Professor Nomafrench Mbombo Budget Speech 2015

Madam Speaker

Honourable Premier Ms Helen Zille

Cabinet Colleagues and Members of the Provincial Parliament

Chairperson of the Standing Committee

Head of Department and Management of the Department of Health

Our Partners at the Academic Institutions, Civil Society and the Health Sector

Members of the various Media

Our special guests such as the representatives from local communities, our consumers of healthcare, our partners in the private sector and business and most importantly, the Citizens of the Western Cape

I feel privileged to lead the Health Department in the Western Cape and give you my maiden Budget Speech for 2015/16.

It is the Department with the largest budget within the Province, receiving 36% of the provincial budget for 2015/2016, which in itself bears testimony to the high priority accorded to Health by the Western Cape Government. Health is said to be the face of service in any government.

The Health Department is not only the largest Department because of its share of the budget, but is the most complex.

The service is rendered at multiple sites ranging from, amongst others, 42 acute hospitals, 11 specialised hospitals, 277 clinics (including that of the City Of Cape Town), larger 8 hour Community day centres and 24 hour community health centres,  49 ambulance stations, 250  ambulance vehicles and patient transport fleet of  82 vehicles and 18 forensic laboratories.

Essential to our functioning is our partnerships with key role players such as the HEI (Higher Education Institutions) private sector, organised labour, civil society other departments and other spheres of government. So providing health services is a truly complex business.

In my first few months in office, as part of my commitment to the people of the Western Cape, I have visited many health facilities across the province.

I have and will continue to do so, in order to see the facilities myself and to engage staff and patients on their experiences in each area.

If we are to prioritise patient experience and improve the working conditions of our staff, these visits are essential.

I can confirm even from the places that I have visited, that we have dedicated staff working under tough conditions due to the service pressure of the health care system in general.

More than 90% of our patient contacts happen in the primary care services and many of the facilities are quite congested.

The majority of the acute hospitals in the metro and some of the rural acute hospitals are functioning above the optimal bed occupancy of 85% - some even at 100 – 120%.

This is fuelled by the increase of our population numbers as well as the escalating quadruple burden of disease with the largest proportion being from chronic conditions, which forms 80% of patients attending our PHC facilities.  Between the two census in 2001 and 2011, the population grew by 28,8% in the Western Cape according to StatsSA. In addition we have had a 2,5% patient increase in our facilities.

The pressure on services are bound to increase for the foreseeable future.

It is worrying that the risk factor trends such as that of obesity and physical inactivity continue to increase and levels of smoking, alcohol and substance abuse remain unacceptably high.  

We cannot continue mopping the floor only - we have to close the tap.

Delivering a health service can no longer be business as usual.

This is why my vision for health in the province is premised on the promotion of wellness and preventive measures.

If we educate and create awareness about the importance of looking after oneself, we will be able to bring down the numbers of those who end up at our healthcare facilities.

The WC Healthcare 2030 – the long term strategic vision and direction of the Department – which has also been endorsed by the Provincial Cabinet is the Road that will take us to Wellness.

Wellness is not defined by merely the absence of disease, but a complete state of physical, mental and social wellbeing.

This is on par with National Development Plan (NDP) 2030 which emphasises the wellbeing of the population as priority.

There will be a greater emphasis and effort around preventive measures such as immunisation, access to antenatal care and prevention of HIV as was mentioned by the Premier in her State of Provincial Address (SOPA).

However, as we know, many of the risk factors for ill health require upstream interventions in broader society and also needs the whole of society.

In this regard, the approach of the Western Cape Government to cluster departments around shared goals is welcome.

Strategic Goal (SG) 3 is to improve wellness, increase safety and tackle social Ills and it involves the Departments of Health, Social Development, Culture, Arts and Sport and Community Safety.

I have been appointed to lead this group.

As part of SG 3, we are creating a living laboratory in Drakenstein whereby all the Departments together with local government and our partners VPUU (Violence Prevention through Urban Upgrade) focus our efforts in a concentrated area to get maximum impact.

We are hoping to create a model of integrated service delivery with optimal community involvement towards sustained impact that can be replicated in other parts of the province.

Health is also working with Education Department and others to tackle youth issues in the Manenberg area.

