Hospital revitalisation, Maxeke Academic Hospital report, National Office of Standards Compliance issues: Gauteng Health Department briefing; Chamber of Mines briefing on Mine Health issues

Meeting report

Chairperson’s opening remarks

The Chairperson noted that all provinces would be asked to brief the Committee on their progress. Whilst the Gauteng Provincial Department of Health (DoH) had been asked to report on its Hospital Revitalisation Programme, this in fact formed part of its work towards norms and standards that would enable its accreditation. This Committee would have to verify any challenges raised by Members and the public, and also issues such as the recent media reports on a misdiagnosis on a professional work, which had indicated problems with attitude and quality of the treating staff.

He noted that the Compensation Commissioner for Occupational Diseases had reported on the challenges around compensation, and this had highlighted the huge gap between the rich and poor, particularly evident in the mining industry, where occupational diseases were rife. The Head of the Chamber of Mines would give a synopsis of mining health issues, and the Committee planned to visit some of the mine hospitals.

Turnaround Strategy, Hospital Revitalisation Projects:  Gauteng Provincial Department of Health briefing
Mr Hope Papo, MEC for Health, Gauteng Province, suggested that it would have been useful for this meeting also to have included Members from the Select Committee, as his provincial DoH participated with them on a number of issues on the ground.

The Chairperson responded that there were differences between the work of the Portfolio and Select Committees. He agreed that the Gauteng DoH should have been called earlier.

Turnaround strategy
Mr Papo noted that the section 100A (of the Constitution) turnaround strategy had to be ready by end-March. Infrastructure work covered all four central hospitals, district hospitals and regional hospitals. The booklet on the turnaround strategy was not as detailed as the Memorandum of Agreement between the Minister and Premier, and did not have time lines. It was emphasised that all stakeholders had to work together. The Minister, Deputy Minister and Mr Papo formed a political team, and a technical committee of departmental officials was formed to deal with the Charlotte Maxeke Academic Hospital and report to the political team. Infrastructure issues involved  human resources and financial management of health systems. The National Health Council (NHC) had agreed on the norms and standards for the whole country and were evaluating facilities.

Mr Papo noted that contractual matters had been disputed in court, and that was being handled as a separate issue. By 2014, it was hoped that the provincial DoH would be stable. Some of the problems were systemic and had accumulated over time, but would be settled. He urged the Committee to assist on financing issues, since one of the critical issues facing the province at the time of the section 100A decision was that the commitments of the Department amounted to R600 million, whilst only R400 million was received from National Treasury (NT). The Gauteng Planning Commission working with Public Health had been asked to determine the cost of rendering effective health services in Gauteng, but no figure had yet been given. Evaluations were being done in central, academic, tertiary, district and regional hospitals. A specific budget of R2.4 billion was requested for Charlotte Maxeke Academic Hospital (CMAH) but R1.7 billion was allocated. A meeting was arranged with the MEC for Finance to discuss the shortfall, as, even during a recession, health must be given sufficient resources. A budget had been submitted to the National Ministry of Health, setting out the amounts required to fill the critical posts. Cost saving measures should not hinder health services, and he noted that now the health sector was seeing the consequences of years of under-funding, as facilities could not employ specialists. The intention was to stabilise four central hospitals, three tertiary hospitals, district and regional hospitals and clinics, and primary health care (PHC) throughout that system.

Hospital Revitalisation Programme
Dr Nomonde Xundu, Head of Department, Gauteng Provincial DoH, briefed the Committee on the current status of infrastructure related projects implemented through the Hospital Revitalisation Grant (HRG). The Department’s . Infrastructure Management Unit was responsible for the planning, provision of equipment to new and existing facilities, and for upgrading and rehabilitating community health centres.

Details were given of each of the hospitals covered by the grants (see attached presentation for full details.

The Bertha Gxowa Hospital (formerly Germiston Hospital) was 96% complete, and was scheduled for completion by November 2012. A budget of R489 million was allocated, and spending to date was R444 million, with expenditure to date in this financial year at R1.9 million. It was a replacement project for a 300 bed hospital. There had been cost escalations due to extensions of time, interest charges on delayed payments, the ICT costs originally being omitted from the budget, and other omissions that arose because the end user was not involved when drafting the project scope. The process of payment between the Department of Health and the Department of Infrastructure Development was problematic, with numerous stages, which delayed the project. Those processes were being improved. The issue of delays between practical and final completion, estimated at three months, were not yet resolved with the Department of Public Works (DPW). Remedial work was ongoing on some latent defects, and some of the services could not be provided in the new hospital. The solutions were outlined in the presentation. A major risk was that a section of the existing hospital building and heritage building was not included in the Revitalisation Project, but since the hospital was likely to keep using this space, it required a grant allocation, which had still to be costed, for provision of Maternal and Obstetric Unit (MOU) services close to the hospital, and accommodation for the expanded Anti Retroviral Therapy (ART) clinic.

The Zola/Jabulani Hospital in Soweto was a 300-bed district hospital. The date for completion was anticipated as 21 November 2012, and the work was 93% complete.

The Chairperson interjected to question the completion date, in light of earlier presentations.
 
Mr Tandabantu Gwebindlala, Chief Director: Infrastructure, DoH, clarified that the original contractual date for completion of the Zola/Jabulani Hospital was February 2012. Because the permit was delayed, the DoH was in breach of contract, and therefore found it difficult to enforce obligations on the part of the contractor. For that reason, the contractor was granted an extension of time.

The Chairperson noted that this had financial implications.

Dr Xundu continued with the presentation. The Family Medicine Clinic (Gateway clinic) should be fully operational from 15 September 2012. The budget was R675 million, of which R607 million was expended; and R50 million was spent in the year to date. The cost escalations resulted from poor performance on a prior contract that was eventually terminated, delays in making payments, extensions to the scope of work and delays around non-consolidated land and power and water connections. Variation orders were approved for two operating theatres, which were under construction. Here, three of the prior contracts were terminated due to non-performance and there was conflict between the different stakeholders around management of the project. The project was three years behind schedule. The current contract commenced in 21 January 2009, and would end on 21 September 2012.

