Public Health facilities audit: Department of Health briefing

NCOP Health and Social Services

19 March 2013
Chairperson: Ms N Rasmeni (ANC North West)
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Meeting Summary

The Department of Health (DoH or the Department) briefed the Committee on the audit of all public health facilities that had started in 2010, with a consortium taking over the exercise later. A governance committee chaired by DoH, with focal persons at provinces was established. Both provincial and district participation was encouraged, with a view to ensure capacity development and local ownership of the whole project. There were six core quality controllers that the Minister always emphasised: namely, availability of medicine, cleaning procedures, patient safety, infection prevention and control, caring and staff attitude, and waiting times. However, this audit went further and looked also at the profile of facilities, investigating whether they were accessible, their ownership, operating hours, condition of infrastructure, from floors to roofs, including laundry and kitchens, sufficient space for nurses and patients to consult, patient care, clinical services, availability of bulk services, equipment and human resources. All of these were designed to establish the kind of services provided and whether they matched patient needs. A brief description was given of how each of these points was measured. Vital measures were described as those that did not compromise patient safety. It was noted that Gauteng was more compliant than the rest of the provinces on vital measures. The country had about R320 billion worth invested in the total health estate, of which 30% was infrastructure that had to be fixed or replaced at a huge cost. The Department was now prescribing that the infrastructure grants must be used to maintain equipment in an optimal way.

It had originally been thought that there were 4 333 health facilities, but it was subsequently discovered that there were 3 808, since some were not functional and some were under renovation. In Western Cape, 21 facilities were not audited because the metro said it complied with the standards. The Department intended to set up a web-based system, as it was the most practical way of ensuring that data was easy to access, especially by Members. In general, the Department faced challenges in sufficient IT skills and security was another matter that was poor overall, no matter whether in- or out-sourced. It was trying to use unemployed graduates with skills in HR, IT and finance to assist. Once the audit had been finalised, facility improvement teams were set up in ten districts to pilot projects – and this was distinguished from the National Health Insurance pilot sites. Some matters were so basic, such as unfinished tasks, that no additional costs or equipment were needed to solve them. Finally, the DoH noted that it was also now providing health services for every Quintile 1 or 2 school, as well as mobile clinics, and these too would give reports that would assist in planning.

Members were appreciative of the initiatives, which would assist the Committee in its oversight. Several Members raised specific problems found in facilities in their provinces, and asked how DoH would address the immediate challenges and avoid spending money on projects that were not properly used. They also raised issues around access, noting that too many people still had to travel too far – often at great cost – to access services. They felt that school health should be extended to other quintile schools who also had children from poor households and said it was important to match school health services with education programmes, and to staff them appropriately. They noted that some retired nurses had been invited back to assist, but there was a problem when the clinics tried to use them full time at the clinics. Members were concerned about patient safety and suggested that intercoms must be fitted, and asked also how DoH would overcome patient complaints being tampered with by nursing staff. Members noted that there was a problem in many facilities of poor staff attitude, and DoH noted that there was indeed a need to change mindsets. A Member from Northern Cape thought that the presentation was biased towards the successes, and urged that the audit results be actually used. The Department responded that the audit must be seen as a tool and whilst detailed information was available, not everything was presented at this session, and it only gave information on facilities, not standards information.  Members asked about the governance structure, laundry services, the fact that Western Cape was not allowing audits, queue management and instances of unfair treatment. The DoH offered to host a workshop on the audit if it could.

Meeting report

Public health facilities audit: Department of Health (DoH) presentation
Ms Precious Matsoso, Director General, Department of Health, said that an audit into the public health facilities had been started in 2010. In February 2011, a consortium consisting of HST, ARUP, Exponant, HISP and MRC was appointed to undertake the exercise. A governance committee chaired by the Department of Health (DoH or the Department), with focal persons at provinces, was established. Both provincial and district participation was encouraged, with a view to ensure capacity development and local ownership.

The audit committee went beyond the six core quality controllers that the Minister always emphasised. The audit looked also at facility profiles, and addressed issues such as whether facilities were accessible, ownership of land and buildings, and operating hours (which was critical also in deciding whether the facility was accessible. Other smaller issues, such as condition of infrastructure, that were sometimes considered irrelevant, were also included, and the infrastructure evaluation had looked at walls, roofs, floors, windows, bathrooms, laundry, and kitchens. The Department also had to ensure there was sufficient space for nurses to consult with patients. Bulk services that were investigated encompassed electricity, water and sanitation and waste removal. Furthermore, the audit had also looked to availability of functional equipment and human resources (HR). From the information divulged through the audit, the Department now knew where vacant posts existed in the system. DoH sought to establish the kind of services provided, and whether they matched the people’s needs, as well as if they were in-sourced or outsourced.