We partner with the Department of Premier, Medical Research Council, and 3 other departments to reduce the impact of alcohol abuse in areas like Nyanga.

Alcohol remains a key risk factor for injuries from both road traffic accidents as well as interpersonal violence, foetal alcohol syndrome and many other health conditions and social ills.

The WCG has therefore identified alcohol as a game changer.

This government has seen the devastating effects of alcohol and substance abuse among the people we serve.

 This is exactly why we have seen the need to streamline our efforts and make alcohol and substance abuse prevention a focus.

South Africa is one of top five heaviest drinking nations in the world.

It costs the South African government R17 billion to deal with alcohol abuse, and the tangible cost to family and society doubles that (R38 billion). 

It also places tremendous pressure on our healthcare system. Injuries and interpersonal violence are one of the biggest contributor to the province’s quadruple burden of disease and this is mostly due to alcohol and substance abuse related.

Maternal and Child health is the bedrock for a functioning health system.

Whilst the Western Cape has improved MCH outcomes compared to other provinces, the death of one woman is one too many.

We intend to strengthen the First 1000 days of life project especially in the metro.

Every pregnant mother will be tracked in the public sector from antenatal care –delivery – post natal care – up to the child’s early development.

The aim of this is, amongst others, is to reduce smoking and harmful alcohol use in pregnancy, provide good antenatal and postnatal care while improving breastfeeding rates.

Keeping girls at school is essential to reducing teenage pregnancy and improving maternal education: a determinant of infant survival. We have to work with Education on the best model.

It is critical that we continue to cultivate our partnership with private sector around wellness.

We will be reviewing the 16 wellness centres we launched with private pharmacies in the first half of last year.

We intend to expand to cover the rural areas for family planning and immunisation services.

The recent partnership between Health, Education and private sponsors through the Health Foundation to launch the school mobile wellness units is an exciting development. This fits neatly into our goal of health promotion in schools. These wellness mobiles provide a crucial service across the province and improves access to screening for learners in grade R and 1 even in the most remote of areas.

The Provincial Strategic Goal 3 first priority is about building healthy and resilient communities.

A whole society approach is key to getting communities taking full responsibilities of their health and promoting crucial behavioural changes across the board.

This year, I will be launching the very first community health Indaba to invite all our stakeholders to take part in it.

We intend to foster sustainable relationships with NGOs, community based organisations, communities, traditional and religious leaders to achieve these key results.

 We need to make the circle bigger for non-state and state actors to participate. Active citizenry will be my legacy.  

The health system does not begin with a healthcare worker at a primary healthcare facility level.

It begins with an individual at home and those leaders who live among them.

This reminds me of the words of the late community icon, Uncle Polly Jacobs, then chairperson of Belhar Health Forum, member of Western Cape Health Forum and colleague at UWC, when he used to remind us that, “ Nothing about us, without us,  on health matters… Tell us where we can assist”.

Uncle Polly understood that health cannot be made a political football. Health is about the lives of people.

Uncle Polly, you will be happy to know I am tabling the Western Cape Health Facility Boards and Committees Bill 2015 for approval by Cabinet ngomso lo usayo.

We give power to the people to take ownership and responsibility of health services in partnership with health care workers.

The intention of the bill is to provide an explicit policy framework to allow for community involvement and oversight to the provision of health services especially at PHC level.

Part of my mission during my term in office is to strengthen the community health worker programme. Currently we have more than 2000 community health workers which we intend to expand.

Primary healthcare approach at all levels of care underpins the service delivery approach with strengthening of district health services as major emphasis.

Improving the quality of care and the patient experience is a central piece of Healthcare 2030. Staff attitude and patient waiting times are major issues, not just in the Western Cape but globally.

The Department will be examining the patient flow within primary care and emergency centres to identify improvements at various steps of the patient journey.  

A key part of improving quality is also amplifying the voice of the patient and the community.

The SMS hotline and the complaints email address and telephone line allows us to get the necessary feedback from our clients.

I will also be setting up an Independent Health Complaints Committee as per the legislation that has been promulgated and whose regulations are being finalised.

This will be the mechanism to further investigate patient complaints if we are not satisfied that they have been adequately addressed within the routine process.

The distribution points of the Chronic Dispensing Unit have been rolled across the province and we intend to increase the alternate sites to 600 so to reduce unnecessary waiting times at our facility.

