Hospital Revitalisation & National Norms & Standards: Western and Eastern Cape DOH; Smoking & Breast Milk Substitutes Regulations

Meeting report

Western Cape Department of Health hospital revitalization plan & Norms and Standards readiness
Mr Theuns Botha, Western Cape Minister of Health, said that most of the Hospital Revitalization projects were going well. They were built quickly and under budget. The Department had been trying to take a ‘patient first’ approach, thus looking at the system through the eyes of the patient and understanding that it was “unacceptable to treat the poor poorly.” There was a 4% vacancy rate for positions in the Western Cape and an over production of nurses. The interaction between patient and staff member was the most crucial part of this. The Western Cape may have the best technology but there was still a need for better patient-staff interaction and as a result of this an sms system had been set up to deal with patient complaints.

Ms Louise Rademan, Hospital Revitalization Programme Monitor: Western Cape Department of Health, went over all of the Hospital Revitalization projects occurring and finished in the Western Cape. She highlighted the construction of the new state of the art Khayelitsha Hospital which was constructed in only two years and was built under budget.

Mr Rademan continued by discussing the challenges of each of the hospitals. This included delays in getting approval from the Department of Health, a fire at the Mitchell’s Plain Hospital and problems with contractors. She continued with a slideshow of photos of the new and revitalized hospitals.

Dr Tracey Naledi, Director of Health Impact Assessment: Western Cape Department of Health, presented on the National Core Standards (NCS). The priority areas were: availability of medicines and supplies, cleanliness, improved patient safety, infection prevention and control, positive and caring attitudes, and waiting times. She compared the performance of hospitals in the province with that of public health centres. In every category besides staff attitude, the hospitals did significantly better in compliance. She explained that some of the reasons for this included a longer history of quality assurance for hospitals and a limited amount of quality assurance officers to cover the public health centres.

Dr Naledi spoke about the future plan of action for compliance. This included quality improvement training for all quality assurance managers, the development of quality improvement plans, provincial quality improvement committee, district and facility quality committees, and a patient centred quality of care. She noted that NCS baseline audits were done for all fixed facilities. There was a very low non-compliance rate as vital measures were in place. There were very high numeric scores especially for the hospitals which meant that most measures were in place. The Department had a plan that was based on the Health Care 2020 principle of patient-centred quality of care.

Mr Botha concluded the Department’s presentation by inviting the Committee to visit the new Khayelitsha Hospital.

Discussion
The Chairperson thanked the Committee for their informative presentation and opened the floor for questions.

Ms M Dube (ANC) said that she was upset that the MEC had been referred to as a Minister and that there was only one Health Minister in South Africa and that was the National Minister of Health.

The Chairperson explained that there were different terms and titles for different positions and in different provinces so he asked the Committee to leave the issue.

Ms Dube said that she was not happy but that she would leave the issue.

Ms B Ngcobo (ANC) asked about the state of facilities when comparing new facilities to the old facilities that were revitalized. She commented that the presentation was very economical in format and did not present the committee with percentages on how complete the projects were. The overspending was also of concern to her and she asked what the maintenance plan was for their technology. She noted that there was only one psychiatric facility under revitalization and asked if there were any more in the province. The Committee should visit as many hospitals in the Western Cape as possible.

Ms M Segale-Diswai (ANC) thanked them for the presentation, yet it was difficult to understand. She asked what retention meant and was curious to learn more about the overproduction of nurses and the vacancy posts. The sms pilot programme seemed interesting but what did people do who did not have access to a cell phone. The public health centres were of a concern to her and that they needed help.

Ms Dube asked about the completion dates and over expenditure and from where the extra money was coming.

Mr D Kganare (Cope) stated clauses from the Constitution that prohibited the MEC from being called a minister.

The Chairperson said to leave the issue. He explained that he did not like fighting and repeated that the issue over the MEC versus Minister title should be left alone.

Ms Dube said that they were not meant to be there to fight but to ask and get answers to their questions.

Mr Kganare said that he was happy about the legal action taken against contractors. He asked why there were so many TB hospitals in the Western Cape.

Ms R Motsepe (ANC) asked if she could see before and after photos of the facilities.

Ms D Robinson (DA) started off by saying that the Western Cape had their own constitution and their own ministers.

The Chairperson again said to leave the topic.

Ms T Kenye (ANC) exclaimed that this was ridiculous and there was only one Minister of Health

The Chairperson asked for order and said to stop it and leave the point.

Ms Kenye stated that the presentation was too pictorial and brief. She expressed her immense concern about the state of primary care centres around the province.

