KwaZulu-Natal & Northern Cape Health Department challenges

Meeting report

The Chairperson asked whether the challenges that were experienced in KwaZulu-Natal and the Northern Cape were a result of a skills shortage. Both provinces did have Members of the Executive Council (MECs) but were there Chief Financial Officers (CFOs) and Heads of Departments (HOD) and did the holders of these posts have the capacity to perform? KwaZulu-Natal had an Acting CFO, this was a critical position for such a big Department, and it was important that a permanent candidate was found for this post. 

The Chairperson questioned the governance structures of the Departments. Internal audit and risk management was needed. If the internal audit unit was effective, the Departments would know prior to the audit outcome what to expect as a province. Was there a manager for the Supply Chain Management Unit, with the skills to perform that job?

The MEC of the Northern Cape was asked to explain why only one hospital had been built in the past 11 years and why it had not been completed; so that the Committee could assist if that was necessary.

The Committee was interested in rural areas because they were interested in service delivery. The National Council of Provinces represented provinces and the Committee wanted to know what was happening in the different areas of performance of the departments.

The Chairperson expressed her hope that the Committee would not meet the Departments again and discuss the same problems. The next time progress would be discussed, and that would be clearly reflected in the audit outcomes in the next financial year after engagement.

KwaZulu-Natal Department of Health

Dr Sibongiseni Dhlomo, MEC, KwaZulu-Natal Department of Health, addressed the Chairperson’s concerns about the skills shortage in senior posts. On 4 June 2015 the Premier would present a successful candidate for the position of HOD, who would start on 1 July 2015. Regarding the acting CFO, the matter was still to be sorted out legally. The MEC was hopeful that the matter would be finalised within the next three weeks in court and the Department would then be able to advertise for the post of CFO. The current acting CFO was working with the manager on those responsibilities.

Dr Dlomo began by discussing some the challenges the Department had with regard to infrastructure. The Department of Health should have its own in-house engineers, so that the Department could account to itself before passing work on to the Department of Public Works or anyone building the hospitals or clinics for the Department. Through the support of the resident engineers in Health, the Department was able to monitor, check and see the problems of infrastructure. The Department was able to showcase some success stories because of that support.

The Department was working hard on their audit and Dr Dlomo hoped that they would overcome their hurdles. The problems the audit identified were mainly with assets and human resources. As a large province there were numerous assets – 84 hospitals and more than 400 clinics – and the Department was committed to bettering its performance in this regard.

The Department also had medico-legal issues, but these were transversal problems. The National Minister had called on all provinces to come together and discuss medico-legal problems as it was a big problem. As a province, KwaZulu-Natal took the lead from the National Minister and they were dealing with it in-house with the specific guidelines given to them.

The availability of doctors, waiting times at district hospitals and access to specialised clinical services also needed to be addressed.

Mr Bongi Gcaba, General Manager: Infrastructure Development, KwaZulu-Natal Department of Health, elaborated on the Department’s infrastructure challenges. The infrastructure was worth about R60 billion. The budget for 2015/16 was R1 551 billion. In the past four years, the Department had consistently spent all of its Infrastructure Grant and Equitable Share budgets. Between 2011/12 and 2014/15, the past four years, the Department had received an overall additional budget of R1.2 billion due to its good performance. In 2015/16 the Department would focus on enhancing its technical capacity from Head Office to facility level, to better manage infrastructure. Great emphasis was placed on the training of engineering graduates and exposing them to various aspects of this high tech industry.

From 2006/7 to 2010/11, there was only one year where the Department did not underspend (2009/10). An intervention was introduced in 2011/12 and for the following four years the expenditure was higher than the budget.

The Chairperson asked why the budget had dropped dramatically.

Mr Gcaba stated that the budget had been growing but it started to drop in 2013/14. This was mainly as a result of the results from the census. KwaZulu-Natal did not actually have so many people anymore. People were leaving the province, so for every person that left, money was being taken away from the budget, mainly from the infrastructure budget.  This was a problem because infrastructure remained no matter who was there and it needed to be maintained. There should always be budget to do so.

Dr Dlomo said that this was an in-house process that the Department needed to deal with. Even though there was a cut in budget across all government departments, this particular unit within the Department suffered the most. That needed to be revised. He was unsure whether the Department would survive.

Mr Gcaba said that the structure of the infrastructure unit was aligned with the national structure. The General Manager would report to the Head of Department. There was the General Manager Infrastructure Delivery Management System (IDMS) which was prescribed by the Division of Revenue Act and all Departments of Health and Basic Education had to follow this system in the country. Beneath this, there were four units: Infrastructure Planning and Real Estate; Programme Delivery, which involved monitoring projects from planning to completion; Health Technology, which covered medical equipment; and Engineering Services, which was more maintenance.

Since February the Department was able to fill 16 posts, covering different disciplines, from architects, to quantity surveyors, to mechanical engineers, to chemical engineers, together with the candidate engineers who were being trained in order to continue building capacity. The Department also advertised 17 other posts which were closed and looked positive. Those posts should be filled by the end of the year, creating a far bigger unit compared to past years.

Primary Healthcare

A challenge faced mainly in places like Ethekwini was that most clinics that used to be municipality clinics were dilapidated. Additionally, they could not be expanded without sourcing more land. Another challenge in rural areas was that the people were very scattered so transport was not always possible. It was difficult for the Department to position a clinic where it would service 6000-8000 people.

The Department introduced programmes aimed at health promotion and outreach programmes to ensure that it was able to deal with primary healthcare in a more decisive manner. The Department was also looking at their vehicles that would be able to move from one area to another, where, due to budget constraints, it was not possible to provide more fixed clinics. There were newly built primary health care (PHC) health facilities aimed at promoting a PHC approach over a hospi-centric approach to health care.

Since 2011/12, around 45 facilities had been built at a cost of just under R600 million. Areas like Ugu, Ethekwini and Umgungundlovu were less rural, while areas like Zululand, which were more rural, received more facilities.

Several clinics were being built, an example of which was SalutogenicIngogo Clinic, on the border of Mpumalanga and Kwazulu-Natal. The Department was trying to build clinics that offered healing on the inside and out. The clinics were built so that outside also felt relaxing.

Okhukho Clinic was in a very rural area. Nurses could not always be found in the area, so skilled nurses have had to be imported and thus accommodation needed to be provided for them.

