leadership

and allocation of adequate resources.

4.1.2. Quarterly and annual reviews of the MPDOH Year Plan should be encouraged and

supported, and it should be followed through at a provincial level. Provincial

managers should lead by example, especially pertaining to feedback on reports

and reviews so as to strengthen accuracy of recording of data and data quality.

4.1.3. ICT and ICT support should be adequate and reliable to support the information

management function in MPDOH.

4.2. USE OF INFORMATION FOR DECISION MAKING

4.2.1. Managers should have the capacity to analyse and interpret available data for

purposes of planning and decision-making. They have to be able to source and

integrate data and information from different systems as appropriate/required to

inform their plans and decisions. This should be part of their job descriptions and

performance agreements.

4.2.2. A skills audit on managers‟ understanding of information management in their area

of responsibility should be conducted and, where applicable, in-service training

should strengthen capacity. This should include computer literacy and the ability to

use computers and appropriate software for purposes of information management

and reporting.



4.3. DISTRICT HEALTH INFORMATION SYSTEM (DHIS)

4.3.1. NDOH should clarify and establish its position in relation to DHIS. Where DHIS is

found to be lacking, NDOH should lead and guide its review and improvement.

4.3.2. NDOH should provide clear, written guidelines, norms and standards for each

component of the DHIS, including data collections tools (forms and registers);

relevant human resources, hardware, software, data flow policies and linkages

between the DHIS and other data collection systems such as the TB (ETR-net),

PERSAL and BAS.

4.3.3. The number of indicators needs to be decreased and definitions for each one

should be unambiguous, easy to understand and standardised.

4.4. OTHER M&E ISSUES

4.4.1. The role and function of information management and M&E in relation to planning

and accountability must be clarified and strengthened.

4.4.2. A central, official repository of information for the MPDOH has to be established.

Information captured into the repository should be quality-assured (checked for

accuracy, validity, etc.). All official reports and other documents should draw on

information from this repository to eliminate duplication of sources of information.

4.4.3. Parallel systems of information (e.g. direct flow of information from facilities to

programme managers – whether at provincial or national level-, and the by-

passing of district management structures) should be discontinued.

4.4.4. Basic record keeping and filing need to be improved at all levels.



Medical Products

1. INTRODUCTION

Box 5: Key findings

1. Stock-outs of medicine and medical products have become widespread and

common in all facilities across the province during the 2008/09 financial year,

affecting many aspects of service delivery.

2. MPDOH has a poor payment record for drug suppliers on national tenders. As

a result, suppliers would favour provinces with better payment records when it

comes to delivering orders. MPDOH would get drugs only after these provinces

have been supplied, by which time stock-outs would often be experienced in

facilities in MPDOH.

3. It is alleged that MPDOH deliberately under-budgets for drugs. Because drug

shortages are highly sensitive and can easily be politicised, MPDOH

apparently sees this as an easy way to leverage more funding from Treasury.

4. Provision of medical products in MPDOH is impeded by an insufficient supply

chain management process and highly inadequate procurement procedures.

2. MEDICAL PRODUCTS

2.1. Challenges pertaining to medical products have to be seen in the context of highly

inadequate supply chain management in MPDOH. The supply chain unit is

severely understaffed and has not finalised a single tender during the past

financial year. This has resulted in wide-spread shortages and stock-outs of

essential medical products.

2.2. Interviews conducted with hospital managers in MPDOH revealed that stock-outs

of medical consumables (including surgical dressings, needles) have become

“unacceptably high”, especially during the past financial year. MPDOH apparently

has a particularly bad “track record” of payment for supplies under national

contracts. When it comes to delivering, these suppliers would deliver to other

provinces and MPDOH would be amongst the “last” to receive stock.



2.3. In 2008/09, RFH was able to maintain stock levels of only 80% for drugs

(compared to the ideal of 90%); and 53% for medical consumables. Mapulaneng

Regional Hospital was transferred from LPDOH to MPDOH in August 2006 after

which it had to implement the logistical information system used by MPDOH

(LOGIS). The CEO has been waiting since August 2006 for training in LOGIS and,

as a result, stock control for this regional hospital has been done manually for the

past almost two and a half years.

2.4. As a result of essential drugs not being available at PHC clinics, patients go

directly to hospitals. This undermines the referral system and increases the cost of

PHC service delivery.

2.5. Many interviewees were of the opinion that problems with the supply of medical

products and pharmaceuticals cannot be ascribed to the recent financial

pressures, as it “goes back a long time”. However, stock-outs have become

especially common since mid-2008. Facility managers are being told to “bear with

it”, since it is apparently a “national problem” because suppliers on national

tenders have cut down on delivery.

2.6. One interviewee mentioned that there is a “history” of deliberate under-budgeting

for drugs and alleged that this is because drug stock-outs can easily result in

unfavourable publicity for MPDOH and is an issue that can easily be “politicised”. It

is alleged that MPDOH top management believe that they can use this to

“leverage” more funding from National.

3. RECOMMENDATIONS

3.1. Capacity and systems in the supply chain management unit should be addressed

as a matter of urgency.

3.2. Budgeting for drugs should be accurate and the alleged practice of conscious

under-budgeting for drugs should be terminated.



3.3. All hospitals should have systems and capacity to manage stock levels

electronically.



Technology and Infrastructure

1. OVERVIEW

1.1. In addition to challenges around the infrastructure funded by Conditional Grants

i.e. Hospital revitalization and Forensic pathology, the joint management of large

capital projects by the MPDOH and the MPDOPW has not worked well and

projects have regularly underspent and fallen behind schedule (See the case study

on Rob Ferreira Hospital below).

1.2. MPDOH is also dealing with other serious infrastructure-related challenges:

1.2.1. At the provincial head office, there is insufficient storage space for files and

documentation. This is particularly problematic for storage of confidential

documentation.

1.2.2. The MPDOH does not have a proper filing system within the provincial offices.

There are masses of boxes and files piled up in corridors and the like.

1.2.3. Accommodation for staff at clinics and hospitals is insufficient and inadequate. In

rural areas, this makes it difficult to attract and retain staff. Where staff

accommodation at hospitals is lacking, it also means that these hospitals cannot

train nurses.

1.2.4. At Mapulaneng Hospital, there is insufficient office space and a section of the

nurses‟ home is currently being used for office space. This structure has been

declared unsafe for human occupation by the DOPW. Nevertheless, and with no

alternative available, about 64 people occupy this building on a daily basis.

1.3. MPDOH does not have the capacity to conduct facility audits. It has requested the

CSIR to assist in this regard.

1.4. With regard to medical equipment, MPDOH has no tenders for the purchasing or

maintenance of medical equipment in process. MPDOH has apparently not



advertised a single tender for medical equipment since 2006. Managers rely on

national tenders and can purchase equipment of up to R500 000 in value.

1.5. There is no standardised list of equipment for tertiary hospitals, or a national

tender in place to facilitate procurement of this equipment.

1.6. Some of the larger hospitals have clinical engineers and technicians to do

maintenance of medical equipment, but the smaller hospitals have to take

equipment to these larger hospitals when there is a need for equipment to be

repaired or routine maintenance to be carried out.

1.7. “Condemned equipment” is a big challenge because the provincial committee

dealing with this is not providing guidance. Condemned equipment is taking up

valuable space in facilities (including hospital wards) and cannot be disposed of

until the province provides guidance.

1.8. ICT is inadequate and not sufficiently reliable or supported to enable the

establishment of a widely used and accessible HIS.

