Minister Nomafrench Mbombo Budget Speech 2016

The following speech extract was delivered by Dr Nomafrench Mbombo, the Western Cape Minister of Health, during the Vote 6 Budget Debate in the Western Cape Provincial Parliament on 18 March 2016.

Honourable Speaker,
Honourable Premier 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, 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 greet you all.

Madam Speaker, “it is better to light a candle than to curse the darkness.” This means, in the face of difficulty or hopelessness, it is more worthwhile striving to do some good, to take action, however small, in response to our circumstances than to only complain.

This is the attitude we are taking into the coming year.

By all accounts, winter is no longer coming, it is here.
Provincial health governments across the country are grappling with the challenge of this fiscally constrained environment. 
According to the IMF, the growth forecast for the South African economy is 0, 7 % in 2016, down from 1, 3 per cent in 2015.

The risk of labour market instability, expansion of unemployment, an increase in the government fiscal deficit, made worse by the public sector wage agreement of 2015, and the present drought, have all colluded to create a weak economic outlook for the country which is to be felt by the health sector.
Members of the House, there is a clear tension between our available resources and the demand for quality healthcare. 
The coming year will test our ability to walk that very tight rope. 
In this 2016/17 financial year, the Western Cape Department of Health is allocated R19, 983 billion to provide quality healthcare to the approximately 4, 8 million people who do not have access to private health insurance. 
This budget allocation represents a 5, 94 % increase from the previous budget.
This is significantly less than the 7, 9 % budget increase in the budget allocation in the 2015/16 financial year. This represents a budget shortfall of R 600 million in the current fiscal year. 
In spite of the slash to provincial budgets, the Department of Health still receives the lion’s share of the provincial budget. This indicates how health is the face of service delivery in the province.  
Our Constitution elevates access to healthcare to a human right. 

Within available resources, as government, it falls on us to create a conducive environment for realising this right. This is not only about providing services. It is also about advancing the dignity of our people.
As a capable government, which respects the rule of law and the values of our constitutional democracy, we dare not fail in our mission! 
Somlomo Obekekileyo, over the medium term, the uninsured population which is largely dependent on the public health service is projected to rise by 3, 58 % by the 2018/19 financial year. 
We need to constantly improve efficiencies, prioritise, get more value for the rand and stay within our budget while we strive to improve health outcomes and the quality of care. 
Speaker, William Osler once said, “The best preparation for tomorrow is to do today's work superbly well.” Over the years, we have done extremely well in this regard. 
Our entrenched governance and management practices, investment in infrastructure, innovation and a culture of caring for both our clients and staff have given us a robust health system capable of weathering the coming proverbial winter.

Reflecting on the past year
Honourable Speaker, in my last budget speech, I highlighted various areas which would form the focus of the 2015/16 financial year. I am glad to now report back on our progress.

Upon becoming Minister of Health for the Western Cape, I promised to formalise a policy framework that would amplify the voice of communities; especially up to Provincial Health Council level, a statutory body chaired by me.
I am glad to announce that we have tabled the Western Cape Health Facility Boards and Clinic Committees Bill in Parliament. 
The public hearings for this Bill set to begin on the 12 May 2016.
The implementation of this Bill will encourage active citizenry within the health system and improve communication between the health facilities and communities. This will give communities ownership of the health system rather than make them passive recipients. 

Honourable Speaker, we value the feedback we receive from our clients. We also strive to improve where there are gaps. 
To this end, a first-of-its-kind Independent Health Complaints Committee was appointed. This is an independent oversight body which will strengthen the complaints resolution measures we have in place.
This committee further enhances the voice of the communities we serve. 
Members of the House, last year, I stressed that achieving increased access to healthcare is important. To do this, I promised to strengthen Community Based Health Care Workers into the province’s primary healthcare system.
We have done this. 

We have approved the Home and Community Based Care Service Design Framework, the first of its kind. 
The framework outlines the implementation of the Home and Community based Care Service in communities, at ward level, in line with the Healthcare 2030 vision document for the province. 
In September of last year, we also hosted the Community Based Health Care Workers Summit with non-government organizations in attendance.
Today, we are joined by Nombulelo Makuba, and Doreen Marumo who are community healthcare workers from our NPO partners. These partnerships are crucial in increasing access to health services and decongesting primary health care facilities. 

Honourable Speaker, making strides towards a person-centred approach to healthcare was high on our list for the past year, and will continue to feature prominently on our to-do list.
We have taken a critical look at bed capacity in acute health facilities. 
Cabinet has, this past year, approved a new Hospital Bed Plan that recognises the gaps in the service and presents a vision of where we need to be. 

Looking Ahead
In the coming year, I look to - 
Continue to strengthen the role of communities in healthcare. This will involve reinvigorating the Health Committees, Hospital Boards, District Health Councils and the Provincial Health Council: all statutory bodies. At each level, the message will be clear: Nothing about you, without you, people of the Western Cape. 