The Department had built about six Community Health Centre (CHC) hospitals, for just under R1 billion. In addition, Jozini CHC would be finished around July or August 2015 at R268 395 000. In Deep Rural Msinga, the Pomeroy CHC was just completed and would be officially opened by the MEC and the Premier. Pictures were shown of the inside of the hospital. Dannhauser CHC was a mini-hospital but also had accommodation for doctors, pharmacists and staff. Pictures of the inside of the hospital were also shown.

Tuberculosis (TB) Control Programme

TB was problem for KwaZulu-Natal so the Department was working on facilities where TB patients would not be in the general ward. King Dinuzulu Clinic was the main TB clinic in Durban that all other facilities referred to. Most of the buildings of the King Dinuzulu facility were new, but one building was expanded as the TB centre.

Mental Health

The issue with mental health was that facilities were not conforming to norms and standards of the facilities so the Department had a lot of work to do, starting from the 72 hour assessment moving to the regional facilities. Townhill Hospital had been restored as the roof was collapsing while patients were inside so it needed to be saved.

Maternal, Neonatal, Child and Women’s Health

Much was done in terms of interventions towards the attainment of the Millennium Development Goals 4 and 5. There was the introduction of Obstetric Ambulances and refurbishment of maternity, neonatal and paediatric wards.

Lower Umfolozi Hospital in the Empangeni area was turned into a mother and child hospital. So no other services were offered at this hospital. The Njunjambili Hospital near Greytown just had refurbishments done to its maternity and paediatric wards. Greys Hospital was KwaZulu-Natal’s provincial tertiary hospital, the neonatal ICU was just upgraded.

Forensic Pathology Services

This was the investigation into unnatural deaths and the causes of it. The Department received facilities that were not compliant from the South African Police Service (SAPS), and the Department had to replace those facilities. In most cases, the Department had to consolidate the small facilities into a centre where the work could be done properly.

An example of a mortuary in Eshowe was shown which was completed. Another example was the mortuary in Phoenix which was just completed last year. This mortuary could carry close to 500 bodies.

Staff accommodation was vital because the province was so rural. The Department spent almost R600 million to deal with the issue of staff accommodation.

Snapshot of other programmes and interventions

A challenge for the Department had been maintenance of buildings that had been left to deteriorate to the point where they required a major capital injection for the Department to get them to the proper standard. Addington Hospital was a 16 floor hospital. The outer wall had been peeling off when patients were still inside so the Department had to go in to save it.

KwaZulu-Natal also had the first children’s hospital in Africa. It used to be called the Addington Children’s Hospital, now it was called the KZN Children’s Hospital. The Department worked with the private sector to try to bring the hospital back to life. Pictures were shown of the dilapidated hospital and those buildings that had been restored.

In Ugu, the Department refurbished the admissions centre for the GJ Crookes Hospital. The Department prided themselves on this project due to the innovation being brought forward for these new facilities. Trees were planted outside for the patients and when they went inside, the facilities should be able to mix with the vegetation outside.

Edendale Hospital was one of the oldest hospitals in Pietermaritzburg. It was a district regional hospital. The Department went in to give it life and worked on the Out Patient Department and the Accident and Emergency Unit.

At Mosvold Hospital, the Department worked on the general wards, bringing them to the right level or state, so that patients feel they were being looked after and given quality treatment.

Hlabisa Hospital Theatres were refurbished and the Male Medical Circumcision (MMC) Northdale Hospital was also worked on.

The Department was called upon to work on the nursing colleges and Edendale Nursing College was one such college.

There had been quite a challenge with the washing of the linen, so the Department replaced some of the laundries in some of the Department’s facilities. The regional laundry in Msheeni was one of the biggest laundries in the world in terms of the capacity it could take.  

The Department refurbished the boilers in order to supply steam and hot water. Air conditioning for theatres and stand-by generators were redone. Dr PixleyIsaka Hospital was currently being constructed in KwaMashu which should be completed within the next four years.

Mr Sihle Mkhize, CFO, KwaZulu-Natal Department of Health, then presented on the audit outcomes.

For the past three years, the Department had obtained a qualified audit on asset management, which had been a constant qualified item for more than three years, and irregular expenditure, which was qualified in 2011/12 but the Department managed to deal with it in 2012/13. The problem arose again in 2013/14, and may be due to reporting in the Department. Another issue was leave liability in 2012/13 due to understatement in the amount that was disclosed as a leave balance at the end, as certain leave forms were not being kept track of. There was an issue of conditional grant last year as a result of interface journals that could not be sufficiently substantiated in terms of reconciling the balance. Leave liability in 2013/14 was resolved. However, the Department was qualified on the basis of the opening balances.

In 2007/08, the Department combined unauthorised expenditure to the value of R2 6278 billion, which prompted the establishment of a joint management team which was comprised of Provincial Treasury and Department of Health senior management.

The task of the joint management team was to turn around the financial management of the Department and strengthen the processes. As a result, the resources were seconded to the Department from Treasury to cover the position of CFO and General Manager (GM) for Supply Chain Management. At the time, a number of senior management staff in the Department had been either dismissed or suspended on allegation of financial misconduct.

To date, only the GM Infrastructure had been filled. The CFO position was filled in October 2012 and was then dismissed 13 months later due to financial misconduct. That matter was currently on appeal. The GM for Supply Chain Management had not been filled yet due to labour relations processes that had only been finalised in May, so the Department was in the process of getting a new person to fill that position.

A lack of strategic work led to poor audit outcomes. There was major financial instability, particularly if there was no CFO or GM. Structure and finance was not geared for management. As a result the Department underwent a process of developing a new structure and made it in accordance with National Treasury to ensure that the critical positions of CFO and GM of Supply Chain Management were filled. The Department was in the process of filling those posts. The position of Demand Management had already been filled.

As a result of the dismissals and suspensions the function of infrastructure and finance was compromised which led to significant infrastructure under expenditure of R700 million. Lack of capacity also contributed to poor contract management in the Department which resulted in a number of contracts not being addressed and resulting in irregular expenditure.

The joint management team attempted to address asset management but found no benefit due to control deficiencies in the Department’s business process of asset management. The identified control deficiencies were as: identification of the location of assets, lack of capacity, asset management policy and standardisation of processes, assets not removed from the register when disposed and details around evaluation were incorrect. The above control deficiencies and assets formed part of the qualification.

Regarding leave provision, the qualification was mainly due to late capturing of leave taken by employees, which misstated the balance at the end of the financial year. The intervention to address the capturing of leave was cleared in 2014 but remained a qualification because of the opening balance not being restated.