Ms P Kopane (DA) asked about the maintenance of the medical equipment and if it was done internally through the Department or outsourced.

Mr Theuns Botha said he respected the Chairperson’s ruling about the discussion of his title. He explained that there was no rule when it came to replacing or rebuilding infrastructure, it depended on the situation and that sometimes revitalization was not wise. Overspending depended on the execution of funds. Maintenance was an issue all over the country. It would cost R800 million to pay out the maintenance backlog. He noted that there were other psychiatric wards. They were determined to change staff attitudes. He believed they had done enough with public health centres. The Western Cape’s system was light years ahead of the rest of the provinces according to the National Minister. They had a contractual obligation to hire nurses. They had 30 000 employees but 34 000 would be ideal. They had offered other provinces their nurses as long as they pay their bursaries. They were trying to decentralize the dispersion of medicine which could save waiting time by up to 40%. He went on to address the question of overspending explaining that if they were overspending then they would be breaking the law and the Western Cape did not break the law.

Mr Botha continued to answer questions. There were three stand-alone laundries in the Western Cape. He explained that there were so many TB hospitals in the Cape because unfortunately the Western Cape had the highest levels of TB in the country. To his knowledge, it also had the highest percentage cure rate in the world at 81%. They had done this self-assessment so that they could get the real facts and figures. He wanted to clarify that the Western Cape did not have the best equipment but it did have very good equipment. Some maintenance of the equipment was outsourced and some of the equipment came with a service contract but regardless, all of the servicing was on time. Mr Botha asked the Chairperson if he could have the opportunity to address the Committee about the Western Cape constitution.

The Chairperson said that they would do that later.

Mr Kganare said that he did not like fighting but he wanted things to be done properly and that the MEC only addressed Ms Robinson and Ms Kopane as Honourable Members and the rest of the Committee as ladies and gentlemen.

The Chairperson said that he wanted to organise a date for the Western Cape to come back or that the Committee go and visit them. He went on to explain that the reasons for those laws was to better South Africa. He did not like to fight but, if he had to, he would be ready for i. However, when there was fighting, service delivery suffered. It was not about who was who, its about providing service delivery to the people and even if you were my enemy, if you were doing something good, it was good. If you were my friend and doing something bad, it was bad. He said that there would be tea now but he would allow the MEC to discuss what he wanted to say to the Committee. They should quickly discuss this so that they could get over it and not forget their focus. While addressing Mr Kganare, he explained that the clauses of the Constitution only explained the functions of the MEC – and not how they should be named.

Mr Botha said that he was extremely disappointed that they used up time for health on non core issues.

The Chairperson asked the MEC to turn of his microphone.

Mr Botha explained that when education failed, one had a child that was uneducated, when there was a failure in health, one had a funeral. He said that in his government, it did not matter if they called Helen, Helen or Premier. It was important what they achieved not what their status was or the type of car they drove. He said that the Committee could call him anything, MEC, Provincial Minister, Pete; it did not matter to him as long as they judged him on his work – but that he must explain the difference between MEC and Provincial Minister. In 1996 Kwazulu Natal and the Western Cape drafted their own provincial constitutions, which was allowed under the national Constitution. These constitutions were approved by all parties of the province and were ratified by the Constitutional Court. In terms of the Western Cape’s constitution, they had a provincial government and not a provincial administration. So whether the Committee or himself liked it or not, it was the law. They had a Provincial Cabinet and not an Executive Council. The Committee could call him anything but he was not a Member of an Executive Council but a Member of a Provincial Cabinet whether he liked it or not. According to the Western Cape constitution, he was a provincial minister. And often he got to meetings like this when his party was in the minority, and he was humiliated by this issue. He just wished the majority would judge him on his work. They were busy altering the Western Cape constitution and all parties would have the opportunity to provide their input. He apologised for calling Ms Robinson and Ms Kopane by their surnames but he happened to know their surnames because he knows them and he happened to know the Chairperson’s last name and apologised if the Committee was offended by calling them ladies and gentleman. He said that the Chairperson had used the words ‘enemy’ and ‘fighting’, and that he had a huge problem with both those words. Mr Botha said that he would not fight against a South African but with a South African because they were all countrymen. The opposition was certainly not his enemy but his opponents, he respected and loved them as fellow countrymen.

The Chairperson thanked the MEC.

Ms Dube went on to say that in Parliament he was a MEC and not a Minister.

Mr Kganare said that it was a constitutional issue.

Ms C Dudley (ACDP) interrupted asking the Chairperson if they could move on because he had made a ruling and said they were out of time, but now they were going off on a tangent.

