As a follow up on earlier presentations by other Provincial Departments, the Gauteng and Mpumalanga Provincial Departments of Health (PDOHs) were asked to update the Committee on the challenges faced by their provinces, with the Committee stressing that whilst it wanted them to be frank, this was done so that the Committee could assess how it might assist. Of particular concern was the fact that only two PDOHs managed to get unqualified audits, and their performance and compliance information showed consistent challenges.
The MEC for Health in Gauteng set out how the PDOH had drawn and was implementing its plans, but did not isolate any specific challenge apart from the fact that there was a shortage of medication, which hopefully was being sorted out. There were several programmes being implemented. These included the ward based system which would assist with reducing patients who visited the clinics, because it would institute systems for regular checkups, and screening systems, as well as tracking beds and patients through new applications. It was scanning around 9 million files, and was investigating other applications aimed at getting patients to disclose their health status. Information was being gathered, for inputting into the system, from visiting community health workers as well as from other internal hospital sources. This PDOH had procured more modern histology equipment, to ensure that the results would be more swiftly released. There were currently 500 wards and it was intended that another 400 would be added. National Core Standards were being implemented by all health facilities, not only the pilot sites. The PDOH also set "Extreme Core Standards", which the Steve Biko Hospital had managed to achieve to a 96% level. The PDOH was no longer under administration, and qualified financial managers had been appointed, with a focus on supply chain management and payment of service providers on time. The main aim was now to get the PDOH to an unqualified audit opinion status, and how to access resources in a more scientific way. Management systems were being improved and it was looking critically at the staffing levels. It was recruiting women and people with disabilities. The Department had managed to spend its full infrastructure budget in the last year, was taking in medical students for training and hoped to improve its performance further. One challenge was that doctors from North West would refer patients to Gauteng instead of to the North West hospitals. Another, which was being dealt with, was the fact that the Province had run short on medicines. It was hoping to achieve an unqualified audit report, despite the disclaimer of 2009 and 2010, and qualified reports since, because it now had consistent management in place.
Members asked about the acting positions, noted that instances of attempting to defraud MVA claims were rife and the PDOH must be alert to these issues, and asked about the recruitment of women to higher positions. Members wanted to know if the supply of linen and blankets at Chris Hani Hospital had improved, how the clinics were operating and enquired as to queue management and staff attitudes. There seemed to be a high turnover of CEOs and the Committee wondered why. The Committee was concerned that the money being spent was not achieving sufficient impact.
The MEC for Health in Mpumulanga admitted upfront that the audit outcome over the last five years for this PDOH had been poor, particularly in 2014/15, where there had been wastefulness, and problems with asset management, human resource management, infrastructure, public works, medical waste management and laundry services, where the PDOH had been reliant on one firm. There had been high staff turnover but two senior appointments were made and the incumbents were now in place, and whenever the PDOH received resignations it would immediately advertise. Incidents reported in the press had been investigated, and the PDOH was working hard to get child mortality figures down. It was also trying to encourage people to go to clinics rather than hospitals in the first instance. Italian sponsorship had been obtained for the building of hospitals.
Members asked about the nursing colleges, how risk management was being handled, encouraged the PDOH to publicise its successes, and urged that vacancies must be filled speedily. They also raised problems of lack of water at the Luphisi Clinic, the need to replace furniture at Rob Ferreira, and said that mental health hospitals needed more focus. The problems with NEHAWU at Rob Ferreira were highlighted, where members were not following the correct channels and processes. The Committee also suggested that better incentives were needed to attract doctors to come to and remain in the rural areas.