Safety 
This year, I will prioritise the safety of healthcare workers and patients at our facilities. We have seen the increased incidents of crime targeting our facilities and emergency personnel on duty. 
The safety and wellbeing of our employees is important to us. It cannot be compromised. Healthcare workers who feel safe, provide a quality service to patients.
I am appealing to members of the community to work with us, the SAPS and community leaders to fight against the victimisation of healthcare workers. 
Members of the House, the Department has also collaborated with the Department of Community Safety to have visible safety kiosks stationed at various facilities including Gugulethu Community Health Centre and Tygerberg Hospital. This is just the beginning. We intend to roll out to more facilities across the province.
The department of health has also committed a further R185 million towards safeguarding patients, workers and facilities.
It gives me great pleasure to announce that the new Police Commissioner for the Western Cape, Lieutanant General Khombinkosi Elvis Jula, has been invited to form part of the Western Cape Provincial Health Council, so as to strengthen our safety efforts, together with South African Police Service.
Crime is a societal problem and no one department can curb it alone. I am convinced a closer collaboration with the SAPS and community safety stakeholders will greatly improve the safety of our staff, patients and facilities.

Quality of care
Somlomo Obekekileyo, we will also continue to strive to improve the experience of clients accessing public health services. 
We intend to do this by analysing the patient’s journey through the system from the primary health care level, all the way to our central hospitals. At each point, we identify weaknesses in the system and where we can, fix inefficiencies.  
Our particular focus area will be to create an electronic discharge summary that will improve the communication between facilities, health professionals and patients when they are discharged. The flow of patients within Emergency Centres is also being addressed. 

Human Resources
In order to provide quality services, public healthcare must be appropriately resourced.  We need enough doctors and nurses to make sure that patients are cared for. 
To this end, the Joint Advisory Governance Council, has endorsed and began the costing process of the province’s medical student’s training plan.
This advisory committee, which I chair, is comprised of the Department of health, four academic institutions of the Western Cape, namely, Stellenbosch University, University of Cape Town, University of the Western Cape and the Cape Peninsula University of Technology. 
Central to this plan for medical students is the agreement with these institutions that they will increase the number of students admitted at their institutions, more so those from qualifying previously disadvantaged backgrounds. 

In addition to this, Stellenbosch University will now be reopening their undergraduate nursing programme which will go a long way to strengthen nursing in the province.
Honourable Speaker, caring for our carers is part of our core business and is something we cannot let fall by the wayside. 
Without our over 31 267 dedicated men and women, in the department’s 482 health service points, we would be unable to meet the needs of the Western Cape’s people.
I salute our dedicated staff members who get up and come to work every day; often under strenuous circumstances.  To this end, the CAIIRR Club programme has now been expanded from 38 facilities to 82 facilities.
I am glad to report that the Barrett survey in 2015 has shown a reduction in the cultural entropy levels of the Department from 26% in 2011 to 21 % in 2015. This is indicative of greater alignment between the personal values of the staff and that of the Department and how this impacts on their performance and productivity. Our staff are expected to uphold the values of caring, accountability, integrity, responsiveness and respect.
While we are all under pressure, there can never be any justification for ill-treatment of people. 
That is why complaints resolution remains prominent in the performance agreements of all hospital CEOs- to entrench accountability. 
Honourable Speaker, speculation has been rife as to whether provincial departments will freeze posts.
During times of austerity people tend to become increasingly concerned about the integrity of services they are to receive. This is understandable.
In response to these conditions, the Department has devised innovative ways to cope with the impact of budget reductions. 
Decision-making on budgets and staff appointments has been decentralized to managers at strategic healthcare facilities.
These managers are on the ground and understand the unique needs of communities better than bureaucrats in ivory towers. 
Those facilities will function as a decentralized business unit, operating within its designated budget and with its own controls and accountability mechanisms.
In prioritizing healthcare allocations, the Department applies the utilitarian approach.  This means that decisions are guided by the philosophy of providing the best value to all citizens of the Western Cape, with the greatest positive impact on public health.