Without our dedicated carers, we can’t implement any of these brilliant ideas.

This is why I would like to acknowledge and congratulate the Three Musketeers of Groote Schuur Hospital. These healthcare workers have completed 46 years of service:

• Mareldia Patton (65)
• Mareen Ross (64)
• Martha Petersen (64)

The increase in population resulted in 2,5% increase in clients utilising public services which puts pressure on our health care workers.

Whilst there is no justification for a health worker bad attitude towards patients, this government understands the circumstances they work under.

As a practising nurse and midwife myself, working 12hour shifts with no meals breaks, I know very well how it feels.

There were times when you felt hopeless because you were just mopping the floor and not closing the tap.

We are currently busy reinforcing caring values to our staff.

The CAIR2 (Caring, Accountability, Integrity, Responsiveness and Respect) Club project is to acknowledge and recognise the commitment of hard working staff at the coal face, to translate the values of the Department into concrete behaviours and actions. Caring for our carers is crucial to improving the patient experience.

Let me turn my attention to the health budget.

Given the slow growth in GDP in the country at large, the health allocation to the Department is projected to decrease in real terms over the medium term.

This will further increase the pressures on the Department as we try to internally reprioritize the budget to address the many challenges as well as give incremental effect to the vision of Healthcare 2030.

 The 2015/2016 Budget

The Department is allocated R18,8 billion. The budget increases by 7.9%.

However, the outer years will be shrinking chronologically by 4% and 5.4% respectively based on the medium term expenditure estimate.   

The Provincial Equitable share amounts to R13 billion and the National Conditional Grants to R5 billion. The major Conditional Grant allocations for 2015/16 include:

• The National Tertiary Services Grant :                                       R2,5bn
• The Health facility Revitalisation Grant :                                  R804m
• The Health Professional training and Development  Grant :R489m
• The Comprehensive HIV/Aids Grant:                                       R1,1bn
• NHI pilot project Grant :                                                               R7m

The National Tertiary Services grant and the Health Professional training and Development Grant only increased by 2,28% and 2,26% respectively which is a decrease in real terms. This particularly impacts negatively on the central hospitals.

The Department has been forced to cross subsidise these hospitals from the equitable share which increases the pressure on the rest of the Department.

Due to the forever dwindling public funds, we have decided to initiate a multi-lateral agreement between the four major institutions in the Western Cape: University of Cape Town, University of the Western Cape, Stellenbosch University and the Cape Peninsula University of Technology.

The aim of the agreement is to incentivise and encourage the sharing of Service Platforms, resources, clinical training and teaching at these major institutions to enable the Department to achieve optimal health outcomes through the training of health professionals.

The Departmental own receipts in 2015/2016 is R503m which is an increase of R7m from the previous year. The Global Fund allocation decreases from R125m in 2014/15 to R99m in 2015/16 as part of its exit strategy. This gap has to be covered  by the equitable share allocation.

From an economic classification point of view, the 2015/16 budget allocation includes :

• R10,9bn for compensation of employees (ie staff costs)
• R6bn for Goods and Services
• R1,1bn for transfers and subsidies
• R743m for capital assets

The Health Budget is divided between the eight programmes with direct operational cost within Programmes 2, 3, 4 and 5 providing  health services amounting to about (82%) of the total allocation to the Department.  Compensation of Employees increases by 6.9% and Goods & Services by 10.4%.

Programme 1: Administration

Programme 1 is allocated R695m, which is 3.7% of the budget vote in 2015/2016. This amounts to a nominal increase of R95 million or 15,89%.

The major purpose of Programme 1 is to conduct the strategic management and overall administration of the Department of Health by promoting efficient use of financial and human resources.

Key priorities in this programme include :

• Expanding the Chronic Dispensing Unit
• Instilling our Care for the Carers priorities
• Improving service delivery through advances in IT at primary healthcare facilities and hospitals. It is important that systems collaborate across the board to increase efficiency.

Programme 2: District Health Services (DHS)

Programme 2 has been allocated R7,3 billion which amounts to 38.9% of the vote. This is a nominal increase of R572m or 8.4%.

The district health system receives the largest allocation within the Department and rightly so as more than 90% of the patient contacts are within primary care and district hospitals. This programme also includes community based services and the HIV/Aids programme.