INFRASTRUCTURE: CASE STUDY RFH

Despite the fact that there are a number of buildings under construction at

RFH, the hospital is underspending on capital expenditure. The reasons for

this are complicated and, despite the fact that the infrastructure unit at RFH is

under-staffed, the situation cannot be ascribed to poor management on the

part of the RFH only. Delays in construction work can be ascribed mainly to

poor contract management in MPDOH (provincial) and lack of capacity in

DOPW. Examples of this include the following:

Construction of Mental Health facilities at RFH (Phase 1) was completed

and taken into use at the end of 2003. However, the construction work has

never been formally signed off. Phase 2 was handed over to the

contractors in 2004, but only the pharmacy has been completed. Phase 3

(new maternity section) was handed over to contractors in 2005 and has

not been completed.



Some of the new buildings have been completed, but the engineers cannot

issue certificates of compliance because some payments are still

outstanding. These outstanding payments are the only reason why

occupancy of these buildings cannot be taken.

Delays with the completion of infrastructure projects have had a knock-on

effect on, amongst others, equipment. At RFH, equipment that was procured in

accordance with the original construction schedule has had to be stored and

could not be installed. In the mean time, the warranties on this equipment have

expired and the equipment itself has never been used.

2. RECOMMENDATIONS

2.1. Backlogs in infrastructural development projects should be addressed through

strengthening MPDOH management capacity in relevant areas, as well as that of

DOPW.

2.2. Lack of capacity and absence of systems for good practice in supply chain

management should be addressed as a matter of urgency.

2.3. NDOH should set norms and standards for equipment in tertiary hospitals and put

a national tender in place to facilitate procurement of this equipment.

2.4. Purchasing of large equipment should be subject to the preparation and approval

of a maintenance plan and budget.

2.5. Current arrangements for maintenance and repair of medical equipment in

MPDOH should be revised and rendered more efficient.



Security

1. OVERVIEW

1.1. The security function in MPDOH is important as it does not only concern security

at MPDOH buildings and facilities, but also vetting and screening of employees.

1.2. MPDOH has demonstrated its commitment to address and improve all aspects of

security by:

1.2.1. Creating a dedicated security department in December 2008. However, it is under-

staffed. The acting head of security is responsible for the provincial office, as well

as two of the three districts (Ehlanzeni has security managers at the district and

regional hospital). One security officer has in the mean time been seconded to

each of the other two district offices, but they have no background or qualifications

in security management and the Acting Head of Security has given them a “crash

course” in this.

1.2.2. Drafting a security policy.

1.2.3. For the first time, making dedicated provision for security management in the

2009/10 budget (it was previously budgeted for under logistics).

1.2.4. Providing in the operational plan of the acting head of security for 2009/10 for an

audit according to which MPDOH managers and staff have to be vetted and

screened.

1.3. Many of the challenges related to security at MPDOH buildings and facilities can

be ascribed to the fact that safety and security for all government departments in

Mpumalanga has been centralised in the Mpumalanga Department of Safety &



Security (MPDOSS)6. Some of the challenges related to this particular

arrangement include the following:

1.3.1. Contract procedures around the awarding of security contracts for provincial

government departments by MPDOSS are considered inappropriate. Despite

performance assessments of service providers by the Provincial Security Forum

(comprising Heads of Security from all provincial government departments),

MPDOSS often awards contracts to service providers with a poor track record of

quality and performance.

1.3.2. MPDOH does security assessments for its buildings and facilities, but the service

providers contracted by MPDOSS do not provide security in accordance with these

assessments because MPDOH does not have any authority over them as they are

not accountable to MPDOH, but to MPDOSS.

1.3.3. Because of contracting arrangements, facility managers are unsure how to handle

complaints related to inadequate security.

1.3.4. MPDOH suffers large losses (equipment, supplies) due to inadequate security.

Efforts to recover losses from responsible security firms have been unsuccessful

and such firms continue to be contracted by MPDOSS.

1.4. The real challenges around security are beginning to manifest in an increase in the

number of cases of litigation due to insufficient security at health

facilities/buildings. Five cases related to negligence on the part of security

companies are currently being investigated (in one incident an in-patient was

raped by a security guard); an amount estimated at between R100 Million and

R200 million for MPDOH is at stake should the litigation succeed.

6 In 1999, through a resolution of the MP Cabinet, safety and security for all government departments in the

province were centralised under the MPDOSS. The MPDOSS handles the entire procurement and contracting

process for safety and security (including tender specifications and conditions, advertising, selection and

contracting) on behalf of all government departments in MP. These departments, such as MPDOH, monitor the

service provider once it is contracted and “on site” and then has to pay the required contract amount over to

MPDOSS on a monthly basis for payment of the service provider.



1.5. Without a dedicated Security Unit and managers in MPDOH, large backlogs have

developed with regard to vetting and screening of managers and staff. It is

estimated that only 5% of managers and staff who have to be vetted have in fact

been vetted. Security breaches through non-vetted managers/staff dealing with

classified, sensitive and confidential information could lead to serious problems

and legal action.

2. RECOMMENDATIONS

2.1. MPDOH security department should be strengthened and supported by the

necessary HR and financial commitments.

2.2. The arrangement whereby contracts management for security at all government

departments was centralised in MPDOSS should be reviewed so that user

departments are also granted a proper voice.

2.3. MPDOH should allocate the necessary resources and support, and mobilise

additional resources if necessary, to fast-track screening and vetting of relevant

staff.



Taking Forward the Recommendations

This section brings together the recommendations from the various sections, and indicates

the main role-players responsible for implementation. It highlights the inter-dependence of

the activities. The public health system as a whole needs to work in unison to achieve

improvement of health system performance, and ultimately the improvement of population

health outcomes.



Recommendations contained in Mpumalanga Department of Health IST Report April 2009 and proposals for allocation of main responsibility for implementation and provision of input Legend: 1 = Main responsibility, 2 = To provide input

RECOMMENDATIONS National Minister of Health

National Department of Health

MPDOH MEC

MPDOH National Treasury

MP Treasury

DPSA

External stakeholders

FINANCE RECOMMENDATIONS

Provincial health budget allocation

The Provincial Treasury should allocate an amount to the MPDOH, which is substantially in line with the equitable share from the National Treasury.

2 2 1

Allocations of conditional grants by the NDOH should be based on clear, objective criteria that are linked to grant specific indicators and not on the equitable share formula.

1 2 2 2

Unfunded Mandates

The operational impact of national policy decisions (e.g. OSD, new vaccine programme) should be determined and must be agreed with the MPDOH prior to implementation.

1 2 2 2

There should be alignment between political decisions and operational implementation and agreement reached for any proposals on increases of service levels prior to their announcement. The availability of funding should also be confirmed.

1 1 2 2 2

Budgeting Process






MPDOH MEC


MP Treasury

DPSA


The budgeting process needs to be seen and used as an extension of the annual performance plan, and needs to follow an iterative process.

1 2 2

All operational units (cost centres) need to have a realistic budget that can be used as a guideline for the financial year‟s activities. Operational plans need to be aligned with available funding to deliver the services.

1 2

Budget virements needs to be linked to changes in operational activity, not merely to balance the number of over- and under-expenditure items.

1 2

The practice of continuous budget reallocations needs to be discontinued. Virement movements which are effected to minimise unauthorised expenditure (over-spending) should not hinder the application of the principles of proper financial management and variance analysis during the course of a financial year.