The New Natalspruit Hospital was a regional, 771 bed hospital that would replace the existing hospital. It was 90% complete. The anticipated completion date was 31 November 2012. The total budget was R1.6 billion, with R1.4 billion expended to date, and year to date expenditure of R59 million. The cost increases were due to 15 variation orders, which were necessary following poor planning and stakeholder engagement omission. There had also been delays in payment of contractor. The extension of time was a challenge, and a legal opinion was pending on the non-approval of delayed payments, with a possible solution being to acquire the necessary approval.

The New Natalspruit Hospital Road Hospital project involved upgrading of the access road to the hospital for transportation, and for ambulances. It was 65% complete, but the contract completion date was 17 October 2012. The budget was R64 million, with R0.4 million spent in this year. There was no increase in cost. There was delay in registering the Joint Venture at South African Revenue Services (SARS), but this was now resolved and four certificates were submitted for payment. The project was in progress, the contractor was able to continue, and no further problems were foreseen.

Kyalami Hospital (formerly Kempton Park) was the re-opening of the existing hospital as a Level 1 District Hospital. Planning began on 26 June 2012, and the expected date of completion was 4 July 2015. The budget allocation was R400 million but no work was started. The challenges included the past attempts to sell the building, then to reopen with Level 1 beds for the public service, whilst vandalism and poor security meant that there had been damage to the property. The  Development Bank of Southern Africa was now contracted as the implementing agent, for procuring and managing professional service providers to plan and complete the project. Part of the DoH’s recovery strategy involved joint planning between the Department of Infrastructure Development and the DoH, specifically around payments, improvements to the supply chain management process and the quality of appointed contractors. The DoH would be participating in the implementation of the Infrastructure Development Improvement Programme (IDIP), and the appointment of an overall project manager and 22 technical experts, which was underway. An Infrastructure Committee sat on a monthly basis to monitor project progress, and payments and instant decisions were required.

Dr Papo added that he and the MEC for Infrastructure had met to look at all the delays, including how to cut down on the twelve steps for payment between the two departments. The two Heads of Department oversaw the Infrastructure Committee.

Discussion
The Chairperson noted that the presentation around the revitalisation issues was important to show how delays affected service delivery. Norms and standards had to be complied with, in order for the provincial departments to get accreditation, and how provincial departments were able to deal with delays went to the core of their ability.

The Chairperson noted that the initial date for Jabulani Hospital completion was stated as 21 January 2009, but three contracts were terminated. He assumed this report referred to the work done by the fourth contractor

 Dr Xundu confirmed that this was correct.

Ms T Kenye (ANC) asked why Tshwane, a pilot project, was not mentioned.

Dr Xundu responded that the Plan did not speak to National Health Insurance (NHI) issues, and there was a separate infrastructure plan through the NHI Grant.

Ms Kenye referred to the challenges experienced on the Bertha Gxowa Hospital project, and asked where the services would be provided. She also wanted to know what would happen with the ART Clinic, and whether Gateway Clinic was also intended to be included.

Mr D Kganare (DA) asked for clarification of the dates for the Bertha Gxowa Hospital.

Mr Gwebindlala said the various dates were expressed as they were contained in the Joint Building Contractors 2010 Contract. The contractual start date was on the day on which work started, with the site being handed over to the contractor. The contract completion date was the day on which the contractor was supposed to finish the work. After doing so, there was another period leading up to final delivery, in which the end user could check the work and identify any problems that had to be corrected. After the final delivery, there was a final consolidated accounting taking into account the original contract price, any variation orders approved and extension of time payments. An invoice would then be issued to the client, for payment of the final account.

The dates showed delays in each of the projects implemented. However, he explained that current processes were not necessarily in place when the projects started as there had been poor planning in the past. The DoH was, however, confident that the processes and tools since introduced would deal with the challenges.

Mr Kganare referred to a rough estimate for R137 million and the cost of renovation against cost of demolition and rebuilding of a specified and appropriate structure. He asked whether a decision had been made yet.

Mr Kganare asked about  the original budget for the Zola/Jabulani Hospital and the cost of all the delays. He hoped that contractor would not be used again.

Mr Kganare said somebody must be responsible for the delays in payment of the contractor for the New Natalspruit Hospital, and wanted to know how DoH would deal with that. He also noted the large number of variation orders on the New Natalspruit Hospital and asked if the plans were approved.

The Chairperson explained that the communities that voted for the Members paid taxes, and expected that the Members would ensure that these were properly spent. Everyone agreed that the health sector had been consistently under-funded, but the problem was now that money was being spend to rectify delays rather than to managing healthcare. The DoH could not complain about insufficient funding when it was mismanaging the funding that it was being given.

Ms M Dube (ANC) was concerned that the Department of Public Works (DPW) seemed to hold the upper hand, commenting that DoH often only seemed to realise the true situation after the event. She also noted that the document only concentrated on health services in the Johannesburg area, whilst Tshwane and other parts of Gauteng were not covered.

Mr Gwebindlala explained again that the projects in the presentation were funded through the Hospital Revitalisation Grant, and were not projects under the Health Infrastructure Grant.

The Chairperson agreed that this was the correct focus; the Committee wanted to hear about the DoH’s preparation for accreditation under norms and standards. However, the question was why the DoH had chosen to deal with institutions around Ekhurleni only.

Mr Gwebindlala responded that the only new project was for Kempton Park, following the Premier’s decision. The other projects, which included the KwaZulu-Natal project, the Tshwane project and the NHI, for which the DoH had applied for funding were not yet approved by the National Department. The rest of Gauteng was covered under other funding sources such as the Health Infrastructure Grant and the Project Fund.

The Chairperson added that people were tending to move into Johannesburg, and not to Pretoria, and all the current hospitals in Johannesburg were already overstretched. He wondered why another hospital was not built in the centre of Johannesburg, to relieve the pressure. The Steve Biko Academic Hospital did not have the same pressure as Baragwanath.

