Human resources & community health workers: Eastern Cape, Free State; Northern Cape; Infrastructure projects; Financial management; Ideal Clinic Initiative - pm

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17 August 2016
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Portfolio Committee met with three provincial health departments – from the Eastern Cape, Free State and Northern Cape – to be briefed on human resources, with an emphasis on community health workers; infrastructure projects; financial management, particularly on issues that had been raised by the Auditor General and their plans to address them; supply chain management and procurement; and progress and challenges regarding the implementation of the Ideal Clinic Initiative.

The Eastern Cape Department of Health (ECDoH) said its key service delivery priorities included curbing the burden of disease, achieving quality improvement, as well as universal coverage. With this set of priorities, ECDoH sought to ensure that it fulfilled its mandate to the people of the Eastern Cape, while ensuring that it contributed significantly towards the implementation of the National Development Plan objectives on health. The current financial situation had caused ECDoH to come up with strategies that would ensure its expenditure was focused on its core business. A moratorium had therefore been placed on the filling of non-essential posts, and a provincial cost-containment committee had been introduced to assist with the close monitoring of the Department’s expenditure. As far as actual service delivery was concerned, it was focusing on strengthening the patient referral system by introducing regional forums; improving the relationship between district clinical specialists and hospital-based specialists; improving the skills of health care personnel through well-coordinated training; the strengthening of complaints and adverse events management, in collaboration with the Ombuds office; and implementing prescribed norms and standards.

The Department had gone through a journey of being disclaimed in 2009/2010, to having qualification matters and compliance findings. This year, it had received an unqualified audit, and had been left with five compliance findings. The majority of work done surrounded the irregular expenditure and qualifications. Assistance had been received from the provincial treasury and the Department had been working closely with the Auditor General to ensure a re-auditing of some of its prior balances. However, there were still a few things that needed to be adjusted in order to achieve the goal of a clean audit in 2018/19 financial year. The two issues of concern were with regard to the irregular expenditure, and fruitless and wasteful expenditure. The irregular expenditure was currently R212 million, but this was based on a previous review, dating back to 2010/2011.
The Free State Department of Health reported that it had five districts, with 221 primary health care (PHC) facilities that rendered services to a population of 2.2 million uninsured people out of a total population of 2.7 million. It was expected that they would all be Ideal Clinics by the end of the 2018/19 financial year. Some of the challenges facing the province included poor infrastructure; inadequate human resources for health in terms of appointments of staff; insufficient budget for the Ideal Clinic (IC) Initiative; and slow supply chain management (SCM) processes to procure IC equipment. Some of the lessons learnt from the past financial year were the need to prioritise budgets for the IC programme, SCM processes for this programme, as well as carrying out weekly monitoring of the IC Initiative’s progress.

The Northern Cape Department of Health indicated that it had received a qualified audit opinion, with emphasis on issues such as movable tangible and intangible assets; accruals and payables; accrued departmental revenue; commitments; irregular expenditure; and SCM, procurement and compliance. The leadership of the Department had experienced a change through the transfer of personnel from various offices to specifically address the issues around the audit outcomes and other service delivery matters. Progress had been made in reducing the number of qualifying paragraphs from eight to five.

The completed project of the new De Aar Hospital had been handed over to the Department, and was ready for operationalisation, provided that some form of funding was received. Other completed projects included the upgrade of a 36-bed mental health unit, which would be ready for operationalisation by October 2016 to commemorate Mental Health Month; accommodation of 25 state patients currently in correctional facilities; the upgrading of the emergency medical service (EMS) station at Calvina; and provision of fencing and guard houses for clinics, hospitals and community health centres.

During the deliberations on each presentation, some of the common themes that Memebers raised were about supply chain management, the revised organogram, community health workers, ideal clinics, vacancy rates, staff shortages, backlogs, male circumcision, infrastructure and maintenance, financial and operational management, and payments of invoices made in excess of 30 days.

Meeting report

The Chairperson emphasised that the process of engaging with the various provinces was aimed at changing the social conditions of South African citizens, as far as the health sector was concerned. The Committee had conducted oversight visits to these provinces, but it also had to ensure that accountability was achieved.

Eastern Cape Department of Health (ECDOH): Presentation
Dr Pumza Dyantyi, Member of Executive Council (MEC) for Health, ECDOH, said that she was in a celebratory mood because ECDoH achieved an unqualified audit for the year 2015/16, and was celebrating the 20th anniversary of the South African government’s collaboration in the programme of medical training for children.