On conditional grants, the qualification dealt with the cost of employees not paid which could not be substantiated. The reconciliation of grants had been implemented. In terms of interventions, asset management also had an audit qualification. The Department got assistance in terms of funding and resources from provincial and national health. In addition, the Department appointed an asset manager at the senior level. A project had been established and was headed by the Department’s asset manager. Its mandate, among other things, was of physical verification of all the assets of the Department, to cover the audit outcome of completeness and existing evaluation of the asset, reconciliation of current assets, development of asset management policy and training manual, training of the Department’s officials on asset management. These were implemented in terms of the project plan. Currently, the auditors were conducting the audit for 2014/15 asset management for completeness, accuracy and evaluation.

On irregular expenditure, the qualification related to the lack of a systems to identify irregular expenditure due to breakdown of system of procurement. Irregular expenditure emanated mainly from month-to-month contracts. There were issues of non-compliance to prescriptive relations for goods and services procurement. Not getting three quotations, awards made to private suppliers as well as overtime being paid above the 30%. In respect of overtime in excess of the 30% of the basic salary, it was mainly represented by health professionals in the areas of scarce skills and radiologists, paramedics, etc.

To address irregular expenditure, the Department had improved contract management, improved reporting of irregular expenditure by developing the irregular expenditure register and the division register for approval of expenditure. The Department had also implemented irregular expenditure guidelines and provide training to bid Committees and Supply Chain Managers. The Department appointed an irregular expenditure Committee, charged with addressing all incidents of irregular expenditure and make recommendations. In respect of the 30%, the Department created a block to perusal when in excess of 30%, and would require the necessary authority to put it through.

The Department was also strengthening the connection with the Department of Public Works, in terms of leases on behalf of the Department where Public Works was taking long to renew leases hence leases were extended on the month-to-month.

Mr Mkhize stated that the province did have an internal audit which was centralised as well as risk management committees. The Department had developed the risk register and Standard Operation Procedures which the Department intended to rollout post audit. It covered all issues of reporting and monitoring. It would be rolled out to all Senior Management who would be trained in order to standardise the reporting. The Department was confident that they would probably see better audit outcomes due to the interventions developed to address those issues.

Dr Dlomo interjected to say that regular meetings were held as MECs with the auditor general to check whether officials were actually submitting documentation on time and that process was working well.

Mr Mlaba, KwaZulu-Natal Department of Health, began by indicating the current number of active claims against the Department. The total number was 1079. The majority of the claims came from Ethekwini District, mostly because it was more densely populated and the Department had a number of institutions within that area. Moving towards the rural areas, the claims become less. This may be because of the level of education and people in urban areas being more aware of their rights and having access to legal services.

Dr Dlomo stated that Ethekwinin was where there were major tertiary hospitals, so all the referrals went to them. Because these were regional hospitals the Department was likely to face challenges there. The main challenge was in obstetrics and gynaecology. There were challenges with doctors specialising in mother and child care. He stated that the Road Accident Fund had run out of money so the lawyers were waiting at hospital gates for any small mistake that the hospitals make, because mistakes were made. It came mainly from surgical disciplines, for example, mothers delivering by caesarean sections.

Mr Mlaba continued to the main areas from which medico-legal issues arose, those being Obstetrics and Gynaecology. He then went on to look at the number of claims received and the trends from 2007/08. There was an upward trend in the number of claims received. Currently, the amount of claims against the Department was around R6 billion. That did not necessarily mean that the Department would be paying that much, they merely received that amount in claims.

In 2007/08 financial year, the Department received 50 new claims, and those claims amounted to R4.5 million. However, ultimately in that year, the Department was only able to finalise 16 claims and paid around R3 million. Hence the Department saved around R1.3 million. This saving was because of the Department going to court and either disposing of the matter or paying less. That was recorded as a savings on the total amount claimed.

Earlier in the year, the Department attended a medico-legal summit which was attended by all stakeholders in the health sector. It became clear at the summit that this was a problem occurring in all the Departments. It was not unique to KwaZulu-Natal, but there would be differences according to the demographics of each province.

A number of resolutions were taken at the summit. As KwaZulu-Natal, particularly the legal services unit, felt that the way of reducing the number of claims was to deal with the manner in which the Department paid them because they were ordered by the court to make payments. Most payments were mainly for future medical expenses and future loss of income. Regarding future medical expenses, the Department felt there ought to be a change of legislation. Currently, once the court gave an order for settlement, the Department had to pay straight away. The Road Accident Fund, however, was able to make undertakings, and the Department should also be allowed to do the same according to law. They should be allowed to offer an undertaking so that they did not have to pay out the full amount, but rather maybe monthly payments or offering the Department’s facilities as and when the person required it. Often the money paid out was abused.

For loss of income the money was paid up front. Mr Mlaba stated that it should be considered paying the money statically, in monthly payments or twice a year. So that if that person died before their time, then the Department would not have to pay or if the circumstances changed such that there was no loss of income, the Department would not have to pay.

Over and above that, under the leadership of the MEC, the province was going to have its own medico-legal summit where they would invite their own internal stakeholders to make sure that one the National Minister was leading at a national level, the province would also come up with strategies that were in line with the national strategy, but also address issues that were unique to KwaZulu-Natal.

There have also been Clinical Forum structures put in place where clinical issues were addressed at a clinical level.

Dr Dlomo stated that the Department failed to settle some claims because doctors had poor writing. Some doctors write little to no notes, and when a claim came forward years later, this made matters difficult. The basic thing was to improve doctors’ handwriting.

Ms L Zwane (ANC, KwaZulu-Natal) requested confirmation that in 2013/14 there were 143 cases and the number of cases settled was 49. She wanted to know what happened to the other 94 cases.

Mr Mlambo responded that if the matter did not get resolved in the financial year then it would be carried over to the following year.

The Chairperson referred to 2007/08 where there were 50 cases and 16 cases were settled. The Department was reporting its savings by comparing the amount claimed from the full 50 cases in comparison to the amount paid out from the 16 settled cases, which was misleading. The savings should be reported based on a comparison of the amount claimed in the 16 settled cases and the amount paid out for those 16 cases.