1 2

Financial management

The staffing crisis of the financial unit needs to be resolved as a matter of urgency, both through permanent appointment of staff and appropriate

1






MPDOH MEC


MP Treasury

DPSA


training.

Cost centre accounting needs to be done at the lowest possible practical level (i.e. facility/clinic level).

1 2 1

Variance analysis needs to be used as a management tool to identify areas that require attention.

1 2 2

The required monitoring structures need to be improved.

1 2 2

Managers should be held accountable for the performance of their operating units and this must be built into the performance management system.

1 2

Quarterly Performance Reports

The accuracy and use of essential performance indicators needs to be improved. The necessary steps must be taken in conjunction with the NDOH to improve the quality of information available in this regard.

1 1 2 2

Variances in specific indicators need to be followed up with actions, and not merely identified

1

There needs to be a link between performance and financial reports. A financial report reflecting actual expenditure compared to budget should also be provided where

2 1 2 2






MPDOH MEC


MP Treasury

DPSA


performance indicators reflect a deviation in operational performance.

Financial reporting IYM (in year monitoring)

The IYM report needs to be expanded to include accruals. The report needs to be compiled on an accrual basis and not only on a cash basis to create a link between operational activity and costs.

2 1 2

The IYM must differentiate between operational budgets and expenditure, and capital budgets and expenditure, and in the case of capital budgets and expenditure a further distinction needs to be made between funding from conditional grants and own funding.

2 2 1 1

The IYM report needs to serve as an accurate forecast of expected expenditure and cost. It has limited use as a monitoring tool when it only reflects actual and expected cash flow, which is not linked to operational activity (expenditure).

2 1 2

Annual Financial Statements






MPDOH MEC


MP Treasury

DPSA


The annual financial statements, while meeting Constitutional and Government Accounting requirements, should be expanded beyond the cash basis of reporting and include accruals as part of reported, aggregated expenditure numbers.

2 1 2

LEADERSHIP, GOVERNANCE and SERVICE DELIVERY RECOMMENDATIONS

General Leadership

There should be a clear separation of roles between the political and administrative heads of health, and all efforts should be made to stabilise the management of the MPDOH.

1 1

There should be explicit and open discussion around the budget and the level of services that can be rendered for that budget. The areas of rationing and prioritisation should be made clear and communicated effectively to all relevant stakeholders.

1 1 1 1 2 2 2

There should be an iterative process to national policies where provincial realities are considered and feedback is given so that either policies can be amended to fit the realities or else additional resources made available so that the level of service delivery can be

2 1 2 1 2 2 2






MPDOH MEC


MP Treasury

DPSA


elevated, consistent with policies.

The NDOH needs to play a far greater and more structured role in ensuring stewardship and assistance to the province which faces intractable problems linked to finances.

1 1 2

Service delivery and budgets need to be linked to each other so that managers are not faced on a regular basis with the making of ad hoc financial cuts.

1 2

Diaries of all managers need to be respected through better time management and discipline.

1 1

Management of over-expenditure is a core senior management function together with its effects on service delivery and needs to be explicitly on the agenda of senior management.

1 2

Short term rationing of important areas (e.g. maintenance of facilities) can influence long term strategies (e.g. run down of facilities) and should be guarded against by ring-fencing these critical components of the budget.

2 1 2 2

Planning






MPDOH MEC


MP Treasury

DPSA


A clear vision and strategic direction for MPDOH should be re-introduced through dynamic leadership and clear national guidelines and targets for the next MPDOH strategic planning process.

2 2 2 1 2

Align planning and budgeting processes and strengthen capacity and systems for evidence-based planning and decision-making. Clear guidelines and parameters should be provided for planning at all levels.

1 2 1 2 2

New planning processes should not be embarked on before performance and delivery on previous plans have been reviewed. This should inform priorities and targets for the next planning cycle and should be reflected in activities and the allocation of resources.

2 1

Plans have to be realistic and informed by availability of resources (including Human and Financial resources). However, they also have to be resourced to levels that would enable optimal implementation. (This applies to planning throughout the system: Facilities. There need to iteration between plans and resource availability.

1 1 2 2






MPDOH MEC


MP Treasury

DPSA


Clear targets for each area of operation should be identified for which managers are held responsible and accountable

2 1

Regular monitoring of plans should be supported by a coherent M&E process embedded in a formal review cycle with a clearly stated purpose and outcomes.

2 1

The STP should be revived, finalised, costed, amended if necessary and then endorsed politically, and communicated to all relevant stakeholders. This should be the foundation on which all other plans rest. As a priority, the STP should inform finalisation of the referral policy and organogram and should provide the foundation on which other plans rest.

2 1 1 2 2 2

The practice of planning and reporting for purposes of compliance should be strongly discouraged.

2 2 1

Governance

There should be clear written guidelines delineating the areas of responsibility for the MEC and the HOD.

1 1 1 2






MPDOH MEC


MP Treasury

DPSA


All senior management appointments should take merit and ability into consideration.

1 1

The NDOH should provide provinces with clear written guidelines regarding the delegation of authority, responsibility and accountability to facility and district managers. Provinces should implement these delegations whilst ensuring that there is sufficient and adequate oversight and monitoring

1 2

Provincial legislation should be passed to ensure that the provisions of the Health Act in relation to the district health system, hospital boards and clinic committees are put into effective operation.

1 2

Service delivery (HIV, TB and MCH)

Management constraints to service delivery in MPDOH should be addressed as a matter of priority. Drastic and innovative measures will be required to address the lack of senior management capacity in MPDOH, including the permanent filling of a large number of posts with appropriately qualified and committed

2 2 1 1 2






MPDOH MEC


MP Treasury

DPSA


managers through recruitment processes free of undue political influence.

A referral system should be established whereby facilities could focus on the packages and levels of care they are supposed to provide. This has to be supported by the requisite resources and management.

2 2 1

The NDOH should produce comprehensive, integrated guidelines covering all aspects of service delivery in relation to HIV, TB and MCH. These guidelines should be in line with the aim of integrated service delivery in a DHS-based system. They must contain affordable norms and standards (including human resources, equipment, drugs, M&E) and should be clear and specific with regard to responsibilities and accountability.

2 1 2 1 2

Plans and budgets need to be arranged so that priority is given to integrated primary care and within that, priority should be given to the three health challenges which give rise to the largest burden of disease.

2 1

Programme managers need to remain mindful of the broader institutional

2 1






MPDOH MEC


MP Treasury

DPSA


vision and the contextual realities within which special programmes are delivered and their roles and performance expectations have to reflect this. Clear communication between programme managers and line service delivery managers at all levels has to be maintained.

Planning must be based on current realities and targets should be set that continuously ensure significant improvement in health outcomes in agreed upon priority areas.

2 1

The clinic supervision programme needs to be strengthened.

1

The current model for rolling out ARV treatment needs review to ensure that it is sustainable, affordable, equitable and addresses issues of access.

1 1 2 2

An investigation should seek to identify the reasons for poor outcomes in MPDOH‟s TB programme and how to address this.

2 1 2

The model of treating MDR TB needs review to cope with the increasing patient load.

1 1

HUMAN RESOURCES RECOMMENDATIONS

Delegations, Accountability and






MPDOH MEC


MP Treasury

DPSA


Responsibility

A policy on decentralisation should be developed and more delegation needs to be given to managers where it is appropriate to do so.

1

The responsibility level of CEOs of institutions and district managers and their district management teams (DMTs) should be reviewed and addressed. This should include a review of financial management responsibilities.