Public-Private-Partnerships 
Members of the house, the old model of governance where state departments were the only force behind providing services is long dead and gone. 
We have long recognised the mutual benefits behind forming partnerships with civil society and the private sector. 
In the past year, there were 249 Metro and 48 Rural District approved partnerships with private healthcare providers for the provision of family planning and baby immunisation services. This initiative obtained a silver award in the National CPSI Innovation Awards. It has since been expanded to include HIV Counselling and Testing (HCT). 
This initiative, branded as iKapa Cares, is delivered through our partners Dis-chem, Pick ‘n Pay and Alphapharm as well as various independent pharmacies. In pursuit of greater access to healthcare, we are in the process of signing a Memorandum of Understanding with Transnet’s Phelophepha Healthcare Train.
I would also like to announce another innovation we will be implementing with the private sector facilitated by the Bertha Centre at the UCT Graduate School of Business. Together with the Department of Social Development, we will begin the procurement process for Social Impact Bonds (SIBs) aimed at improving health and development outcomes for pregnant women and children from conception to five years old.  
This compliments the Department’s ground-breaking First 1000 Days Programme which we officially launched earlier this year to promote child health.
We believe that the First 1000 Days in a child’s development, starting from conception, moving through pregnancy, birth, and up to the first two years of life, are crucial for securing a child’s bright future. 
Research indicates that both the physical and mental development of infants advances rapidly during the 1000 Days period – the brain grows up to 80% of its size in this time. The building blocks of this period are healthy eating, love and play
Wow!
In line with the Department’s long term strategic roadmap for achieving wellness – the Healthcare 2030 – we will continue spreading the gospel of wellness, promoting positive behavioural change and lifestyle related disease prevention. 

Honourable Speaker, physical inactivity, unhealthy eating and harmful use of substances including smoking and alcohol, are considered major risk factors for a number of adverse health outcomes. 
These include obesity, diabetes, hypertension and other cardio vascular diseases. I am urging fellow members to look after themselves and their health. It is important that as leaders we lead by example.
For us, WOW! (Western Cape on Wellness) is one of our key intervention strategy for wellness.
This initiative forms part of the Provincial Strategic Goal (PSG) 3 intervention, a transversal operation between the Department of Social Development, Cultural Affairs and Sport and Community Safety, which aims to increase wellness, improve safety and tackle social ills within communities.
This initiative represents a unique transversal and cross-sectoral partnering platform designed to activate, expand and maintain a healthy lifestyles.
This week marked the end of the prototyping phase and the start of the maintenance and scaling of WoW! Champions and Clubs in the Western Cape. This is a huge milestone for the province as wellness has started to make the shift from optional intervention to a mainstream health indicator.

Nationally, the Obesity Strategy borrows many of its principles from WoW! The Drakenstein pilot project represents integrated service delivery with optimal community involvement towards sustained impact that can be replicated in other parts of the province.
This is exactly what we mean by moving away from silos, to a more integrated approach.
In the Paarl East area one of the key projects we have established is the Local Drug Action Committee which has already begun its work in combating substance abuse. This is just one example of the various projects we are bringing to this area.
This transversal project highlights the effectiveness of integrated services which this pilot seeks to rollout. 
The Western Cape Government has already identified alcohol and substance abuse as a Game Changer that requires all hands on deck.
In line with this, my Department will implement Teachable Moment interventions at healthcare points such as Khayelitsha Hospital and Heideveld CHC.
These aim to identify clients in our health facilities who show high risk signs of harmful alcohol and other substances abuse and provides on-site interventions designed to promote positive behaviours and healthy lifestyles. 
To achieve this, requires our collective efforts as a whole of society. 
Speaker, with this said, I direct the House’s attention to the specific programme allocations within the Health budget. 

The Budget
As I stated earlier, Department is allocated R19.983 billion. 
The Provincial Equitable share amounts to approximately R14, 5 billion and the National Conditional Grants to approximately R5, 1 billion.
The major Conditional Grant allocations for 2016/17 include:

•          The National Tertiary Services Grant :                                                       R2,706bn
•          The Health facility Revitalisation Grant :                                                   R673m
•          The Health Professional training and Development  Grant:                  R510m
•          The Comprehensive HIV/Aids Grant:                                                         R1,267bn
•          NHI pilot project Grant :                                                                               R17,3m

The National Tertiary Services Grant and the Health Professional Training and Development Grant increased by 4, 32% and 4, 29% respectively which is a decrease in real terms. This has increased pressure on central hospitals.

From an economic classification point of view, this year’s budget allocation includes:
•          R11, 8 billion for compensation of employees;
•          R6 billion for Goods and Services;
•          R1,1 billion for transfers and subsidies
•          R 664 million  for capital assets

The Health Budget is divided between the eight programmes. 
Compensation of Employees increases by approx. 7, 5 % and Goods & Services by 5.9%.
The budget is decreasing in real terms while patient numbers are increasing and it is estimated that the budget per patient decreases by about 3 % from 2015/16 to 2016/17. 
In spite of the constrained fiscal envelope, service delivery priorities are protected. Various projects have been initiated to ensure that the Department will be able to do more with less. 
Subsequently, each budget sector has developed a plan to minimize the implications of the reduced budgets. Progress with the project and sector plans is monitored on a monthly basis. 

