Limpopo Department of Health: Hospital Revitalization Grant Progress Report; State of Readiness for Implementing Norms and Standards

Meeting report

Ms B Ngcobo (ANC) was elected as Acting Chairperson as Mr B Goqwana was in Tanzania representing Parliament. She noted the Committee was unhappy because Limpopo had sent its report late. She said that some Committees turn away delegations for doing that but that this Committee would not do that today. 

After Mr Norman Mabasa, Limpopo MEC of Health and Social Development, had introduced his delegation, the Acting Chairperson said she was a little surprised that they had not brought their Chief Financial Officer.

Ms Daisy Mafubelu, Head of the Health Department in Limpopo, said that the CFO was on suspension for allegations of misconduct. She said that they have two presentations to make, one on hospital revitalisation and one on the norms and standards.

Limpopo Hospital Revitalisation
Ms Daisy Mafubelu stated that the Budget was R301, 901 million and they had spent R127, 070 as of 31 August  2012, which was 42,2% of the budget. She broke down the expenditure into components consisting of infrastructure development, health technology, organisation development, quality improvement and project management office. All of these components were spending less then what they were supposed to except for infrastructure development. She believed that by the end of the financial year they would break even and that the grant would not go under spent. Ms Mafubelu then looked at the individual hospitals and how the budget had been spent on these facilities around the province. The previous year there had been cash flow problems with the Department and they were not able to process some of the payments but now the cash flow problems had been resolved. She went on to describe the ongoing projects in the province at present. These projects included 33 under construction; nine on retention and two were in the preplanning stage.

Ms Mafubelu said that challenges included slow performance by contractors, cash flow constraints, poor and insufficient monitoring of projects by implementing agents and a shortage of personnel. However they did have planned interventions for these challenges that included: fast track filling of vacant posts using the DoRA funding (posts advertised and appointments targeted for November 2012), ensuring that conditional grants were available for their intended purpose and a review of service level agreement with implementing agents to strengthen monitoring of projects. Ms Mafubelu continued with a detailed account of the projects going on at individual facilities in the province (see document).

Limpopo Norms and Standards
The presentation  looked at purpose, approach, number of facilities assessed, a sample graph of the facilities, an overview of sampled facilities, challenges and ensuing strategic interventions taken; level of readiness by the Limpopo Department of Health in complying with the prescribed norms and standards to ensure that the province was ready.

Ms Mafebulu stated that they had conducted a self-assessment and had had external training on baseline assessment and quality improvement projects. They also had a facility audit follow-up by facility improvement teams in Vhembe. Between 2010-2012, they had assessed 40 hospitals, 13 community health centres and 190 clinics. She described the facilities visited by both the Office of Health Standards Compliance and its Provincial M&E unit. They had readiness inspections planned for October in the Vhembe district to be conducted by the National Health department and the Provincial M&E. The seven core standards used in these assessments were: patient rights, patient safety and clinical governance and care, clinical support services, public health, leadership and corporate governance, operational management, and facilities and infrastructure. She presented a graph showing a sample of four facilities and their scoring in the assessments. The graph included Mankweng, Seshego, and Warmbath Hospitals, and also Warmbath Clinic. The facilities scored from 22% to 75% on each of the different criteria while Warmbath clinic consistently scored the best amongst the four. Ms Mafubelu said it had been an eye-opening experience looking at these assessments.

Ms Mafubelu described the baseline assessments of three specific hospitals: Jane Furse, Letaba and Mankweng. She explained that the graphs showed an acceptable percentage for each individual category was 40% but the province wanted to get the categories to 80%. None of the hospitals met the 80% mark in any of the criteria yet Letaba Hospital scored under 40% in three categories: Leadership and Corporate Governance, Patient Safety/Clinical Governance/Clinical Care and Patient’s Rights. She explained the scoring and summary for compliance. Vital categories required 90%, essential 80% and developmental 60%. After they had looked at the 243 facilities, they had come up with a list of priority areas, what the challenges were there and how they could be fixed. Ms Mafubelu explained the list of priority areas. Positive and caring attitude was hindered by a shortage of staff, which had resulted in a burnout so they had put in place a program of continual recruitment and retention of staff, a programme that they have intensified recently. The equipment (in particularly the X-ray machines) were not working which frustrated the workers and affected their attitude. They had begun an audit of all of their equipment.

