Hospital Revitalisation Programme; National Core Standards: Mpumalanga, Northern Cape, North West Health Departments reports

Meeting report

Mpumalanga Health Department briefing
Dr Clifford Mkasi, MEC of Health in Mpumalanga, said his province’s hospital revitalization grant was R356 million for 2011/12. Total amount received was R365 million while actual expenditure was R296 million (83%) with a “committed” under-expenditure of R59.7 million but with an approved rollover of R59.5 million. The 2012/2013 grant was R300 million and as of 30 June 2012 they had received R31.7 million and the actual expenditure as of the same date was R 31.9m. The monitoring capacity was looked at. They had filled 90% of available posts in the Hospital Revitalisation Programme (HRP). He noted the specific posts that were not filled. Monitoring practices included twelve monthly reports, four quarterly reports and an annual report to the National Department of Health (NDOH). There were monthly site visits to the hospitals by HRP Unit. National Treasury and NDOH also made site visits. There were also political visits from the Premier, Portfolio Committee and the MEC. There were monthly steering committee meetings, monthly site and technical meetings with consultants and monthly interdepartmental meetings with Public Works.

Reasons for under-expenditure included poor performance of implementing agent (IDT) and inadequate expertise, unforeseen site conditions and inclement weather conditions. But there were measures being made to improve programme management and spending which include joint collaboration with the National Department of Health to form governance committees, filling vacant infrastructure and monitoring positions. They had also wanted to have two state accountants and centralised health technology management for fast tracking equipment procurement. They wanted to appoint new contracts with proven capacity to deliver on big projects, strengthen inter departmental partnerships, strengthen the capacity of the infrastructure and appoint a Resident Engineer. Mr Mkasi said that they had been struggling with filling this particular position for a very long time. He closed by showing a chart of progress on projects under implementation.

Discussion
The Chairperson said that the presentation did not cover whether the hospitals were accredited or not but it was something that could be addressed during the discussion. Referring to the hospitals undergoing construction, the Committee did not know when these projects were started.

Ms B Ngcobo (ANC) thanked the MEC for his presentation. She saw the reasons for under spending but she was curious about the fact that he wanted to terminate the contractors that were due to complete projects by 2014. She asked if there was a recovery plan for that. She asked about the lack of a second accountant and if they had contacted the Department of Health about this matter.
 
Mr G Lekgetho (ANC) said he was impressed with the presentation and their admission of the challenges but also the way that they would be dealt with. His only concern was about the number of unfilled posts.

Ms D Robinson (DA) said she was encouraged by the appointments that had been made in the province. She asked about the infrastructure management position that had not been filled and if there had been people who applied or if it was just hard to find people with qualifications. She asked what the criterion was for a job such as that.

Ms C Dudley (ACDP) asked if the current budget of R300 million was specifically for what they had given their presentation on. In terms of the positions they had filled, it seemed as if that date was as of 2009 so she was curious about what was exactly being said there. Who was responsible for the under spending and how exactly did it happen.

Mr D Kganare (COPE) had a long list of questions. His impression about the allocated 356 million grant was it was only for that year. He would like to see the whole project and was confused because it must be a multiyear grant yet he had the impression that it was for the whole project. He was also curious about the appointed monitoring and evaluation manager, they said it was optional when it was filled, yet it must have been budgeted for thus how was it optional at all? He asked what penalties were applied to contractors who failed to deliver. What were the steps taking against the Independent Development Trust (IDT) so that they never get work from the department again and was the dispute in termination which caused the delay. He asked why the contractors were not required to pay penalties for delays and why these people had not already been fired. He was impressed that the new ones had proven themselves. The ongoing status of the projects was questioned. What did “ongoing” mean exactly and when this happened what was the initial budget and what was the finished budget? Was it a money problem or was it a performance problem? He was very concerned with this because every project seemed to be behind schedule. To him it seemed the projects were not in line in terms of time and yet no action was being taken against these companies. He asked if they were over budget and if so did they have money to complete the project or was it in danger. There should be consequences when companies take chances and contractors did not deliver but take the money. He knew a man who ran an engineering company. He was not an engineer but he just had “contacts”, what were the consequences for people like this. He apologised for asking so many questions.