For this current term, ECDoH had identified focal areas as key service delivery priorities for health, which included curbing the burden of disease, achieving quality improvement, as well as universal coverage. With these set of priorities, ECDoH sought to ensure that it fulfilled its mandate to the people of the Eastern Cape, while ensuring that it contributed significantly towards the implementation of the national development plan’s (NDP’s) objectives on health.

The past financial year had been a strenuous one in the Department, based on the challenging fiscal outlook that also affected the country as a whole. Despite this challenge, it had still maintained its commitment of service delivery, especially with regard to non-negotiables. This financial situation had caused ECDoH to look deeper and come up with some strategies that would ensure its expenditure gave priority to the core business. A moratorium had therefore been placed on filling of non-essential posts, and a provincial cost-containment committee had been introduced to assist with the close monitoring of the Department’s expenditure. This had resulted in ensuring that it had spent its budget according to priorities.

During the current financial year, ECDoH was determined to make use of the previous initiatives to achieve its service delivery obligations to the poor people of the province. ECDoH was determined to improve efficiency in public health care, in order to make a significant impact on the lives of the people of Eastern Cape, who were the beneficiaries.

Dr Thobile Mbengashe, Head of Department (HOD), ECDoH outlined the content of the presentation, saying that the presentation would start with the human resource status in the province, which would highlight the different categories of the available skills, as well as the levels of vacancies that existed; progress on infrastructure projects; 2015/16 audit outcomes; supply chain management and progress on procurement; progress and challenges in the implementation of the ideal clinics realisation programme; and strategies to deal with medico-legal claims.

Ms Karen Campbell, Deputy Director General (DDG), Human Resources and Corporate Services, ECDOH, reported on the human resource (HR) status of the department, noting that as at 31 July 2016, the headcount was 48 432, which included 8 859 abnormal appointments. The number of posts on ECDOH’s organogram was 45 426; filled posts were 39 573; vacant posts were 5 853; and this resulted in a vacancy rate of 12.9%.

ECDOH was currently prioritising the appointment of core service delivery posts, otherwise known as clinical posts. Priority was also being given to the appointment of all outstanding HR accruals, as well as payment for the performance management and development system (PMDS). A turnaround plan had also been put in place to pay all outstanding leave gratuities by 31 December 2016.

The number of medical students that ECDoH had in Cuba was highlighted. There were nine students at the first year level, and their completion date was 2022; 90 students at the second year level, with a completion date of 2021; 97 third year students, with a completion date of 2020; 84 fourth year level students, with a completion date of 2019; 11 fifth year level students, with a completion date of 2018; and five final year students who would qualify in 2017, as they were currently doing the South African aspect of their medical studies. The 11 other final year students would complete their studies in 2016.

ECDOH’s community health worker (CHW) programme was a community-based cadre that resided within the community, was familiar with the community, elected by the community, and participated in the community formations. CHWs were an extension of health promotion that provided technical support to communities in terms of providing preventive, early identification of diseases, referral and promotion of health services.

ECDOH operated a community-centred model that was driven by health promotion managers, practitioners and community health workers. Phase 1 of the model dealt with community mobilization, engagements and dialogues aimed at assisting to identify the community needs, refer after-community triaging, and link with the Masiphathisane War Room. Phase 2 was managed by professional nurses that treated and provided clinical support, referred to the next point of care, and linked with mobile clinics for further management.

The challenges facing the CHW programme and solutions proffered were highlighted. The first challenge was the formal employment of community health workers, and the solution put forward was to have a skills audit for community health workers and channel them towards formal training in and out of the Department. Another challenge was in relation to the public workers’ reporting system, and the solution proffered was for the Department to work with public works to intensify reporting and employ data capturers that would ensure optimal reporting. A challenge was also noted in home care kits, identification uniforms and badges. The solution here was to procure home care kits and provide uniforms for the CHWs.  Clear job descriptions and activity reporting of CHWs was another challenge, requiring a review of job descriptions, ensuring uniformity and making sure all CHWs operated in war rooms. The last challenge identified was in relation to CHWs’ debriefing sessions, and the solution proffered was for all sub-districts to host debriefing sessions for the CHWs to deal with bottlenecks.