The Chairperson thanked the Western Cape again and told them to go well.

Eastern Cape Department of Health hospital revitalization plan & Norms and Standards readiness
Mr Sicelo Gqobana, MEC of Health: Eastern Cape, said that if the ‘norms and standards bill’ that is, the National Health Amendment Bill [B24-2011] was passed now that they would have to shut down. They were currently revitalizing the very dilapidated Eastern Cape infrastructure. The Superintendent General would go over the specific challenges facing the province. The Eastern Cape’s budget was very little and that they needed to ensure that they could pay the doctors and nurses that they recruited. They needed to ensure that the places where they work were improved. They were making progress but the lack of funding was a huge obstacle.

Mr Siva Pillay, Superintendent General of Health in the Eastern Cape, apologised to the Committee for writing on the presentation “Standing Committee” instead of Portfolio Committee. He explained that he wanted to show the Committee where they were in terms of revitalization preparedness but they also wanted to express some of their concerns with the new ‘norms and standards bill’. The only budget that the department had for infrastructure were the conditional grants. They went through a period of if they did not spend their budget, they would lose it and their budget was now one third of the budgets of other provinces. If there was going to be national norms and standards, there should be a standard budget for all the provinces. He explained that they had had problems with expenditure but they were catching up. They had had labour disputes with their revitalization but they had resolved that now. The Department was very concerned about the Bill because of their budget. They had huge backlogs but they did not have the money to fix them. There were hospitals that were found unfit for human living but they had no budget to resolve this. They had problems because they would build something and they had no budget for maintaining it. Most of the Eastern Capes medical buildings were not structurally sound, six institutions had been condemned yet they still had to use them because there were no other facilities. There were 17 clinics without piped water, 16% of institutions did not even have a telephone, and 68% of their hospitals did not have essential equipment. They had trained nurses but they could not employ them because they had insufficient funds. They would need an additional R9 billion to fill the vacant clinical posts.

He had heard one of the Members state that Primary Health Care was close to her heart. However, it was an irrational way of doing things because they had over 800 clinics and 60 hospitals, and in order to maintain all of them, they would need over R1 billion but they only got a fraction of that. Their hospital revitalisation budget could only be used for hospitals and not clinics. They had problems with traditional leaders because many times they owned the land and had the ability to tell them to stop building.

When the department overspent, the Treasury stopped the payments so they were unable to pay their contractors and had to go to court, which took two to three years. This created budgeting problems because it forced them to catch up. Rollovers and grants were only allocated in October, so how could the department finish their money by the end of the financial year. There was a confusion between how the infrastructure budget must be used the relationship with Public Works. The Department of Public Works signed the contract with the contractors yet the Department of Health was responsible so there was the question: who was responsible when it came to management and litigation? He explained that the situation was not all dull and gloomy because they were finally appropriating and spending their budget properly. During the World Cup that they had shown the capacity to do things because they had completed hospital wards in nine weeks.

He explained that they wanted to build an in house maintenance team to help keep the facilities and equipment functioning. There was no way with the current budget that they could meet the standards so they must look at alternatives. In additional they must find alternatives for the excessive rentals on their buildings.

Discussion
The Chairperson noted time constraints and asked the Committee to ask questions quickly.

Ms Segale-Diswai said they had inherited a troubled province. She asked when the projects were started and when they would be completed. At what percentage of compliance was the Eastern Cape currently?

Ms Robinson said she was very concerned and that there was a crises in the Eastern Cape. She asked if there was a link between the completion of a clinic and a hospital at the same site. If a clinic only had one doctor, did that mean that they did not have an emergency service? What were the ambulance services like if the conditions were so dire? She wondered if they had people who were specialists that could deal with maternity matters. She asked if they had the basic equipment.

Ms Dudley noted that the National Core Standards did not seem realistic for the province. What were possible solutions for this and what could the Committee do? People had been talking about a Carte Blanche television episode that gave the impression that the Eastern Cape had no staff but it did have the budget for it. Yet that was quite different from what Eastern Cape Department of Health was saying there today. Why were they getting money for things that meant “they were putting the cart before the horse?” How was the province trying to procure the R9 billion for staff?

The Chairperson stated that they could not pour in money where there had been mismanagement.

Ms Kenye thanked them for their presentation. She stated now that they had money, what was there priority: maintenance or building from scratch? She was confused about the projection completion dates.

