Presentation to the Portfolio Committee on Health24 April 2013

Strategic Plan (2013 2015) &Annual Performance Plan (2013/14)

Medical Bureau for Occupational Diseases & Compensation Commissioner for Occupational Diseases

Barry Kistnasamy, Muzimkhulu Zungu & Sam Molautsi

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OverviewHistoryDiagnostics of IssuesStrategic PlanAnnual Performance PlanBudgetWay forwardConclusion*

In HistoryBarrier Miner (Broken Hill, NSW : 1888 - 1954), Monday 13 November 1922, page 1National Library of Australia http://nla.gov.au/nla.news-article45589068MINERS' PHTHISIS IN AFRICATile South African Union legislature's select committee on public accountsreports that the compensation fundout of which compensation has to bepaid to miners' phthisis victims onthe Rand has still to face a liabilityestimated at l4,000,000. As the exhaustedmines close down it falls withcumulative effect on the survivingmines. The committee considers thatno time should be lost in laying downmeasures to ensure the adequacy of thefund. Miners Phthisis Act 19 of 1912*

In SummaryProblem governance, claims management, service delivery, infrastructure, sustainabilityParadox lots of dataPressure multiple fronts (1867 diamonds; 1886 - gold)Potential for change, Auditor Generals reportPromise .*

InterventionsUnified management structure (Medical Bureau, Compensation Commissioner)All activities now in one buildingSupport from National Department of HealthDevelopment of the strategic plan and annual performance plan

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Strategic Plan (2013-2015)Combines the Compensation Commissioner and Medical Bureau (Occupational Diseases in Mines & Works Act (1973)Vision:An accessible and effective occupational health system and services that ensure ..compensation for workers and their beneficiariesMission:Enhancement of the health system to prevent occupational diseases and provide servicesValues:

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Policy InitiativesAmendments to the Occupational Diseases in Mines & Works Act (1973)Expanding the coverage of controlled mines & worksDecentralised services for workers & ex-workersExplore models for service delivery (within & outside South Africa)Alignment of compensation (Department of Labour & Treasury)

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Past Performance (Financial Year 12/13)Poor performance (annual reports; compliance; management)Administration covered by Department of Health (R34.4m) 1.4% of FundCompensation Fund (R2.4b)Mines account, Works account, State account & Research accountR336m revenue & R149m expenditureCompensation for occupational diseases (workers & ex-workers in controlled mines & works) (R140m)Pensions (R2.9m) (188 pensioners)Eastern Cape project (R54 000 to 20 claimants)Actuarial valuation problems

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Eastern Cape Project

R54m was available & R38m paid18 569 ex-mine workers were identified R2 700 per beneficiary14 114 ex-workers or beneficiaries paid to dateR16m available for a further 4 455 possible claimants (close on 31 Mar 2014)Inter-departmental committee (Deputy President)

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2003/042004/062007/082008/092009/102010 /112011/122012/13AmountR13,3mR16,9mR337 800R5,5mR1,7m R135 000R110 700R54 000Number of claims49416259 125 2045 633 50 41 20

Past Performance (Financial Year 12/13)Medical Bureau for Occupational DiseasesNo annual reports since 2000Medical examinations of workers and ex-workers183 service providers (private & public)Review and certificationTraining and outreach (provincial hospitals)Risk Committee non-functional since 1998 (controlled mines & works)*

Strategic Plan: GoalsMake policy and legislative changesImprove governanceOptimise managementEnhance service deliveryEnsure sustainability of the Compensation Fund

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Strategic ObjectivesPolicy & legislative changesImplement the strategic planImprove corporate governance (various committees)Reorganise claims administrationConsolidate outreach activitiesEnsure financial sustainabilityDevelop a surveillance systemConduct appropriate research Assess the human resource, technical and infrastructural needs

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Policy & LegislationExternalised health, social & environmental consequencesInternal cohesion (Medical Bureau & Compensation Commissioner)Alignment of compensation systems (Department of Labour)Alignment with Department of Mineral ResourcesInspectorateRisk CommitteeAdministrative provisionsTransport, Accommodation, IntermediariesLocal services & outside South Africa (medical examinations, claims and payments)*

GovernanceAdvisory, Adjudication and Audit & Risk Committees (CCOD)Certification, Review and Joint Committees (MBOD)Risk CommitteeInternalHealth & SafetyEquity & SkillsInternal Audit & RiskService providers