Ms M Segale-Diswai (ANC) thanked the presenter and asked why there were under-expenditure, and it was a good thing there was a roll over. The Health Department should be at 25% but they were only at 17% expenditure. The under-expenditure of R59 million was a lot of money so it really caused a concern. She was confused by the 90% positions filled as there were so many important positions not filled. Did they see the IDT as a poor performer and what did they do about it? From a layperson’s perspective how did they miss the huge rock that prevented the building of a hospital? She asked for a timeframe and the anticipated completion date. They talked about new contracts that had the capacity to deliver on big projects yet they said that there was a poor performance of contracts with good Construction Industry Development Board (CIDB) ratings.

Ms B Ngcobo (ANC) asked how many times had they had to roll over this budget. Did they sign a service agreement with Public Works and, if they did, why was this happening? They were one of the provinces with a National Health Insurance (NHI) site – when this kicked in where did they think your performance would be?

The Chairperson commented that there were two major issues, the completion of hospitals in a timely manner and the issue of corruption which was always there. The Committee had been to KZN and they had met an engineer there that said that he was going to deal with this issue of corruption head on. Mpumalanga was a province of tourists and it was a beautiful area but he was not confident that if he went there that he would get good health care. There were public and private institutions but where did the tourists go if they needed medical help. He asked for more information about the problems in completing projects. He asked about the new problem of sinkholes and how the engineers could identify such problems when building if they could not even pick up a large stone that had prevented building.

Mr Mkasi replied that the National Department had come in and done an audit. Of all the institutions and facilities in the province, there were none that were 100% compliant. This had to attend to all the issues identified by the audit and had formed committees to deal with these. He knew the standard and that they needed to make sure that they had complied. Inspection teams had looked at the facilities and there were reports that could be forwarded to the Committee. The infrastructure problem had existed when the current government took over in 1994. The province had not been on par since then. When he got into his position the problems were there, there were challenges. Restored facilities had been completed but there had been both good and bad workmanship. The under spending was as of the end of the year but invoices were still being submitted at that time. ‘Committed’ under expenditure meant that those funds had already been committed but the invoices had not been paid by 31 March 2012 – so in reality there had been only just over R2 million of under expenditure. The recovery plan for the under spending was that they had requested a rollover and that they wanted to use some of it for the maintenance of the structures. He wanted to let the Committee know that they did not have an accountant but that they had advertised and that the statistics for positions filled were just for those required for Hospital Revitalisation unit. Talking about positions that needed to be filled in the entire provincial Health Department would have to be a completely different discussion. Mr Mkasi said that the projects had commenced as such:

Piet Retief Hospital: commenced in 2003 and completed in 2006
Ermelo Hospital: commenced in 2004 and to be complicated in 2014
Rob Ferreira Hospital: commenced in 2004 and to be completed in 2014
Themba Hospital: commenced in 2004 and to be completed in 2014.

Mr Mkasi said the Department was not getting the sum of money in full lump sums so that construction had to be in phases and that the delays made the process take longer. Problems with delays existed mostly with the hospitals that were being revitalised as there were already existing patients in the hospitals, they had to be moved around during the different phases of construction.

The Chairperson interrupted and said that they should be planning for this. He said to have had a hospital take ten years to build was very hard to understand.

Mr Mkasi said they first finished planning and design but even the smallest of the delays could cause changes in the planning.

The Chairperson said that it was very confusing. If everything was planned, how could it take ten years?

Mr Mkasi said that it would not take ten years. The delays that were happening were because of the contractors. He gave the example of Piet Retief, the reason for its quick construction was because they built a new site. In his view, they should just build new sites. Revitalization was more expensive and inconvenient. The infrastructure of the old sites sometimes could not support the new structures.

The Chairperson said that he thought that it was time to give another province a chance to speak because he suspected that there would be similar questions for all of them. He asked Northern Cape to go next.

Northern Cape Health Department briefing
Mr Mxolisi Sokatsha, MEC of Health in the Northern Cape, said that he wanted to be up front as they had sent through a report to the Committee that had many problems. He had been misquoted before so he just wanted to be upfront at the beginning that the report that they had before them today was the correct report. They would actually have two reports, of which one was about hospital revitalisation.