Primary care services is allocated 44,8% of this programme’s budget. The focus is on improving the quality of care and manage communicable diseases.

The are 34 District Hospitals which have been allocated 36,7% of the Program 2 Budget.

The focus is to address the service pressures by increasing the number of beds in the metro and rural areas.

HIV/Aids receives 16,48% of the Program 2 Budget.

The Department intends reducing the TB clients defaulting on Treatment from an estimated 8% in 2014/15 to 7,3% in the coming year.

Strengthening the basics in Mother, Women and Child Health remain a priority focus area.

Programme 3: Emergency Medical Services

The EMS has been allocated a budget vote of R930 million which is 4,94%of the total budget and a  a nominal increase of R56 million or 6,4%.

This programme includes the ambulance services for emergencies, the air ambulance service, special operations that manages the Department’s response to disasters and major incidents or events (including sporting and cultural events), Emergency Medicine specialist training and service oversight,  as well as the planned outpatient transport of patients within towns or between referral centres.

I also take the opportunity of recording my sincere appreciation to the EMS staff who worked alongside the firemen and many other role players to ensure the safety of our people in the recent widespread fires in the province.  

The focus here is to implement the new IT system within the communication centres of EMS which will achieve a response rate of Priority 1 Calls for both in metro and rural areas.

To address the ever growing need for immediate emergency care, the Emergency First Aid Responder (EFAR) project through which community residents are trained, certified, and respond as an (EFAR) will be strengthened.  In the event of an emergency, the EFARs serve to provide immediate care to the patient, until the ambulance’s arrival. As the EFARs are community residents, they are in a unique position to provide expedited care to an injured or acutely ill patient that might otherwise be without immediate care. 

Programme 4: Provincial Hospitals 

The Provincial Hospital services is allocated R2,9 billion, which is 15,78% of the vote and a nominal increase of 8.8%. The programme provides the following services – General specialist hospital services and specialised hospitals which includes tuberculosis, psychiatric, rehabilitation and dental training hospitals.

The 5 general specialist or Regional Hospitals have been allocated 54,87% of the Program 4 budget.

The 4 Psychiatric Hospitals receive 25,5% of the Program 4 Budget.

The remaining 20% of the Program 4 budget supports the Western Cape Rehabilitation Centre, the 6 TB hospitals and the Dental Training Hospitals.

Programme 5: Central Hospital Services

The two Central Hospitals (Tygerberg and Groote Schuur) and the provincial tertiary Hospital (Red Cross War Memorial Children’s Hospital) are allocated R5,3 billion which is 28,26% of the vote in 2015/2016.

The funding of these hospitals comes from Conditional grants as well as the equitable share. The conditional grant allocations over recent years has not kept pace with inflation nor with the patient loads being experienced.

The hospitals serve as essential referral points for patients with serious and complicated medical needs from the province and beyond.

Programme 6: Health Sciences and Training 

This programme has been allocated R335 million and R79 million of this is spent on bursaries for health students. It is 1.78% of the budget vote.

This Programme is responsible for rendering training and development opportunities for serving and prospective employees of the Department and includes the nursing and EMS training colleges. We expect 550 nurses to graduate in 2015/16 within the province at HEIs and Nursing Colleges. For this budget vote, we will be spending R78 million on bursaries for all applicable categories of health care worker training. We intend to explore possibilities of an increase in medical training through NDOH support.

The department continues to offer internship and learnership opportunities to recent matriculants and graduates – this includes HR, Finance and data capturer internships, Pharmacist Assistants, assistant-to-Artisan training and Forensic pathology assistants.

Programme 7: Health Care Support Services

The allocation for this Programme is R405 million for the 2015/2016 financial year, which is 2,15% of budget vote.  This programme handles laundry, engineering services, forensic pathology services and the Cape Medical Depot (CMD).

The Laundry Services have been allocated R82m, which is 20,26% of the Program 7 budget.

Engineering Services is allocated R117,5m which is 29% of the Program Budget. Key priorities include a greater focus on maintenance and improving compliance with health waste and fire regulations at facilities.