Dr Mbengashe presented an update on the organogram process of the Department. He said that every department was saddled with the responsibility of reviewing its organogram after a period of five years, and assess if the organogram still aligned with the priorities of the department. ECDOH’s organogram had been in place since 2007, but a review process had commenced in 2012. The MEC had provided clear guidance, which was to the effect that the organogram should be apt and be more aligned to the priorities of the Department of Health (DoH), which was to respond to community needs and prioritise frontline services. In providing the design of the programme, the people that supported services had to be brought closer to the service areas, particularly because achieving stronger service delivery would require having strong units in the areas of finance, HR, supply chain management (SCM), information, connectivity and Information Communication Technology (ICT). The MEC had also instructed that the organogram should be streamlined to consist of fewer people and fewer levels of managers, and instead focus on recruiting as many operational people. This process also included the dis-establishing of sub-district offices. About 29 sub-districts had existed before the introduction of the process of reviewing the organogram. However, these sub-districts had been moved out and people within such offices had been moved to the service delivery areas.

The last component of the review process was making sure that the head office was streamlined to consist of fewer, but highly skilled, individuals. The head office would support the eight districts, ensure that the districts were stronger by providing stronger leadership, as well as ensuring that eight major hospitals were strengthened.

The revision of the organogram took into consideration the different hospital services in terms of the service platform, and it used the ministerial gazette of August 2012, which provided that a district hospital had to have a minimum of 50 beds. It had been noticed that there were 18 hospitals that had fewer beds than was required. Such hospitals had then been reclassified as community hospitals, which continued to provide services to the communities but had lower levels of referrals. Cases that required a higher level of competence and skill than such community hospitals could provide, were directed to district hospitals. It was therefore necessary to ensure that each layer had the right level of professionals, with the right level of skills and the right numbers, with the ability to provide the necessary support.

The first version of the organogram had started in 2012, and had cost a sum of R23.3 billion for 81 774 posts. The considerations already alluded to were then implemented to revise the organogram. ECDoH had also made use of a scientific approach in the revision process, which was to make use of the patient load of hospitals to design HR services that would match the required capacity needed for service delivery. A number of scientific methods had also been used for the review process, and they were referred to as workload variabilities. A national tool, known as Workload Indicator of Staffing Needs (WISN) had also been used for the review process. This tool was a workload assessment tool developed by the World Health Organisation (WHO), which calculated the numbers needed for assessment. The district health information system (DHIS) was then used to provide the numbers.

Using these aforementioned tools, the first reviews of the organogram reduced the amount to R16 billion, but this was still above the Compensation of Employees (COE) budget allocation of R13.5 billion. The Department therefore decided to look into the way hospitals were being managed in terms of the provision of services, which included the 24-hour services, the competence of staff providing the services to patients, as well as the number of doctors and specialists making use of theatres. It was discovered that the average occupancy rate of most district hospitals was around 65%. This percentage was then used as the baseline occupancy rate for hospitals. It was also discovered that there were more professionally trained nurses when compared with the number of enrolled nurses and enrolled nurse assistants, with a ratio of eight to five to three, respectively. It was then decided that more enrolled nurses and nurse assistants should be provided for the professionally trained nurses in district hospitals.

The second review of the organogram reduced costs to R10 billion, and this had been used as the baseline for further reviews of the organogram. The third phase of the organogram involved engaging and consulting with each of the facilities to consider areas and posts to where more people should be recruited. This process was able to assist the Department in addressing specific areas that needed attention and gaps to be closed. It was in the final stages of recompiling the data and it was expected that the organogram should be finalised in September, with costs at about R12 billion.

The Department also engaged with its social partners and unions in the review of the organogram. The unions had raised concerns of people losing their jobs as a result of the review process, but the MEC gave an undertaking to reassure the unions that there would be no loss of jobs, but there may be movement of people from units that were overcrowded, to other units. A migration plan had been developed explicitly to state the process that would be taken in moving people, and to ensure transparency in the movement of people from one service unit to the other. This migration plan had been presented to the social partners of ECDOH, and the Department was in the final stages of engagement.

The last process would require the MEC to visit the 18 hospitals that had been converted into community hospitals to discuss the review process, and to reiterate that there would be no revision or reduction of services, except if it was discovered that any of such community hospitals provided services beyond their operational scope. The timelines for the final stages of the organogram were highlighted.

Mr Mlamli Tuswa, Infrastructure Manager, ECDOH, said that his presentation on infrastructure progress would cover six areas, which included the overall performance of the programme, maintenance strategy, medical equipment, progress made in internal capacity building, public works programme, and accommodation projects in terms of providing decent living spaces for health professionals in the province.