Mr Lesetja Mabona, Director: Hospital Revitalisation Programme and Infrastructure for the Department of Health in the Northern Cape, thanked the MEC and noted that the Northern Cape currently had four projects. Three of the hospitals were at implementation stage and one was at the planning stage.

Prioritisation of projects was made from the Service Transformation plan. The project was submitted to the implementing agent for a minimum of 24 months prior to implementation. The Project budget was then allocated per project stage hence the multi-year budgeting. The first project was the Mental Health Hospital in Kimberley. It started in 2005 and had a budget of R290 540 000 and was supposed to take 24 months but the contractor was terminated in 2009 due to poor workmanship when the projected was 70% completed and R420m was already spent.

The Chairperson interjected to ask when they thought that the project would be completed.

Mr Mabona said that they were completing the project in 2014 and it would not be another ten years. He had terminated the contract. The next hospital was Upington. The hospital was fully completed with 90% of staff accommodation, 70% of internal roads, 50% of the Emergency Medical Service (EMS) station, 60% of the TB ward , and 30% of external roads completed. The initial budget was R158 but they had only spent R47. De Aar Hospital began construction in 2006. It had staff accommodation complete at 100% and 92%. The fence and reservoir had been completed while 60% of the TB ward and 29% of the main hospital had been completed. This hospital had a budget of R180 million but it had spent R45 million already.

The Chairperson asked when the projects would be completed.

Mr Mabona said that Upington would be completed next year and De Aar would be completed in 2014.

The Chairperson asked to clarify if it had been started in 2006.

Mr Mabona said that the earthworks had been started in 2006 and then due to insufficient budget, they had to stop the project and restart it in 2010. The last hospital to be discussed was Kuruman which was still in the planning stage. It had completed feasibility studies, a business case, a project brief and the construction was to comment in 2016 with a budget of R1 billion.

Mr Richard Jones, Chief Director of Quality Management and Infrastructure in the Northern Cape (a new post created in 2009), said he was going to present on the facility improvement programme. He apologised for sending the first report as it was an internal report sent by mistake. Although the MEC had said that he would rather the Committee not read it, it might be interesting to read because it showed how seriously the Department was taking this matter.

He explained that the province had the smallest number of facilities in the entire country, since the distance between towns and cities created enormous managerial and cost problems. There was a National Baseline Assessment and there were six basic standards that needed to be met: availability of medicines and supplies, cleanliness, patient safety, infection prevention and control, positive and caring attitudes, and waiting times. He explained the graph on page 2 of the presentation and that the country was doing poorly as a whole with those standards.

The Chairperson said that he was slightly confused by the graph.

Mr Jones said the left hand side was percentage outcome against the standards and the right hand side were the percentage of facilities that failed the standard. Northern Cape’s failure rate was about the same as the national average. However the left side of the graph showed that as much as the country had a problem meeting standards; the Northern Cape had an even greater problem. They had been working with an external improvement team. They did a SWOT analysis of the Northern Cape Health Department. On the notion of Facility improvement, they found five systems that needed attention: management systems, infrastructure, equipment, human resources and financial management. The National government had now made a non-negotiable and minimum equipment list so now audits had to be conducted for that.

Mr Jones said a project implementation plan had been created and there had been workshops on the six most critical areas including waiting times, patient satisfaction, staff satisfaction and clinical audits. There were three main issues that he wanted to sort out. Infrastructure was being dealt with by a newly established Provincial Joint Collaboration Committee, a baseline infrastructure assessment which concluded that in the Pixley Ka Seme region the province need R40 million in backlog maintenance so if one multiplied that by five it would mean about R200 million for the province despite the budget of only R98 million. In terms of human resources, it was clear that there were shortages, particularly in frontline staff, which they were trying to start out. An example of this would be in the new Upington Hospital where they had been given a budget of R130 million for staff and non staff but in reality they needed a budget of R400 million. The last topic was financial management which was weak in the past but they were rapidly fixing it, including decentralizing.

