Presentation to the Select Committee on Social Services Annual Performance Plan and Budget – National Department of Health 2013/ /16 23 APRIL 2013

VISION AND MISSION VISION Long and healthy life for all South Africans MISSION To improve health status through the prevention of illnesses and the promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equity, efficiency, quality and sustainability. 2

MTEF PRIORITIES The MTEF priorities of the Department is derived from:  10 Point Plan  Government’s outcome-based approach to service delivery. The Health sector is responsible for the achievement of Outcome 2 : A long and healthy life for all South Africans Four outputs identified: –Output 1 : Increasing Life Expectancy –Output 2 : Decreasing Maternal and Child mortality –Output 3 : Combating HIV and AIDS and decrease the burden of disease from Tuberculosis –Output 4 : Strengthening Health System’s Effectiveness  Millennium Development Goals  Health Goals from the National Development Plan 2030.

HEALTH SECTOR’s PRIORITIES NATIONAL DEVELOPMENT PLAN:HEALTH GOALS, INDICATORS AND ACTION POINTS TOWARDS THE 2030 VISION 4 NSDA OUTPUTS POINT PLAN HEALTH RELATED MDGs Average male and female life expectancy at birth increases to 70 years. 2.Progressively improve TB prevention and cure 3.Reduce maternal, infant and child mortality 4.Significantly reduce prevalence of non- communicable chronic diseases 5.Reduce injury accidents and violence by 50 percent from 2010 levels 6.Complete health systems reforms 7.Primary health care teams provide care to families and communities 8.Universal health care coverage 9.Fill posts with skilled, committed and competent individuals 1.Increasing life expectancy; 2. Decreasing child and maternal mortality rates 3.Combating HIV and AIDS and STIs and decreasing the burden of disease from Tuberculosis 4.Enhancing health systems effectiveness 1.Provision of Strategic leadership and creation of a social compact for better health outcomes 2.Implementation of National Health Insurance (NHI); 3.Improving the Quality of Health Services; 4.Overhauling the health care system 5.Improving Human Resources, Planning, Development and Management; 6.Revitalisation of infrastructure 7.Accelerated implementation of HIV and AIDS and Sexually Transmitted Infections National Strategic Plan, and reduction of mortality due to TB and associated diseases; 8.Mass mobilisation for better health for the population 9.Review of Drug Policy; and 10. Strengthening Research and Development MDG Goal 4 MDG Goal 5 MDG Goal 6

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/14 – 2015/16 Improve Life Expectancy by implementing following key strategies:  Expansion of the ARV coverage  Reduce new HIV infections.  Reduce burden of Tuberculosis  Reduce Maternal Mortality  Reduce Infant, Child and Youth morbidity and mortality  Improve collaboration and Reduce burden of Communicable and Non- communicable diseases. Interventions for all of the above key strategies are outlined in the next slides IMPROVE LIFE EXPECTANCY

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/14 – 2015/16  Improved health system’s effectiveness by implementing following key areas: Improve quality of health services Re-engineering of Primary Health Care Functional District Health System Preparation for the implementation of the NHI Improve health workforce planning, management and development. Efficient management of health technology Accelerate delivery of health infrastructure Interventions for all of the above key areas are outlined in the next slides IMPROVE HEALTH SYSTEMS EFFECTIVENESS

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 REDUCE NEW HIV INFECTIONS KEY INTERVENTIONS INCLUDE:  Conduct at least Medical Male Circumcisions during 2013/14, this will increase to during 2015/16.  Test at least 98% of all TB patients for HIV by 2015/16.  Increase contraceptive prevalence (couple year protection rate) from 32.5% during 2011/12 to at least 38% during 2015/16.  Expanded PMTCT Programme for pregnant women (to be outlined in the coming slide)

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 EXPAND THE ARV COVERAGE KEY INTERVENTIONS INCLUDE:  Initiate at least new clients on ARVs per annum.  Initiate at least 85% of all TB and HIV co infected patients on ARVs, with up to 97% by 2015/16.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 EXPAND PMTCT PROGRAMME FOR HIV + PREGNANT WOMEN KEY INTERVENTIONS INCLUDE:  Increase HIV+ pregnant women initiated on ARVs from 80.4% in 2011/12 to at least 97% in 2015/16  Reduce the proportion of HIV positive babies born to HIV positive mothers from 4% in 2011/12 to at least 2% by 2015/16