Ms Mafubelu said that there needed to be a reduction in waiting time but there was a shortage of health professionals and too few consultation rooms To fix this, the department was implementing a retention strategy, and by introducing “fast lanes” to some facilities. They would continue their revitalisation. They also had problems with drug availability, which was because of an inability to deliver the required stock by suppliers and a shortage of pharmacy personnel. Much of this had to do with their inability to pay towards the end of the year. There needed to be improved cleanliness because there had been a shortage of cleaners. The improved patient safety category performed poorly because there was inadequate security at their facilities and a lack of infection control because of a shortage of infection control personnel and dilapidated infrastructure. The last few pages of the presentation showed how the criteria were sub grouped into more specific criteria.

Discussion
Mr D Kganare (COPE) commented that the presenter said that balances in red indicated over spending and for Jane Furse hospital almost everything was red, which was very confusing because of the categories. On the first slide on the revitalization, they put a budget of R301, 000,000 but he would have preferred a total budget. Under expenditure this year was only 11% for organizational development and 18% for quality improvement. Why had so little been spent and why was the Department’s reason for this a lack of a dedicated officer? He commented on expenditure per institution – there was a big problem and it was discouraging how little of the budget was spent. The presentation did not give a good picture of the reasons for this underspending including the reason: “Non payment of contractors from December 2011 to April 2012”. This was confusing as it made it sound as if the project was only from 2011 to 2012. He asked when the project started and how far behind they were on all the projects. He noted the challenges and asked how slow the contractors were and how much money had the government received in penalties from these poor performing contractors. In terms of service delivery, how much damage had been caused by this slow performance? He asked when it became apparent that their monitors were not performing properly and what had they done about it.

Mr G Lekgetho (ANC) thanked the presenters for their presentation and said it was quite informative. He asked how many vacant posts they had in the department. He noted they said that these posts would be filled by November 2012 so he asked if they could inform the Committee if those posts had been filled. The presentation spoke of unfilled PMO positions, what did this acronym mean? He asked in terms of recruitment and training, why in Limpopo at colleges, the government was at peace with the bursary system debate. He asked which of the two systems they were using to recruit and train their staff.

Ms M Dube (ANC) thanked the presenters but said receiving the document late was really a disadvantage. She asked what exactly the phrase “lack of dedicated officials” meant. She was curious about how long these posts had been vacant. In terms of non-payment of contractors, who was not paying because the presentation did not state the reasons? She enquired about the facility in Nkhensani that started with a budget of R1, 500,000 but had an expenditure of R3,137,000 – where had they got this extra money? She asked about the insufficient monitoring and the renewal of a service level agreement. She asked if there were penalties for the slow performance of contractors.

Ms M Segale-Diswai (ANC) emphasised the need for the documents prior to the Committee sitting. She knew Public Works was one of the monitoring agencies but asked what the other ones were. She had expected them to bring Public Works with them and asked what the relationship between Public Works and the Department of Health was like. She asked what the consequences of late payments were. There were a lot of problems with revitalization in Limpopo. They gave a starting date and an ending date but not an actual date of completion. They saw the balances as positives but she had no idea if that was true because they did not know how much the final project would cost. On one of the pages it showed that an entire building was completed and occupied except for a linen store so she asked how an occupied building dealt with linen if there was no linen store. It was worrying that they only talked about start dates of projects and not completion dates. What would happen to these facilities that were continually below standard? In terms of recruitment, she asked what strategy they had to combat this. She understood that Limpopo was rural so it was hard to recruit people. Limpopo was under administration because of over-expenditure and unauthorized expenditure. She asked what was the current status of the Department. What were they doing so that after she left this room she could say something positive about Limpopo.