2 1 2

Human Resource Planning

Planning should be aligned with strategic priorities, service transformation and HR staffing needs (short, medium and long term) at the various service delivery levels.

1

Clear and consistent key HR statistics and indicators should be developed and reported on.

1 1 2

Feedback loops should be established to update plans and define cost and service delivery impacts should new priorities arise.

2 1 2 2 2






MPDOH MEC


MP Treasury

DPSA


Clear decisions and direction at various levels (national, provincial and district levels) in terms of service delivery should be communicated – if fewer HR resources and decreased funds are available, priorities need to be adjusted and communicated accordingly.

1 1 2

Staff Establishment Restructuring, with a view to establishing minimum staffing levels, should be undertaken based on a number of factors, including objectively agreed benchmarks, the provincial disease burden profile, optimal application of scarce skills and service delivery priorities as well as on available resources. Special consideration should be given to: Structuring should allow for the optimal use of scarce skills. Structuring should also allow for re-allocation of lower level duties to lower graded staff; Appropriate management ratios and levels should be reviewed.

1 1 2

Job titles and job grades should be consistent across various areas.

2 1 2






MPDOH MEC


MP Treasury

DPSA


PERSAL should be corrected to accurately reflect personnel positions and staffing numbers as reported in the Budget Estimate and Annual Report statements.

2 1 2

Norms and standards from NDOH should exist to guide provinces to determine correct structures and establishments. This should include guidance on management levels, ratios and grading of positions.

1 2 2

DPSA should provide more support and assistance to NDOH and provinces to support changes to structures in a more efficient manner.

2 2 1

Recruitment A thorough review and improvement of recruitment procedures and processes should be urgently conducted with a goal to shorten appointment time and prevent undue political influence in the process.

2 2 1

Performance Management Performance contracts at job level 13 and above should be clearly linked to organisational priorities and key indicators that drive organisational performance.

1






MPDOH MEC


MP Treasury

DPSA


The performance management system should be utilised as intended and incorporate: Efficient documentation and

recording of processes and recommendations

Organisational performance; Staff development and

involvement; Reward based on clear

performance goals and determined consistently.

1 2

Team performance should form part of performance standards and evaluation.

2 3 2

Retention A national health professional and scarce skills retention strategy should be developed by the NDOH.

1 2 2

The provincial retention needs should be analysed with a view to attracting qualified staff more readily, and a policy on this development.

1 2

Rewards A total reward strategy (monetary and non-monetary) review should be undertaken at national level to address issues of employee compensation, overspend, skills scarcity and staff retention – including highlighting the

1 2 1 2 1






MPDOH MEC


MP Treasury

DPSA


importance of

A thorough costing of any change in the reward system which must be done in collaboration with the affected parties and include an assessment of affordability at various levels.

1 2 1 2 2

Rewards should be linked to organisational, employee and team performance

2 2 2 2 1

Lessons learned from the current OSD implementation review for nurses should be captured to inform future implementation of other improvement initiatives.

1 2 1 2

Learning and Development Training needs should be properly and objectively determined.

2 1

Well considered and prioritised commitments to relevant training should be maintained even during times of cost containment. Training and development programmes should be clearly defined and aligned to the service delivery priorities of the province.

2 1

The possibility of more effective involvement of PALAMA and tertiary educational institutions should be explored. In such an exercise, a key

1






MPDOH MEC


MP Treasury

DPSA


need is to link management education and training within the context of Health.

HR information systems

An assessment should be undertaken to establish reasons for under utilisation of systems and improved measures should be implemented, including the full use of PERSAL as a HR management tool.

2 1

INFORMATION MANAGEMENT RECOMMENDATIONS

Overall M&E Establishment of a comprehensive MPDOH HIS, within an overall national framework should be a priority supported by the necessary political leadership and allocation of adequate resources.

1

Quarterly and annual reviews of the MPDOH Year Plan should be encouraged and supported, and it should be followed through at a provincial level. Provincial managers should lead by example, especially pertaining to feedback on reports and reviews so as to strengthen accuracy of recording of data and data quality.

1

ICT and ICT support should be adequate and reliable to support the

2 1






MPDOH MEC


MP Treasury

DPSA


information management function in MPDOH.

Use of information for decision making

Managers should have the capacity to analyse and interpret available data for purposes of planning and decision-making. They have to be able to source and integrate data and information from different systems as appropriate/required to inform their plans and decisions. This should be part of their job descriptions and performance agreements.

1

A skills audit on managers‟ understanding of information management in their area of responsibility should be conducted and, where applicable, in-service training should strengthen capacity. This should include computer literacy and the ability to use computers and appropriate software for purposes of information management and reporting.

2 1

District Health Information System (DHIS)

NDOH should clarify and establish its position in relation to DHIS. Where DHIS is found to be lacking, NDOH

1 2






MPDOH MEC


MP Treasury

DPSA


should lead and guide its review and improvement.

NDOH should provide clear, written guidelines, norms and standards for each component of the DHIS, including data collections tools (forms and registers); relevant human resources, hardware, software, data flow policies and linkages between the DHIS and other data collection systems such as the TB (ETR-net), PERSAL and BAS.

1 2

The number of indicators needs to be decreased and definitions for each one should be unambiguous, easy to understand and standardised.

1 2

Other M&E issues The role and function of information management and M&E in relation to planning and accountability must be clarified and strengthened.

1 2

A central, official repository of information for the MPDOH has to be established. Information captured into the repository should be quality-assured (checked for accuracy, validity, etc.). All official reports and other documents using information should draw on information from this repository to eliminate duplication of sources of information.

2 1 2






MPDOH MEC


MP Treasury

DPSA


Parallel systems of information (e.g. direct flow of information from facilities to programme managers – whether at provincial or national level, and the by-passing of district management structures) should be discontinued.

2 1

Basic record keeping and filing need to be improved at all levels.

2 1

MEDICAL PRODUCTS, LABORATORY RECOMMENDATIONS

Capacity and systems in the supply chain management unit should be addressed as a matter of urgency.

1 2

Budgeting for drugs should be accurate and the alleged practice of conscious under-budgeting for drugs should be terminated.

1 2

All hospitals should have systems and capacity to manage stock levels electronically.

1

TECHNOLOGY AND INFRASTRUCTURE RECOMMENDATIONS

Backlogs in infrastructural development projects should be addressed through strengthening MODPH management capacity in relevant areas, as well as that of DOPW.

2 2 1 2

Lack of capacity and absence of systems for good practice in supply chain management should be

1 2






MPDOH MEC


MP Treasury

DPSA


addressed as a matter of urgency.

NDOH should set norms and standards for equipment in tertiary hospitals and put a national tender in place to facilitate procurement of this equipment.

1 2

Purchasing of large equipment should be subject to the preparation and approval of a maintenance plan and budget.

1 2

Current arrangements for maintenance and repair of medical equipment in MPDOH should be revised and rendered more efficient.

1

SECURITY RECOMMENDATIONS

MPDOH security department should be strengthened and supported by the necessary HR and financial commitments.

1

The arrangement whereby contracts management for security at all government departments was centralised in MPDOSS should be revised so that user departments are also granted a proper voice.

2 1 2 2

MPDOH should allocate the necessary resources and support, and mobilise additional resources if necessary, to fast-track screening and vetting of

1






MPDOH MEC


MP Treasury

DPSA


relevant staff.