Ms Matsoso identified the six priority areas that mattered most as availability of medicine, cleaning procedures, patient safety, infection prevention and control, caring and staff attitude, and waiting times.

The availability of medicine and supplies challenges, as identified in the report, included stock control and management, availability of tracer medicines, prescribing practices, storage, and patient and staff interviews. In regard to cleanliness, the Department inspected records of daily inspections of cleanliness, cleaning procedures, and looked at toilets, bathrooms, kitchens, laundry and grounds.

Issues considered on patient safety included physical safety measures, emergency services response time, and management of adverse events.

On infection prevention, it was important to look at surveillance and reporting systems, health-care associated infections, waste management, and management of infectious diseases.

The positive and caring attitudes indicators encompassed patients’ perceptions of service, patients’ knowledge of their rights and responsibilities, the complaints management system, privacy, and staff satisfaction.

In 2010, the Department indicated there were 4 333 facilities, but it had since been established that there were 3 808 facilities in the country. The Department sought to understand what had happened to the rest of the facilities in the public services. It was discovered that some were no longer functional and did not even have to be audited, whilst other facilities were under renovation. This was an indication of the value of the audit. In the Western Cape, 21 facilities could not be audited because the relevant Metro indicated that it followed the required standards. Some provinces even relied on private sector facilities when they treated patients.

DoH also assessed vital measures, which Ms Matsoso described as those measures that did not compromise the safety of patients. Gauteng province was more compliant than the rest of the provinces on vital measures. The majority of the districts in Gauteng had facilities that were compliant.

The report also looked at five functional areas, which were: clinical services, infrastructure, management, patient care, and support services. Clinical services included blood services, laboratory, health technology, pharmacy and radiology. It was not every facility that would have these services, and where they were not present, the challenge would have to be addressed in another way.

South Africa had about R320 billion worth of assets in the “total health estate”. 30% of this was infrastructure that had to be fixed or replaced at a huge cost, and 5% of this was investment that had to be maintained routinely, in order to prevent collapse and decay. DoH had tried to match these figures with the outcome of the audit. It was recommended to provinces that the infrastructure grant allocated should be used to fix problems identified in the facilities. Every province would have to provide DoH with a plan of every facility where challenges had been identified, and indicate how these would be addressed. In future, any infrastructure planning had to be informed by access and quality.

The Department had a full report that showed challenges with the infrastructure. Where there was lack of space, DoH was insisting that the infrastructure money had to be used to create space.

The audit had also looked to management, and here in particular it sought to establish whether there was a Chief Executive Officer (CEO), and whether all management units like finance and human resources (HR) were functional.

The Department intended to set up a web-based system. This was the most practical way of ensuring data was easy to access, especially by Members. This would assist in the oversight function of the Committee as it was recognised that all Members had to have an idea of how the facilities looked.

Although the Department had 100% security at some facilities, it was challenged in general on IT skills. DoH did not have an internal capacity for IT services and so the majority of the IT services were outsourced. The Department ran a programme where it used unemployed graduates with skills in IT, HR and finance. Ms Matsoso emphasised that the problem was not that there was a real lack of skills, but that the right graduates had to be found and used in such relevant fields as revenue collections.

When the audit was finished, DoH agreed that it needed facility improvement teams to help at provinces. It piloted this in ten districts. She emphasised that this pilot should not be confused with the National Health Insurance (NHI) pilot districts. Some of the challenges in projects identified in the ten districts were so basic that they needed no additional resources, as they were basically just a matter f following up on things that were left unfinished. The objective was to improve on the audit findings. People at facilities already had solutions available to them and there was no need to bring consultants.

Ms Matsoso reminded Members that it had been decided that DoH must also provide health services at every school that was Quintile 1 or 2. DoH went to the schools also to profile them, and it now had detailed information on each school’s health needs. The children in those schools should be able to access services immediately, and for those who could not, they must be able to rely on mobile clinics. This was information required by the Committee especially for oversight purposes, and the information gained from these routes would also be enormously useful for planning.

The Chairperson said the information would help the Committee in understanding some of the issues that had been encountered on oversight visits to hospitals. She cited an example of a recent visit to a facility in eLukwatini (Mpumalanga) where an NHI Pilot hospital was dilapidated. Although used by the communities regularly, it was found that walls were collapsing; and the floors were not properly finished off, posing dangers to nurses and patients.