Ms Dube asked how the Zola/Jabulani Hospital could be completed if the land was not consolidated.

Ms Dube asked for clarity on the Bertha Gxowa Hospital contractual start dates, up to final completion. She asked, in general, what happened around the expenses that resulted from extensions of time, and to what extent the DPW and DoH were responsible. She also wanted to know if contractors who were not performing, were penalised.

Ms M Segale-Diswai compared the infrastructure process with the previous year’s report from the Auditor-General (AG). The Zola/Jabulani Hospital had been started in 2005, and the AG had already reported overspending of 244%.

Mr Gwebindlala added it was true that the Zola/Jabulani Hospital started in 2005. There were three contractors whose contracts were terminated. The project cost was originally around R300 million but three contractors did not perform, and the costs had escalated because of this, and the addition of the Natalspruit project, to R607 million. Those projects were not designed properly, and for this reason DoH had to add in other facilities.

Mr Kemraj Ojageer, Deputy Director General, Gauteng Department of Infrastructure Development, confirmed that the initial contract was entered into at the end of 2005. The initial contractor failed to get the necessary rating from the Construction Industry Development Board, and then the subsequent contractor could not get SARS certifications. The Zola/Jabulani original tender was for a 200 bed single-storey hospital, but the revised plans were for a  300 bed double-storey, so the cost escalation had more to do with the design than the project. The re-tendered price was around R547 million.

Ms Segale-Diswai said the problem of budget was chronic, and historic, but the waste of money in infrastructure alone was problematic. She was concerned that DPW should also account, as many of the delays were occasioned by this department. She was very concerned at the statement that the end-user, DoH, was not involved at planning stages and questioned how a hospital could be built without the DoH management input.

Ms B Ngcobo (ANC) suggested that she would have like to see the strategic plans, because it looked as though there was no, or very poor planning when the infrastructure project was put in place.

Dr Xundu agreed that there had been serious problems with infrastructure planning, both in the DoH and Department of Infrastructure Development (DID). The User Asset Management Plan was not used to inform the service transformation plan, and ad hoc decisions were taken. That also addressed how poor implementation affected service delivery One of the core challenges identified and addressed in the Turnaround Strategy was health infrastructure, and when it was realised that this was not in place, the DoH started to develop a Five-Year Plan, which would speak to service delivery to strengthen primary health care. All provinces and districts had raised the poor infrastructure in clinics.

Mr Gwebindlala added that it was clear, from the report, that there were serious problems with infrastructure in Gauteng. The problems were mainly related to planning, but to some extent also to the supply chain management. The DoH and DID had now streamlined the planning processes. The User Asset Management Plan was a master plan for all facilities in Gauteng, highlighting the areas that were critical for a hospital to function, with estimated costs. That would be used to set the priorities. A meeting was scheduled for the following day to set priorities in the DoH, with input from the unions, hospitals, and staff. The project brief outlined how many beds and patients the facility would service, and then design must be done in a set way, followed by a Project Implementation Plan (PIP), which would include project start date and construction start dates. The tender documents were based on that. This process had not been used in the past.

Mr Ojageer added that the DID was currently increasing its capacity and had already started the process of employing 280 highly qualified technical people, including electrical, mechanical and civil engineers, architects and quantity surveyors. They were to be deployed to the seven regions around the hospitals and would be dealing directly with issues relating to hospitals.

Ms Ngcobo was sure the DoH had signed a service level agreement with the DPW, and asked what this contained around services to be rendered, and penalties for non-delivery. She commented that these delays affected whether value was achieved for the money spent.

Mr Gwebindlala responded that the Service Level Agreement had now been refined, to put in time frames and to specify what responsibilities lay with each of the two departments. In addition to that, a committee had been established to communicate from project level to the Infrastructure Committee.

Ms Ngcobo asked whether it was still necessary for DoH to use the DPW for infrastructure, because the latter was not delivering, and noted that this was a problem expressed by all provinces. She wondered if this should not be raised at the next MinMEC meeting.

Mr Ojageer responded that DID inherited these projects from DPW. He agreed that in the past, planning had been incorrectly done, and too much trust was laid on the design team, with DoH being left out of the process. The design teams were not sufficiently competent to build hospitals, and were rushing to meet targets for the FIFA World Cup. Contractors sometimes did not meet some of the health standards, and inappropriate decisions were taken. For instance, the Natalspruit Hospital, with 700 beds, was expected to be finished in fifty months but the reality was that for a good product, at least 75 to 100 months were required. If time frames were reduced, the whole hospital would be put at risk.

The Chairperson said Parliament wanted to know if DID was going to change the situation around.

Mr Ojageer responded that since taking over the operation of the projects from DPW, the DID had requested the contractors to furnish their plans for completion. DID had commitments from the contractors that Zola/Jabulani would be finished by December, and Natalspruit would also be finished by December. Germiston Hospital was completed, and ready for handover, save for rectification of minor latent defects still under the guarantee of the contractor, so this was being addressed. All projects implemented in future would have Scope Block which meant that no project changes would be allowed. Turnaround times for payment had been set, since January, and invoices were paid within 72 hours of receipt. The legal contracts that had been finalised for the Joint Venture were not favourable to government, since there was a clause that required payment of contractors within 21 days, even if the processes would not be completed by then. However, this was to be addressed.

Ms Ngcobo said that this Committee, at the end of October, would be finalising the Budget Review and Recommendation Report, and some serious questions were likely to be raised there about the Gauteng issues. She asked that details of any litigation must be given to the Committee. Some provinces worked within limited budget constraints, and did their best.

The Chairperson pointed out that when he had been MEC for Health in the Eastern Cape, this province had managed to build 100 clinics in one year, without any delays.

Ms D Robinson (DA) expressed her dismay at the report, which showed lack of planning and lack of coordination, and work done in non-integrated silos. Neither the DoH nor the DPW were serving the people. When insufficient funding was granted, it was then even more important to plan carefully to see that the money was used optimally. In the health sector, people’s lives were at stake, and the fact that DoH had not been involved in the planning was a tragedy that was costing lives. She questioned if those appointed to do the work were competent, and whether there was performance monitoring, and holding of contractors to account.