In terms of the overall performance of the province, 118 projects had been recorded for the first quarter. These projects were divided in accordance with the eight programme categories of the Department, which included upgrading of clinics and community health centres (CHCs); the provision of bulk support services in terms of water and sanitation; maintenance of district hospitals; three projects done in the provincial hospitals; maintenance and upgrading of the emergency medical service (EMS) base; the provision of guard houses and fencing; and general maintenance and repairs.

ECDOH’s budget for this year was an average of R1.4 billion, and it had been allocated to the eight critical programmes. About R233 million had been spent in the first quarter, which was equivalent to 17% of expenditure, as opposed to the 25% that should have been spent in terms of the straight line projection. The bulk of the budget was derived from the Department’s equitable share, followed by the municipal infrastructure grant (MIG). The Department had derived R3.8 million from the Expanded Public Works Programme (EPWP).

The Department was behind by 8% in terms of the straight line projection because of the current procurement of medical equipment. Two projects that needed the appointment of contractors for execution had been targeted for the first quarter, and they had been appointed in the last month of the first quarter, but the projected cash flows for those two projects would be realised only in the second quarter. Also, two contractors had been appointed for the building of the EMS training college and EMS base projects. One of the implementing agents of the Department had been faced with tax issues between May and June, and the Department had been unable to pay the agent. Nevertheless, the issue had been resolved. All these factors had contributed to the under-spending in the first quarter.

With regard to the maintenance strategy of the Department, the province was divided into eight municipal regions, which was an approach that would enable it to attend to the particular regional facilities. The second aspect of the maintenance strategy was the creation of a centralised maintenance management system, which was important for gathering information on all plant and machinery in a central repository. A centralised call centre had also been established to receive all infrastructure related calls. The Department had procured specialist consultants in the field of clinical, mechanical and electrical engineers. Contractors based within the eight regions had also been procured. This was aimed at using locally-based people, and in effect to deal with issues of the development of small and medium enterprises, attain quick dial time or responses to issues, and create employment.

The Department was investing in quality assurance for each region. It was also making sure that feedback was given to clinical service users. Work packages were being identified to be done by in-house employees. Value for money was stressed as a priority in terms of completing projects within the targeted time, cost and scope, and accountability was ensured.

As far as the work packages were concerned, 11 different packages had been developed, which included packages on demand emergency maintenance that focused on life-threatening support services; non-demand emergency maintenance; scheduled maintenance; facility management; interim repairs; an accelerated backlog repair programme; special repair programmes; clinical repair programmes; a compliance upgrade programme; a housing backlog programme; and a backlog planning programme.
The maintenance projects that were completed in the first quarter were outlined.

Regarding the procurement of medical equipment, the department had adopted a different a different approach, which was a framework contract. In other words, it was no longer buying equipment for one purpose, but was instead creating contracts with the intention of ensuring the existence of ten contracts that had facilities that any other provincial facility could make use of; maximisation of buying; taking advantage of the latest technology in the industry; as well as putting issues of maintenance and warranties into consideration.

There were six categories of equipment that were currently being procured, which were imaging equipment, critical or life support equipment, diagnostic and rehabilitation equipment, medical furniture equipment, office furniture and cleaning equipment, and surgical instruments and linen, or clothing. All six categories had gone through the tender process. The first batch had gone through the Bid Adjudication Committee (BAC) and National Treasury, while the second batch was with the bid evaluation committee and would go to the BAC. Batch Three and Four had been tendered out, and the tender would close on 26 August 2016. Batch Five and Six would be put out to tender shortly. Some of the equipment existed within the transverse tenders that National Health was running.

Some progress had been made in terms of infrastructure capacity building. Some positions that had been filled included the post of the general manager; mechanical and electrical engineers; quantity surveyors; civil engineers; three architects; and five clinical engineers who dealt with medical equipment. Some challenges faced in filling the vacant positions completely could be traced to the stringent requirements provided by the Division of Revenue Act (DORA) process, which required people to be registered with various appropriate associations, while people who had applied did not belong to any of these associations. Although the Department had appointed some people, such people would need to take their appointment letters and bargain at some other provinces. The Department had written to Treasury requesting a reconsideration of some of these stringent requirements.