Chairperson's introductory statement
The Chairperson noted that this was a continuation of hearings by the Committee on the challenges facing provincial Departments of Health (PDOH), which also considered how the Committee could assist the provinces to overcome the challenges. However, she stressed that this should not be seen as an opportunity for financial assistance to be requested. The Committee had heard from Free State, Limpopo and Eastern Cape already. The Committee was concerned that since 2014, some provinces had been under-performing, a fact noted by the Auditor-General, and in this year only two PDOHs had received unqualified audit opinions. The Committee now wanted to hear of their reasons for under-performance, problems that they might be facing and why they were unable to account for work assigned. Although good and hard work may be done, it was still worrying if the audit reports were qualified. Although the Committee did not necessarily want to talk about disclaimers or issues of qualifications, it would be looking for feedback on progress made after today's interaction. The Select Committee had a particular mandate to represent the provinces, and thus wanted to know what was happening at provincial level.
The Chairperson noted that the MECs were present. The Committee was interested to hear whether the Heads of Department (HODs) and Chief Financial Officers (CFOs) had the capacity to perform the job assigned to them, and whether the problems of low performance were attributed to structural management, lack of capacity, over-work, and what would be required of this Committee to assist the PDOHs to move out of their problems.
Provincial Department of Health briefings
Challenges in Gauteng PDOH: Briefing by MEC
Ms Qedani Mahlangu, MEC for Health, Gauteng, noted that this province's plans were aligned with the State of the Nation Address, National Development Plan (NDP) and State of the Province Address and it had also entered into performance agreements with the MEC and Premier. The province also had a cluster approach,and the MEC chaired the social services cluster.
She made reference to the Premier’s talk about accelerated social transformation, and said that Gauteng was moving towards modernising health services and the way services were delivered in the province. There was talk of broad band led by the Department of Finance, and the Road Map connection, for scanning of all patient records, and these were a few of the measures that the PDOH had implemented in an effort to make service delivery more effecient.
The PDOH currently had 300million patients’ records and was currently scanning about 9 million files. It was working together with Telkom on a broad based infrastructure within the hospital parameters looking at developing health solutions, including the PAC system, so that patients did not get shuffled around and all must go to the central hospital anchor point. The equipment must enable patients to be screened at that level. The PDOH was also looking at the PASOP application, through which it would talk to citizens to get an idea of their health status in relation to HIV, TB and other health issues. In this programme there was a team of doctors that answered to the concerns that the citizens raised. A "bed bureau" was introduced to help the PDOH to know who was occupying the 16 000 beds in the province, for how long, and that was linked by the EMS. There had also been an application developed to capture the information gathered from the community by health workers, procurement, and computer aided dispatching of ambulances, which were not yet integrated into one system. The PDOH had procured more modern histology equipment, to ensure that the results would be more swiftly released. Toxicology results were taking far too long to be obtained, and there was an investigation being done into how to speed up this process.
She spoke to primary health care (PHC) engineering. There were 500 wards in the province and it intended to roll out another 400, under the ward-based system. Health workers were, as mentioned, capturing data. The PDOH was also implementing the 1990 UN principles that 90% of South Africans must know their HIV status and 90% of those positive must be on ARVs, who must be on a high viral load supply.
National Core Standards were being implemented by all health facilities, not only the pilot sites. The PDOH also set "Extreme Core Standards", which the Steve Biko Hospital had managed to achieve to a 96% level. All hospitals were expected to do that. She noted that there was other information in the presentation that Members could read in their own time.
In relation to performance on administration, she noted that a turnaround strategy was developed by the Gauteng PDOH some time ago, and it had delivered results. Gauteng PDOH was no longer under administration in terms of section 18. There were qualified financial managers in place. There was a particular focus on supply chain management and payment of service providers on time. The main aim was now to get the PDOH to an unqualified audit opinion status, and how to access resources in a more scientific way. Management systems were being improved and it was looking critically at the staffing levels.
She further highlighted that there continued to be recruitment of women and people with disabilities. Certain improvement issues were highlighted but not discussed in detail (see attached presentation) and these included mother and child issues, health performance, planned patient transport and Emergency Medical Services (EMS), as well as the plan implemented at Steve Biko Hospital, which would now be extended across other hospitals, by the end of July,including the central and provincial hospitals. It had a quality assurance including for its intake of medical students annually and the number of South Africans being sent to Cuba.