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Claims Administration & Service DeliveryRegistryQuantify filesMake one fileVerify dataSort files (year, mines or works, claim type etc)Tender (filing & process)

Verification (database of 246 controlled mines & works; The Employment Bureau of Africa (TEBA), Home Affairs & South African Revenue Service)

Link IT systems (Registry, Mineworkers System & Accounting System)

Reconciliations

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Infrastructure*

Claims Administration & Service DeliveryFront officeConduct feasibility study of call centreCustomer relations trainingFeedback (claimants & stakeholders)Benefit medical examinationsDecentralised pilot (Eastern Cape, Swaziland) Back officeCompleted formsTraining of service providersFraud & corruption*

Outreach & AwarenessUpdate communication materials; improve marketingInvolvement in various forums (Health, Labour, Mineral Resources; Development Partners; conferences & workshops)Meetings with trade unions and employersInspections of controlled mines & worksContinuing professional development of health professionals & service providersLinks to provincial health departments and district health facilitiesLinks to parliament, portfolio committee & their outreach activities*

Sustainability of the Compensation FundEnsure a functioning Risk CommitteeDustsVapours, gases, any other factor affecting riskExpansion of controlled mines and worksRevenueCollection of levies / penalties / interestInvestmentsRe-insuranceInspectionsVerification of data (risk shifts, contractors)Prevention interventionsCorrect the base for actuarial valuation

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Actuarial ValuationMines ? 500k??? Ex-workersDepends on base (CCOD, MBOD, outside system not diagnosed, do not know their rights)Depends on disease process (latency, more than 1 disease)

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Occupational InjuriesAbrupt break in AGENT HOST ENVIRONMENT balanceCause established

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Occupational DiseasesNot diagnosed / mis-diagnosedLack of knowledgeMasked by other diseasesLong lag timeNeed special investigationsDifficult to find cause

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Need Special Investigations*

Diseases caused by Silica DustNormal*

Surveillance data for action (Giesecke, 1999) ongoing, systematic collection, analysis & interpretation of data for planning, implementation & evaluation (CDC, 1988)*

Surveillance DataMHSC / DMR / CoMDoL, DoHPathautSpecial surveysTB incidenceDust surveys*

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ResearchRisks in mines and worksScientific approach to valuationQuantification of numbers of workers / ex-workers at risk + modelling studiesOperational research (models for delivery of services)

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Human Resource, Technical & Infrastructural NeedsBased on Strategic PlanNeed for legal, accounting, economic, actuarial, health & social sciences, logisticsTechnical Information Systems & Technology; digital X-rays, GeneXpert, lung function; financial modelsInfrastructural buildings, vehicles & equipment, decentralised servicesTraining & capacity building

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Annual Performance Plan (2013/14)Policy & legislative changesImplementation of strategic planGovernance & managementService deliveryRe-organisation of claims administrationOutreach activitiesHuman resource, technical & infrastructural needsSurveillance systemAppropriate researchSustainability of the Compensation FundLeviesInspections

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Objectives & Targets*

Objectives & Targets*

BudgetMedium Term Expenditure Framework (2013 2015)*

BudgetOccupational Health (Department of Health)

The Compensation Fund (Trading Entity in Department of Health)*

Occupational Health (Budget) 2% of Compensation Fund Value *

R 00012/1313/1414/1515/16Employees compensation23 29423 790Goods & services14 58423 559Transfer payments2 9163 062Capital2 2772 389TOTAL43 07152 80055 20057 739

Staff Establishment (Feb 13)*

No of PostsManagementFilledVacantProfessional & Support StaffFilledVacantAdministration4554140337Claims Processing5722055478Clinical Services202021899Revenue & Inspections174221367Governance2110101TOTAL14114951279532

The Compensation FundCash Value (31 March 2013): R2.38b *

R 00012/1313/1414/1515/16Revenue335 871353 702371 382390 038Expenditure148 674156 554164 538172 601

Investments (projection)2 352 2532 469 8662 593 3592 723 027Fund Value (projection)2 443 2762 710 9772 680 3592 823 359

Workers CompensationPhase 1Effective and efficient compensation system for miners / ex-minersClear backlogsImprove Turn-Around-Times (benefit examinations, certification, claims processing & payments)Ensure financial sustainability of the FundAwareness*