Dr Dlomo said that the problems with the availability of drugs in the country was not as dramatic as portrayed in the media. There were a series of meetings to deal with this as provinces but also as the National Department of Health. The National Minister returned from Geneva because of the alarm around the shortage of medication, particularly in KwaZulu-Natal. Dr Dlomo wanted to establish that a patient was asked to present a story in media that there was a shortage of drugs. When that that patient was further interrogated, that patient was not even receiving medication at that clinic. The patient had also received medication by medipost, which was a programme which allowed patients to avoid going to the clinic to collect their medication.

The previous month there had beenhortage of a drug called Apakave which was a solution mainly for children with human immunodeficiency virus (HIV). That had since been sorted out. All other medication, like antiretroviral medication (ARVs), had never been in shortage. The Department was actually encouraging clinicians to move patients to single dose or fixed dose, which was easier to take. Almost 80% of the province was on the fixed dose. Those few remaining were because they had other diseases which make them incompatible with the fixed dose.

There were certain drugs not available in the country. This was not because government did not have money or was not paying, but was a result of a shortage of Active Pharmaceutical Ingredients (APIs) that were used to manufacture medication in India and China.

There was a meeting with the Minister two weeks ago in which 34 pharmaceuticals from across the country indicated that they had tenders for certain drugs but they were not able to supply all the medication needed in the tenders. It was the actual supply that was creating the problems. However, there were alternates to the regular drugs.

All children, when they were born, had to have the Bacillus Calmette–Guérin (BCG) vaccination as protection against TB. The country did not have this drug. A company called Novatise had closed down in terms of manufacturing BCG. The country was getting a new company found in India to manufacture the drug. The country did receive a new batch of BCG, but they were not ready to give it out to patients as it had to go through quality control. It was currently in the laboratories in Bloemfontein going through that and the BCG would be given in 3 weeks. All new mothers now were recorded so that once BCG did roll out, those mothers would be called and the drug would be administered to the children. The Department was managing the drug issue.

Another issue was waiting times. It was one of the 18 non-negotiables in the country. The Department checked the waiting times of three districts. In the emergency areas, there was an average waiting time of 16-20 minutes, admissions waiting area took one to two hours, having been seen by a doctor before being admitted to a bed and the outpatients area, the average time was one to three hours. The pharmacy waiting times were 53 to 102 minutes.

The Department had vast disparities. However, the other issue of waiting time was the availability of staff. Without enough staff, waiting times would be long. The most rural areas were the most affected. Doctors were few and far between. Few doctors were willing to go further out into rural areas. That was why the Department was relying heavily on the doctor training, their mandate being to come back and work where they came from.

Access to specialised clinical services was covered largely by the infrastructure portion of the presentation, those were psychiatry and TB. The Department was not excited about having to open Multi-Drug Resistant (MDR) TB hospitals. These were for patients who never had proper treatment for TB. This occurred when patients were sent away from a clinic and told to come back, or when patients themselves thought they were getting better and stopped taking their medication. More MDR hospitals were being opened in the province, such as King Dinuzulu which was expanded. There was another one closer to Mozambique called Manguzu Hospital, and Catherine Booth in Uthungulu, both of which were specialised MDR. Dr Dlomo was looking forward to closing those clinics as MDR hospitals were not something to be proud of.

The other area was mental health. The Department had not completed Mathatheni hospital. The Department was expanding mental health in the province but not far enough. The province was not doing exceptionally well in terms of access to specialised services.

Northern Cape Department of Health

Mr Mack Jack, MEC, Northern Cape Department of Health, said the Northern Cape was the biggest province in terms of land mass, but the smallest province in terms of population. Comparatively speaking, Northern Cape was one twelfth of KwaZulu-Natal in terms of population, and Northern Cape was the smallest province in terms of the budget. The infrastructure budget of KwaZulu-Natal was the same amount as the Northern Cape Department’s whole health budget.

The Department was working towards the vision of a population that lived longer and healthier lives. They were striving towards health service excellence for all. This was underpinned by quality health care services to the people. The Department was committed through support and clinical staff, facilities and all other aspects that helped Northern Cape to this end. However, there were challenges that made the vision difficult to achieve. These included generic matters affecting the world, the country and the province. Generally, financial management, human resource management and supply chain were challenges. The Department spent a lot of time trying to normalise these matters.

The Northern Cape was a rural province that was very vast with a small population spread throughout the province. The challenge was to get clinical personnel to the rural areas. In certain settlements or towns, there were just people and no social activities, making it difficult to live. The province was struggling particularly with nurses. Thus the Department was using retired nurses. However, at a certain point the Department would be caught wanting. The Department was trying to recruit young nurses from colleges, but this was inadequate. Nurses did not want to work in the rural areas, either because they wanted the social activities or because they wanted to further their studies. Sometimes, one professional nurse would manage two clinics. That made it difficult for the Northern Cape to realise their vision.

The HOD that had been appointed, was legally appointed and had the capacity to fill the role. There was an acting CFO, but Mr Jack was hoping to have appointed a CFO by the end of July.

Government structures, the internal audit Committee and risk management were present in the Northern Cape. There was a supply chain manager. There was a very small team on infrastructure. The National Department had said that provinces needed their own teams to deal with technical matters, but in particular maintenance of clinics, hospitals and other facilities, because the Department could not build new structures when they were unable to look after the existing structures.

Mr Jack agreed that the Department had been in the process of building the Mental Health Hospital for a long time. He acknowledged that has been 10 years since they started building. In 2013, he was acting MEC, and he was called by Parliament's Standing Committee on Public Accounts (SCOPA) to explain why it was not complete. The current Director-General (DG) for the National Department of Health said in that meeting that it would be cheaper to just demolish the hospital they were building. If that decision had been taken, the government could have saved a lot of money. Then, the expenditure was around R900 million. Currently, he said it was moving towards R2 billion. This was a serious problem. Building the hospital was taking away from money that could be used to improve service delivery, to build more clinics, to extend the existing clinics and so on.

The Department, together with Provincial Treasury, the Department of Public Works and the Premier’s Office, were working to get the hospital finalised by 2016. Parts of the building were being demolished and rebuilt. There needed to be an investigation commissioned to discover what the real underlying issues were, because there was no movement that was convincing everybody that the hospital would be done. But the Department has the vision that by the end of 2016, the hospital would be done. He welcomed suggestions and technical solutions.