Appendices

1. APPENDIX 1: TERMS OF REFERENCE

1.1. PROJECT TITLE

1.1.1. Integrated Support Teams (ISTs): Finance, Health Systems Strengthening and

Management & Organisational Development (M&OD)

1.2. BACKGROUND

1.2.1. The UK Government‟s Department for International Development (DFID) is providing

technical assistance funding through a Rapid Response Health Fund (RRHF) to

strengthen the office of the Ministry of Health and National Department of Health

(NDOH) to achieve the objectives of the national HIV and AIDS and STIs strategic

plan and strengthen its responsiveness and effectiveness in addressing key health

priorities identified by the new Minister of Health, Barbara Hogan.

1.2.2. This is a 12 month programme which commenced in November 2008. HLSP

(through its UK based DFID Health Resource Centre) has been contracted by DFID

to manage the programme and to undertake procurement.

1.2.3. The key partner is the Ministry of Health (MOH), with selected clusters being

supported at the National Department of Health (NDOH). This document provides

Terms of Reference for the appointment of consultants to provide specialised

technical assistance to newly proposed Integrated Support Teams (ISTs). The ISTs

will comprise experts in Finance (sourced and engaged by Deloitte), Health Systems

Strengthening (HSS), and Management and Organizational Development (M&OD)

(these latter two consultancies sourced and engaged by HLSP). These teams will

work at national and provincial levels to undertake a range of financial, managerial

and health systems assessments. The selection and allocation of teams will take

place collaboratively between the Ministry of Health, Deloitte, and HLSP.



1.2.4. Purpose of the IST Review

1.2.4.1. The Ministry and NDOH are aware of a pattern of overspending on health services in

the provinces (with the exception of Western Cape) that poses a major constraint to

the Ministry‟s and National Department of Health‟s ability to revitalize and reorient

South Africa‟s response to HIV/AIDS and support health systems strengthening to

achieve service delivery improvements.

1.2.4.2. The purpose of the IST consultancy is to provide the Ministerial Advisory Committee

on Health (MACH) with a thorough understanding of the underlying factors behind

this trend including:

when the cost overruns began

how they have accumulated over time

operational challenges and constraints

identifying the major cost drivers, and quantifying their relative importance and

impact

identifying types of data available for planning and identification of provincial

health priorities and budgeting

assessing the planning, budgetary and administrative capacity in the

departments

assessing what systems were in place, if any, to flag potential over expenditure

and prevent such overruns occurring

1.2.4.3. In addition, the ISTs will review health service delivery priorities and programmes and

will make recommendations on where and how cost savings can be made into the

future through improved cost management.

1.2.4.4. The overall review will be led by the IST Coordinator (Deloitte) who will be

responsible for ensuring that deliverables are of high quality and that the ISTs adhere

to reporting deadlines. The IST Coordinator will have overall technical oversight and

will be responsible for delivering the IST terms of reference to the Ministry of Health.

It is recognised that HLSP has overall management responsibility for delivering the



Rapid Response Health Fund Logical Framework, of which the IST terms of

reference are a component, in accordance with HLSP‟s contract with DFID.

1.2.4.5. At an operational level, the IST review will be conducted by teams of six consultants

working at national level and teams of three working at provincial level (nine

provinces). The teams will each comprise consultants with the following expertise: 1)

finance, 2) Health Systems Strengthening and 3) Management and Organisational

Development. The IST Coordinator and the teams will report to the Ministerial

Advisory Committee on Health (MACH).

1.2.4.6. The national level team will begin work in early February 2009. The provincial teams

will commence by mid-February 2009. Overall, it is envisaged that the review process

will be completed by April 24 2009 and the report findings presented in mid May

2009.

1.2.5. Aim and Scope of Work

1.2.5.1. Aim of the ISTs: To conduct a review of financial and strategic planning and

operational plans and recommend efficient and effective cost saving strategies, that

will lay the foundation for the development and implementation of a turn- around

strategy that will revitalise and reorient health services for implementation by national

and provincial DoHs during the 2009/2010 financial year. The IST teams, in

partnership with national and provincial departments of health, will identify causes of

over expenditure within the health system at both national and provincial levels. The

IST will identify common or unique causes of over expenditure and the effect of these

on service delivery. The IST team will identify a national and collective response for

service delivery improvement despite these funding constraints.

Although the technical focus of the three different streams will be different, the

integration and synthesis of these focus areas into practical recommendations which

will improve the overall functioning of the departments is of pivotal importance.



1.2.5.2. Review Scope of Work for Finance Consultants

Participate in the development of a provincial review template and attend

orientation to the project and training on the use of the provincial review template

prior to deployment to provinces

Participate in the development of fact files (see below)

Determine when the cost overruns began

Determine how they have accumulated over time

Identify the major cost drivers

Identify what systems were in place, if any, to flag potential over expenditure and

prevent such overruns occurring

In collaboration with HSS and M&OD consultants, propose cost management

strategies for more cost efficient and cost effective programme delivery

Participate in the preparation of a consolidated report of national and or provincial

findings required to reorient policy implications to the MACH.

Conduct a national or provincial review, submit and present a report of national

and or provincial findings including planning, policy implications and financial

controls required to strengthen financial systems and budget management to the

MACH

Attend IST related meetings and produce minutes and reports of meetings and

their outcomes

1.2.5.3. Review scope of work for Health Systems Strengthening Consultants

Undertake a desktop review of strategic and operational plans and health service

delivery data of national and provincial DoHs and compile a fact file

Identify key health programme and systems focus areas and key districts for field

visits from the desktop review, informed by the fact files, including financial data

from the finance consultancy



prior to deployment to provinces


and or provincial findings including planning, policy implications and financial



controls required to strengthen financial systems and budget management to the

MACH

Work with financial consultants to formulate joint recommendations on cost

management strategies and budget realignment across key service delivery

components


their outcomes

1.2.5.4. Review scope of work for Management and Organisational Development Consultants

Undertake a desktop review of management and organisational structures and

policies at national and provincial DoH and compile a fact file.

Identify key management and organisational structures for field visits from the

desktop review, informed by the fact files, noting financial data from the finance

consultancy.



prior to deployment to provinces.


and or provincial findings including management and organisational systems

strengthening required to reorient policy implications to the MACH.

Work with financial consultants to formulate joint recommendations on cost

management strategies and budget realignment across key service delivery

components.


their outcomes.

The IST review will focus on the following key issues: relevance, appropriateness,

effectiveness, outputs or results achieved, efficiency, operational plan

management and coordination and sustainability of planning, delivery and

management of health sector programmes and budgetary systems.



1.2.6. Project Phases

The project will be conducted in three phases:

1.2.6.1. Phase 1-National Team only

Perform an analytical review based on budgeted and actual spending, the

objectives listed in the strategic and operational plans and specifically comment

on the following:

Document recent trends in utilisation of services, and analyse this against costs

Assess management and systems delivery to identify more efficient and effective

options for delivery of services

Assess systems factors that may have resulted in recent overspend, and suggest

strategies for ensuring this is avoided in future.

Consider health service implications of reductions in funding, and suggest

mitigation strategies

Review the Conditional Grants and submit and present data analysis reports on

the status of these grants by province.

Review provincial IST reports and participate in the development of a

consolidated IST report

Based on the review, prepare a national final review report that will:

Identify and recommend corrective actions needed in priority sequence and

approaches for managing costs

Recommend and assist national and provincial departments of health to better

align financial processes with programme implementation and reporting systems

Submit and present a review report with recommendations to the MACH and

provide overall recommendations for improving DoH‟s effectiveness, efficiency

and financial management.

