1. NATIONAL DEPARTMENT OF HEALTH National Health Insurance Grant Select Committee on Appropriations Hearing on 3 rd and 4 th Quarter Expenditure 4 th June 2013

2. Index Background Provincial Expenditure Summaries (IYM) – Q3 and Q4 figures (incl. Province specific challenges) – Total Grant Expenditure Summary of challenges impacting on Expenditure Monitoring and Evaluation matters Way Forward 2Select Committee on Appropriations_4 June 2013

3. Background R150 million allocated for 2012/13 FY – Each pilot District received R11.5 million Focus: – To test innovations that are necessary for the implementation of NHI – To undertake health system strengthening initiatives in identified Districts – To provide strategic resources for supporting the pilot Districts in implementing selected health service delivery interventions 3Select Committee on Appropriations_4 June 2013

4. Eastern Cape Q3 and Q4 Expenditure (R’000) 4Select Committee on Appropriations_4 June 2013

5. Eastern Cape: Challenges Provincial office delayed notification of the availability of funds to the District District capacity constraints – Lack of key HR in essential categories; – Inadequate technical support Supply Chain hurdles – Delays in getting approvals 5Select Committee on Appropriations_4 June 2013

6. Free State Q3 and Q4 Expenditure (R’000) 6Select Committee on Appropriations_4 June 2013

7. Free State: Challenges Reprioritisation of funds allocated to activities SCM hurdles 7Select Committee on Appropriations_4 June 2013

8. Gauteng Q3 and Q4 Expenditure (R’000) 8Select Committee on Appropriations_4 June 2013

9. Gauteng: Challenges No support/guidance from relevant officials at Provincial Office Significant hurdles in procurement processes Delays in getting information on budget codes – Staff shortages in key areas Lack of ability to employ staff on long term basis using NHI-CG funding e.g. clinical staff, sessional doctors, etc. 9Select Committee on Appropriations_4 June 2013

10. KZN Q3 and Q4 Expenditure (R’000) 10Select Committee on Appropriations_4 June 2013

11. KZN: Challenges Structural administrative process – Bureaucratic processes that hamper innovation The process for obtaining signatures needs to be streamlined – Huge delays at Provincial office Limited delegations to allow for activities to be undertaken – District level delegations very limited Significant Supply Chain hurdles – Lack of clarity regarding long delays in getting necessary approvals 11Select Committee on Appropriations_4 June 2013

12. Limpopo Q3 and Q4 Expenditure (R’000) 12Select Committee on Appropriations_4 June 2013

13. Limpopo: Challenges Challenges around budget matters – Inappropriate / incorrect budget coding SCM hurdles – Significant delays in getting approvals Challenges in identifying relevant providers to undertake some activities due to limited database Technical and administrative support from Province inadequate 13Select Committee on Appropriations_4 June 2013

14. Mpumalanga Q3 and Q4 Expenditure (R’000) 14Select Committee on Appropriations_4 June 2013

15. Mpumalanga: Challenges Majority of the DHMT not appointed – Too many vacancies to undertake activities Non-existent / limited delegations to allow for activities to be undertaken – District level delegations very limited SCM hurdles impacting on key activities 15Select Committee on Appropriations_4 June 2013

16. Northern Cape Q3 and Q4 Expenditure (R’000) 16Select Committee on Appropriations_4 June 2013

17. Northern Cape: Challenges Delays in Provincial Treasury providing information regarding availability of funds SCM hurdles Significant delays in getting necessary approvals and lack of technical support in key areas Challenges in identifying relevant providers to undertake some activities due to limited database Contextual factors also impact on programme: – Majority of key staff complement based in Kimberley DHMT has limited delegations 17Select Committee on Appropriations_4 June 2013