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 REDUCE MATERNAL MORTALITY KEY INTERVENTIONS INCLUDE:  Increase the proportion of antenatal clients attending a health facility before 20 weeks from 40.2% in 2011/12 to at least 68% in 2015/16.  Increase the proportion of deliveries taking place in health facilities under the supervision of trained personnel in a public health facility from 89.3% in 2011/12 to at least 97% in 2015/16.  Increase the percentage of mothers and babies who receive post-natal care within 6 days of delivery from 56.9% in 2011/12 to at least 84% in 2015/16.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 REDUCE INFANT, CHILD AND YOUTH MORBIDITY AND MORTALITY REDUCE INFANT, CHILD AND YOUTH MORBIDITY AND MORTALITY KEY INTERVENTIONS INCLUDE :  Maintain the percentage of children fully immunised under 1-year of age at minimum 90% throughout the MTEF period  Maintain the measles immunisation coverage rate of 90 % throughout the MTEF period  Expand the implementation of the Integrated School Health Programme 70% (9,666 of 13,809) of quintile 1 and 2 schools to benefit from the integrated School Health Programme (ISHP) during 2013/14, with up to 95% schools benefiting during 2015/ schools translates to 297,000 Grade 1 learners and 80,200 Grade 8 learners benefitting from the ISHP during 2013/14.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 REDUCE THE BURDEN OF TUBERCULOSIS KEY INTERVENTIONS WILL INCLUDE:  Increase the TB cure rate from 73.1 % in 2011/12 to the WHO target of 85% by 2015/16.  Reduce the TB treatment defaulter rate from 6.8% in 2011/12 to less than 5% by 2015/16.  Reduce turnaround time of TB test results by increasing the number of tests conducted using the GeneXpert. Estimated tests to be conducted using GeneXpert during 2013/14, increasing to 1m by 2015/16.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 IMPROVE COLLABORATION BETWEEN TB AND HIV PROGRAMMES TO REDUCE THE CO-INFECTION BURDEN IMPROVE COLLABORATION BETWEEN TB AND HIV PROGRAMMES TO REDUCE THE CO-INFECTION BURDEN KEY INTERVENTIONS WILL INCLUDE:  Increase the percentage of TB patients tested for HIV from 82.9% in 2011/12 to at least 98% in 2015/16  Increase the number of HIV positive patients that receive Isoniazid Preventative Therapy (IPT) from patients in 2011/12 to at least in 2015/16

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 STRENGTHEN MANAGEMENT OF NON-COMMUNCABLE DISEASES STRENGTHEN MANAGEMENT OF NON-COMMUNCABLE DISEASES KEY INTERVENTIONS:  Conduct public education campaign on salt reductions in line with published regulations  Expanding the chronic care model to 15 districts by 2015/16.  Revision to the regulations of warning labels on alcohol products.  Development and implement the Health Promotion strategy.  Develop regulations for graphic health warnings on tobacco products  Establishment of the National Health Commission to develop and implement an Intersectoral approach for the prevention of NCDs.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 REDUCE THE BURDEN OF DISEASE FROM COMMUNICABLE DISEASES REDUCE THE BURDEN OF DISEASE FROM COMMUNICABLE DISEASES KEY INTERVENTIONS INCLUDE:  Establish a National Public Health Institute to reform and strengthen the capacity of National Institute of Communicable Diseases (NICD) over the MTEF  Improve access to cataract surgery to at least operations per million population in all 9 provinces.  Increase the cervical cancer screening coverage from 55% in 2011/12 to at least 60% by 2015/16  Decrease the incidence of Malaria from 0,58 cases per 1000 population in 2011/12 to at least 0.45 per 1000 population at risk in 2014/15, in keeping with the target to eliminate Malaria by 2018.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/14 – 2015/16 IMPROVE QUALITY OF HEALTH SERVICES KEY INTERVENTIONS INCLUDE:  Improve complaint resolution by ensuring that at least 85% of all resolved complaints have a turnaround time within 25 days.  Develop and implement standardised protocol for conducting Patient Satisfaction surveys  Increase the number of districts supported by Facility Improvement Teams to 20.  Ensure gap assessment are conducted at all health facilities by 2015/16. (30% facilities to be assessed during 2013/14)  Fully establish Office of Health Standards Compliance by 2015/16.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 RE- ENGINEERING OF PRIMARY HEALTH CARE KEY INTERVENTIONS INCLUDE:  Increase the number of municipal ward based primary health teams to 750 in 2013/14, 1000 in 2014/15 and 1500 in 2015/16  Improve access to primary health care services with an increased utilisation rate of at least 3 visits by 2015/16.  Expand the number of districts with the full complement of members of the District Clinical Specialist teams to at least 20 Districts in 2013/14, up to 25 during 2015/16.  Improve access and quality of PHC supervision. Develop and implement a manual for capacity building for PHC supervisors and facility managers Increase the monthly supervisor visit rate from 66.6% in 2011/12 to at least 85% in 2015/16  Implementation of Integrated School Health Programme School Health services refer to slide 11