The MEC noted that, for the first time, the PDOH had managed to spend 102% of its infrastructure budget in the last financial year. It had seen an under-spending on performance, which had also not happened before. Revenue collected was around R500 million. The PDOH had exceeded its targets and planned to continue to improve on it.
The PDOH continued to engage with state departments to settle outstanding debts. She noted that sometimes doctors in North West sent patients to Gauteng for a matter that could actually be attended to in North West, and this issue must be addressed. On the issue of paying service providers within 30 days, 74% of Gauteng invoices had been paid within 30 days but getting to 100% on this point remained one of the Department's challenges.
The MEC noted that a disclaimer audit opinion was given in 2008/09. Seven areas were higlighted on compliance. In 2009/10 the Department received a disclaimer again, with matters of non-compliance. In 2010/11 the Department received a qualified opinion with three matters raised by the Auditor-General (AG) around non-compliance. In 2013/14 there were fifteen issues of non-compliance. The HOD and CFO had been dealing with the issues of revenue. The Department was confident that in this year it should be able to achieve an unqualified report. It was notable that when there was a consistent management structure in place, the audit outcome was better. Where there had been inconsistency in leadership, the audit outcomes tended to fluctuate.
In terms of senior management, the MEC reported that the appointment of HOD had been finally approved and there was a CFO. The PDOH still needed to fill the EMS post. There was a Deputy Director General for infrastructure and someone had just started in supply chain, and in legal services.
The Chairperson inquired whether the HOD was still in an Acting position. She noted that she was informed that he had been appointed, but the officials were apparently not. She also noted that although the MEC had mentioned some of the posts filled, she wanted to know about others/
Ms L Dlamini (ANC Mpumalanga) said that the Committee was not looking for problems, but wanted to be of assistance.
Ms Mahlangu responded that the one challenge facing the Department was that it was running short of medication. Other issues were being dealt with.
Ms Dlamini made the point that, as the MEC had stressed, Gauteng was the economic hub, and everyone was looking to it to be a good example, which meant that things would have to run smoothly.
Ms T Mampuru (ANC, Limpopo) appreciated the fact that page 43 noted that the PDOH had a particular focus on training women. In Limpopo she worked for the Registry Office, and had noted how many people were trying to defraud the system by mis-claiming from the MVA Fund. This was something that the Department needed to be alert to
Ms M Tlake (ANC, Free State) wondered why there were no women in the Gauteng delegation and at higher level in the PDOH. She asked how it could happen that clinics were opened and operating with no doctors present. Patients were still going to the hospital rather than clinics in the initial stages, and that could cause serious influx of numbers. She enquired about the current PHC status. She knew that in the past, at the Chris Hani Hospital, patients were at one stage having to provide their own blankets, and the hospital was in a generally poor state and she wanted an update on its current state. She asked if nurses were still being trained there.
Ms T Mpambo-Sibhukwana (DA Western Cape) asked if previously there had been under-spending, and, if so, the reason. She asked about the child mortality statistics and initiatives in Gauteng. She wanted to know more about the shortage of medication.
The Chairperson asked how long it would take for a patient to get medication, and said that whilst administration was one point, what it was actually delivering was another. She asked what the staff attitude was in the health facilities. The Chairperson was worried about the turnover of CEOs, and asked why they were leaving and what they were being offered elsewhere that the PDOH was not giving them. She commented that it was a correct criticism that patients were being referred to Gauteng from other provinces. She asked how the PDOH was dealing with the mental institutions and the state of increase in the youth.
The MEC responded that there were not many acting CEOs. In the case of Pholosong, the PDOH had felt that there was not sufficient perfomance. The position of George Mkhari had just become vacant. The posts were pressurised, and some could not handle that and would leave. However, if the PDOH wanted to change the perception of health in Gauteng, a lot of work would be needed.