Discussion
Ms Segale-Diswai said when there was a delay, they wanted to know how that delay affected service delivery. She asked when the Mental Hospital in Kimberly would be completed.

The Chairperson said that the slides were confusing but that essentially it was saying that the province had to do a lot of work to achieve the norms and standards.

Mr Kganare (Cope) stated that he did not understand how a contractor could be hired to finish 30% percent for R400 million and it was as if they had started from scratch. Looking at the document that they had been sent by mistake, under the SWOT analysis, they had taken ‘experienced leadership’ out from under their strengths and asked the reason for that. If in fact they did have experienced leadership, how could they have problems with all of these matters. He was very interested in why that was expunged. He asked frankly if the report was honest. He understood that they had done a lot, given the geography of the Northern Cape which was very difficult, but they needed to know the truth.

The Chairperson said that they were all South Africans and these issues affected them all whether they were part of an opposition party or not.

Ms Dudley said that in the SWOT analysis, it was mentioned that the budgets were not being increased rapidly enough. In the presentation there was no overall budget – including any mention of an over expenditure or under expenditure – and that would help them put things into context. In terms of the six most critical aspects of healthcare, she asked if there were new incentives because she assumed that these had always been critical areas.

Ms Robinson said that she more muddled now then she was before. The fact that there was a document that sent to them in error and that there were graphs in the report that could not be interpreted was not the brightest sort of thing. She thought that they were there to tell them what was wrong. The presentation should be user friendly because the Committee could help them analyse where the problems. As with the Mpumalanga presentation, she thought it a catastrophic situation if a hospital took ten years to build, as it would be obsolete by the time it opened. The issue of rebuilding instead of revitalising was interesting because a hospital could be planned in a modern way with modern technology. She asked who was pulling the wool over one’s eyes. She wanted clear information because of the bad state of affairs.

The Chairperson said that the difference between Health and other departments was that it caused people to die and that was what was bothering the Committee.

Ms Robinson said that they seemed to be muddling along and why did they not have experts coming from overseas to help them with the problems.

Ms H Msweli (IFP) said that she understood that the project was supposed to be implemented within 24 months so what had happened? She wanted to understand why this was happening with every project.

The Chairperson said that when Health was called before the Appropriations Standing Committee, they had explained why there were delays but the sad part was that it had created more questions.

Ms Ngcobo said that they had visited a rural hospital that had been built many years back which was being revitalised and was doing wonderfully and that they had been given the percentages and phases of the project. She did not get that joy from these presentations. The value for money was a huge factor and the issue of contractors and litigation was problematic. She asked who had to pay for litigation and if the province was responsible, where did they get the funds? She asked why they kept the underperforming contractors.

The Chairperson said he had met a young engineer from KZN and he was so against corruption, which was the bottom line. He said he was prepared to die to stop the corruption, firing people despite the connections that they had. He had the support of the MEC and the Premier.

Mr Lekgetho said that he had visited hospitals in his area and that in the former Bantustans the conditions were terrible. It needed to be discussed at some stage. In the presentations, weaknesses have been identified but these needed to show how these were to be addressed with solutions or a time frame.

Ms Kenye (ANC) asked about the contractors and their grading system. She also asked about human resources and financial delegations

Response
Mr Mabona, Head of Infrastructure for the Department of Health in the Northern Cape, said the mental hospital had started in 2005 while the main hospital had started in 2006. It was supposed to take 24 months. The contractor was fired in 2009. They were deducting penalties. Litigation was paid for by the Department of Public Works and the new contactor had started work only in 2011. They had under expenditure before. The main hospital was supposed to be constructed in 24 months. In terms of the rollovers, they applied for the rollover because of the delays with the contractors and with their grading. They relied on the ability of the CIDB to grade the contractors and that they chose based on that.