1.2.6.2. Phase 2- Provincial Teams

Perform an analytical review based on the strategic and operational plans

including budget (provincial-specific) and specifically comment on the following:

Document recent trends in utilisation of services, and analyse this against costs



Assess management and systems delivery to identify more efficient and effective

options for delivery of services

Assess systems factors that may have resulted in recent overspend, and suggest

strategies for ensuring this is avoided in future.

Consider health service implications of reductions in funding, and suggest

mitigation strategies

Utilise provincial templates with standardised and unique items adjusted for

provinces

Attend an orientation to the review and travel to allocated provinces

Conduct interviews with provincial Heads of Department (Hood), CFO‟s and

managers

Conduct field visits to selected districts

Review the outputs and outcomes against strategic and operational plans, budget

and expenditure.

Identify and quantify major cost drivers

Assist provinces to identify financial planning and management problems

Review management and administrative systems for monitoring, evaluation and

reporting of outputs and outcomes against operational and financial plans.

1.2.6.3. Phase 3- All Teams

Based on the review, field visits and interviews –prepare national or provincial

review reports and a consolidated report detailing common findings and

recommendations.

Identify and recommend corrective actions needed in priority sequence and

approaches for managing costs

Recommend and assist national and provinces to better align financial processes

with programme implementation and reporting systems

Submit and present a review report with recommendations to the MACH and

provide overall recommendations for improving DoH‟s effectiveness, efficiency

and financial management.



1.3. IST PROJECT MANAGEMENT

1.3.1. The project will be led by and operations managed by the IST Coordinator (Deloitte)

and will follow best practice, including the relevant portions of the System

Development Life Cycle Management and Project Management. IST Coordinator

responsibilities include:

1.3.1.1. Process management and reporting, including ensuring task completion to agreed

standards

1.3.1.2. Managing issues that arise – such as delays, problems, contractual matters

1.3.1.3. Liaison with stakeholders – provinces and national

1.3.1.4. Management of provincial and district visits

1.3.1.5. Collating reports and finalizing the consolidated provincial reports.

1.3.2. Only three provinces (Eastern Cape, KZN and Gauteng) will have field visits

conducted up to 4-5 weeks, the remaining 6 provinces will have field visits up to 3

weeks per province concurrently.

1.3.3. The MOH, Deloitte and HLSP will jointly appoint a Team Representative (TR) for

each provincial team, who will have overall responsibility for leading the team and

producing reports. The TR will be responsible for communicating with the IST

Coordinator on an ongoing basis and will provide weekly updates on the progress of

the review to the TR, the CFO of the NDOH and HLSP. The TR will be responsible

for report content and technical quality and will be required to attend project related

meetings at National level. The TR will also provide project direction at provincial

level, delegate tasks per the provincial template, ensure liaison with relevant

stakeholders and provide progress reports to the provincial HoD as required. The TR

is expected to be a senior consultant with extensive experience in leading and

delivering high quality reviews in a health care environment and in possession of a

relevant tertiary qualification in Finance, HSS or M&OD.



1.3.4. A Steering Committee comprising of representatives of the NDOH, Deloittes HLSP,

and the Ministerial Advisors will be established to provide support and guidance to

the work of the IST.

1.4. ROLES AND RESPONSIBILITIES

1.4.1. Role of NDOH and Provincial DoH

1.4.1.1. It is anticipated that the NDOH and provincial DoH will provide relevant

documentation, facilitate meetings and consultations, select and make appointments

with key informants to be interviewed. In addition, they will provide administrative

support and office space to the consultants. Consultant reports and invoices must be

signed off by the CFO in the National Department of Health (and the HLSP Technical

Manager) prior to payment.

1.4.2. Role of Consultants

1.4.2.1. Consultants will work full-time with the NDOH, Deloitte and provincial DoHs. Each

consultant will report to their TR and conduct work delegated by TR according to the

standard review template. It is expected that the consultant will:

Understand and comply to the principles laid down in the Public Finance

Management Act (PFMA)

Liaise with national, provincial and selected districts

Ensure project implementation to time and quality

Compile weekly progress and final reports

Work closely with provinces and national team

1.5. EXPECTED OUTCOMES AND DELIVERABLES

1.5.1. This refers to both national and provincial ISTs.

1.5.1.1. Standardised provincial and national review templates



1.5.1.2. Summary Progress Reports and national and provincial DoH fact files

1.5.1.3. Align Review Report with linkages of budgetary process and strategic and

operational plans

1.5.1.4. Detailed review reports on conditional grants and consolidated provincial reports

(National Team)

1.5.1.5. National and Provincial Reports focusing but not limited to:

1.5.1.6. An executive summary of key findings by provinces and overall national status

1.5.1.7. The extent to which provinces have met and complied with the objectives set out in

their operational plans

1.5.1.8. The extent to which provinces have over-expended on the budget based on their

financial statements

1.5.1.9. The impact of over-expenditure on the DoHs and implications for future operational

plans and service delivery

1.5.1.10. The quality of services and cost-effectiveness of programmes delivered

1.5.1.11. Recommendation on lessons learnt from the review, and how, if any, to address

challenges in the management and implementation of the provincial operational plans

to improve service delivery and reduce over-expenditure

1.5.1.12. Oral presentations on the key findings of the review and roadmap to the MACH

1.6. COMPETENCY AND EXPERTISE REQUIREMENTS

1.6.1. The following skills will be expected of the Finance component of Consultancy:

1.6.1.1. Leadership experience and people and technical management skills



1.6.1.2. Extensive experience and understanding of Finance, the effective integration and

presentation of information from diverse sources, the Public Finance Management

Act (PFMA) and provincial DoH with relevant qualifications and track record

1.6.1.3. Experience and understanding of South African public sector budgetary management

systems

1.6.1.4. Computer literacy, good communication and writing skills

1.6.1.5. Data analysis and reporting on administrative, health management and financial

issues

1.6.1.6. Operational and financial management of large projects and programmes

1.6.1.7. Good team management and team work (interpersonal) skills

1.6.2. The following skills will be expected of the M&OD and HSS consultants:

1.6.2.1. Extensive experience and understanding of the South African health system, PFMA

and provincial DoH with relevant qualifications and track record

1.6.2.2. Experience and understanding of South African public sector management systems

1.6.2.3. Experience in health system strengthening and organisational development

Computer literacy, good communication and writing skills

1.6.2.4. Data analysis and reporting on administrative, health management and financial

issues

1.6.2.5. Operational and financial management of health projects and programmes

1.6.2.6. Good team management and team work (interpersonal) skills



1.7. REPORTING REQUIREMENTS

1.7.1. It should be noted that HLSP is responsible for the quality of the outputs of the DFID

Rapid Health Response Programme. This includes providing technical support to the

project partner on the quality of work produced by service providers. HLSP will

therefore form part of the Review Panel for the preferred consultants, will participate

in the planning of work at the commencement of the contract, and will be present at

progress meetings on a regular basis during the implementation of the contract.

1.8. TIMING AND SCHEDULING

1.8.1. The national review is commencing on the 26th January 2009, while the review of the

pilot province is scheduled to commence on the 16th February 2009. Provincial and

consolidated final reports are expected to be submitted by the 1 May 2009. The oral

presentations will be completed by the 8 May 2009.

1.8.2. All communications and queries about the terms of reference can be directed to:

Kevin Bellis (Technical Manager) and Sphindile Magwaza (Technical Advisor) at

HLSP: [email protected] and [email protected] respectively.