18. North West Q3 and Q4 Expenditure (R’000) 18Select Committee on Appropriations_4 June 2013

19. North West: Challenges Incorrect capturing of budget at Provincial level – District submitted an incorrect business plan to Provincial Treasury Poor prioritisation of allocated funding – Need to reprioritise to other activities Lack of technical support in key areas – Need Provincial NHI Coordinator – Challenges in identifying relevant providers to undertake some activities due to limited database Inability to spend on Infrastructure i.e. clinics, motor vehicles, etc 19Select Committee on Appropriations_4 June 2013

20. Western Cape Q3 and Q4 Expenditure (R’000) 20Select Committee on Appropriations_4 June 2013

21. Western Cape: Challenges Delays in finalising business plan impacted on progress – Approval only granted in August 2012 Encountered some challenges in undertaking work around Governance arrangements at Community level i.e. CHCs – Delays in getting a supporting legal opinion on the exact roles, responsibilities and functioning of Clinic Committees 21Select Committee on Appropriations_4 June 2013

22. Summary of Quarter 3 Expenditure (R’000) 22 Select Committee on Appropriations_4 June 2013

23. Summary of Quarter 4 Expenditure (R’000) 23Select Committee on Appropriations_4 June 2013

24. DORA: Implementation Select Committee on Appropriations_4 June 2013 24

25. Total Expenditure by Province (%) (April 2012 – 31 March 2013) 25 Select Committee on Appropriations_4 June 2013

26. NHI-CG Provincial Commitments/Roll-Overs 2012/13 Financial Year

27. PROVINCE TOTAL NHI-CG ALLOCATION COMMITMENTS COMMITMENTS AS PERCENTAGE OF TOTAL BUDGET EC11 500 000.003 229 000.0028.1 FS16 500 000.007 163 000.0043.4 GP31 500 000.0012 026 000.0038.2 LP11 500 000.006 382 000.0055.5 KZN33 000 000.0014 949 000.0045.3 MPU11 500 000.00325 000.002.8 NC11 500 000.001 578 000.0013.7 NW11 500 000.002 083 765.0018.1 WC11 500 000.001 615 000.0014.0 NATIONAL150 000 000.0049 350 765.0032.9

28. Summary Challenges Weak HR capacity in some Districts Weak Provincial technical support Delays in budgets being communicated to some pilot sites – Incorrect budget capturing Significant Supply Chain management challenges in many Districts Lack of necessary delegations to perform outlined activities 28Select Committee on Appropriations_4 June 2013

29. Monitoring and Evaluation Matters Monitoring and Evaluation undertaken by Grant Management Unit and Directorate: NHI – Financial, Health Economics and Monitoring and Evaluation skills appointed All Provinces have submitted Month on Month financial data – Used to compile IYM data Quarterly reports and meetings with all sites – Mutually identified shortfalls and challenges; – Mutually identified “quick win” activities and interventions; – Expedited Expenditure on commitments in approved Business Plans – Assessed progress on operational plans Prioritisation process Focus on quality spending – Evidence gathering 29 Select Committee on Appropriations_4 June 2013

30. Way Forward (1) Inherent underperformance in early part of the 2012/13 cycle: – NHC Intervention resulted in improvement in Q3 and Q4 DORA framework to adjust the purpose, focus activities and funding allocations to Provinces: – Allows NDOH a stronger and more interventionist approach: – Influences the scope of work to be undertaken at National and pilot site levels: – Changes in allocations across Districts 30Select Committee on Appropriations_4 June 2013

31. Way Forward (2) For 2013/14, the grant has been split into 2 components: – Direct: District piloting (Schedule 5) – In-kind: GP contracting and Central Hospitals work (Schedule 6A) New focus areas: – Strengthening SCM; – Supporting the roll-out of PHC streams and their role within the District referral system; – Strengthening District level Monitoring and Evaluation capacity Mobilised funding for appointment of Provincial NHI Coordinators: – Majority appointed to post; – Assist in coordination, project management and Monitoring and Evaluation functions 31Select Committee on Appropriations_4 June 2013

32. THANK YOU Select Committee on Appropriations_4 June 2013 32