Ms Robinson asked if, on the Bertha Gxowa Hospital project, there was a project management team, where the blame for all the delays lay, and pointed out that the rectification work cost money. She wondered if DoH was simply throwing good money after bad. She wanted to know who the contractors were and why their workmanship was not checked. In the Zola/Jabulani Hospital project, she wanted to know what the planning processes involved, pointing out that the land was not even consolidated. She also wanted to know the cause of the delays in power and water connections, and who was overseeing the project, given the continuous problems around processes and systems.

Ms Robinson also noted the conflict between the different stakeholders, and lack of consensus in terms of contract and management of the project, and asked if any action was being taken. In the New Natalspruit Hospital, it was unacceptable that the psychiatric wards did not comply with the Mental Health Act guidelines, and that the needs of the patients were not being considered. She commented that not enough attention was being given to mental health issues, although they were on the increase.

Ms Robinson commented that the multiple variation orders had again pointed to lack of involvement of the end users. Whilst she noted that the DoH acknowledged the problems, she urged that they had to be urgently remedied. She questioned if the country did not have guidelines on how a hospital should be built and questioned why experts were not called in. Noting the challenges facing the Kyalami Hospital project, which included vandalism and poor security, she commented that this was chaotic, and wondered who was in charge. She welcomed the introduction of an Infrastructure Committee, but asked who it comprised, what their qualifications were, whether they looked at overall planning and whether they were competent.

The Chairperson emphasised that the mistakes made in Health could not be reversed.

Ms P Kopane (DA) wanted to know the original cost estimates for the Bertha Gxowa Hospital, and how the variation orders affected this. She too was worried that some of the services provided in the old hospital would not be provided in the new one, and asked for a setting out of those services, and plans to address this problem. She asked why a section of the existing hospital building and heritage building was not included in the Revitalisation Project. She commented, in general, that instead of the DoH stating the problems, she wanted to hear how the DoH intended to resolve them. Any solutions also came with cost implications, so the costs and timeframes were also needed.  there were a lot of variation orders and the initial cost would have brought more clarity.

Ms Kopane referred to the financial status of the Zola/Jabulani Hospital project. She appreciated the reasons for the cost increase but asked about the financial implications of each of the listed reasons. She wanted the names of the three contractors whose services were terminated previously.  

Ms C Dudley (ACDP) agreed with other Members that the poor planning had huge financial implications, and demanded to know who was being held responsible for that, and to what extent the blame lay inside the DoH. If the responsibility lay outside the DOH, then she stressed that contractors should be blacklisted to prevent such gross incompetence recurring. She wanted more detail as to how the SARS requirements had held up the projects.  She wanted clarification on the attempts to sell one of the buildings.

Mr G Lekgetho (ANC) said the Committee needed to intervene. He wanted details of how much the total HRG was, how much was used, and how much remained.

Dr Xundu responded that the budget for the current financial year for HRG was R795 million, but the allocation was reduced because of DoH’s previous poor spending on the grant. Similar problems arose with the equitable share. The allocation of budgets to various departments took into consideration the departments’ readiness to spend and implement projects, and if projects were found wanting, no money was allocated. Infrastructure delivery had now been strengthened within the DoH and more generally within the whole province.

The Chairperson asked that, although Members had asked other questions, the presenters’ responses must concentrate on the Revitalisation Programme and how it affected service delivery. If the Revitalisation Programme was not going well, some institutions were clearly not on track.

Mr Papo responded that he understood the importance of engaging with the Committee and submitting a frank report. The responsibility for the projects lay with the two departments. One of the main problems had been the tortuous processes, involving so many steps, between the departments. He clarified that the fact was not that there was no money. There was money available to run the hospitals, and for infrastructure, but the under funding related to goods and services and human resources. Most of the revitalisation projects were long ongoing, with numerous projects, and after Parliament raised questions around why contractors were kept on, the contracts were terminated. The MEC for Infrastructure agreed that if delays were caused by subjective elements, there had to be consequences. The DPW in Gauteng was running 700 projects for the DoH, some of which were still to be completed, and others merely had to be handed over. The Executive Council took the view that in future no project would be started in Gauteng without the input of DoH.

He clarified that with Kempton Hospital, there had been a challenge from a private hospital who feared competition and tried to stop government from starting Folateng. A decision had to be taken then to develop the hospital to Level 1.

The Chairperson added that the private hospital did not fear the DoH as a public institution that would not offer any competition.

Mr Papo said there were other reasons that lay behind the decision as well. The existing Folateng had not been assessed and there were some problems with the model, some of which were caused by the Department’s own staff members in those hospitals, related to HR issues, whilst other problems arose through not involving the public hospitals in the surrounds to Folateng. Some staff were using the Folateng Hospital for their private patients. There had to be a decision on how to strengthen the model, and to answer why the Folateng model was not bringing in money that could be injected into the public hospitals. The Executive Council was suggesting that the hospital structures may need to be consolidated. However, it was not all doom, as the Department was developing plans to deal with the issues.

Ms Robinson asked Mr Papo to expand on the Folateng model.

The Chairperson said Parliament wanted to hear a commitment that this would not happen again.

Department of Health’s State of Readiness for independent audit and certification by National Office of Standards Compliance
The Chairperson said the Committee wanted to know whether, once the relevant legislation was passed for the National Office of Health Standards Compliance , the DoH would be ready for accreditation.

Dr Xundu briefed the Committee on work done by the DoH to prepare health institutions for the implementation of quality norms and standards. The DoH had conducted sessions, during 2010/11 with all stakeholders around the preparation of health establishments for the implementation of NHI, using the Core Standards and the Six Priority Areas. Self-assessment was done and certification processes were implemented. Senior management in the DoH, and other stakeholders, including unions, were engaged with during meetings in February 2011. Workshops and training sessions were conducted for Heads of Hospitals (CEOs), and Senior District Managers, including those in the local authority, on the National Core Standards (NCS) and the six priority areas. Around 3 000 members of staff were trained, and a number of Quality Assurance Coordinators were appointed at all levels, and trained through the University of Pretoria.