R2.8 million had been allocated for the EPWP programme in the current financial year. 50 young professionals had been recruited, and were receiving workplace training opportunities in various areas. 31 of them were receiving training in clinical engineering, and had been deployed in hospitals. Their exit point would be to obtain trade certificates that would qualify them as technicians. 14 people had been deployed in the soft services, which focused on laundry and kitchen services, while five had been deployed as administrative staff.

The Department had allocated money to focus on accommodation projects for health professionals. Six projects had been targeted for the year. These were Mthata nursing college accommodation refurbishment; Taylor Bequest Hospital in Eludini; All Saints Hospital in Engcobo; Nessie Knight in Tsolo; Mjanyana Hospital in Engcobo; and Madwaleni Hospital in Willowvale. An update on each of these projects was provided. Other hospitals for which accommodation would be considered in the current year were Isilimela, Canzibe, Greenville, Tafalofefe, Cofimvaba, Nompumelo, Frontier, Nelson Mandela Academic, and Mthata Regional hospitals. A business case had been produced for the aforementioned projects, and the Department would be approaching National Treasury on Monday to bid for the projects.

Mr Simon Kaye, Chief Financial Officer (CFO), said that the Department had gone through a journey of being disclaimed in 2009/2010, to having qualification matters and compliance findings. In 2010, the it had had 11 qualification items and 26 compliance findings. This year, it had recorded an unqualified audit, and had been left with five compliance findings. The majority of work done involved the irregular expenditure and qualifications. Assistance had been received from the provincial treasury and the Department had been working closely with the Auditor General (AG) to ensure a re-auditing of some of its prior balances. However, there were still a few things that needed to be adjusted in order to achieve the goal of a clean audit in the 2018/19 financial year.

The two issues of concern were with regard to irregular expenditure, and fruitless and wasteful expenditure. The irregular expenditure was currently R212 million, but it was based on a previous review, dating back to 2010/2011. There was a need to recalculate this expenditure in terms of the appropriate channels, which could be done at the departmental, provincial or national level. The Department had also recorded an average of R90 million in unauthorised expenditure in the previous financial year, but a lot of work had been done to eliminate this issue. Specific provincial cost-containment measures had been put in place, and committees had been set up to ensure that all procurement, payments or cash flows came in through the programme managers, but would be prepared and dealt with at the district level.
The impact of medico-legal claims on the Department had been horrific, because it had received quite a number of claims that had not been budgeted for.

In terms of the progress on the SCM and procurement, the previous permanent general manager (GM) for SCM had been appointed in 2009. Another permanent GM had been appointed in December 2015. The centralisation of procurement plans had become increasingly important. The only challenge being faced with the procurement plans was the possibility of them becoming quite burdening. In considering progress on the procurement plans, the non-negotiable items that formed the key areas of focus in reporting were highlighted. They included physical security, medicine, capital equipment, infrastructure, laboratory services, waste removal, patient food and cleaning services. These items were reported on, on a monthly basis.

The majority of the large contracts awarded were in respect of medical equipment. Procurement of medical equipment was always challenging, because of the specifications, but the Department had taken a collective decision to focus on these areas. The creation of rate-based term contracts meant that it could carry out procurement on a rate basis, while any institution within the province could purchase against those particular contracts.

The major focus with local procurement was on security, waste removal, patient food, cleaning services and furniture. The idea behind local procurement was to have services provided by the local communities, and not necessarily imported from the big cities or other provinces. It was aimed at boosting the local economy.

Dr Patrick Maduna, DDG: Clinical Management Services, described the progress on the ideal clinic (IC) programme, which was aimed at getting primary health care facilities to function optimally. In terms of the IC revitalisation programme, an ideal clinic was defined as a clinic with good infrastructure, adequate medicine and supplies, and good administrative processes, and made use of applicable clinical protocols, policies, guidelines, and stakeholder support. The ten components of ICs were highlighted.

Various levels of status determination were used in assessing ICs. These stages included facility management; the perfect permanent team for the IC realization; peer reviews by other provinces; as well as the use of a software programme to get updated reports on the progress of the Department.

At the time of compiling the presentation, the system used for assessing ICs revealed that 98% of the clinics in the districts had conducted their status determination. The best and worst performing facilities identified in the province, with a record of 70% and above, were highlighted (See attached document).