The Committee had also visited Limpopo, where it discovered an unused state of the art hospital, on open land. She asked how the DoH intended to address these challenges, and avoid a situation where money was spent on projects that were not used.

Mr Les Govender (IFP, KZN Legislature Portfolio Committee on Health) commented that the audit work was intensive and gave the Committee a good insight in terms of where the country stood with primary health care. He commented that KwaZulu Natal (KZN) was a very rural province with unfriendly terrain. The issue of getting health care closer to the people needed to be addressed in that province.

Ms Matsoso agreed the KZN province was largely rural. The importance of the information coming out of the audit was that it located the health services in all areas, and indicated also where, for instance, GPs were situated. The audit revealed clearly that there was a need for a good contracting model, particularly as it pertained to getting GPs to work in more facilities. DoH knew now where they were, and their contribution per community. This approach would be extended to KZN.

Ms Matsoso noted that in Zululand one facility was discovered that was in a valley, and every time it rained, the facility was flooded. It was agreed that the facility needed a park home, in a safer environment, where people did not have to worry about getting wet.

Ms Melaine Wolmarans, Deputy Director General: Policy and Integrated Planning, DoH, explained that the Department was now receiving satellite photos from the Space Agency and that could help in determining the issues of accessibility. This kind of information was vital for planning. With that knowledge, DoH could assess where people were and the natural landscape they lived in.

Mr Govender commented that his other concern related to medical waste management. There were many instances where medical waste in KZN was simply dumped along the roadside, putting in danger not only the patients but also road users.

Mr Govender sought clarity on the provision of health care to Quintile 1 and 2 schools. He wanted to know about Quintile 3, 4 & 5 schools that also catered for people living in shacks and low cost housing projects. This needed to be kept in mind when doing the long term planning, as it must be remembered that poor people in these schools also needed assistance.

Ms Matsoso replied that school health was being addressed in a phased approach; other Quintiles would be looked as well in due course, but in the first phase, Quintile 1 & 2 were given priority.

Ms G Boroto (ANC Mpumalanga) commented the information provided cleared up some of the questions the Committee had raised. It seemed that there could be improvements, depending on the type of the public servants the country managed to obtain. The presentation spoke to raising the level of accountability on the part of public servants. She concurred that improvements in many facilities did not require resources, but behaviour change.

Ms Boroto said it was important to match school health services with education programmes. This approach was vital, but there would be challenges with staffing the school health services. At times, HIV/Aids counsellors were being used as staff nurses, although their training standards were not the same. Put simply, some of the health challenges in schools were caused by shortage of staff in the schooling system.

Ms Matsoso replied that the Department had invited some retired nurses back to assist, in order to match the school health needs. She said DoH had a database of 400 such people, and more nurses had indicated they wanted to help. The challenge was that some nurses were used to fill gaps at clinics. This was unacceptable, as most of the nurses were too old and unwilling to accept fulltime involvement in the profession, but merely wanted to help out where possible.

Ms Boroto said the base line audit information was crucial if it could be used to determine the necessity for the Carolina (Mpumalanga) clinic. The building in which this clinic operated was collapsing. It had been built from asbestos. Members had, however, suggested that it was not desirable to move the clinic from the area, as it was ideal to have facilities closer to people.

Ms Matsoso replied South Africa should not have a single facility built from asbestos, due to the risks of asbestosis. Such structures should have been done away with a while back already.

Ms Boroto praised the Department on displaying a serious approach to service delivery to the people. However, the presentation had taken a general overall national view, and the Committee would have preferred if the presentation had focussed on provincial break down.

Mr T Makunyane (ANC Limpopo) commented there was a project in Limpopo to renovate a psychiatric hospital. In a recent meeting, the province indicated that the money for renovations had to be diverted to the construction of Freedom Hospital, a Presidential Infrastructure Project. He asked if the Presidential projects got money from the National Department, or if they were prioritised over all other current projects to the extent of stopping work, and channelling all allocated resources towards the Presidential Projects.

Ms Matsoso replied that the Members was rightly concerned about this issue. It should not happen that resources were redirected. The case the Member quoted was a special project that fell under the Presidential Infrastructure Coordinating Committee (PICC). Resources should be redirected to those places where access was a challenge. Freedom Hospital was one of the facilities that had to be built from scratch and it had been neglected for a long time. DoH had to decide how it prioritised projects.

Ms D Rantho (ANC Eastern Cape) sought clarity on whether intercoms were fitted in hospitals, especially in light of concerns around safety at most facilities.

Ms Matsoso replied that the issue of intercoms had not been looked into, but would be addressed going forward. This form of communication was critical, and had been noted for follow up.