Mr Mxolisi Sokatsha, MEC of Health in the Northern Cape, said that they used to under spend a lot of money but they were now making sure that they spent the money. The National Board of Health had been there last week. They wanted to assure the Members that they had hired a new contractor that had started in January. When he came into his position, the former MEC said that one of the major issues in clinics and hospitals in the country was the attitude of the staff. If that problem could be solved, it would solve 50% of the problems in the country. This was a severe issue and part of that problem was that these places were understaffed. He explained that cleanliness was a real problem along with the other core standards. He apologised about the graph but for some reason the memory stick with the graph in colour would not load. Most of his facilities were very small and in terms of delegations, all of their district delegations were taken away by the provincial office and in particular the financial delegations. They were trying to take back those powers to the district levels. They want to appoint the correct people at the correct posts. When he entered the department, the vacancy rate was at 42%, it was now it was at 20%.

The Chairperson thanked the MEC for the explanation but said that there were still questions. He asked if they could sort out the litigation problem once and for all. If people sleep on this that they could not be considered leaders and that politicians were paranoid and do not what they were telling them but what they are not being told. If the leadership shows a good attitude then the people underneath them would follow. He thought one of the unintended consequences of democracy was that respect became unintended to be used.

Mr Kganare said that he wanted to clarify why the second document did not state ‘experienced leaders’ and asked what they were hiding. Why were they spending R400 million if the project was already 70% complete? He thought people should learn from KZN about how that province was dealing with corruption.

The Chairperson wondered again how a project that was “almost completed” could cost almost as much as the entire initial project.

Mr Sokatsha replied that the original project had structural damage and that if the building had to be demolished, then the price could even escalate.

North West Health Department briefing
Dr Magome Masike, North West Health MEC, noted the North West had six mine hospitals. He provided an overview of National Core Standards (NCS), assessment criteria/domains, facility assessments, measures to address NCS, and infrastructure compliance plans. The National Core Standards include improved life expectancy, reduced impact of HIV and TB, improved mother and child health, and improved system effectiveness. The assessment domains would be: patient rights, safety and clinical risks, clinical support which includes governance, public health, leadership and corporate governance, operational management, facility and infrastructure and the six ministerial priorities.

Dr Robinson, North West Health Head of Department and Deputy Director-General, said that the Word document showed where they stand in terms of core standards. They had had quality assurance before the core standards so most of the hospitals were used to this. He explained the table and how the system worked including why a hospital could get an A but also be non compliant. If one did not score 100% and get an A then one was not compliant in the core standards. There was a national competition for cleanliness and the North West had won by outperforming the Western Cape. He continued by explaining the compliance with specialized hospitals which they were doing very well in. It was not a matter of money but a matter of leadership and attitude. They had a very good idea of where they complied and did not comply. Some of the North West district hospitals performed very well like Lehurutshe District Hospital.

Dr Robertson explained that they had just used a sample of clinics but they were using NGOs to help assess the 360 plus clinics in the province. They wanted to start using a business model like that of franchised companies such as Wimpy, the way in which everyone was the same, that same idea would be used with clinics. He reiterated that they had a long standing quality standards programme which prepared them for these National Standards. All hospital facilities had drawn up operational plans to meet the gaps in standards. Management ability and not money was key to meeting the standards. The capacity for monitoring levels was being met again by NGOs and that the people in control of managing these tasks had the expertise to do so.

Dr Masike stated that they knew what the gaps were and how to meet them in terms of infrastructure.

The Chairperson asked if when they did these assessments, they allowed the people that use these facilities to speak because he had had a letter about the state of conditions.

Dr Masike replied that Members of Parliament had asked some people but they did not get a proper sample of patients.

Mr Kabelo Motene, Infrastructure Manager: North West Health Department, took the Committee through infrastructure compliance, noting hospitals that had been and were being completed within the revitalisation programme. All major positions had been filled, besides the deputy director of financial management, for which interviews had been conducted. They had a budget of R2.1 billion and had used R1.7 billion on facilities. He looked at each hospital individually on their short term and long term plans (see document).

Mr Motene stated that in terms of hospital expenditure they had spent 99.02% of their annual budget in 2011/12 and thus far this year they had spent 44.2% of their budget. Although they were showing the Committee the infrastructure plan, they also highlighted the challenges in complying. They currently had over R2 billion in backlogs in renovations, upgrades, and maintenance – this came from an assessment of all facilities. There was also a backlog of about R2,8 billion for health facility gaps relating to service delivery. They only had about R654 million for 2013/14, R681 million for 2014/15 and a possible R710 million for 2015/16.

