District hospitals and clinics in Limpopo: Availability of medicines, equipment, role of health district officers: Public Service Commission briefing

Meeting report

District hospitals and clinics in Limpopo: Availability of medicines, equipment, role of health district officers: Public Service Commission briefing
Ms Irene Mathenjwa, Acting Deputy Director General: Monitoring and Evaluation, Office of the Public Service Commission, said that in 2012/13 the Public Service Commission (PSC or the Commission) had conducted inspections to establish the availability of medicines and medical equipment, and to look into the role of district medical officers, in Limpopo and in other provinces. The PSC Commissioner had led  both announced and unannounced visits in six districts to eight hospitals. The objectives of the inspections were to:

• Determine the availability and adequacy of medicines and equipment at clinics and district hospitals
• Establish the role of district health offices in ensuring availability of adequate medicines and equipment in hospitals and clinics
• Establish whether provincial departments had developed guidelines and procedures to manage selection, procurement, distribution and use of medicines and maintenance of medical equipment in line with the National Drug Policy of South Africa. 
• Follow up on PSC's 2009 recommendations
• Establish service sites compliance with the implementation of the Batho Pele framework

Some of the findings included

• Therapeutic committees were established at all hospitals, district and provincial levels for identification of new drugs
• District offices ensured identification of new drugs, and disease prevalence in communities served was taken into consideration
• Product selection was well institutionalised and contributed effectively towards the availability of medicines at health care facilities
• Supply of medicines was done through a medical depot for provincial hospitals, District hospitals were allowed to use direct delivery vouchers in case of urgent needs.
• The Limpopo medical supply depot was found to be operating without a pharmaceutical licence as its building was found not to be in compliant with the South African Pharmacy council
• The fact that Limpopo Province was placed under a section 100 order meant that it was not able to take certain decisions in relation to procurement
• Limpopo thus had approached Gauteng for a partnership to purchase medical supplies in bulk.
• Most storerooms and pharmacies were located next to the out-patient dispensary, which impacted on confidentiality
• Some hospitals did not have sufficient space to accommodate medical supplies and some did not have curtains
• There were allegations of officials stealing medicines.

Ms L Sizani, Commissioner, PSC, said the general cleanliness of hospitals should be attended to, to prevent some of these hospitals becoming health hazards. Some of the hospitals researched and visited had dilapidated infrastructure, with leaking pipes and mosquitoes prevalent. The Committee must tell whoever was responsible for the repair and maintenance of hospitals to attend to the hospitals named in the report.

Discussion

Mr I Mosala (ANC) said the Committee should be appreciative of the investigation by PSC, highlighting the critical challenges faced by some health facilities. The issues raised could be followed up when the Committee did its oversight visits. He asked the PSC what experience it had had, with the Department of Health and other government departments, into implementing the recommendations it raised and whether there had been an action plan created to deal with the findings. He asked if centralised purchasing of medicines was beneficial to hospitals, or if hospital self-procurement was better. He asked if PSC had followed up on what happened to the personnel who had stolen medicines. Of concern to the committee was that these medicines were used for drug abuse, and making nyaope. He asked if PSC looked at the state of water supply and sanitation in hospitals, especially Limpopo, which was a rural province.

Mr H Volmink (DA) thanked PSC for the excellent report. However, he commented on the methodology, noting that whilst PSC engaged officials in hospitals, and the outside public, it seemed to have forgotten the patient perspectives. He asked if PSC faced any resistance from officials. He noted also that Musina health facility, which the report noted as having dilapidated infrastructure and which needed urgent attention, had only spent 19.8% of its budget spent. It was also one of the National Health Insurance pilot districts and only 38.3% of the NHI grant had been spent. He asked if invocation of section 100 had worked in Limpopo.

The Chairperson said the report was excellent, but silent on the shortage of staff categories of clinicians and administrators. She asked if the hospitals had told the PSC where certain medicines were not available and asked if PSC was going to make another follow up visit. She asked if PSC reported the findings to the national Department of Health and, if so, asked what response it had received. The report should also have documented the response of communities at large.