Promoting Occupational HealthPublic Health ApproachAction beyond workplaceAll health determinantsAll workers (contract)All stakeholders

Overall policy / legal frameworkTraditional Occupational HealthOnly at workplace

Only work-relatedPermanent employeesEmployers responsibilityWorkers & employers

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Occupational Health Services: Core FunctionsPreventiveRisk identification, assessment & managementRecognise high risk groups & prioritiesHealth PromotionOptimal physical & mental healthHealthy lifestylesCurative servicesGeneral practice levelReferral to specialists First aidRehabilitation & Compensation*

Conceptual Model Delivery of Services*

PHC Nurse / CHWFamily Medicine / OHN / Occ Hyg Occ Med Spec +Academic / Reference UnitsOccupational Health Service ModelREFERRALSUPPORT*

Delivery of ServicesLinks to Primary Health Care1 nurse at each facility trained to recognise work related injuries & diseases1 doctor, 1 nurse and 1 occupational hygienist at district hospital trained to manage work related injuries & diseasesLinks to social services & Community Health WorkersLinks to private providers*

Occupational health unit at specialist hospital to manage workers with ill-healthOccupational health academic unitsLinks to National Health InsuranceEnsure collection systems in pilot districts get revenue from compensation system for work related diseases and injuriesDelivery of Services*

Links with relevant government departments in those countries dealing with migrant workers

Link with Ministries of Health for delivery of services (benefit examinations)Harmonisation of interventionsAppropriate referral systems as per South Africa (ex-workers can access higher levels of system in South Africa)

New models for compensation paymentsDelivery of Services(outside South Africa)*

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Occupational Health SystemPhase 2Innovative models for occupational health servicesSupport the development of an integrated social security system for workersDevelopment of infrastructure and human resources for occupational healthEnsure appropriate funding for the occupational health system (prevention, treatment & care, rehabilitation & compensation)Work with the Departments of Mineral Resources, Labour and Public Service & Administration in achieving a better health system for worker's health*

Service Delivery ChallengesHuman resources (occ. health practitioners; nurses; occ. hygiene, etc)Curative focus (non-renewable human capital)Fragmented service delivery Little or no quality assurance (radiology, audiology, spirometry, occ. hygiene, laboratory)Dumping syndrome / Referral system

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Occupational Health Human Resources4.1 / 100 000 doctors (712) 4300*0.77 / 100 000 hygienists (100 or 450) - 1340*15.4 / 100 000 nurses (2000) 8670*0.6 / 100 000 ergonomists (80) Safety practitioners, ventilation etc? Education and training inputs* needD. Rees, NIOH. 2012*

FinancingOccupational Health System tax based; solidarity; public private; fees; development partnersCompensation part of social security package (government or employer contributions)Models for informal sector ?*

Planning for the future is a complex businessBUT what we plan now will only bear fruit in the long term - 20 yearsWhat we decide determines the character and culture of the Occupational Health SystemWhat do we want this future to look like?What is it we have to do differently?Planning for the FutureMatsoso MP. Director-General: Health. 2012*

Costs of Mining (1951)Vast capital resources and the labour of hundreds of thousands of Africans are devoted to making deep holes in the Rand from which gold is extracted only to be carried across the Atlantic and buried again at Fort Knox.If, however, it were only futile it might be harmless. It is, however, causing great harm by diverting vast manpower resources from the production of food in a continent and indeed a world which is growing progressively shorter of food.Memorandum from the Governor of Nyasaland Geoffrey Colby to the UK Secretary of State for the Colonies, 2nd May 1951.

Jock McCulloch: AJ Orenstein Lecture, University of Witwatersrand. April 2013 *

There is light at the end of the tunnel!*

***What Does Silicosis Look Like?This slide shows a cutaway of a cross section of two lungs. The one in the upper right is simple silicosis and the lower picture is a view of complicated silicosis.

Looking at the simple silicosis, the small round black or dark objects in the mid and upper lung regions are the scar tissue development. You can see that they are widely spaced throughout the mid - upper lung regions and they do not consume much area.

Complicated silicosis however, consumes much more lung area, decreasing the lungs ability to exchange carbon dioxide for oxygen.

The darkness of the scar tissue in these pictures is a result of cigarette smoking which discolored the scar tissue black. Silica dust (centre) causes silicosis, emphysema, lung cancer and predisposes to tuberculosis.***