Ms Kopane asked the names of the specific facilities that did not have water so that the Committee could know what was happening. They said that they did not have sufficient funds, but in terms of their administrative staff, how many of them were there because sometimes there was unnecessary administrative staff. She was curious why there was not a binding legal agreement with the traditional leaders so that they could not halt work when they pleased.

Ms Ngcobo was worried that the health system was on the verge of collapse.

Ms Dube asked if the Department was entering into formal agreements with the traditional leaders. She wanted to invite the national department or whoever was funding them to find out why the Eastern Cape was not getting its money.

Ms Robinson said that they did need to look at the financial problem and perhaps the Committee needed to invite the finance department.

Mr Kganare said that he would not want to be in the MEC’s position because he was expected to run a Department which could not be run. The problem was not with the Department of Health so they must find out the root of the problems.

In his response, Mr Gqobana said that this meeting had brought attention to the need to move with all necessary speed to use the resources at their disposal to meet the needs of the norms and standards. The Auditor General had said that they were the most improved department in the country. The Department of Health in the Eastern Cape was allowed to convert from a healthcare to a 'tender-care' institution. He said that there was a loop in the supply chain, and money disappeared in the process. They were engaging with district municipalities, which had become necessary in order to fix issues such as lack of water and electricity. There needed to be intergovernmental engagement when it came to certain issues in the province.

Mr Pillay said they agreed that the Committee needed a report about the progress with infrastructure. Due to the Department’s lack of funding and past, people became unmotivated as there were never enough funds to do things. He wanted to put it on record that if they were given money that they would spend it properly. The Auditor General had said that there was reliability now in the department. They had lost over R1 billion to corruption but had recovered over R400 million of that amount.

The Chairperson said that he hated to cut it short but they had another presentation so he ask him to summarize it all up.

Mr Pillay said that their budget had been cut so before they even started, they were already R28 billion short. They now had the ability to produce reports so they would forward a report to the Chairperson. They had made a request to Treasury to relax the regulations.

Mr Kganare said the more Mr Pillay spoke, the more questions he had.

Mr Chairperson said that the way the MEC summarized was good so that they should just leave it there. The problem was beyond the Department. He thanked the presenters.

Regulations on Foodstuffs for Infants & Young Children: briefing
Mr Alf Khumalo, DoH Chief Director: Legal Section, thanked he Committee for the invitation to be there and handed over to his colleague to do the briefing.

Mr Gilbert Tshitaudzi, Acting Director of Nutrition, said currently the Department had a challenge on their hands due to the erosion of breast-feeding in communities. The aggressive marketing of breast-milk substitutes such as milk formula in South Africa was undermining the nutrition of infants and young children. He referred to the Foodstuffs, Cosmetics and Disinfectants Act and explained that the Department of Health had a responsibility to ensure the provision of safe and adequate nutrition for infants and young children. South Africa actively promoted, protected and supported exclusive breastfeeding and acted to demonstrate this commitment. There would be national regulations on the marketing of breast milk substitutes which should be concluded within twelve months.

The purpose of the regulations was to contribute to the appropriate nutrition of infants and young children by setting standards, protecting exclusive breastfeeding for the first six months of life, and promoting continued breastfeeding up to two years and beyond with the introduction of complementary foods at six months.

The regulations would apply to manufacturing, supply, marketing and information for the correct use of the designated products. It would also make provision for labeling and packaging while the products would be prohibited from making any health, medicinal or nutritional claims. No person would be allowed to undertake any promotional advertising about the availability of the products. Health care personnel and establishments would be prohibited from promoting the products. Hospitals and personnel would be prohibited from giving gift packs that contained or refer to any of the designated products.

The International Code for Marketing of Breast Milk Substitutes was adopted by the WHO in 1981 and it urged member states to support to the implementation of the international code and translate it into national legislation. South Africa had drafted its own code in 1986 but it did not provide for the monitoring of the implementation of the international code which allowed for violations by some companies in South Africa.

In order to monitor the implementation of the regulations certain things had been put into place. Any person or group could submit a complaint to the Director General. Inspectors would be appointed who would conduct unannounced inspections. Suppliers, importers and manufacturers that violated the regulation would be legally responsible.

the draft regulations had been published for comment and DoH had received a wide range of submissions. Comments included major concerns from manufacturers about the draft regulations such as the perceived violation of constitutional rights, the legality of the regulations, perceived conflict with the Consumer Protection Act, some of the regulations exceeded and differed from the requirements of the International Code for Marketing of Breast Milk Substitutes and there were factual inaccuracies.

In conclusion, the finalising of these regulations would enable South Africa to make a strong contribution to regional and international best practice on infant and young child feeding.