In line with the National Health Act, the Inspectorate was established in August 2011, with the main role of monitoring compliance to the prescripts of Core Standards and the priority areas. It was conducting clinical audits and health care inspections on a regular basis, averaging of 31 clinics, 2 Community Health Centres (CHCs) and one hospital monthly. It also ensured implementation of its recommendations made after any complaints. Inspectors were drawn from various disciplines, including doctors, nurses and environmental health practitioners. The Infection Prevention and Control Unit (IPC) was headed by a trained IPC Officer, and 14 retired nurses were part of the team, specifically focusing on neonatal units and maternity sections. This had already resulted in a 50% reduction in Neonatal preventable infection incidences during the 2011/12 financial year. A customer care unit was established within the QA directorate to deal with all complaints from patients and the public. A complaints call centre was established and there was also a toll free Telkom hotline. The most common complaints were about staff attitudes, waiting times for medical interventions, hospitality services and alleged medical errors.

Projects were implemented to address the 17 non-negotiables. A partnership was established with Industroclean, and with the Professional Development Foundation. Industroclean sponsored the cleanest hospital competition and offered forty bursaries to train cleaning staff. The Professional Development Foundation was in the process of training 100 cleaners at selected institutions. There was an outcry from most of the clinics about shortage of cleaners.

Most institutions were found to be compliant in terms of reduction of waiting times at frontline areas such as Outpatients Department, Pharmacy and Emergency Areas. There were, however, major concerns and challenges around non-compliance with the NCS. These had mostly to do with infrastructural limitations of the infrastructure, since some hospitals and clinics were not designed as health care facilities, buildings were dilapidated, and there were budgetary and staff constraints. Only seven of the 32 hospitals assessed between April 2011 and March 2012 consistently obtained A status non-compliance, which was explained as the facility not satisfying one or more vital and non-negotiable measures.

Gauteng Province had already implemented the norms and National Core Standards, including the six Ministerial quality priority areas, at all health institutions, including hospitals and clinics. There were improvements in compliance to the norms and standards, though some areas needed strengthening.

Department of Health Report on Charlotte Maxeke Johannesburg Academic Hospital
Dr Xundu said the Charlotte Maxeke Hospital (the Hospital) was a pressure point in the Department, mainly because of huge demands for the service in the area, and there were challenges around stabilisation of this institution. The Hospital was under particular pressure because of the reductions in the budget for compensation of employees, which resulted in staff shortages, especially medical doctors and specialist nurses. The Hospital experienced service delivery challenges, leading to negative media reports. The Premier, the MEC, and management in DoH had visited the Hospital on 14 August 2012. Heads of Clinical Departments attended the meeting and presented their concerns to the leadership of the provincial Cabinet. Two days later, the Hospital also received visits from the Minister and Deputy Minister of Health, the MEC, the Director General of the Department of Health, the Gauteng HoD for Health and other management authorities.

The issues were quantified into seven core areas. Human Resources, and the delay in filling of identified critical posts, due to underfunding, was the first problematic area. There were delays in procurement of equipment, and problems around service, maintenance and repairs of life saving equipment. In the Pharmacy, the optimum stock levels were not maintained. The reduction of web cycles and accrual transactions needed attention. On the financial side, the Hospital needed to acquire IT hardware, and fix its Local Area Network (LAN). Finally, on the infrastructure side, there was a need for servicing, maintenance and repair of identified infrastructural requirements.

Since the intervention in August, DoH had managed to fill 41 posts, including 17 medical specialists, 11 medical officers, 3 medical registrars, 2 clinical technologists, and 2 radiographers. 35 candidates would start on 1 September 2012 and 6 on 1 October 2012.

The Chairperson interjected to ask what number of staff were needed to bring this Hospital to normal requirements.

Dr Barney Selebano, Chief Executive Officer, Charlotte Maxeke Hospital, responded that the staff establishment of medical specialists of all categories at Charlotte Maxeke was around 800, including medical officers and registrars. That was not ideal, because there were shortages in highly specialised areas that resulted from the general shortage of skills, not from lack of efforts by the DoH. Annually, the Hospital lost about 90 doctors, most of whom emigrated.  The actual shortage in August was about 70.

The Chairperson said there were set ratios for a “normal” functioning: for instance, in outpatients, one nurse was required for each 34 patients, and in the wards, one nurse to ever 14 patients, one nurse per patient in ICU. He asked for more details on this.

Dr Selebano replied that the normal ratio for ICU was 1:1 specialist nurses, and 1:5 doctors. In High Care the ratio for nurses would be 1:3, but doctors included a wider range of specialist skills, although sometimes, because of the skills shortages, adjustments were necessary. In outpatients, the ratios of nurses to patients were 1:1, but specialist nurses were 1: between 2 and 4.  would have to adjust as one worked.

The Chairperson said that when planning, the DoH should be looking at what population was to be serviced, how many beds and how many clinics were needed, and how many specialists to deal with the patients, and he would like to hear what the normal calculations would be. He pointed out that this Hospital also serviced people from other countries.

Dr Selebano responded that the Hospital had 1098 beds, but the ratio was skewed with every 60 locals compared to 40 from Zimbabwe, Mozambique and the SADC countries. It was an operational issue, and sometimes more beds were required.

The Chairperson was still not happy with the information.

Ms Dube suggested, and Mr Papo confirmed, that the details would be put in writing, since the DoH was not aware that these figures would be required.

Ms Robinson noted that 17 medical specialists were appointed and asked what the target number was.