Ms Rantho commented that having a suggestion box for patients’ complaints was a good idea, but nurses tendered to “doctor” the feedback as they had access to the boxes. She asked how DoH would ensure that the idea was owned by the whole clinic, and that everything in the suggestion boxes was correctly recorded.

Ms Matsoso replied that the suggestion box was a challenge that would be addressed once the office of the Ombud, as envisaged in the Office of Health Standards Compliance Amendment Bill, (OHSCAB), had been established. The Ombud would ensure that complaints were dealt with, and this would not be left to the discretion of the nurse or doctor. At least there was a solution, and DoH had to ensure implementation.

Ms Rantho commented that rural areas also needed to be taken into consideration when looking at the question of accessibility to health facilities. The walking distance to access clinics and hospitals was a challenge for rural folk. She asked if new facilities would be built where this would ensure that the distance that rural people had to travel was reduced.

Ms Matsoso responded that planning for services had to take into consideration issues of transport and roads. The audit contained detailed information on the kind of roads to access facilities, and other pertinent issues of the maintenance of mobile clinics that were used in gravel roads were also considered. The life span of equipment used on gravel roads had to be looked into. She was well aware that long walking distances were a reality and DoH had insisted that when any new buildings were erected, the planning should take access as a prime consideration.

Ms Rantho said some of the things that happened in facilities at the secluded towns were so gruesome that people were opting not to use the facilities. She said nurses seemed not to care about emergencies unless the patient was brought in by ambulance. The attitudes of nurses was of great concern, and had to be addressed. She asked what the DoH could do to correct this.

Ms Matsoso replied that attitude was a behavioural issue that required a mindset change. She agreed that changes were needed but the question was how to change behaviour. There were good facilities that functioned well, but there were others that were bad.

Mr F Faber (DA Northern Cape) commented that the presentation only focussed on the good stories from the Northern Cape. He noted that the new Barkley West hospital was in a sorry state, and even looked completely deserted from outside. The computer system in that hospital was not working and many of the services were outsourced. He asked how a hospital could function without a computer system. All the equipment had been centralised to Kimberley, and if the hospital wanted to do anything it had to order from Kimberley. The hospital had only very recently acquired the services of a doctor.

Mr Faber said he was also worried about the data collection tool. It did not help to have a system that was not being implemented, otherwise it was a complete waste. Most of the facilities he knew of in the Northern Cape were not operating on the base line data system. He commented again that it was important to also highlight where the Department had failed and not always paint a rosy picture.

Ms Matsoso replied the presentation was only about the Pixley ka Seme district in the Northern Cape, and not all of the province. If the whole story of the province were to be told, she agreed that the picture was gloomy. The Department was merely highlighting the challenges and could not throw all its resources at a problem. The audit needed to be viewed as a tool to help Members in their oversight role. The information shared now was the kind of data that ought to be availed to all Members about every single facility. This would also help members of the public locate facilities. She further noted that information about the general practitioners (GPs) was included in the audit.

She added that DoH had provided training for every Head of Department (HOD), planners and the information teams in the province. The challenge was that five out of nine HODs were only in acting positions at the moment. She said 123 people had been trained on the use of the information. However, stability in the departments proved a problem because when someone left, another person had to be trained again. DoH wanted the information to be used to its fullest extent.

She also wanted to stress that this was an audit of information about facilities, and did not go into standard health information. Standard health information was a process that required investments. The country had already spent R4 billion on health information systems, and yet the information was not yet fully in place.

Mr M De Villiers (DA Western Cape) asked for more information on the composition of the governance structures as this related to provincial steering committees and districts.

Ms Wolmarans replied that the governance structure was something vesting with the national steering committee, that met bi-monthly. Deputy Director General Mr Yogan Pillay, and other key members from DoH divisions such as primary health care, finance, infrastructure and HR represented the Department. The Consortium was also represented. The Committee was tasked with project management, and therefore must ensure correct management and governance of projects. At a provincial level there were also steering committees whose key focus was to support the person coordinating the work within the province. They must, however, also make sure there was skills transfer.

Mr de Villiers asked if the laundry situation at the Carolina Hospital had improved, and asked that he also be briefed on the extent to which laundry services were a challenge throughout the country.

Ms Matsoso replied that a hospital had five components, one of which was hospitality services, like catering, laundry, clinics and security. There had to be a model of how the services were rendered, and provinces must comply. The second component was administration that looked at issues of IT, HR and finances, and there too there must be set standards for how these functions were performed, with which all provinces must comply. She said the compliance had to be developmental, but at the same time it must be recognised that sanctions would be imposed if there were not sufficient improvements, as DoH could not afford to allow compromise of quality where people’s health was involved.