Programme 1: Administration
Programme 1 is allocated R710 m, which is 3.56 % of the budget vote. This amounts to a nominal increase of 12, 35 %. 
Key priorities include the Change Management programme which aims to improve the organisational culture in the Department by strengthening the leadership at all levels of the organisation but especially at the local facility level.
ICT is also recognised as a key enabler with enormous potential in improving the performance of the Department and the quality of care for patients. We will be developing an ICT vision that will provide a roadmap for the various initiatives. This is in line with the Province’s values of innovation.

Programme 2: District Health Services (DHS)
Allocated R7, 8 billion or 39.17 % of the vote. This amounts to an increase of R464.450 million or 6.31%.
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.

Programme 3: Emergency Medical Services
EMS is allocated 4.99 per cent of the vote in 2016/17. Over recent years, strengthening Emergency Services has been a priority. The focus of this programme is improving response times to get patients who are ill to emergency care as soon as possible and, importantly, provides patients with transport in between facilities. 

Programme 4: Provincial Hospitals
This budget programme caters for General specialist hospitals as well as specialised hospitals for TB, Psychiatric, Rehabilitation and Dental. Allocated R3, 1 billion for the 2016/17 financial year. This is 16, 01% of the vote. This amounts to an increase R209.218 million or 7, 00 %.

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 R 5, 6 billion or 28, 5 % of the vote. 
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 R340 million. R 84 million of this is spent on bursaries for health professionals’ training. We expect 470 nurses to graduate in 2016/17 within the province at universities and Nursing Colleges. 

Programme 7: Health Care Support Services
This programme handles laundry, engineering services, forensic pathology services and the Cape Medical Depot (CMD).
The allocation is R405 million, experiencing a 0, 16 % increase.  The programme represents 2, 03% of the total vote. 
Honourable Speaker, Climate change is recognized as a major risk globally and we need to mitigate our contribution to the problem in addition to strengthening of the health system to respond to the consequences and impact of climate change. In this regard, the Department has set firm targets to reduce its electricity and water consumption and set up a monitoring system to measure performance at hospitals against benchmarks.  

Programme 8: Health facilities Management
Programme 8 is for the Planning, design, construction, upgrading, refurbishment, additions and maintenance of health infrastructure. This program is allocated R806 million or 4.04 per cent of the vote in 2016/17. The Department will continue to focus on improving and modernizing the health infrastructure as a matter of priority in PHC, the emergency centres and psychiatric observation units.
We are increasingly shifting the focus to maintenance of facilities to address the historical backlog in this regard.

Honourable Speaker, the people have spoken, as such the business case for infrastructure planning for GF Jooste Hospital was approved by National health.
The search for a site is also at an advanced stage and we will be communicating these details soon. 
In the 2015/16 financial year, we completed the following infrastructure projects:
1.         A new CDC in Symphony Way, Delft;
2.         A new CDC in Nomzamo, Strand;
3.         A new dental suite at Worcester CDC; and 
4.         A new Emergency Centre and Paediatric Ward at Wesfleur Hospital in Atlantis. 
5.         Paarl Psychiatric Unit.

Over the coming year, we will achieve Practical Completion of the following projects:
1.         Beaufort West- Hill Side Clinic- replacement;
2.         Citrusdal Clinic- Upgrade and Additions;
3.         Citrusdal Hospital: Upgrade and Additions to Childrens Ward, EC and Calming Room;
4.         Piketberg Ambulance Station – replacement;
5.         Worcester Hospital-  final phase of the upgrade
6.         Groot Schuur Hospital: new Hybrid Theatre; and
7.         Worcester- WCCN Boland Campus: new student accommodation upgrade 

Conclusion
Given the budget pressures, it cannot be business as usual. Increasing efficiency and productivity in every corner of the Department is mandatory to get the best value for the health rand. In the words of Nelson Mandela, “let our choices reflect our hopes and not our fears”. 
The current financial challenges we face have not been the first and will not be the last. We have to be innovative and solution seeking. We have to creatively and collectively consolidate our interventions in these very trying times. 
I want to take this opportunity to thank the Premier, my cabinet colleagues for their support, Dr Engelbrecht and her management team for their leadership and support, our partners for their collaboration and most importantly thank every member of staff for their dedication and hard work, without which our performance would not have been what it is – amongst the best in the country.
I would also like to thank those members of the public, members of faculty and student representatives at academic institutions who took the time to send us their thoughts and advise on the 2016/17 budget.
Significantly, I would like to acknowledge Dr Frans Krige from the Overberg District Health Council and Mr Nick Wayne from the Tygerberg Student Council, at Stellenbosch University for their ideas in this budget process. It is indeed, The People’s Budget. 

 I also thank the staff in my office whose unstinting support is invaluable in enabling me to conduct my duties. Lastly I would like to thank my family and friends whose understanding, sacrifices and support has enabled me to do what I do. 
I now table this budget for vote. 

I thank you.