1.9. CONTRACTING AND INVOICES

1.9.1. Funding for the implementation of projects within the DFID –RRHF is secured from

the UK Government Department for International Development (DFID). DFID has

appointed a Procurement Service Provider, HLSP, to manage the appointment of

Consultants and disbursement of consultancy and project funds.

1.9.2. HSS and M&OD consultants will be appointed on a contract issued by HLSP, the

Procurement Service Provider, but will report to the IST coordinator (Deloitte) on a

day to day basis. Deloitte will provide all Finance Consultants.

1.9.3. Invoices will be submitted to the HLSP for verification and authorisation in line with

the HLSP Service Provider Handbook. Deloitte invoices and individual service

provider invoices must be signed off by the CFO of the NDOH. The IST Coordinator



is responsible for signing off on all consultant timesheets prior to submission to

HLSP.

1.9.4. Payment will be made monthly in arrears within 30 days of receipt by the consultant

of an approved invoice and full supporting documents.

1.9.5. No payment will be made for extra work done out of the scope of the review or if the

IST Coordinator and CFO are not satisfied with the standard of delivered outputs.

1.10. GENERAL INFORMATION

1.10.1. CVs will be assessed using the following technical criteria:

1.10.1.1. Experience in consultation with Departments of Health, finance, health systems

strengthening and organisational development in developing countries, including

South Africa

1.10.1.2. Experience with review methods including primary data and secondary sources

1.10.1.3. Experience in writing review or evaluation report

1.10.1.4. Availability within the review time frames

1.10.1.5. Short listed consultants may be interviewed by the project partner or HLSP.



2. APPENDIX 2: LIST OF DOCUMENTS REVIEWED

2.1. PLANNING

2.1.1. Mpumalanga Department of Health. Service Transformation Plan. October 2008.

2.1.2. Mpumalanga Department of Health & Social Services. Vote 10 (Health): Annual

Performance Plan for MTEF Period 2008/09 – 2010/2011; Strategic Planning Period

2005/06 – 2009/10.

2.1.3. Mpumalanga Department of Health. Three-Year Annual Performance Plan 2007/08 –

2009/10.

2.1.4. Mpumalanga Department of Health & Social Services. Strategic Plan for Financial

Years 2005/06 to 2009/10.

2.2. REPORTS

2.2.1. Mpumalanga Department of Health (Vote 10). Annual Report for the period April 2006

– March 2007.

2.2.2. Mpumalanga Department of Health & Social Services (Health Component). 9 Months

report: April 2007 – December 2007.

2.3. FINANCE

2.3.1. Mpumalanga Department of Health. Budget Policy. (2009)

2.3.2. 2007 Mpumalanga Budget Statement.

2.3.3. Provincial Conditional Grants; 2004/05 – 2010/11.

2.3.4. Hospital Revitalisation: Rob Ferreira Hospital Project Implementation Plan 2009/10.



2.3.5. Hospital Revitalisation: Themba Hospital Project Implementation Plan 2009/10.

2.3.6. Hospital Revitalisation: Ermelo Hospital Project Implementation Plan 2009/10.

2.3.7. Hospital Revitalisation: Tertiary - Psychiatric Hospital Project Implementation Plan

2009/10.

2.3.8. Mpumalanga Department of Health: Report on the budget and expenditure outcomes

as at 28th February 2009 (Vote 10: Health Services.)

2.3.9. Mpumalanga Department of Health. Vote 10: Audit Finding Action Plan 2007/8.

2.3.10. Report of the Auditor-General to the Mpumalanga Provincial Legislature on the

Financial Statements and Performance Information of Vote No 10: Department of

Health and Social Services: Health Component for the year ended 31 March 2008.

2.3.11. Mpumalanga Department of Health. Internal Audit Report: Tintswalo Hospital. (May

2008)

2.3.12. Mpumalanga Department of Health. Internal Audit Report: Standerton Hospital. (May

2008)

2.3.13. Mpumalanga Department of Health. Internal Audit Report: Amajuba Memorial

Hospital. (March 2008)

2.4. HR

2.4.1. Public Service Commission. 2008. The Turn-over Rate of Heads of Department and

its Implications for the Public Service. Pretoria: Public Service Commission.

2.4.2. Mpumalanga Department of Health and Social Services. Health Component. Revised

Overtime Policy. June 2008.

2.4.3. Mpumalanga Department of Health. Draft Leave Policy. July 2007.



2.4.4. Mpumalanga Department of Health. Draft Employment Equity Policy. (Undated)

2.4.5. Mpumalanga Department of Health. Accommodation Policy. (Undated)

2.4.6. Mpumalanga Department of Health. Reviewed Policy on Accommodation. (Undated)

2.4.7. Mpumalanga Department of Health. Draft Incentive Policy. (Undated)

2.4.8. Mpumalanga Department of Health. Draft Policy on Appointment and Compensation

of Employees acting in higher vacant and unfunded posts. (Undated)

2.4.9. Mpumalanga Department of Health. Abscondment Policy. (Undated)

2.4.10. Mpumalanga Department of Health. Draft Policy on the payment of Subsistence and

Transport Expenses. (Undated)

2.4.11. Relocation Expenditure. 2003.

2.4.12. Mpumalanga Department of Health & Social Services. Draft Policy on Resettlement.

(Undated)

2.4.13. Mpumalanga Department of Health. Workplace HIV/AIDS Policy. (Undated)

2.4.14. Mpumalanga Department of Health & Social Services. Policy on Suspensions.

(Undated)

2.4.15. Mpumalanga Department of Health & Social Services. Policy on Termination of

Services. (Undated)

2.4.16. Mpumalanga Department of Health & Social Services. Policy guidelines on transfers

within the public service. (Undated)

2.4.17. Mpumalanga Department of Health & Social Services. Fleet Management Policy: GG

vehicles. (Undated)



2.4.18. Mpumalanga Department of Health. Salary Administration and Human Resources.

(February 2005)

2.4.19. Mpumalanga Department of Health. Asset Management Policy. (November 2008)

2.4.20. Mpumalanga Department of Health. Loss and Disposal Policy. (November 2008)

2.4.21. Mpumalanga Department of Health. Asset Management. (2005)

2.4.22. Mpumalanga Department of Health. Standard Operating Procedure: Ordering Stock

from Suppliers. (April 2006)

2.4.23. Mpumalanga Department of Health & Social Services. Provisioning and Procurement.

(February 2005)

2.4.24. Mpumalanga Department of Health. Organisational structure and establishment. (July

2003 - Final Version).

2.5. OTHER:

2.5.1. Barron P, Day C, Monticelli F (eds). 2007. The District Health Barometer 2006/07.

Durban: Health Systems Trust.

2.5.2. Barron P & Roma-Reardon J (eds.). 2008. South African Health Review 2008.

Durban: Health Systems Trust.

2.5.3. Health Systems Trust (for the Mpumalanga Department of Health). Scoping of

Requirements to establish a Monitoring & Evaluation system for the Mpumalanga

Provincial Department of Health and Social Services. Final Project Report: October

2007.

2.5.4. Helen Schneider, Peter Barron, Sharon Fonn. The promise and the practice of

transformation in South Africa‟s health system. In Buhlungu S, Daniel J, Southall R,

Lutchman J. State of the Nation South Africa 2007, 289-307. HSRC Press, 2007.