The Chairperson said if he understood correctly, it was the aggressive marketing that prompted all of these regulations and not research on the subject. He said that they did not show in the presentation any studies that showed that they were more harmful then breast milk. He then handed over to the presenters again.

Regulations on Smoking: briefing
Ms Vimla Moodley, Direct of Health Promotions, said the purpose of the Tobacco Products Control Act was to deter people, especially the youth, from using tobacco products while protecting non-smokers from exposure to smoke and encouraging existing users to quit. There had been a decline in smoking in South Africa but there were still 44 400 smoking-related deaths a year (8%-9%

of all deaths).

The Reduced Ignition Propensity regulations were gazetted on 16 May 2011 and would come into effect on 16 November 2012. Its main purpose was to reduce fires and to test tobacco products at accredited laboratories.

The second set of regulations were the Display of Tobacco Products at Wholesalers and Retailers. They had been published for public comment between 24 August 2012 and 24 November 2012

. Research showed that tobacco displays increased sales. Ex-smokers complained that displays trigger craving.

 Displays had been banned in Iceland, Canada, Thailand, British Virgin Islands, Ireland, England, Wales and Northern Ireland.

In South Africa, the Constitutional Court had denied the British America Tobacco South Africa (BATSA) an appeal against an order made by the Supreme Court of Appeal that a ban on the advertising and promotion of tobacco products under the Tobacco Products Control Act was “reasonable and justifiable in an open and democratic society”. They also found that there were powerful public health considerations for a ban on the promotion and advertising of tobacco products.

The third set of regulations dealt with the Smoking in Public Places and certain Outdoor places. These were published for public comment between 30 March 2012 and 30 June 2012. NDOH was reviewing these public comments for finalisation of the regulations. Key areas of concern were entrances to public places; outdoor eating or drinking areas; health facilities, schools, child care facilities, covered walkways, stadia.
Currently the regulations allow for 25% of an indoor place to be designated for smoking. Indoor public places would now be 100% smoke free.

The fourth set of regulations dealt with Graphic Health Warnings on tobacco products. Currently there were only text messages, but they were testing pictorials and health messages. Plain packaging would also be tested. The draft regulations were to be finalised for public comment by March 2013.

The smoke free laws were excellent examples of primary health care and health promotion in action. They empowered people by making clear rules about where you may or may not smoke. They promoted an active citizenry who could demand the right to clean air. Citizens - not the police - could insist on shopping malls, workplaces, public transport being smoke free.

Non-smokers felt that existing laws did not support them adequately. The majority of smokers and non-smokers supported these regulations.

Mr Khumalo said that there was not any draft legislation on alcohol available so there would be no presentation on it.

Discussion
The Chairperson said that due to time constraints the Committee must quickly ask questions.

Ms Kopane asked why the Department had published the new regulations if they had not yet done a study of the old ones. Did the Department have information on the number of businesses that were not aligning themselves to the current regulations. She also asked who commented on the regulations.

Ms Segale-Diswai said there was not enough time for discussion. In terms of foodstuffs, whose reasoning was it for the aggressive marketing. She was of the opinion that breast milk was very good and they should promote it. She was confused because looking at the people the Department had consulted, she did not see the women of the nation. However, if she wanted to breastfeed, she would breastfeed – but she did not tell others what to do. She explained that perhaps she had an attitude because a man had presented it.

The Chairperson requested that the Committee ask questions but the presenters return to answer the questions.

Ms Dube said that they had shot themselves in the foot because they had invited so many people to do briefings all on one day. She asked what would happen to certain businesses after these smoking regulations were put into place. They could be hurt financially by the regulations. On breast feeding, she asked what happened to women if they wanted to continue to breast feed after their allotted six months of maternity leave. The rationale behind this was confusing.

Mr Kganare asked exactly what were a “designated food”. The perceived violation of constitutional rights could perhaps be real. From where was the information coming that non-smokers felt as if existing laws did not protect them. His perception was that they were basically banning smokers everywhere. During the World Cup where smoking was banned at stadiums, there were still people smoking everywhere – so how could this even be enforced? He thought that perhaps they were over regulating

Ms Robinson said that these regulations had been sprung upon them and they did not have enough information. The information should be available more widely so that the public could be informed.

Ms Kenye asked how the regulations would reduce fires. There need to be precautionary measures such as informing mothers about the risks of smoking while being pregnant.

The Chairperson thanked the Department of Health for the presentations on these regulations. The Committee would give them a future date to return because they were very interested in the regulations.

The meeting was adjourned.