She commented that 43% of management were women.
The Chairperson noted that this question had to do with gender equity.
The MEC told the Committee that women were given priority and the PDOH would support women in business.
She noted that the PDOH was currently sitting with the biggest claims in the country but was talking to families to avoid court processes. In most cases, the bulk of the money would go to lawyers, not to the claimants. If a genuine mistake had been committed the Department would record everything fully. A retired person was assisting the legal team.
The staff attitude and changing that would be something that would take some time. People had been used to doing things wrongly for a long time.
She noted that the PDOH had implemented management of waiting times. Standard Bank was assisting with this, with 80 people, and MacKenzie was also helping with the links of PHC and ward-based care. Hopefully the ward-based outreach would decrease the number of people going to the clinics. This had been implemented in Soweto and Pretoria.
The MEC confirmed that Chris Hani Hospital was no longer a training college for nurses. The PDOH had suffered a further setback: 1.5million prospective students were disqualified from qualifying as nurses because of drug tests testing positive.
In relation to blankets and bedding, the normal supply was 5 linens per patient, but that had dropped at one stage to two. Old Mutual was helping to supply more and a factory had been found. She conceded that standards of cleanliness were not where they should be, but the PDOH was working on this and would be doing spot checks and unannounced visits.
She conceded that there had been under-spending, but presently the PDOH was ensuring that all money allocated to health was being used. On the shortage of medicines, she had been told that this problem had been happening over a long period, but Pharma was not delivering. She hoped that there would be an improvement. In relation to mental issues, it had been decided that, as far as possible, people with mental health issues must be treated from home. The PDOH was currently monitoring the situation to decide how many patients could be discharged. She said that one worrying aspect was the trend that mental health was on the rise, as were depression and cervical cancer, and this was something that all the departments would need to look into.
The Chairperson appreciated the response and the good work being done. She reminded the MEC that it could approach the Committee. The main concern was that spending was not having an impact on families and waiting lists remained long. On the staff attitude, much more had to be done to achieve improvement. She was aware that this was a process, but it must be focused on. She requested that the PDOH must ensure that it paid the municipalities, for there was a dispute around that, and money owing to the National Department. She disagreed on the point that there had been much change in CEOs, saying that the turnover was too high. The Committee appreciated the work done at Chris Hani and the involvement of the women. One of the issues raised at the Women’s League conference was that women must take a greater part in the economy of the country.
Mpumalanga PDOH briefing
Mr Gillion Mashego, MEC for Health, Mpumalanga, told the Committee that the audit outcome had not been good over the last five years. In 2014/ 15 the PDOH saw severe challenges around finance, wastefulness, asset management, human resource management, infrastructure, public works, and this remained one area where the PDOH had continuing problems. There had been problems in medical waste management and laundry services, where the PDOH was reliant on one company. Provincial Treasury had assisted with investigations, and Cabinet had suggested implementing the plans but the Department of Health in Mpumalanga were struggling. There had been two new appointments - starting that very day - of Chief Financial Officer and Director of Infrastructure, both of whom were present and were introduced. The Department had a challenge of high staff turnover. He noted that there had also been many nurses leaving the Department but as soon they tendered their resignations, the Department would immediately start recruitment processes.
In an effort to strengthen supply chain the PDOH had prioritised the rotation process. It had been unable to find a skilled supply chain officer and SCOPA had suggested that the requirements be looked at critically.
The PDOH was opening a college to train nurses, at Marapyane. An issue reported at Kwa Nyamazane had been investigated. He would be looking into getting more women into managerial positions. Under litigation, the PDOH intended to ensure that all the issues were dealt with immediately. The main challenge was still seen as child mortality, as although the PDOH was able to report a reduction, it could not say that it was as yet satisfied that enough had been done. Staff attitude was a general issue and training was being given to staff. In relation to waiting times, he noted that he was aware that there were long queues, but that was mainly to do with the fact that people tended to bypass the clinics and call straight to the hospitals, because they had a perception that they would be better assisted in hospitals. That was something that the Department was looking into. He said that no person should need to wait more than two hours in a queue.