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 IMPROVE HEALTH WORKFORCE PLANNING, MANAGEMENT AND DEVELOPMENT IMPROVE HEALTH WORKFORCE PLANNING, MANAGEMENT AND DEVELOPMENT KEY INTERVENTIONS INCLUDE:  Development and implementation of norms and standards for health workforce planning.  Increase the number of medical students registered at South African Universities by at least 10% every year over the MTEF. This will increase the number of new students from 1800 in 2012/13 to at least 2395 in 2015/16.  Increase the number of hospital managers trained as per the training programme developed by the Academy for Leadership and Management in Health – 105 during 2013/14, 100 during 2014/15 and 100 during 2015/16

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 FUNCTIONAL DISTRICT HEALTH SYSTEM KEY INTERVENTIONS INCLUDE:  Develop and implement an Intersectoral Framework for addressing the Social Determinants of Health  A District Quarterly Review Guideline will be developed during 2013/14 to institutionalise district quarterly reviews  Strengthen the disease outbreak response by establishing trained disease outbreak teams in 20 districts by 2013/14. This intervention will be implemented in all 52 districts by 2015/16 financial year.  Revised District Health System strategy which is inclusive of a District Health Authority.

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 PREPARATION FOR THE IMPLEMENTATION OF NHI KEY INTERVENTIONS INCLUDE:  Preparation of the legal framework for the establishment of the NHI 2013/14 White Paper on NHI finalised and gazetted 2014/15 NHI Bill tabled to parliament 2015/16 Implementation of regulations  Develop a conceptual framework for the creation of the NHI Fund in 2013/14 with the first phase of implementation in 2014/15  Increase Revenue collection in Central Hospitals – 4 in 2013/14, 7 in 2014/15 and 10 in 2015/16  Contracting of the General Practitioners (GPs) and other health service providers. 2013/ GPs contracted to work in 533 clinics in NHI Pilot Districts

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 EFFICIENT MANAGEMENT OF HEALTH CARE TECHNOLOGY KEY INTERVENTIONS INCLUDE:  Continue with the implementation of the Health Technology Strategy  Publish Essential Equipment lists for all levels of care in 2013/14  Finalization of the standards for the use and maintenance of Health Care Technology

IMPLEMENTATION OF THE HEALTH SECTOR’S RESPONSE DURING 2013/ /16 ACCELERATE THE DELIVERY OF HEALTH INFRASTRUCTURE KEY INTERVENTIONS INCLUDE:  Accelerate the delivery of health infrastructure through the following key activities: During 2013/14 - Issue RFP, procure and sign agreement for Chris Hani Baragwanth. RFQ and RFP for Limpopo Academic Hospital. Completed feasibility studies for Dr G Mukhari, Nelson Mandela Academic Hospital and King Edward VIII projects. Procure Transactional services for Mpumalanga Tertiary and Tygerberg hospital projects  Five of the seven planned tertiary hospitals (Nelson Mandela Academic (EC); Chris Hani Baragwanath (GP); Dr. George Mukhari (GP); Limpopo Academic (LP); King Edward VIII (KZN)) would have commenced with construction by 2015/16.

