NATIONAL DEPARTMENT OF HEALTH

National Health Insurance GrantSelect Committee on Appropriations

Hearing on 3rd and 4th Quarter Expenditure 4th June 2013

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

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

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Eastern CapeQ3 and Q4 Expenditure (R’000)

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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

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Free StateQ3 and Q4 Expenditure (R’000)

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Free State: Challenges

• Reprioritisation of funds allocated to activities

• SCM hurdles

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GautengQ3 and Q4 Expenditure (R’000)

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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.

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KZNQ3 and Q4 Expenditure (R’000)

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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

LimpopoQ3 and Q4 Expenditure (R’000)

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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

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MpumalangaQ3 and Q4 Expenditure (R’000)

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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

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Northern CapeQ3 and Q4 Expenditure (R’000)

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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

North WestQ3 and Q4 Expenditure (R’000)

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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

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Western Cape Q3 and Q4 Expenditure (R’000)

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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

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Summary of Quarter 3 Expenditure(R’000)

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Summary of Quarter 4 Expenditure(R’000)

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DORA: Implementation

Select Committee on Appropriations_4 June 2013 24

NATIONAL HEALTH INSURANCE GRANT

Province

R thousand

Eastern Cape 11 500 11 500 11 500 11 500 8 093 100.0% 70.4% 8 093 3 407 3 229 Free State 16 500 16 500 16 500 16 500 9 337 100.0% 56.6% 9 337 7 163 7 163 Gauteng 31 500 31 500 31 500 31 500 8 066 100.0% 25.6% 8 066 23 434 12 026 KwaZulu-Natal 33 000 33 000 33 000 33 000 16 127 100.0% 48.9% 16 127 16 873 14 949 Limpopo 11 500 11 500 11 500 11 500 4 118 100.0% 35.8% 4 118 7 382 6 382 Mpumalanga 11 500 11 500 11 500 11 500 5 570 100.0% 48.4% 5 570 5 930 325 Northern Cape 11 500 11 500 11 500 11 500 8 005 100.0% 69.6% 8 005 3 495 1 578 North West 11 500 11 500 11 500 11 500 8 818 100.0% 76.7% 8 818 2 682 2 084 Western Cape 11 500 11 500 11 500 11 500 9 885 100.0% 86.0% 9 885 1 615 1 615 Total 150 000 150 000 150 000 150 000 78 019 100.0% 52.0% 78 019 71 981 49 351

Preliminary (over)/under

Roll-Overs Requested

Division of Revenue Act, 2012 (Act No.

5 of 2012)

Total availablePayment

Schedule: Year to date

Received by province:

Year to date

Provincial actual

payments

% Transferred of national allocation

% Actual payments

of total available

Preliminary outcome for

financial year

Total Expenditure by Province (%) (April 2012 – 31 March 2013)

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NHI-CG Provincial Commitments/Roll-Overs

2012/13 Financial Year

PROVINCETOTAL NHI-CG ALLOCATION COMMITMENTS

COMMITMENTS AS PERCENTAGE OF TOTAL BUDGET

EC 11 500 000.00 3 229 000.00 28.1

FS 16 500 000.00 7 163 000.00 43.4

GP 31 500 000.00 12 026 000.00 38.2

LP 11 500 000.00 6 382 000.00 55.5

KZN 33 000 000.00 14 949 000.00 45.3

MPU 11 500 000.00 325 000.00 2.8

NC 11 500 000.00 1 578 000.00 13.7

NW 11 500 000.00 2 083 765.00 18.1

WC 11 500 000.00 1 615 000.00 14.0

NATIONAL 150 000 000.00 49 350 765.00 32.9

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

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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

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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

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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

THANK YOU

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