The Chairperson stressed that when the CEO and MEC made mention of “challenges” they should compare these to what the normal situation would be. A clinic, in order to be accredited as such, had to have five nurses, one doctor and a certain number of cleaners. Cleanliness and attitude were important, but the ratios of human resources were also important, as well as other details around the fittings and equipment, such as how easily they were able to be cleaned. A standard had to be in place against which to measure. He commented that this information should have been presented up front, but he suggested that  it could be sent on.

Dr Selebano committed to sending the information the following day.

Dr Xundu asked for a more specific request from the Committee, in terms of how a central hospital should be run and managed. She was aware that, internationally, work was being done on development of norms and standards, as the DoH had given in a report. DoH was in discussion with National and Provincial Treasury around the equitable share allocation. She did not believe that it addressed issues of migration. The DoH was grossly under-funded. DoH was working on norms and standards, but could, in due course, present a plan for managing hospitals in Gauteng.

The Chairperson agreed that DoH needed to present this report, reiterating that challenges at Charlotte Maxeke Hospital had to be presented in the context of what the norms for other hospitals were. DoH should have had this information readily available if Parliament was to assist the DoH.

Turnaround strategy: Department of Health briefing
The Chairperson said that since the presentation on the Turnaround Strategy was long and detailed, Members should first be given time to read through the documentation.

Ms Ngcobo said not all the questions asked earlier had been responded to.

The Chairperson agreed that whilst specific responses were not always given, many had been covered in the answers outlining the bigger picture.

Ms Ngcobo said that she was particularly concerned that most of the provinces had problems with litigation, and asked how much the Department was spending on litigation.

Mr Papo responded that it was currently estimated at R1 billion. Sometimes the Department had to contest litigation brought against it, and DoH and the Office of the Premier were coordinating some of the matters. In some cases, the legal fees were almost equivalent to the claims, and that clearly did not make sense. Some cases were won, and others rejected when the Department did not send specialists. The Minister had indicated that a team would be put together at National level to assist provinces with their litigation. He noted that the Road Accident Fund amendments had a serious implication for the 2013/      14 budget and this had previously not had enough attention paid to it.

The Chairperson summarised that there were a number of issues on which more responses were needed. He pointed out that more people were learning about medical conditions and rights from the radio and media, and this was likely to increase the litigation against the DoH. He said that, although this was not directly the responsibility of the DoH, there were questions as to how the professionals were trained, and why some had failed to pick up on conditions. He asked if clinics and individuals were being monitored, and whether the South African Council of Nurses was training its graduates properly. He cited several instances picked up by the media of medical malpractice and negligence, and suggested that the DoH was not adducing sufficient specialist medical evidence. He agreed that where there were clear cases of negligence, people should be held responsible.

Dr Xundu agreed that good quality services were required and DoH and the Province were working hard to ensure that this happened. The DoH’s Legal Unit was managing the cases, although perhaps it was not hiring the best specialists in defence of its cases, although she herself always asked who had been consulted. The Legal Unit was advertising for legal specialists at the level of Deputy Directors General. Doctors had to be trained how to give evidence in court. The DoH had a responsibility to provide an environment conducive for provision of good quality health care services, after medical staff had been accredited by the Health Professions Council of South Africa. Equipment must be in place, junior doctors must be supervised and monitored and a comprehensive approach was required. .

Mining Health Issues: Chamber of Mines Presentation
Dr Thuthula Balfour-Kaipa, Medical Officer of Health, Chamber of Mines, noted, at the outset, that employment levels in the  mining industry were closely linked with how the economy was performing. The figures cited in this presentation showed the position in 2009, after the global economic depression. Currently the mining sector employed about 490 000 employees, with most working in the platinum sector, since the gold industry was in decline.

There were more than 1 000 mining companies in South Africa, but in 2009 the Chamber only represented about 48 of the big mines. The Chamber represented about 20% of mines, but 85% of employees. There were many more small companies, who often posed challenges in not meeting health and safety standards. The three largest gold companies accounted for 80% of employees, and this had significant implications around tuberculosis (TB).

Dr Balfour-Kaipa noted that the statistics around occupational diseases in the mining industry were collated by the Chief Inspector of Mines. The Department of Mineral Resources (DMR) produced statistics for health and safety. In 2009/10, the key health issue, showing the highest number of incidents, was occupational TB, followed by silicosis and Noise Induced Hearing Loss (NIHL). Although the claims in the latter had been reduced over time, there was a need for a radical shift in how to remove machinery that was emitting excessive noise.

In relation to silicosis, statistics  from 2004 to 2010 showed that most of the silicosis occurred in miners working with gold, and most platinum workers showing silicosis had also previously worked with gold bearing rock, which was the reason why the numbers of silicosis incidents were not declining despite the move in production to platinum. Silicosis depended on exposure over a length of time, so if a person was exposed for a long time the silicosis was cumulative.

Trends for TB from 2004 to 2010 showed stabilising and indications of decline.

It was decided that each company needed to assess and manage its risks for these diseases developing in its workers. The Mining Occupation Safety and Health (MOSH) Learning Hub was an industry initiative by the Chamber of Mines, and there was also a tripartite initiative of government, unions and employees. The Mine Health and Safety Council (MHSC) was established under the Mine Health and Safety Act (the Act), which governed health and safety. The MHSC was funded through levies from companies, and had tripartite representation. It produced guidelines and audit tools, and acted as a forum and secretariat for ensuring that at all times the tripartite partners would meet. In the last year, for instance, it had produced guidelines on noise and air pollution, and also had controls on dust. The audit tools included dust control, and were used for Ministerial audits and to track on programmes in companies.

The actual regulation and monitoring was done by the Department of Mineral Resources (DMR), in terms of the Act, which stipulated the duties of employers to review hazards, and risks, take occupational hygiene measurements and establish medical surveillance. Employers also had to submit regular reports of occupational diseases, and inspection of occupational health services. That was critical when it came to TB, because under the Act the employer was required to have a programme that tracked development of occupational diseases, especially TB.