Discussion
The Chairperson said that there was still a question unanswered. It seemed that they were raising budgets in the areas of the advantaged at the expense of the disadvantaged.

Ms Ngcobo said that “with tongue in cheek” she would like to congratulate the province on its cleanliness award. She suggested to the Chairperson that the North West be the next province that the Committee should visit. She asked, in terms of NGOs, did the province have community health workers and if the province could have an in-house maintenance team. She had a problem with all the invoices at the end of the financial year and asked if it was just a dumping project.

Mr Dikobo said he was concerned about the R2 billion backlog and if they had raised this issue with the Minister.

The Chairperson said that it seemed as though there were serious challenges in the provinces.

Ms Segale-Diswal wanted clarification on the areas of compliance and what exactly was going on with the time frame for the completion of Brits hospital. She said in these beautiful health centres, there were sometimes only two examination rooms working out of nine or the x ray machine was not working.

Ms Kenye asked more about the non compliance and the reasoning for the high level of it.

The Chairperson said that they should go there and confirm what they had heard.

Dr Robinson said with National Standards one could get an A score yet still fail to comply. He gave an example of having 100 perfectly working toilets in a hospital but if one was dirty, that one dirty toilet would make the hospital non compliant in that portion. North West was decentralising its health care. It would be better for the patients but there was difficulty in staffing and the expenses would not be cheaper. He said, yes, there would be health workers and about 700 had been trained.

Mr Masike said that the way that the core standards were set up, you could end up with an 80% and yet if one nurse did not wash her hands once, that could make it non compliant. They had partnered with Toledo University to come up with innovative ways of dealing with patient safety by drilling it into hospital workers. The patient also had to be better educated about medication but the numbers that a hospital had made this impossible sometimes. The mines and their numbers added to this.

Dr Robinson put in a comment about hand washing: the figure was less then 80% percent of doctors in America and Europe washed their hands between patients.

Ms Kenye said that her question had been reduced to ‘hand washing’ but that she was concerned about patient’s rights and other serious matters.

The Chairperson said that perhaps he misunderstood, but what he was saying was “lets not lose hope” that eventually they would able to meet the standards. He just used hand washing as an example and did not put down the question.

Mr Motene said that the CFO was ensuring that they had in house maintenance teams. Tere was no dumping at the end of the month but the way in which Brits hospital was being funded made the budget look that way. He explained that the MEC may approach National Health for assistance and that the information regarding private company funding would be made available. Brits Hospital started on 25 November 2008 and the first contract was terminated in August 2009. The current contract started in July 2010 and it would be completed by August 2012.

The Chairperson asked the MECs to sum up their presentations.

Dr Magome Masike, North West Health MEC, thanked the Chairperson for holding them accountable because they were constructively criticising them. He talked of a clinic in the North West that was renovated by a man for free and he spoke of other projects that were being funded by private companies including Anglo-American. In terms of cleanliness, during the competition four of their hospitals made the grade including the cleanest hospital in the country award. They did not like to do fiscal dumping but there was a tendency to put pressure on at the end of the year.

Dr Clifford Mkasi, MEC of Health in Mpumalanga, said that maybe we should have answered the question that the Committee was asking by saying they cannot meet the core standards. The resources were low but they would give them a complete assessment. There was a shortage of medical professionals and only 48% of doctor positions were filled in the province.

Mr Mxolisi Sokatsha, MEC of Health in the Northern Cape, said that the shortage of nurses in the Northern Cape was severe but there was stability. The province had had problems with the outcomes of the audit. Their relationship with Public Works had increased. With regards to the mental hospital, it was mess. He invited to take the Committee to the Kuruman area where the hospital there was built in 1929 and the conditions were horrible.

The Chairperson said he welcomed their honesty but there must come a time where one must say I’m honest but what must I do? There was under spending and other things which affected service delivery. But he was happy that they were making plans to fix things. He was told that there were going to be engineers in all of the provinces but this did not seem to be happening. He thought that the President had done a very good thing for starting a Department of Rural Development and that perhaps that needed to be looked at. The Committee would assist them where it was needed.

The meeting was adjourned.