Ms Robinson said that the report was very revealing and that she was grateful for the new bill on norms and standards because it would give something to work by and to hold them to. She agreed with her colleagues that the situation in Limpopo was dire. The Committee needed the assistance of the Limpopo Department of Health because people’s lives were at risk. The underspending was of major concern and asked the details of the CFO’s suspension and if the underspending was a result of his mismanagement. She asked what the cash flow problems were. She enquired about how the contractors were appointed. She reiterated the importance of qualified managers and monitors. One thing that she was surprised about was the shortage of cleaners because it was a relatively low skilled job and with the unemployment in the country, she could not understand how they had too few cleaners.

Ms Robinson said that because they had not received the report early enough that she had to do some digging so she had a few questions about what she found. She found a hospital that had had laundry facilities not functioning for three years and she would like to know the details about that. There were places with not enough food and supplies so no wonder the staff was unmotivated. She heard that there was an informal enragement with Mpumalanga where they share supplies with Limpopo, she asked how they reconcile this arrangement with the funding. She was curious if this just happened during emergencies or was this was an ongoing process. She exclaimed that there was a surgical warehouse in Polokwane that was taking over from a private supplier and it was now not functioning. She finished off by saying that the Head of Department had spoken about the X-ray machines not working, but she had heard that the people who took care of them were unlicensed which was unacceptable.

Ms T Kenye (ANC) asked what their strategy was for retaining workers. She asked if they had quality assurance. She asked if there were even enough consulting rooms where they had already completed revitalization. Looking at the issue of the National Health Insurance, she asked if the pilot was completed or still under construction. She asked more about the construction delays and what made them delayed.

Ms R Motsepe (ANC) said she was worried when it came to unfilled vacancy posts. She wanted to know what the percentages of facilities were that were compliant with the National Norms and Standards.

The Acting Chairperson said that they should be fair to the Department because it was the province that decided that health and social development were joined together. However, the Department was very “economical” with their presentation. It did not tell the Committee what the percentage of each project was in terms of completion. It would help them to see how far the construction had gone. She asked if there was a way of recouping funds from a contractor that went too slowly. The report seemed as if it was prepared in a hurry. The Committee was not there to persecute them but to help them and establish if service delivery was occurring. They had visited Limpopo and were impressed by some of the things that they had seen there. She asked if all of these concurrent projects were too overwhelming for the province to manage. Lastly when advertising for jobs, she hoped they made sure to show people that they were building all of these new living facilities for staff.

Response
Ms Mafubelu thanked the Chairperson and the Committee for their questions. She first wanted to apologise for not sending the reports on time. She promised that in the future they would be on time and that she understood how it could help the Committee and the Department. She explained that the red coloured numbers were a mistake and that they were supposed to be black. She hoped that they could return to the Committee so that they could provide an updated report including a multi-year budget. She apologised again for the hurry that the presentation was done in because she felt that some of the proper insight that could have been there was not.

She wanted to clarify that in terms of organizational development that when they said a “lack of a dedicated officials” it meant that they did not have someone who made themselves in charge of that part of the Department. In terms of the contractors, some of them had performed slowly because of their own problems in which case they were given penalties. Other contractors performed slowly because of the Department. The National Director and Limpopo decided to take funding from infrastructure so that they would not have over-expenditure in terms of paying their employees and staff. The contractors were Construction Industry Development Board (CIDB) approved. However some of them were subcontracting their work, if they were doing multiple projects, to sub-contractors that did not have a CIDB rating.

She went on to explain that Public Works (DPW) was one of the implementing agencies but so was the Independent Development Trust (IDT), and the Department of Water Affairs. They found in the last financial year that DPW was not performing well. The Department of Water Affairs had spent none of their R10 million budget because they delayed in awarding tenders. There had been meetings between the MEC of Public Works and of Health but if things did not improve they would have to look at other implementing agencies. They had not had a Service Level Agreement with Public Works but now they did so. This would go a long way in addressing some of the issues because it explained what was expected from each side. One of the major things in the agreement was that the Department of Health would take part in the awarding of tenders with Public Works.