DMR had been issuing a number of warnings in terms of the Act. Dr Balfour-Kaipa noted that a section 65 notice would warn companies of transgressions discovered during inspections, and a section 64 order would close the mine on the basis of medical concerns, which often happened while deaths were being investigated. Mine workers had to have a certificate of fitness annually, and when a person left the mine he had to have a certificate to show what the level of exposure was at that time, because it would highlight the potential future health problems, such as development of silicosis problems in twenty years time.

Dr Balfour-Kaipa outlined the industry milestones and set out the targets for 2013, which included ensuring that no people should suffer more than 10% hearing loss (the qualifier for compensation), and that machine noise levels above a certain decibel rating would be excluded. 95% of all exposure measurements should be below the Occupation Exposure Level (OEL) for silica and in 2013 there was a target that no new cases of silicosis should occur amongst previously unexposed individuals. It was noted that the risks for TB for migrants not living with their spouses were twice as high as those living with their partners, and the risk of miners developing TB was three times as high as the average in other sectors of the population in South Africa.

It was noted that the MHSC organised two annual summits on Health and Safety. There were new commitments for health. The MHSC would be re-examining the return of miners with HIV/AIDs, TB and Silicosis, into a risk-work environment. It would be investigating the policy and regulatory framework to reduce the silica OEL in line with international benchmarks. DMR must, in future, verify dust measurements reported by companies.

Dr Balfour-Kaipa noted that the MOSH Learning Hub had been identifying good practices but to date these were not effectively shared, and this would be addressed. New commitments made by the Tripartite Summit had included the setting up of a referral system to ensure access to continued treatment, after employment. There was already progress in that regard, with many companies using the main recruitment agency to keep track of former employees, even in neighbouring countries, and ensure that their medical records were forwarded on. A national repository of health information was being set up. Renewals and new mining licence applications would include criteria around strategic and operational plans for TB, HIV and AIDS. Access to health services would be promoted for families of miners and the surrounding communities. The Chamber of Mines itself had a TB Task Team, TB Reviews and a TB Interest Group. The TB Review tool had been developed by the MHSC, and identified areas of weakness and strength in the TB programmes. External reviews had been done for the gold sector in 2011, and would be done on the platinum sector this year.

Dr Balfour-Kaipa said that there were fairly complex procedures around compensation for occupational diseases. The Compensation for Occupational Injuries and Diseases Act (COIDA) was administered by the Department of Labour, and the Occupational Diseases and Mine Workers Act (ODMWA) by the Department of Health. COIDA covered all employees in the country, including mineworkers, in terms of general injuries, but if mineworkers suffered heart or lung diseases, those fell under ODMWA. COIDA, administered by Rand Mutual and other companies, on behalf of the Compensation Commissioner, assessed risks and premiums charged to employers would rise with increased claims. Workmens’ Compensation claim forms would be completed by the employer and submitted to the Commissioner, for compensation of medical claims. ODMWA, on the other hand, was not originally structured to function as a full compensation system, and there were challenges around DoH having to provide set services, given its priority now on HIV and TB. The Constitutional Court ruling on ODMWA, in the case of Mankayi versus AngloGold Ashanti, was significant because it had decided that, given the paltry compensation under this Act, an employee should not be precluded also from lodging a claim against the mining employer, in the case where fault was established.

The main difference between the two pieces of legislation lay in the benefits provided. Under ODMWA, lump-sum compensation only was awarded, but no pension. COIDA allowed for a pension. The benefits were outlined (see attached presentation) and it was emphasised that under ODMWA, in respect of TB, a miner would be entitled to 75% of earnings for six months, and then a lifelong right to free medical treatment. Under COIDA death benefits could be paid to dependents, if the death was due to work injury or occupations disease, but this was limited to ODMWA and dependent on a post-mortem.

There were administrative challenges with ODMWA, with short term inefficiencies leading to non-payment of competent claims, whilst the claims process itself was burdensome. Very few mineworkers, even if they did qualify for compensation, actually received it, as many would have died by the time the claim was dealt with.   The last inflation adjustment under ODMWA was made about three years ago, and there was no indemnity for employers. Over the medium term, there would be inadequate funding under ODMWA, as the liabilities were accumulating and there were problems with data which made the deficit quantum uncertain. The Ex-Mineworker Project recognised the challenges in the compensation, and tried to resolve them, by improving access of miners through joint efforts between the Department of Health, National Union of Mineworkers and the Chamber of Mines. R42 million funding was set aside over six years. from 2007, to support health examinations through a fund, and to improve the administrative bodies’ functionality. A socio-economic development component was also built in.

The Eastern Cape had the highest number of ex miners in the country, yet had the poorest services for benefit examinations. Benefit examination sites were set up or strengthened in Nongoma, Mthatha, Butterworth, North West and the Free State. KwaZulu-Natal took over the project and showed good leadership. However, the progress was slow, because it was dependent on provincial departments of health and there were still blockages in systems at the Compensation offices. Given the dire financial straits of ex-mineworkers, the situation was untenable and an urgent review of the compensation systems was required. It was suggested that a ‘no fault’ functioning compensation system must be restored.

Firm proposals were not being made at this point, however, because of the political issues around compensation. In 1999, Cabinet had resolved to integrate the Occupational Health and the Compensation systems, but although some proposals were made, it was dropped in 2008. Since then, there had not been much further dialogue. The Chamber of Mines would like the Committee’s support to take the matter further.  

Discussion
The Chairperson thanked Dr Balfour-Kaipa for the presentation, and said that it would have been useful to have heard this during the previous session when compensation was debated. There were concerns about the lack of coordination in the systems, and whilst it appeared that compensation funding was available, the haphazard processes had to be corrected. He emphasised that it was important to bring down dust levels that were causing TB and silicosis, and that departments must work together.  

Ms Kenye appreciated the presentation, but expressed concerns about the numbers of professional emigrating, and what was being done about preventative health.

Dr Balfour-Kaipa responded that the Chamber of Mines was concerned with preventive health, as the DoH would essentially become involved once a person left the mine. Strong programmes were supposed to be provided by all mines, with audiovisual presentations for those who had literacy difficulties. The main problem was that a person might appear healthy on leaving the mine, but the problems would manifest themselves years later, which was why continuing education and contact was important. There were cultural objections to holding post-mortem examinations, but relatives must also be informed.