As far as the implementation progress was concerned, components or areas with partial, full or no implementation were highlighted. 241 clinics had been targeted for the 2015 financial year. The Eastern Cape had been assessed by KwaZulu-Natal. 15 of the provincial clinics assessed had achieved ideal clinic status.

The evaluations and assessments had been taken into consideration for the development of interventions for poor performing facilities. Some of the interventions included the training of health professionals on integrated clinical service management (ICSM); procurement of medical equipment; implementation of medicines management at primary health care (PHC) facilities; dissemination of new protocols, especially those with high impacts on waiting times; implementation of signage and notices in PHC facilities; implementation of development partners’ support; implementation of a PHC patient recording system; appointment of data capturers in the Buffalo City health district; and the procurement of internet access routers for PHC facilities.

Other interventions for poor performing facilities demanded the strengthening of leadership and governance of hospitals. The Department was looking to address this through the appointment of chief executive officers (CEOs) for hospitals, clinical heads of units and departments, PHC facility managers, hospital boards and clinic committees. In terms of medical products and other commodities, central chronic medicine dispensing and distribution (CCMDD) projects had been rolled out to all districts. Medical equipment for all facilities was also being procured. In terms of information systems and technology, the Department had rolled out health record booklets to all facilities.

As far as actual service delivery was concerned, the Department was focusing on strengthening the patient referral system by introducing regional forums; improving the relationship between district clinical specialists and hospital-based specialists; improving the skills of health care personnel through well-coordinated training; strengthening complaints and adverse events management in collaboration with the Ombuds office; and implementing prescribed norms and standards.

Dr Mbengashe introduced the aspect of the presentation which dealt with the strategy to deal with medico-legal claims currently being faced in the province. The Department was being targeted on the basis of not using the Road Accident Funds to fund lawyers. The Minister of Health had held a national workshop with a number of experts in the medico-legal field, and had highlighted the major strategies that would be used in dealing with medico-legal claims. The first of these was aimed at dealing with the huge number of claims that had been received. The Department had recorded contingent liabilities estimated at R14 billion, which was derived from an average of eight million claims. These claims were not necessarily debts recorded against the Department. After claims had been made against the Department, letters of demand would be sent to it. The Department would then forward such letters to the legal team, who would then formally respond in the common form of defence, and notify the court of its intention to defend such claims. A case management system existed within the Department to assess the validity of each case.

Regarding the outcome of claims, it was noted the total expenditure on claims for 2013 amounted to R32.5 million, as opposed to the claims of R390 million that had been forwarded to the Department. In 2014, claims amounting to R1.8 billion had been received, but the expenditure on such claims had been R49 million. In 2015, the claims had increased to R4.8 billion, but the Department had paid out R75 million. In 2016, the claims had further increased to R6.9 billion, but the Department had ultimately paid R266 million in claims. The total amount that had been paid in claims since 2012 was R424 million.
The specific provincial interventions in relation to claims would be provided to the Committee.

The average medico-legal settlements paid in the last four years had been about R52 million per annum. Both national and provincial interventions were being implemented to manage this problem. A thorough assessment of the claims brought against the Department revealed that majority of the claims were brought for cases of cerebral palsy, with the second area being orthopaedics, while the third area focused on brain or head injuries.

The Department admitted that medico-legal claims came only as a result of the quality of service delivery. It was also admitted that although incidences of cerebral palsy suggested traces of negligence in service delivery, there were other areas that were beyond the control of the Department. It was discovered that the biggest issues surrounded cases of mothers who were not progressing appropriately, and had not been promptly referred to district hospitals. Other issues identified in claims of cerebral palsy included delays in ambulance services, districts hospitals not having the appropriate facilities to monitor the condition of babies in pregnant mothers, delays in performing caesarean sections where necessary, and resuscitation of the babies.
Four major hospitals battling with the above challenges had been identified for intervention in this regard. The proposed interventions included the re-training of the clinical staff to identify and detect problems early, encouraging mothers to visit the hospitals for antenatal care as early as possible, and placing ambulances in strategic locations to transport mothers to referral hospitals. The Department was also procuring equipment for every hospital to enable them carry out continuous monitoring of the delivery of babies. The capacity of doctors carrying out caesarean sections was also being improved, protocols for keeping babies warm were also being introduced into the system, and all documents would be digitised for easy archiving.

In addressing medico legal claims, one of the strategies adopted was the constitution of a team of specialists to engage with heads of departments from the different provincial hospitals, and to assess the various cases on their merits, and then decide on the strength or weaknesses of such cases. Another strategy was to build a strong layer of legal defence. The last strategy was to address cases through the use of a mediation processes.