He noted that there were staff positions to be filled in a few towns, such as Bongani and Standerton. At Ermelo the PDOH had appointed a director. The Premier in the province had led a delegation in Italy and the Province was intending to build five hospitals from the donations solicited. The PDOH was intending also to employ 400 cleaners and 100 groundsmen. He confirmed that in relation to money owed to municipalities, the CEO had been at the meeting where this was discussed, and the Province would be ensuring that money was paid where owed. There were four municipalities that had complained, but these matters had been dealt with.
The Chairperson thanked the MEC and said that the questions were asked not so much to put the provinces under scrutiny but to ascertain where the Committee could be of assistance.
Ms Mampuru said that she had recently attended a workshop where people were apparently being encouraged to take out their pension savings. She asked about risk management and what it was doing. She asked where the nursing colleges were situated.
Ms Tlake wondered why the Department was not being proactive in publishing its good intervention projects, so that it was not only the negative news about Mpumalanga that found its way to the press. Other provinces might also be able to emulate some of the success stories.
Ms Mpambo-Sibhukwana thanked the PDOH for its good presentation and honest approach.
The Chairperson asked that vacancies must be filled with speed. The vacancies had been long in existence and more efforts had to be made. She noted that at Rob Ferreira, it was necessary to replace some of the current old furniture. She urged that payments must be made on time to ensure that the PDOH did not owe too much money. She commented that there was no water at the Luphisi Clinic, and this was something that would have to be addressed. The Mental Health Hospital also needed more attention paid to it. She was pleased to note that the issue of doctors and orthopaedics specialists was being attended to. She urged the CFO to become actively involved in issues, outside of the office. She pointed out that sometimes people were attending the Mangwani Clinic already at 04:00, would wait the whole day and not be attended to.
Mr Mashego responded that some of the challenges were that the HODs had been slow to act, and this was not acceptable. He noted that the company Tsoma had been appointed to deal with retirement issues. In relation to asset management, he had been asked to step in because there had been complaints that there was lack of skills. The PDOH was now attending to this issue, as well as risk management, and a risk manager was in place.
He commented that it was most unfortunate that the media would not attend and report upon progressive programmes but would be seen only where there was negative news.
Ms Mampuru reported that the NEHAWU union was a problem in Rob Ferreira, and when these union members had a problem they would tend not to follow the correct channels and procedures, but to run to the media.
Mr Mashego said that the Province would be moving faster on the nursing colleges. It was accepted that the Province had to appoint more nurses at lower levels. There was a shortage here at the moment, and this meant that the professional nurses were ending up by doing a double job. He had noted a poor staff attitude, but said that this was also because the staff were over-worked. In respect of the Lupisi matter, the Director here was present and it would certainly be attended to. The cleaning committees reported directly to the MEC. The municipal issues would be addressed. In respect of doctors, the main challenge was that they preferred to work in the urban areas.
Ms Mpambo- Sibhukwana said it was necessary to add more incentives to attract doctors to come to and stay in rural areas, where they were needed.
Ms Mampurur repeated that NEHAWU was a problem. Anybody could be a shop steward, without any screaming, and those who spoke the loudest were the ones appointed.
The Chairperson agreed that attracting doctors to rural areas was a problem and the point was also that nobody wanted to be associated with areas where there was negative news. She thanked the MEC and asked that the Committee be updated regularly.
The meeting was adjourned.
- Gauteng Department of Health Performance presentation
- Mpumalanga Health Department: Review of Progress RE: Implementation of Turnaround Strategy
- Mpumalanga Health Department: Key Challenges in the Department
- Mpumalanga Health Department: Hospitals and District Health Services Weekly Reporting Template 2015/16
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