Ms Gugulethu Matladpane, HOD, Northern Cape Department of Health, said there were five districts in the province: Francis Baard, Dr Pixley-ka-Seme, John Taolo Gaetsewe, ZF Mgcawu and Namakwa. The Department had made strides in improving the service delivery despites issues. The National Health Insurance (NHI) pilot was a priority district and work was being carried out as planned. There was a reduced maternal mortality rate but a lot still needed to be done. There was also a reduction in the number of HIV positive babies.

Strengthening Health Systems Effectiveness

For the public health care system to be effectively strengthened, there was a need to overhaul the health delivery platform from one that was largely based on a curative high-cost model, to one that promoted prevention and low cost primary health care, delivered as close to peoples’ homes as possible.

In an attempt to improve proactive preventative health care the Department would be conducting health profiling of all citizens in the NHI district to proactively identify the risks patients might have and consider early treatment. The Department was collaborating with other provinces on the tertiary and quaternary platform.

Dependency on the HealthCare System

85% of the population was without medical aid and therefore relied on the public health services for their health care needs and treatment. The number of individuals who were reliant on the public health system had increasing steadily between 2010 and 2012 ranging from 14.2% and 19%. Public facilities were therefore over-burdened.          

Access to Primary Health Care

Primary health care services were provided by 130 clinics, 29 mobile units, 46 satellites and 33 Community Health Centres. The vastness of the province led to a need for more health facilities, especially in far-lying and hard-to-reach places, to cater to all citizens. However, a major challenge was the under-utilization of many primary health care facilities due to the by-passing of these services and referral (including self-referral) to higher levels of care. The Department had prioritized selected Community Health Centres for 24 hour operationalization to help address this.

Maternal mortality

The province had shown a marked improvement in reducing maternal mortality with a substantial reduction from 247 per 100 000 in 2010/11 to 167 per 100 000 in 2011/12 and an even further decline to 127 per 100 000 in 2013/14.

Although all facilities provided antenatal care, late bookings by pregnant women continued to pose a major challenge. Nevertheless, it was within the capability of the province to achieve the national target for the maternal mortality rate of 2014/15.

Reduction in HIV+ babies

The prevention of mother to child transmission coverage for HIV positive antenatal patients had resulted in a significant decrease in the number of HIV positive babies. Babies that tested HIV positive at six weeks decreased from 7.5% in 2010/11 to 5.3% in 2011/12 and a further drop to 2.7-3% in 2012/13/14. The province also rolled ART service points to all primary health care facilities to increase access to ARV treatment, care and support.

TB treatment success rate between 2008/09 and 2013/14

In the financial year 2008/09, there was a success rate of 75.4%. This steadily increased until 2010/11. In 2011/12 there was a drop of 0.4% from 80.4% the previous year. In 2012/13 there was a further drop to 72.4%. In 2013/14, it increased again to 80%.

Functionality of primary healthcare facilities

The Northern Cape did not currently conform to the national standard definitions of health facilities. For instance, most community health centres did not operate for 24 hours due to lack of staff and poor infrastructure. This placed strain on the day staff as many had to be on call during the night, while still having a full day shift.

Functionality of District Hospitals

Another situation giving effect to inefficiencies at district level was the incapacity of Level 1 Hospitals to function at the correct level. More than 60% of the 11 district hospitals were not rendering the required package of services, resulting in the confident in the primary healthcare system being undermined by the community. This also placed undue strain on the higher levels of care; the regional hospital in Upington and the tertiary hospital in Kimberley.

Quality Improvement

Quality improvement initiatives as part of developing NHI focused on reducing waiting times, improving cleanliness, reducing infection, ensuring drug availability, ensuring the safety of patients and staff and improving staff attitudes.

The initiatives were driven though the following programmes: national core standards compliance, a permanent perfect team for ideal clinic realisation and maintenance, ministerial non-negotiables, management performance assessment tool, risk management and primary care reengineering, including ward-based outreach teams, district clinic specialist teams and school health.

National Health Insurance

Dr Pixley-ka-Seme District was one of the ten NHI pilot districts in the country. The following teams were critical for the introduction of the NHI: District Health Specialist Teams, which comprised of a gynaecologist, paediatrician, physician, midwife and paediatric nurse; School Health Teams; and ward-based outreach teams. These teams were in place but the challenge was still the high turnover and shortage of specialised staff.

The Department faced the challenge of attracting medical personnel in Northern Cape. The province was able to recruit 25 nurses from the Western Cape, but out of those 25, only 9 were left in the Northern Cape, the rest left for other provinces.

Reducing Waiting Times.

Patient waiting time in clinics went up to five hours, with almost 79% if the time in the clinic spent by the patient waiting. Interventions were being introduced to address the challenge, such as the Integrated Chronic Disease Management and the Integrated Services Management Model, support to clinic to adjust hours of operation to increase accessibility, implementation of queue management processes and a patient booking system and communication of clear expectations for waiting times and the process of care.

Ideal Clinic Initiative (part of Operation Phakisa)

Operation Phakisa was a national initiative. The National Council of Provinces had resolved that all clinics in all provinces should reach ideal clinic status by 2018/19. This project was central to the success of the National Health Insurance and as a result provinces were expected to commit to delivering this goal by 2018/19. The Northern Cape had developed a 3 year roll-out plan, however, the availability of resources remained a problem.

The Chairperson wanted the HOD to highlight key issues and challenges as there were time constraints and the Committee had not yet heard about finances or the audit outcomes.

Emergency Medical Service

The challenge here was the provision of two person crews in ambulances. Currently in the Northern Cape, most ambulances had only one crew member. The other challenges was the issue of the mushrooming of informal settlements, which led to delays in finding the patient where ambulances sometimes did not find street names.

Another issue was the rolling plan to replace each ambulance after three years or 300 000km, was introduced in 2012/13. 60 ambulances were replaced each year. Currently Northern Cape had a shortfall; there were currently 108 instead of 184.

EMS Training College

The Department recently completed building an EMS College and a business case for additional teaching staff had been submitted to Treasury.

Mental Health

Mr Jack had covered most points of mental health but the HOD just added that the Northern Cape only had 107 beds in general hospitals or in the community. The province did, however, provide 72 hour assessment in several general hospitals.

State patients housed within prisons remained a challenge. There were currently 25 in prison, 16 in hospital ad 17 on approved leave of absence from the hospital.

Regional Hospital: Dr Harry Surtie in Upington

The Dr Harry Surtie hospital was officially opened last year by the President, but the Northern Cape faced the challenge on recruiting medical staff; doctors, nurses and health workers.