The MEC concluded the presentation by saying that medico-legal claims remained a serious area of concern for the Department.

Mr H Volmink (DA) commended the efforts that had been put into ensuring an accurate assessment of the human resources needed for the Department to run at full capacity. Clarification on the role of bid committees for SCM was requested. Had any officials involved in any of the irregular SCM practices alluded to in the presentation been identified, and what had beenthe consequences meted out for such irregularities?

Ms L James (DA) said that the revised organogram would assist the Department in service delivery. She noted that only a few of the 241 clinics had been able to achieve ideal clinic status. What timeframes had been set for the turnaround strategy for other clinics to achieve the ideal clinic status?

Mr D Khosa (ANC) raised the issue of CHWs being elected by the communities. He wanted to know if such CHWs were directly employed by the Department after such elections, or if they were afforded other training to see if they met the minimum requirements. Who was responsible for such training, if it existed, and if not, what was the reason for its non-existence? He wanted to know what challenges had been faced in electing CHWs, and how such challenges had been dealt with. The Department had mentioned the ten best performing and ten worst performing ideal clinics in terms of facilities. However, he wanted to know the total number of facilities available for all ideal clinics; if the Department had analysed the reasons for the poor performance recorded in some ICs, what the results of the findings were, and if operational managers had been assigned to such facilities. He also asked if the Department was in a position to disclose its infrastructural backlog, the extent to which such backlogs affected service delivery, and if there was a turnaround strategy to deal with such backlogs.

Mr S Jafta (AIC) said his concern was with regard to the Department’s 12.9% vacancy rate. He wanted to know what plans had been put in place to address this issue, what the Department was doing to address the issue of the absence of operational managers in some district hospitals for more than five years, as well as addressing the non-payment of those appointed to act as operational managers in the interim. He sought clarification on the election of CHWs, whether or not the CHWs were directly employed by the Department, and issues of non-payment of some CHWs in the event that the Department was responsible for their direct employment. He asked what interventions had been put in place in the provinces for male circumcision, especially because the high rate of deaths recorded during initiations, and whether the Department had considered the need to train more male health workers to assist with the initiation process. He asked for the reasons for the small number of clinics that had achieved IC status, and whether the lack of medicines in some clinics served as a contributing factor to this, and the strategies put in place to address this problem.

Dr P Maesela (ANC) asked for clarification on the 8 859 abnormal workers in its 48 432 total of staff in the Department, as well as explanation for the abnormal appointments. He also wanted to know how it was dealing with the abnormal situation of not recruiting or employing people, despite the increasing population and the challenge of a shortage of staff. Was the challenge of medico-legal problems caused by a lack of skilled personnel in particular areas, like maternity sections, and were sufficient registrars available to supervise staff in these critical areas?

Ms C Ndaba (ANC) commended the Department on achieving an unqualified audit. It was noted, however, that the AG’s report had revealed some findings with respect to employee benefits. She wanted to know what the issues relating to these findings were. With regard to the revision of the organogram, a detailed report containing the cost of funding vacant posts was requested. She also wanted to know how long it took for pensioners to get their pensions paid out in Eastern Cape; how the head office assisted the district procurement offices with regard to SCM; how the CHWs’ role had been integrated into reengineering PHC; what the role of the National Department of Health (NDoH) was in relation to CHWs in the Eastern Cape; and how the Department worked with civil society and non-profit organisations in relation to CHWs.

Mr A Mahlalela (ANC) said that during the Committee’s oversight visit to the province, it had encountered a huge outcry over the issue of vacancies. The presentation, however, had reported a different situation. He asked if the vacancy rate presented was a true reflection of the actual vacancy rate in the province. He also wanted to know if the percentages of the vacancies could be disaggregated to reflect the vacancies at both clinical and administrative sectors. He asked if any of the students who had completed their medical training had been deployed to any of the medical facilities, and how many had been deployed, how such students were performing, and if the programme had been assessed to determine its impact.

He sought clarification on the number of ward-based CHW teams the Department had, how many wards had been covered, how many wards were outstanding, what projected time had been set to cover the outstanding wards, how the accountability of these teams were being managed, as well as ensuring that their existence created an impact on PHC services. If CHWs received benefits, what type of benefits were they given, and why were there no benefits if the reverse was the case? Did the CHWs constitute abnormal appointments? For how long were they elected, and what were the election criteria? How did the Department manage political structures in the communities?