In an attempt to improve efficiencies and reduce our carbon footprint, provincial benchmarks have been set for the reduction in energy demand and water consumption at hospitals. Comparative energy and water consumption tables comparing hospitals to each other has helped foster healthy competition between facilities as well as raise questions about outliers.

Forensic Pathology Services receives R145,9m which is 36% of the Program allocation and will aim to respond to 78% of the cases within 40 minutes.

The Cape Medical Depot receives R59,7m which is 14,7% of the program budget. The CMD focus is to ensure that at least 97% of the pharmaceutical stock is available at the Depot, notwithstanding the recent challenges that have been experienced with the late awarding of national tenders. The Department has met with suppliers, awarded certain items on provincial tenders and continues to spread the available stock between facilities until the situation has stabilised.

Programme 8: Health facilities Management

For the 2015/2016 financial year this programme has been allocated R826 million, that is, 4.39% of budget vote. This is a nominal increase of R80m or 10,8%. R186m is allocated to new and replacement assets and R266m to maintenance and repairs.

The Department is increasing its emphasis on maintenance of infrastructure as evidenced by the 18,7% increase in the allocation.

The Department will strengthen its capacity to plan capital projects better and continue to engage with the WCGTPW department as the implementing agent to improve value for money, spending and implementation of projects. This will enable the Department to bid for additional funding made available at National through the performance based Incentive process.

The following capital projects will be completed in 2015/16:

• Cape Winelands: Worcester CDC Dental Suite
• Cape Winelands: Worcester Nurse College: New student accommodation
• Cape Winelands: Paarl Psychiatric Unit 
• Cape Winelands: Worcester Hospital Revitalisation phase 5
• Metro: Mfuleni CDC
• Metro: Strand Nomzamo CDC
• Metro: Valkenberg Hospital Administration Building Upgrade
• Metro: Wesfleur Hospital Emergency Centre and Paediatric Unit 

The Health Technology allocation in 2015/16 will fund, amongst others, the PACS/RIS which is the digital radiology and information system that allows for images like X-rays and CT scans to be viewed and stored digitally. This technological innovation will be rolled out at Khayelithsha, Mitchells Plain, George, Worcester and Paarl Hospitals.  This budget will also fund the radiotherapy upgrade at GSH, the theatre upgrade at New Somerset Hospital and the Ophthalmology unit at TBH.

Conclusion

I want to thank the Premier, the Provincial MEC of Finance, Mr Ivan Meyer, my Cabinet colleagues and Treasury for recognising the importance of Health and Health Services and in making tough choices in allocating the budget you have to Health in 2015/16.

I inherit a Department that has a proud track record of having amongst the best health outcomes in the country, operates within its allocated budget and has received an unqualified audit for the last ten years. These achievements are the result of hard work, dedication and commitment of the staff and management of the Department.

Notwithstanding the financial challenges over the medium term, we have to collectively find the space and the resilience to implement the vision of Healthcare 2030 in the interests of patient centred care. I call on all of us, both within and outside of the Department, and government, most importantly communities themselves, to join hands with us to address the significant challenges facing health. This is not a luxury but a necessity. With our collective efforts we can take the health service and health of our people in this province to greater heights.

I wish the HOD Designate, Dr Engelbrecht, who takes over the reins from Professor Househam from 1 April, 2015 everything of the best. She has been a member of the Management Team for more than a decade so continuity amongst senior management has been secured. I know we will work well together.

I take this opportunity to thank Professor Househam for his sterling leadership of the Department for more than a decade. He can comfortably retire knowing that he has built a sustainable leadership and Department that can continue the good outcomes he and his team have achieved.

I also thank each of the staff members as well as our partners for your efforts in enabling the Department to achieve the good health outcomes in this province.  

Lastly, I would like to thank members of my office – whose support has enabled me to make the smooth transition to Health. I know I am a difficult person to work with because of my weakness: of being a perfectionist that results in slowing the progress because I want to dot every “I” and cross every “t”.

Lastly to my former colleagues, friends: I thought being an academic is 24 hour job, but I just discovered that there are actually more than 24hours in a day of a politician.  Until I reach my goal, I will never depart from the golden rule, so says lyrics from SA midwife song. I solemnly pledge, ndiyajoyina.

To my little persons, my appeltjies, my worst critics, thank you for your generosity by sharing me with people of Western Cape and SA at your expense.

Nangamso.