Tertiary Hospital: Kimberley Hospital

Kimberley Hospital was the only tertiary hospital in the Northern Cape. The shortage of hospital staff in regional and district hospitals led to patients coming to this tertiary hospital without referral from other levels of facilities.

Kimberley Hospital required a total number of 74 specialists to render the complete tertiary service package. It currently had 31 specialists but required an additional 43. It currently had four special technologists but required an additional 11.

HR: recruitment and retention

This remained a challenge for the Northern Cape because if its vastness and that it was a rural province. There was a challenge where towns like Upington and Kimberley, which were also in rural areas had to also be paid a rural allowance, but the provincial budget did not allow for it.

Information and Communication Technology

Completing the staff complement of the information technology (IT) Directorate had been a challenge that was at this stage partially resolved. Only up until last year, did the province not have the IT Directorate in the Department. There was poor connectivity in rural areas, and this remained a major obstacle to service delivery. Under-utilisation of data and information to inform decision-making in the Department had been addressed by strengthening the Monitoring and Evaluation capacity.

Infrastructure: Implementing Agents

The Department was using IDT and the Department of Public Works as its implementing agents. The challenge was that sometimes IDT used a different supply chain procedures and protocols, however they were in negotiations with IDT. A specialised infrastructure supply chain management sub-unit was considered to fast-track maintenance, technical and infrastructure procurement.

De Aar District Hospital

This hospital was supposed to be completed in May 2015, but due to the slowness of the contractor, it would only be completed in November 2015. The challenge was the number of beds.

Maintenance

Maintenance policy, standard operating procedures and day-to-day maintenance was rolled out to all facilities. The Department was in the process of recruiting technical people to assist in all facilities.

Audit Outcomes

Mr Daniel Gaborone, Acting CFO, Northern Cape Department of Health, said that the province faced serious challenges in terms of financial resources, mainly because of the size of the province. The province had tried to advance the idea of a special dispensation for the Northern Cape in terms of the equitable share formula, to compensate for the issue of distances. It was a serious issue causing pressure on the budget.

In the previous financial year, the Department overspent its budget by R91.6 million. The issues were those mentioned above, and it was also related to the level of accruals as a Department. The Department was in the process with Provincial Treasury to resolve the issue of accruals. The level of accruals was standing at 322 as of the end of March 2015, of the 266 accruals were on goods and services. The budget this year for accruals was R1.2 billion. Putting 266 of accruals into R1 billion, meant the Department had three months of accruals to pay and thus did not have funds for three months of the current budget. That was a risk to the sustainability of services within the province.

The project mainly dealt with the reliability, credibility and completeness of accruals. It was also to deal with the actual funding to be able to fund the accruals. Thirdly, it was cost containment within the Department to see how to reduce level of accruals in the Department. Mr Gaborone emphasised the impact of this on the sustainability of services.

The other issue to discuss was that of revenue. The challenges here were mainly around systems and capacity in terms of human resources. In some of the province’s rural hospitals they did not have IT infrastructure capacity to deal with the systems implemented there for them.

The Department lacked the human resources to deal with revenue, hence the Department only collected 80% of its targeted revenue by the end of the financial year. Provincial Treasury did give the Department some funding to fill holes in this area. The Department was hopeful that was that was done, it would be able to face some of the challenges.

In terms of conditional grants, the challenges surrounded the agent services provided by Public Works and IDT. In infrastructure there was an underspending of R69 million. The Department had submitted to National Health and it was hoping they would be able to roll over those fund for the Department to complete and finalise the projects funded through that grant.

In terms of a cost containment measure, the Department had implemented the National Treasury policy on cost containment measures. The Department was in the process of enhancing those including their own cost containment measures to reduce the impact of accruals that the Department currently had.

Moving onto the Audit Action Plan, the Department had, for a number of years, gotten a disclaimer opinion from the Auditor General. There was progression in 2012/13 where the Department moved from disclaimer to qualification and the Department hoped to maintain that in 2013/14. The Department had eight qualification paragraphs in 2012/13 and nine in 2013/14.

The areas of qualification were immovable assets, intangible assets and moveable assets, irregular expenditure, fruitless and wasteful expenditure, accrued Departmental revenue, employee related costs, accruals and commitments.

Through the assistance of the Department’s Audit Committee, the Department had developed an audit management plan. The audit management plan was a blueprint document within the Department, a high level document, which determined the direction of resolving the audit outcomes. In line with that plan, the Department was in the process of developing nine projects linked to those audit qualifications. These nine projects would be led by members of the executive. The Department decided to escalate the action plan to the executive. There was the project champion who was the executive manager, and additionally there was the technical lead of the team, who would be a manager responsible for a certain function within the finance unit.

The executive was now able to see the challenges faced in finance, for instance, the project was not going to limit solutions to processes only. The solutions would be comprehensive. They would deal with the issues of HR capacity, technical capacity, processes and so on. When the project manager went to the executive to say there was an issue with lack of human resources in a particular area, the executive must then make a decision to ensure that that plan becomes part and parcel the processes of the Department. The Department hoped to see results in the 2016/17 audit outcomes because by then they would have implemented some of the plans.

Parallel to the plans, the technical leads in the projects need to advise in terms of finance what the quick wins were that the Department can take. The Department realised there were simple things they could implement, and that they do not need to wait for the end of the financial year to do, like simple issues of reconciliations on a monthly basis. The Department had found that there was a lack of undertaking in those functions. That was just one of the things the Department could do to ensure they had dealt with the audit outcomes by the end of the financial year.

The Audit Action Plan had been approved by accounting officer, which meant it was a document that the Department as a whole needed to comply with, and it was adopted by the executive Committee. This plan was different in the sense that it would be managed in highest levels of management within the Departments. They specifically addressed the items on the audit report, but not limited to them.

The Chairperson requested an expansion on staff attitudes, medico-legal matters and waiting times.

Ms Thembi Mazibuko, Director: Communicable Diseases, Northern Cape Department of Health, expanded on the issue of waiting time at facilities and the new issues of staff attitudes.

The Northern Cape did have a challenge, specifically because they had 27% of facilities in rural areas still being managed by a single professional nurse. With the number of patients that visited the facilities, there were instances where patients did have to wait a long time. The presentation outlined the interventions put in place to try and deal with this challenge. The first was the integrated chronic disease management. It was a national approach in terms of the national core standards for improving waiting times, and this related to sorting patients. The majority of patients were coming for chronic disease management (45-55% of the headcount).