Mr D Mhkwanazi, PSC Commissioner, Mpumalanga, said provinces did implement the PSC's recommendations, but the biggest problem was leadership stability. When a follow up visit was made, there would often be a new chief executive officer, new head of department and chief financial officer from the last visit. The major problem was that many departments did not respond immediately. and perhaps not until the issue started receiving media attention.

Ms Mathenjwa replied that PSC had the option to summon the head of department if recommendations were not implemented, but it did not want to create such strained relations as a matter of course. The other problem was that sometimes the report would sits on a table of a busy HOD or MEC who had no time to read the report. As a result, PSC chose rather to try to work with hospital mangers. It did face resistance sometimes, but the Office of Health Standards Compliance had made it a criminal offence for a hospital to operate, if it was not compliant with standards of hospitals prescribed. Decentralisation was much better because it meant local suppliers could be used, and made for quicker delivery of medicines when the suppliers were paid on time. The Limpopo Province sometimes procured from Gauteng, showing use of intergovernmental relations. The stealing of medicines was raised strongly as a concern to the National Department of Health (NDOH) and it was looking into that.

She noted that there was no water problem in Limpopo, but in the North West three hospitals had perennial water supplies problems, resulting in the outbreak of diarrhea.

The method used by the PSC had tried to achieve representivity of rural and urban hospitals. Some people in rural areas did not complain because they had been subjected to low standards for a very long time. Some patients, for instance, might reach the hospital at 5am and yet only reach the dispensary at 4pm to collect their medicine, but regarded this as the norm. Those residing in urban areas were more vocal on their rights. The other challenges included the fact that there might be one doctor to see 50 patients. There was no real resistance from staff, because they were of the opinion that if they raised their problems, this would be conveyed to the principals and hinder their career opportunities.

She added that one major limitation of the report was that it had been created by public administrators researching a medical field which was unfamiliar to them. PSC did not drill down on the under-utilisation of the NHI grant. Musina also had a challenge that it was next to the border and some people from neighboring countries would come there looking for health services. Steve Biko Hospital in Gauteng treated patients from Gauteng, Limpopo and Mpumalanga and outside the country, which resulted in huge pressure upon the hospital. When the section 100 supervision was implemented there was a need to decide the impact on the local level, as people on the local level needed to be capacitated. The shortage of nurses, doctors and administrators was a continuous problem in the public service; for instance, in South African Police Services (SAPS), there was no school of detectives. In the health sector, the rural areas suffered from lack of incentives to attract doctors to work there. Lack of sedatives caused some hospitals simply to transfer patients to others, but some of them had problems with emergency services in that sometimes nurses transferred patients in their own cars.

All of the of hospitals visited in 2009 had implemented the 2009 recommendations. The PSC had been  following up on those recommendations in four provinces and would forward the results to the NDOH. It did some research with citizens, known as citizen satisfaction surveys, researching on ten drivers of satisfaction as informed by Batho Pele. These reports would be made available to the Committee.

The Chairperson welcomed the reports from other provinces, saying that they would help the Committee when doing oversight. She asked if the PSC followed up on something when it had been reported in the media. She asked if PSC had spoken to all levels of staff, from the general assistant to the matron and CEO, about the attitude of health workers.

Ms Mathenjwa said that some nursing staff had a problem with attitude, since the right level of care was no longer displayed.

Ms Sizani added that the PSC would be pleased to receive an invitation to present on the level of dissatisfaction by health workers by cleaners, nurses and doctors. It had been receiving continuous notification of grievances by doctors from Tygerberg and Groote Schuur hospitals. When people were dissatisfied, they tended to adopt a certain attitude. The PSC did not have power to enforce recommendations. The surprising thing had been that the PSC was only reporting directly  to the Portfolio Committee on Public Service yet it was doing work across all government departments. The level of non- compliance, starting in the NDOH, was a problem.

Mr Mhkwanazi said reports on Steve Biko, Baragwanath, Emfuleni and Rob Ferreira Hospitals were ready. In his home district, the hospital used to have three doctors, although the organogram listed thirty, and after making several calls to the MEC, eight more were appointed and ten were contracted from the private sector to make regular visits.

The meeting was adjourned