Ms Kenye asked how information was disseminated to miners.

Dr Balfour-Kaipa said there was a gap in dissemination, once the miners left the company.

Ms Kenye asked whether Occupational Health Officers were employed to interact with the mineworkers.

Dr Balfour-Kaipa responded that the Act required all mines to have a medical practitioner and a hygienist, the latter being a person with some environmental knowledge of ventilation and exposure to dust. DMR had medical and occupational hygiene inspectors of its own, but the assessments gave poor results at the moment.

Ms Kenye noted the need for an effective compensation system, and was concerned about the issue of post mortems.

Dr Balfour-Kaipa responded that the DOH had documents and guidelines that were sent to the clinics but she conceded that some clinics may struggle to lay their hands on that information in order to then educate the relatives.

Ms Kenye asked whether there was follow up for those ex-miners who only showed symptoms years after returning home.

Dr Balfour-Kaipa responded that ODMWA required that benefit examinations be provided by the DoH, free of charge, but the ex-mineworker needed to present himself to the relevant facility to get that examination. The problem was that, although ODMWA was a national piece of legislation, the medical examinations were, at the moment, only conducted in Johannesburg, with no regional offices.

Ms Kenye also asked how the immediate families were contacted.

The Chairperson commented that somebody had to inform ex-miners and their families about the possibility of compensation. Lack of information was the responsibility of DoH, particularly in the provinces that had a large number of ex-mineworkers.

Ms Dube remarked that the tragedy at Marikana opened the eyes of South Africa to the great disparity between mining houses and miners. She asked what links there were between the various departments and the Chamber of Mines.

Dr Balfour-Kaipa responded that the Chamber of Mines had a working relationship with DoH, particularly with strong interaction on TB. In ODMWA and the Tripartite Summit, an advisory committee advised the Commission, the DoH and the unions, but the Commission tended to fluctuate in what it was doing. The Chamber of Mines would be meeting with DoH to hear how it saw challenges around compensation.

Ms Dube thought the mines were now using water to control the dust, so that miners were working in wet conditions.

Dr Balfour-Kaipa clarified that the MHSC was doing research on dust control, and this should be followed up.

Ms Dube also noted that more people seemed to be aware of their right to compensation. She asked how the labour situation was monitored, asking whether the unions were looking after concerns of individuals and MHSC were attending to monitoring of conditions.

Dr responded NUM was the strongest union and was adamant that no decisions on matters affecting miners should be taken without involving it. Most committees and forums in the mining sector functioned quite well and the unions were involved in investigations into fatalities.

The Chairperson said that this was one sector in which work was needed to reduce the gap between the rich and poor. The mining industry was the biggest money-makers in the country, but had been using cheap labour without giving adequate compensation. Part of the health problems may be related not only to wet conditions, but also pressures of being so deep in the mines, and that was one factor that had to be further investigated.

Ms Segale-Diswai referred to the Tripartite as government, the unions and the employer, and wondered whether new unions were included.

Dr Balfour-Kaipa responded that anyone having health and safety issues would be included, although one union would tend to be involved in the bargaining processes.

Ms Segale-Diswai stressed that the mining industry also had an obligation to educate people about the occupational diseases, and the tendency to dismiss those who were sick and therefore no longer productive, must be addressed. She also commented on the high cost of TB drugs and said that the mines seemed to obtain these from the DoH, which was already under-resourced.

Dr Balfour-Kaipa responded that the drugs were indeed provided for the miners by the State, because TB was a public health concern, over which the DoH had to exercise control. The private sector did not feature much in TB control. The cost of the drugs was not that high, especially in comparison to the cost of other medication, and whether the mines obtaining this from DoH was putting a drain on the public purse could be investigated, but it must also be weighed up against the fact that for the miners to obtain them from private sources would be considerably more expensive.

Ms Segale-Diswai referred to the relationship between the mines and the DoH, saying that there seemed to be discrepancies in statistics for TB, cure rate and defaulters. Because people were registered electronically on the mine register, there would not always be communication if they were dismissed. She wondered if the Chamber of Mines attended to any issues around conditions of contract.

Dr Balfour-Kaipa responded that the Chamber of Mines had suggested that, in order to protect employer and employee, a service level agreement should be signed, outlining everything, including terms and conditions around pay and treatment. However, where companies used their own resources to hire staff, different figures were sometimes set. There were complexities around using outside contractors. However, the Chamber of Mines had a good relationship with the National Department of Health, as well as provincial and district levels, and suggestions were made by Gauteng on better coordination. The State was also very strong on TB control, and this knowledge was passed on to the Chamber of Mines.

The Chairperson clarified that the main concerns were with health issues after miners left the mines.

Ms Kopane noted the Tripartite Summit commitment that there must be a referral system to ensure access to continued treatment beyond employment, and asked if the Chamber of Mines would follow up with the employment agencies to show how effectively the problems were being addressed.

Dr Balfour-Kaipa responded that it was mostly two of the gold-mining companies who used the agency and they were happy with the work being done.

Ms Kopane was also concerned about the commitment to ensure that there be pre-conditions around TB, HIV and AIDS plans for renewals and new mining licences. She asked if there were penalties for non-compliance.

Dr Balfour-Kaipa responded that the Mining Charter did not have clear penalties around licensing, and it was the DMR who was considering how it would effect and implement the conditions. The Chamber of Mines could present an update, in the next year, on this.

Mr Lekgetho was also interested in the New Tripartite Summit commitments and asked whether the Committee could get more documentation on that.

Dr Balfour-Kaipa responded that the strategic plans and those documents were available on the website and Chamber reports were also available on the Chamber’s website.

The Chairperson said the key was for Members of Parliament to look more closely at the system of compensation and whether it was acceptable that some diseases be compensated under one system, with others falling under another. It was agreed that the Commissioner and Chamber should attend the next presentation together.

The meeting was adjourned.