With the introduction of the Central Chronic Disease Drug Distribution KwaZulu-Natal had referred to medipost in their presentation. This allowed patients to receive chronic medication faster. This was started in NHI pilot district, and the intention was to roll it out to all those facilities that were identified.

The Integrated Service Model was about introducing fast queues. Patients coming for cold cases, like family planning or information, would not have to wait through all the different queue, like registration, observation and consultation. The Department was taking baby steps in the non-pilot districts. But in the Pixley-ka-Seme district the interventions were quite advanced.

On staff attitudes, there was a challenge. Some of the medico-legal adverse events were related to attitudes, for example, where staff attitude may have led to negligence. In those instances, there were management processes, where after the investigation was concluded and the staff member was found to have led to the adverse event, then disciplinary processes ensued. There had been instances where people had lost their jobs because of this.

On a programmatic level, the Department had partnered with Danosa, which had a programme called Health Workers for Change. It was piloted in Francis Baard and Pixley-ka-Seme but only ran for two years. The Department believed that if resources allowed, they could expand the programme in order to reteach staff and appeal to staff conscience in how they treat the public.

Ms Matladpane stated that the Department currently had summons that amounted to R102 million. The most recent one was received last month, for R32 million, as a result of a baby who had contracted cerebral palsy in one of the Department’s facilities.

Mr Richard Jones, Chief Director, Northern Cape Department of Health, added on to what Ms Mazibukwe said about staff attitudes. The Department had done significant analysis in the Kimberley Hospital but they had difficulty doing those surveys in the very rural, sparse clinics. The Department was currently exploring using some technology, for example, tablets, to try and collect data. The Department believed that there was a correlation between staff attitude and staff satisfaction. When staff were dissatisfied, they tended to treat people badly. The Department was trying to identify where that staff dissatisfaction was and linking it to patient satisfaction. At the moment the challenge was collecting reliable data.

Mr Gustav Pistorius, Chief Director: Infrastructure and Technical Services, Northern Cape Department of Health, wanted to highlight the challenges faced on the technical projects and infrastructure. The province was unable to get technical staff with qualifications. He pointed out that the two implementing agents had no engineers. That resulted in several problems. The Department appointed an experienced monitor engineer. What he found was that the designs for the projects were done by inexperienced engineers which resulted in design problems and mistakes.

Mr Pistorius wanted to correct the MEC on the Mental Health Hospital – the first contractor that was appointed completed 50% of the work at an expenditure of R458 million. The design and work was so badly done that the Department had to replace that contractor. The replacement contractor did not have sufficient staff. At this point 65% was complete. The contractor was supposed to complete the project by January 2014, but because of bad workmanship and the bad designs of the first contractor, he got an extension time until May 2015, but he could not complete. The project would probably be completed by the end of 2016. Currently the Department had spent a total of R900 million, and would complete the projection at around R1.2 billion, not R2 billion.

Nationally, what needed to be looked at was how to get engineers and get them the experience by means of mentoring. The Department could not get fully qualified engineers, they got recently graduated engineers with minimal experience but they were good people. Mr Pistorius recommended that they look at the mentorship programme. Most other provincial Departments shared the common problem of requiring experienced people. He was of the opinion that if this was done infrastructure would improve a lot.

The Chairperson apologised for the time constraints. She heard that the first contractor did 50% of the work with almost the entire budget meant for the hospital. The other contractor did only 15%, since the hospital was now at 65%, but the Chairperson did not see much difference. She said the project may very well end up costing R2 billion. It was not good enough or acceptable to finish in 2016 some measures needed to be put in place to get it done. Suggestions could be made as to how to resolve this matter. Investigation may be necessary, which should have been done long ago as it was in the MEC’s hands. The Chairperson wanted to know why the designs were bad because in her understanding, the designs were not done by the contractor. The other issue was why the other contractor was even appointed when he did not have sufficient staff.

Ms L Zwane (ANC, KwaZulu-Natal) took note of the difference in demographics between the two provinces.

KwaZulu-Natal demonstrated that they had plans on how to improve the audit outcomes. Part of that was ensuring appropriate staff were appointed to do the job. The MEC of KwaZulu-Natal did say that the HOD was going to be appointed. It was hoped that soon after the CFO would be appointed. What stood out for Ms Zwana was that every time there was a presentation before the Select Committee, there was an outcry about lack of capacity, especially in areas like supply chain. However, before giving people jobs, interviews were conducted. During this process you were able to pick up wither people possessed the capacity the Department required to run the finances. Issues like three quotations not being called were surprising. Ms Zwane wanted to know why this was happening if the people were being interviewed and those with the requisite skills were being appointed.

The Department had done a lot of good regarding infrastructure in the province. There were still challenges, but there was still good work being done in infrastructure development. Particularly, also, she commended the Department for the appointment of in-house engineers and the other staff that ensured that structures were sound and built in accordance with the norms and standards that were required.

Regarding the legal issues, Ms Zwane, said that there were people who were responsible, the professional staff like doctors and nurse, so she wanted to know what steps were taken because they were causing unnecessary expense for the Department. There should not be such negligence from professional, experienced staff that cost the Department so much money. She wanted to know if people had lost their jobs due to such negligent acts.

She acknowledged the outcry for the introduction of legislation that would enable the Department to offer a follow up and it save the Department a lot of money. She said that the Committee should look into this.

There were many issues in the Northern Cape that were remarked on by Mr Jack. The reason may be demographics but with the mental health hospital, there should have been interventions long ago, by way of research to find out what the problem was. The Department seemed to be avoiding something that stopped them from opening a Commission of Inquiry into this matter rather than spend so much money. The Department was spending their already meagre budget on this one facility. Ms Zwane suspected there was some kind of corruption that needed to be investigated very speedily.

Ms Zwane was impressed by the reduction in the maternal mortality rate, and in all the other areas where they had affected change and improvement. Despite being a small province, they still had a lot of positive issues. She wanted to raise the issue of professionals not wanting to work there because the area was rural. The Department had said that the whole province was rural, and yet in the presentation it was said that there were areas that were not deemed to be rural. She would think it would be equal, not to pick and choose specific areas.

The last issue regarded staff working during the day and night, which Ms Zwane thought was bordering on labour issues. She said this could also be contributing to staff attitude. When people were tired they could not render the best services. The Department needed creative ideas how to get incentives for people to stay in the province and provide the necessary skills.