RESOURCE ENVELOPE FOR IMPLEMENTING OF THE NATIONAL DOH PLANS FOR 2013/14 to 2015/16

PROGRAMME ALLOCATIONS FOR 2013/ /16 Programmes R’ million 12/1313/1414/1515/16 Administration National Health Insurance, health Planning and System Enablement HIV/AIDS, TB, Maternal and Child Health 9,26511,02912,86714,546 Primary Health Care Services Hospital, Tertiary Health Services and Human Resource Development 17,35117,91119,07319,903 Health Regulation and Compliance Management ,002 Total Budget Allocation28,05730,70633,92536,684

ECONOMIC CLASSIFICATIONS ALLOCATIONS FOR 2013/14 TO 2014/15 Economic Classification 12/1313/1414/1515/16 Compensation of Employees Goods and Services8871,1001,2701,336 Total Transfers & Subsidies 26,64828,24230,39333,055 Payment of Capital Assets ,6941,696 Total28,05730,70633,92536,684

EXPENDITURE TRENDS  The Department’s expenditure grew from R19,2 billion in 2009/10 to R27,9 billion in 2012/13 at an average annual rate of 13,3 percent.  Over the Medium Term period, expenditure is expected to grow to R36,7 billion, at an average annual rate of 9,4 percent.  The increase in both periods is driven largely by transfers to provinces for the conditional grants, with the main increase being on the HIV and AIDS and the introduction of NHI grant.

MEDIUM TERM ALLOCATION FOR 2013/14 – 2015/16  The Budget includes additional allocations of R800 million for 2015/16 for the scale up of the provision of antiretroviral treatment.  R100 million for 2014/15 and R384 million for 2015/16 to partly offset the decrease in funding over the medium term from the US President’s Emergency Plan for AIDS Relief (PEPFAR). This programme has contributed roughly R4 billion per year towards the South African national HIV and AIDS and tuberculosis response.  The amount is likely to decrease by 50 percent over the next five years.

MEDIUM TERM ALLOCATION FOR 2013/14 – 2015/16  R90 million, R100 million and R250 million for the Medical Research Council to strengthen its capabilities and infrastructure and to support partnership on high priority diseases, such as HIV and AIDS, tuberculosis and malaria, with development partners, such as Gates Foundation.  R15 million, R31,5 million and 31,5 million to strengthen the National Institute of Communicable Diseases and address the decrease in PEPFAR funding support  R30,1 million, R30 million and R30,3 million most of which comes from internal reprioritisation savings, for the infrastructure unit systems support programme, which provides capacity building support to the department and provinces.

MEDIUM TERM ALLOCATION FOR 2013/14 – 2015/16  R15 million in 2015/2016 for the South African National AIDS Council for HIV and AIDS programmes.  R22,1 million, R28,3 million and R41 million for improved conditions of service to cover high personnel costs.  R6 million in 2013/2014 for emergency medical services during the 2014 African Nations Championship.  The department expects to reprioritise R19,6 million, R37 million and R51,8 million over the medium term in non-core goods and services items.

MEDIUM TERM ALLOCATION FOR 2013/14 – 2015/16  Cabinet has approved reductions of R531 million over the medium term.  The three health infrastructure grant will be reduced due to slow spending and weaknesses in performance.  Reductions of R26 million (R11 million, R10 million and R5.2 million) over the MTEF period have been made to the National Health Insurance grant due to slow expenditure.  The department reviewed the staff establishment in 2010/11 to its human resources needs and the functions assigned in terms of the approved budget structure. The establishment is projected to increase moderately to strengthens skills and experience

INFRASTRUCTURE SPENDING  The three health infrastructure grant (Hospital Revitalisation, Health Infrastructure and Nursing Colleges and schools grants) have been consolidated into a single direct grant, called the Health Facility Revitalisation Grant with three windows.  It is envisioned that the new configuration will allow more flexibility to shift funds in between and ensure timely delivery of health infrastructure.  Spending on infrastructure increased from R3,2 billion in 2009/2010 to R5.8 billion in 2012/2013, and is expected to increase to R6,5 billion over the medium term.  The Health Facility Revitalisation Grant has been allocated R14,9 billion over the MTEF period (R5,1 billion, R4,7 billion and R5 billion).

INFRASTRUCTURE SPENDING Infrastructure Spending continue  The new indirect schedule 6A grant has been established called National Health grant. This grant will have two components, one for National Health Insurance (NHI) and one for Health Facility Revitalisation grant.  The new National Health Grant contains a Health Facility Revitalisation component. This grant has been allocated R4.2 billion over the MTEF period (R807 million, R1,7 billion and R1,7 billion) and is a grant in kind to the provinces.