Ms Mafubelu said that the vacant posts referred to in their document were 11 vacant posts. They hoped and prayed that they could find engineers that would want to come and help. They had a real problem with finding someone who was an expert in infrastructure and project management. They had finalized their recruitment and retention strategy and had revised it. They had to implement it. She explained that bursaries were part of the new strategy so that students would work for them after they completed their studies. The biggest challenge in this strategy was actually filling the posts because they had no money to hire doctors or nurses. They were told that they had to reduce their staff so this would affect the recruitment and retention strategy. A task team was formed to look at students and they had recommended that all students be put on bursaries with books, stipend and uniforms She thought that this would help the Department but there were negative effects if they dropped out.

In order to deal with the over expenditure in Nkhensani, they would have to rely on the rollover funds. She thought there was a little confusion over the page that dealt with the balances of the projects. In hindsight she should have provided the percentage of completion of each individual project and in the future she would do that. She explained that in terms of the norms and standards, they had a long way to go, although some of their institutions were doing better than others. She hoped by the time the NHI was rolled out that Limpopo could participate because they had met all the norms and standards. Being put under administrative control had helped a lot because they had the opportunity to work with their colleagues in national government, especially in financial, asset management and information technology.

She explained that they had not had any unauthorized expenditure in the 2011/2012 financial year, which she saw as a positive. They did not register any over expenditure. The CFO was suspended in mid July due to reasons of financial mismanagement and not ensuring that things were being completed properly. She could not say for sure how much money he was being charged with mismanaging. The cash flow problems occurred because they had an allotted budget but the money was not actually given to them. The laundry matter had been fixed using the capital works budget. An audit on machines would focus on non-medical machines such as washing machines and kitchen equipment which were critical.

In terms of the pharmaceutical depot, it was taken over by the Department at the beginning of the year but she believed that there had been an underestimation of the difficulty of taking it over because the private service provider took all of their employees with them. The department started to employ contract workers, some of whom had worked at the depot before. They had now started advertising for full time positions at the depot. The depot was turning around. There had been an upward trend since May and it was functioning at 66% and it hope to be eventually at the required 95%. They had now started to have accredited companies take care of the X-ray machines and there would be action taken against those responsible for hiring non-accredited service providers.

The Acting Chairperson interrupted to say that they were out of time and asked Ms Mafubelu to send the remaining answers to the questions by 21 September and asked the MEC for his final remarks.

Mr Mabasa thanked the Chairperson and Committee. He then said that if they wanted to understand the problems with Limpopo, they had to understand that they only had R3.7 billion to do everything and they did not have enough money for employing doctors. He highlighted that they had a 70% vacancy rate for doctors. In terms of cleaning staff, when the aging cleaning staff retired, he had to use that money to employ professionals so now they had dirty hospitals as a result. He explained that the budget contradicted itself. He pointed out that they only had 1% of specialists in the entire country and that they needed R150 million per month for medication yet they only received R500 million for the entire year. With these kinds of problems he needed more then just help. Speaking about ambulances, the fleet had gone far beyond the time it was supposed to last. He had had asked for R100 million for three consecutive years for new ambulances for the districts. In explaining from where they had come and where they were now, he had been meeting with hospital boards from each hospital personally and they would fill pages with complaints about lacking basic necessities. Now they were not complaining about lacking basic necessities because they had them. He had received a call from a colleague who works in Gauteng as a cardiologist who told him that Gauteng now admired Limpopo because Gauteng was so bad. On a budget of R3,7 billion with a population of 5,6 million plus the countless number of people coming in from other countries, he concluded that Limpopo was surviving on a shoestring but that they were still breathing.

The Acting Chairperson said that they would lobby the Chairperson to invite Limpopo back in the near future and thanked them very much for the presentation.