The Committee would be watching the interventions regarding the audit outcomes, as this was not the last time the province would be presenting. The Committee would later on in the year, look at how the province was doing, and whether they were progressing towards a clean audit.

Ms P Mququ (ANC, Eastern Cape) addressed the provinces in Tshwane.

Mr M Khawula (IFP, KwaZulu-Natal) began with the medico-legal matters, for which KwaZulu-Natal had high numbers. There was an advert on Ukhozi FM some 3 years ago, where a particular company was advertising offering to assess and launch claims for people. So there was going to be a problem. He wanted to know whether it was wise to include stakeholders, or whether it would cause the matter to drag on. Instead maybe they should convene an indaba or summit of the Department so that it was in-house. If everyone was involved, those who wished to continue would do so and just look for new ways of diverting the loopholes.

It was a good thing that Departments were trying to capacitate themselves in terms of infrastructure programmes. However, the downside was what would the Department of Public Works do now? If everyone had the function that Public Works had in the country, even at a National Level, there would surely be a shortage of the people needed. Not everyone would get the skills they needed. Some provinces would suffer, especially the rural provinces. Private consultants paid better than government as well.

MECs should discuss this matter at their meetings, and discuss how they could help each other. For example, the mental health hospital in Northern Cape could have sourced help from another provincial Department to ensure that the designs would not be problematic in the future. Technical skills will not become available unless provinces began helping one another. MECs should take this issue to their meetings.

Regarding the issue of penalties in the Northern Cape when signing contracts. When the mistakes happen, were the contractors being let off without a penalty? Mr Khawula requested clarity on the contracts, what they said about expectation of contractors and what happens if the contractor fails to perform, and were the contractors being paid up front. 

The Chairperson stated that the Committee was in a position to understand the challenges faced by provinces but she also acknowledged the achievements in both provinces.

When Mpumalanga presented with Gauteng they also felt small, but principles were principles. No matter the size of the province and population, the manner in which projects were implemented was the same. The Committee did take note of the problems raised in terms of the scattered population. It was expensive to run the province with the budget given according to the number of people per province.

It was also an issue with the health facilities that so many people were needed for building a facility, but the Chairperson said it was more a policy or legislative matter, so the Parliament had a role to play in dealing with the issue.

The Chairperson stated that she was sure the other members agreed with the suggestion made by Ms Mququ of the need to visit the Northern Cape to see the facility.

The performance of the provinces was affecting Members directly. Everyone was affected, especially the ruling party.

A lot of good work went unseen because provinces were not communicating. She suggested a “Health Month” to showcase all the good things being done by the Departments.

Regarding the issue of waiting times, despite the good work being done, that good work needed to result in good services for the people. The clinic may be beautiful on the outside but if services were not good at clinical level, those patients would not care about that the building itself.

Sometimes there was a close relationship between dissatisfaction of nurses and patient dissatisfaction. But sometimes they were used to it. People would come to a clinic and wait until late; the nurses would only attend to the patients late and then leave. They were not being supervised and they knew no one would come. Supervision and monitoring in health facilities was important to see that service delivery was improving.

Addressing the HOD, the Chairperson said that the Committee would not have known certain issues if the MEC had not brought them up first. The Chairperson was not convinced that they would be able to deal with some of the challenges. There were serious challenges in the Northern Cape, but the Committee was to be assisted by the HOD. Where it was beyond HOD control, she should go to her principal, the MEC, to see how she could be assisted by the collective. Some issues complained about were within the HOD’s control, especially as an accounting officer. The Chairperson was not convinced that there were precise plans to deal with those issues.

Regarding audits, the Department was hoping to maintain the qualification and that was not good enough.  The Committee wanted a clean audit but first to talk about an unqualified report. They did not want the Department to maintain qualified status, they wanted the Department to move towards unqualified and then clean audit because it was possible.

There was a suggestion of standardising designs of major hospitals or primary health care facilities, depending on size of people being serviced. The Department of Education had done this. There was a standardised school that could be modified. There was no need to start a completely new design each time. Something like this should done in health especially with the lack of skill labour.

The Chairperson agreed that KwaZulu-Natal was doing well with infrastructure and wanted to communicate about the good work being done. This was important because if the issue of Nkandla was looked at, it was not the President, it was the officials. Now it was a matter of the country.

The Department was not given an opportunity to present on HIV/AIDS. KwaZulu-Natal was still number one for HIV after so many years. Big provinces came with big problems. KwaZulu-Natal was number one since 1994. Programmes being put in place for that needed to be looked at.

Land was an asset; everything on top was a top structures and improvements. The government builds hospitals and clinics on the land but they forget to transfer it. Land may have belonged to the municipality or tribal authority. Provincial government then loses the asset when they do not transfer it. Since 1994, when provinces began, most properties were transferred to municipalities. Now schools belong to the municipalities and later transferred to provinces, but sometimes this did not happen.  When registers were checked, assets were missing. Transfer needed to happen.

Medico legal matters were critical. People were taking advantage of the opportunities, but they were using the government’s mistakes. Some of the mistakes could be avoided. The number of claims was too high. The Chairperson agreed with Mr Khawula to start internally. There could be a summit that included everyone but it was important to understand where the problems came from. Some of the claims were coming from far, they needed to prevent them happening. 

This was not the last meeting, the time was up but the Chairperson invited written responses. The Committee would be interested to get the quarterly report. The Chairperson suggested that Departments get the Auditor-General to assist with the books for the quarterly report. By the time you to the end of the financial year and the audit period, all issues for qualifications would have been dealt with. Next time they would be discussing progress. The problems could be dealt with.

In terms of appointment of HOD, those were critical posts. Those appointments must be put through. If people were deployed, because the ruling party was accused of having its own employment policy, it must be ensured that the person was qualified. Each MEC was given a chance for closing remarks.

Mr Mack Jack welcomed the visitation to the mental hospital in Kimberley and the Committee getting first-hand information on it. He suggested that that visit should be preceded by a comprehensive report of the hospital itself because this presentation was merely a summary, so that report would include the evolution of the hospital and other matters which include the finances. He thanked the Committee for the encouragement and for being forthright with the issues because that would bring change. Some of the issues brought up were underlying strategic interventions to improve on service delivery.

Dr Dlomo had left, but another delegate spoke on his behalf. He credited the Northern Cape for implementing certain programmes. Regarding the new hospital, it was complete and the roads to the hospital were resurfaced.

The Chairperson thanked everyone for their time and closed the meeting.