CONDITIONAL GRANTS ALLOCATIONS 2013/ /16

 Schedule 4 grants: specifying allocations to provinces to supplement the funding of programmes or functions funded from provincial budgets;  Transfer payments cannot be withheld based on non performance or compliance, however, the new Division of Revenue Grant allows a 5% withholding while interventions are put in place.  Grants included are: National Tertiary Services, Health Professions Training and Development.

CONDITIONAL GRANTS ALLOCATIONS 2013/ /16 Schedule 5 : specifying specific-purpose allocations to provinces. Grants included are: HIV and AIDS Grant National Health Insurance Grant. Health Facilities Revitalisation Grant. Schedule 5 grants may be withheld for non performance and or compliance. Interventions must also be put in place for compliance.

KEY SPECIFIC GRANT REFORMS IN NHI GRANT R291 million is allocated to the National Department: 1. R40 million is allocated for Diagnostic Related Groupers (DRG’s) for Central Hospitals 2. R251 million allocated for contracting of doctors (GPs) 36

KEY SPECIFIC GRANT REFORMS IN HEALTH REVITALISATION Health Facility and Revitalisation Grant deals with selected projects managed at the National level that are related to upgrading of Nursing Colleges, Revitalisation and Health Infrastructure projects R807 million will be allocated to NDOH and is based on a project list Procurement of contractors for all the selected projects will be managed by National Department of Health Merging of Infrastructure grants into 1 grant with 3 sub components at Provincial level 37

KEY SPECIFIC GRANT REFORMS IN HEALTH REVITALISATION R807 million will be allocated to NDOH and is based on a project list Distribution per Province as follows: 38 ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

2013 DIVISION OF REVENUE BILL SCHEDULES Purpose of schedule2012 DoRA numbering 2013 DoRB numbering Supplementary Grants to Provinces44A Specific Purpose Grant to Provinces55A Allocations in-kind to Provinces76A 39

COMPREHENSIVE HIV AND AIDS GRANT (5A) ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

NATIONAL HEALTH INSURANCE GRANT (5A) ProvinceDistrict NameAllocation % allocation versus budget Easter capeOR Tambo District Free StateThabo Mofutsanyana GautengTshwane District KwaZulu-NataluMzinyathi KwaZulu-NataluMgungundlovu LimpopoVhembe District MpumalangaGert Sibande District Northern CapePixley ka Seme District North WestDr Kenneth Kaunda District Western CapeEden District TOTAL

NATIONAL TERTIARY SERVICES GRANT (4A) ProvincesBudget% allocation versus budget Eastern Cape % Free State % Gauteng % Kwa-Zulu Natal % Limpopo % Mpumalanga % Northern Cape % North West % Western Cape % Total % 42

HEALTH PROFESSIONS TRAINING AND DEVELOPMENT GRANT (4A) ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

NATIONS CHAMPIONSHIP CONDITIONAL GRANTS (6A) ALLOCATED TO NDOH ProvincesBudget% allocation versus budget Free-State Northern-Cape Limpopo Western-Cape Total

HOSPITAL REVITALISATION GRANT ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng Kwa-Zulu Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

HEALTH INFRASTRUCTURE GRANT ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng Kwa-Zulu Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

NURSING COLLEGES AND SCHOOLS GRANT ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng Kwa-Zulu Natal Limpopo Mpumalanga00.0 Northern Cape00.0 North West00.0 Western Cape Total

NATIONAL HEALTH GRANT (HRG, HIG AND NCSG COMBINED – 5A) ProvincesBudget% allocation versus budget Eastern Cape Free State Gauteng Kwa-Zulu Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total

CONCLUSION  National DoH Annual Performance Plan 2013/ /16 reflects interventions to improve the health system and health outcomes for all South Africans.  Achieving the health sector objectives will require fundamental reform of the health system in the country, which includes amongst others: focus on improved infrastructure; human resources for health and improved management capacity, including norms and standards for staffing; accountability in planning and budgeting, as well as development of capacity and systems in financial management; health financing reform and reform of key strategic institutions.  The Department will continue to work towards improving healthcare equity, quality and access through the introduction of the National Health Insurance, and building human resource capacity in the health sector through various initiatives.

Thank You