2.5.5. Human Rights Commission. 2009. Report of Public Inquiry into Access to Health

Care Services in South Africa.

2.5.6. Malcolm Segall. Review of public health service delivery. “The bottle is half full”.

Policy oriented overview of the main findings. May 1999

2.5.7. MEC of the Mpumalanga Department of Health. 2008. Policy and Budget Speech,

Vote 10 – 2008/09.

2.5.8. Naledi Consulting. 2005. An investigation into the management of public hospitals in

South Africa: Stressed Institutions, Disempowered Management. (Report

commissioned by the Department of Public Service and Administration.)

2.5.9. Stiaan Byleveld and Ross Haynes. District Management Study - A National

Summary Report. A review of structures, competencies and training interventions to

strengthen district management in the national health system of South Africa. Health

Systems Trust, Durban 2009.

2.5.10. Venter S, Loveday M and Smith J. 2006. Mpumalanga: Health Information Audit

Report. Durban: Health Systems Trust.

2.5.11. World Health Organization. The World Health Report 2000, Health Systems:

Improving performance. Geneva, WHO 2000.

2.5.12. Africon (for the Mpumalanga Department of Health). Development of a Service

Transformation Plan: Change Readiness Assessment Report. 2008.

2.5.13. Africon (for the Mpumalanga Department of Health). Development of a Service

Transformation Plan: Stakeholder Management Strategy and Plan. 2008.

2.5.14. Africon, in association with EOH Consulting (for the Mpumalanga Department of

Health). STP Workshop: Fact Sheet. 22/04/08 – 24/04/08.



3. APPENDIX 3: SCHEDULE OF INTERVIEWS

Provincial Department Level

Department/Area Person(s)

Interviewed Position

Date of Interview

Top Management Dr Sinbongile Zungu Head of Department 6 April 2009

Finance

Ms C Hoon Acting CFO 6 April 2009

Mr Steven Shabangu Acting Director: Management Accounting

1 April 2009

Mr Kenneth Nkosi Acting Director: Financial Statements

Mr Bheki Motau Director: Internal Audit 2 April 2009

Strategic Planning

Ms Milani Wolmarans

Director: Strategic Planning 30 March 2009

Supply Chain Management

Ms Carol Mnisi Director: Supply Chain Management

2 April 2009

Human Resources

Ms Jackie Botha-Greyling

Assistant Director: Human Resource Management

1 April 2009

Strategic Health Programmes

Ms Idah Makwetla Chief Director: Primary Health Care

30 March 2009

Ms Sarah Gumede Director: Chronic Diseases and Geriatrics; Also Acting Director: PHC Programmes

Ms Sipho Motau Director: EU PHC Partnership Programme

6 April 2009

Hospital Services Dr Brenda Khubeka Chief Director: Hospital Services 6 April 2009

Rob Ferreira Hospital (Level 2; providing some Level 3 services.)

Dr S Mohangi CEO

1 April 2009

Dr G Goosen Medical Manager

Ms A Landman Nursing Services Manager

Ms T Ngwenya Acting Financial Manager

Mr BL Mnisi Administration Manager

Ms HW Phiri Human Resource Manager

Ms G Nkosi Supply Chain Manager

Security Mr Johnny Phillson Head of Security 2 April 2009



District Level: Ehlanzeni



Date of

Interview

District Management

Ms Thalita Madonsela

District Director 7 April 2009

Financial Management

Mr Peter Mhlongo District Finance Manager 8 April 2009

Information Management

Ms Lehana Buurman District Information Officer 7 April 2009

Hospital Services Dr Gabrielle Mashile CEO: Mapulaneng Regional Hospital

3 April 2009

Strategic Health Programmes

Mr Ishmael Mtungwa Deputy Director: Primary Health Care: Bushbuckridge sub-district

3 April 2009

Provincial Treasury



Date of

Interview

Task Team investigating issues of financial management in MPDOH

Ms Janet Bezuidenhout

General Manager: Financial Governance

3 April 2009 Ms Claudia Makwetla Senior Manager: Accounting Services

Mr Wynand Ngoma Senior Manager: Norms & Standards



4. APPENDIX 4: FINANCIAL TABLES REFERENCES

Table 1 Allocation of Provincial budget to Health (including conditional grants)

Financial year

R m

Provincial Budget


R m

Health Budget



R m

Adjustment Provincial Budget

R m

Adjustment Health Budget


2005/067 11 295 N/A 2 472 N/A 21.9% 12 027 2 653 22.1%

2006/078 12 805 13.4% 2 912 17.8% 22.7% 12 832 3 032 23.6%

2007/089 16 211 26.6% 3 595 23.5% 22.2% 16 846 3 718 22.1%

2008/0910

18 740 15.6% 4 242 18.0% 22.6% 20 390 4 656 22.8%

2009/1011

22 545 20.3% 5 429 28.0% 24.1% N/A N/A N/A

2010/1112

24 633 9.3% 5 874 8.2% 23.8% N/A N/A N/A

7 Mpumalanga Provincial Budget Statement 2007/08 Page22








Table 2 Allocation of Provincial budget to health (excluding conditional grants)

Financial year

R m

Adjustment Provincial Budget (Incl Grants)

R m

Adjustment Conditional Grants

R m

Adjustment Provincial Budget (Excl Grants)

R m

Adjustment Health Budget (Incl Grants)

R m

Adjustment Health Grants

% year on year increase in health Grants

R m

Adjustment Health Budget (excl Grants)

% allocation to Health

2005/06 12 027 1 01013

11 017 2 653 30014

N/A 2 352 21.3%

2006/07 12 832 1 20815

11 624 3 032 34516

15.0% 2 688 23.1%

2007/08 16 846 1 90817

14 939 3 718 48518

40.6% 3 233 21.6%

2008/09 20 390 2 36819

18 022 4 656 66920

37.9% 3 987 22.1%

2009/10 22 545 3 10121

19 444 5 429 81722

22.1% 4 612 23.7%

2010/11 24 633 3 38523

21 247 5 874 1 00024

22.4% 4 874 22.9%

13

Mpumalanga Provincial Budget Statement 2006/07 Page 15 14











Mpumalanga Provincial Budget Statement 2008/09 Page 305





R 000


R 000



Comprehensive HIV/AIDS Grant 2005/06 1 150 10825

81 39226

7.08%

2006/07 1 616 21427

107 47928

6.65%

2007/08 2 006 22329

121 19030

6.04%

2008/09 2 885 40031

151 84932

5.26%

2009/10 3 476 20033

200 22634

5.76%

2010/11 4 311 80035

261 54436

6.07%

National Tertiary Services 2005/06 4 709 38637

42 22438

0.90%

2006/07 4 981 14939

44 75740

0.90%

25

Estimates of National Expenditure 2008, page 279 26




















R 000


R 000



2007/08 5 321 20641

54 99542

1.03%

2008/09 6 134 10043

66 62144

1.09%

2009/10 6 614 40045

81 41046

1.23%

2010/11 7 398 00047

91 87948

1.24%

Total Conditional grants to Provinces 2005/06 8 907 34649

260 45250

2.92%

2006/07 10 206 54251

300 38352

2.94%

2007/08 11 736 67853

412 07354

3.51%

2008/09 14 362 80055

643 00456

4.48%

2009/10 15 578 40057

702 14958

4.51%

41





















R 000


R 000



2010/11 18 012 80059

811 33660

4.50%

Note: Only tables with reference citations are listed above. The complete set of financial tables is found in the Financial Review of the report.

57