Mr De Villiers related a story of a facility he visited where family visitors were asked to vacate the hospital because nurses were changing shift. This was a challenge in the Western Cape and he wondered if this was something that the audits had considered.

Mr De Villiers said he was also worried to hear that some clinics in Cape Town did not allow the Department to do audits. The Department should have the information on all the different clinics. He requested that the information on these clinics be given to the Committee, so it could be followed up with the provincial authorities. He asked if the information found in the Western Cape had been submitted to the MEC of health in the WC, and, if so, what had been his response.

Ms M Makgate (ANC North West) commented that the Western Cape was not a republic and it deserved to be treated like other provinces. Whatever happened in other provinces should also happen there. She also noted that it was not as if everything was up to standard in the Western Cape and the Committee was aware of instances of non-delivery in this province too.

Ms Matsoso replied that the Western Cape was indeed part of South Africa, and compliance would be enforced across the board. There was a presentation given, where both the MEC and the HOD of the provinces were present. The information was discussed with them.

Ms Makgate commented that the presentation shared some light on the status of facilities in the country, and gave government a starting point. This audit was evidence that the DoH was itself changing and she applauded the initiative. She requested more elaboration on the issue of security in hospitals, and said that the practice of checking motor vehicle boots was not sufficient.

Ms Matsoso said detailed information on security was needed. DoH looked at the insourced and outsourced security information at facilities, and had found that there was little difference no matter which was used as generally it was concluded that security was poor at all facilities. Different provinces had a combination of in-and out-sourcing, and a breakdown of information could be provided to the Committee, in a detailed security report. DoH’s sample of facilities in different provinces had also included a costing of how much provinces paid for outsourcing of security services.

She said that linked to this was the issue of patients’ safety. DoH had compiled a leaflet entitled “Our promise to you”, but the response was that patients did not trust the Department. That was revised into “Our duty to you”, and that seemed more acceptable to the patients. The campaign was started to try to bring back confidence of the people about the services that had been provided, in line with “our duty to you”.

Ms Makgate sought clarity on who could be blamed, and into what category the transgression fell, when incorrect medication had been prescribed, and she wondered how this was justified.

Ms Makgate noted that smaller towns were challenged with the issue of referrals. There were some facilities in smaller towns, but often people would be referred to other centres far distant. Another problem was the cost, since most residents of the smaller towns were relatively poor.

Ms Matsoso replied that the large walking distances were a reality. She repeated that DoH was now insisting that access for the people in surrounding areas be a prime consideration in planning. She agreed that another matter often not taken into account was the amount that people had to pay for transport to access services. Ideally, poor people should be able to get free access, including free transport. It was also important to ensure that roads leading to clinics and hospitals were in proper order, and that transport alternatives were provided.

Ms Makgate asked how unfair treatment was dealt with in faraway places, and in farms. She cited a case of an isolated facility that still had separate sections for whites and blacks, which was exposed in the media. A more subtle way in which that kind of racism was perpetuated was the differential treatment according to whether a person had medical aid or not. Health practitioners in those secluded towns did not really care because their facilities were not frequented by inspectors.

The Chairperson sought clarity on how facilitating the flow of queues was being addressed. In some facilities this was a challenge. She also wanted to find out if every issue of broken infrastructure had to wait until it was attended by the Department of Public Works.

Ms Matsoso replied that some of the challenges did not need an intervention from the Department. However, there was sometimes a problem that a culture of not solving the problems on own initiative had become entrenched. There was nothing stopping people from solving the basic problems at local level, without having to wait for intervention from another department. She illustrated the need for mindset change by citing a clinic in Sedibeng, where clean laundry was locked away in boxes and patients were put in beds without sheets. The explanation given was that once laundry was sent to the central laundry area, it either would not be returned to the correct facility, or would be damaged, so they decided to lock it away. They had meant well, but had failed to apply the right problem-solving processes. DoH was seeking to take the approach that sought to collectively address the problems.

Ms Matsoso noted that some facilities had innovative ways of dealing with queues, whilst others used marshals. In some facilities, the flow patients in the pharmacy area was changed and that had brought about an improvement. DoH was trying to encourage innovative ways of doing things.

Ms Matsoso explained that a number of different details were available for facilities. If possible, the Department could organise a workshop for Members on how to use the information.

Adoption of Minutes
The Committee adopted the minutes of 26 February; and 05 March 2013.

The meeting was adjourned.


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