Mr Mahlalela also wanted the national DoH to confirm if it was dealing with the infrastructure challenges at Bambisana hospital, including the staff accommodation and equipment. The Committee had been informed on its oversight visit that the challenges with availability of equipment was due to reasons such as the absence of a tender system, expired tenders, or the existence of a centralised system. The Department was asked to give a detailed response on how it was addressing the problem of equipment and other critical areas, like the provision of food in various medical facilities.

Regarding the financial management system, he wanted to know if the Department could recover irregular expenditure and if so, the process through which it could be recovered; how fruitless and wasteful expenditure could be condoned; if the cumulative irregular expenditure could be separated into various years and amounts spent for each year; what difficulties existed in regularising the recurring irregular expenditure; as well as progress in resolving the issues causing dissatisfaction to the nurses, and the tension between the governance structures and the managers.

The Chairperson wanted to know the cause of the delay in finalising the provincialisation agreement, which would result in the transfer of the previously municipal-owned clinics in Nelson Mandela Bay and Buffalo City metropolitan municipalities. She also wanted to know what maintenance and repair work had been carried out at Bambisana Hospital, as the Committee had not seen any such work carried out during its oversight visit; the reasons for the inefficiency at Coega in the implementation of projects; elaboration on the training of health promoters and community health workers aimed at educating pregnant mothers and the wider public, as well as on the radio stations where public awareness was conducted; and whether the empowerment process of MomConnect was in the rural or urban areas of the province.
She was of the opinion that the infrastructure programme of the Department focused more on the eastern part of the province, rather than the other areas. The western side of the province was also faced with serious infrastructural challenges, and the Department was asked to dedicate resources to address these challenges as well.

With regard to the best and least performing ICs, the Chairperson noted that the Committee was aware of the visit of the Office of Health Standards Compliance to some provinces. She wanted to know what assessments had been carried out by the Department to determine which ICs should be categorised as the best and worst performing ICs. Regarding water and sanitation, did it have a relationship with the municipal department of water and sanitation?

She commended the Department on achieving an unqualified audit after about 12 years, but wanted to know the specific findings on the audit. It was also commended for recruiting skills from the TVET colleges.

She recognised that the Department was doing away with sub-regions, and wanted to know if it had covered all the regions, and if so, a detailed report on the regions that had been covered.
The Department had been silent on outsourcing versus insourcing, which was one of the areas that the Committee had picked up during its oversight visit as a contributing factor to the challenge of catering in hospitals. The Department was asked if it would be confident enough to insource the provision of quality food in hospitals to communities.

ECDOH response
The MEC began the answer session by responding to the issue of medicine shortages. The Department had addressed this challenge by giving all clinics demanded codes so that they could place orders directly at the depot, especially since it had been discovered that small clinics needed to order via big or district hospitals, resulting in delays in the small clinics receiving their medicines. The challenge of a shortage of medicines had therefore been resolved, and shortages would be found only in clinics with a lazy manager.

During the MEC’s budget and policy speech, an amount of R9.9 billion had been allocated to cover, among other things, the appointment of 289 operational managers for all PHC facilities which had been without operational managers. Some of these managers had been appointed, while some were yet to be appointed.
With regard to male circumcision, it was noted that this process came under the operations of the Department of Cooperative Government and Traditional Affairs (COGTA). The involvement of ECDoH in the process had come about only because it was held responsible for the people who died from the process. It had therefore put in place the necessary measures to help with the process, which included inspecting the places where the circumcisions were carried out, recruiting trained district medical officers (DMOs), and contracting private general practitioners. R20 million had been allocated for all seasons of initiations this year in order to ensure the provision of all the resources needed. It had been discovered that most of the initiates died from dehydration, and some from too much beating. Adequate water was now being provided, and efforts were also being made to identify illegal initiation schools.

Abnormal appointments referred to contract workers such as CHWs, counsellors, and peer educators, and for whom a special arrangement had to be made for them to get their stipend. The Department had gone ahead to seek legal opinion on how to handle the CHWs, who fell under the category of foot soldiers within the PHC system.

Hospital boards formed a component of the MEC. The Mthatha board had been wrongly appointed, as no advertisements had been placed. The board had not been dissolved, however, because it was for a central hospital. The board wanted to micro-manage the hospital, but the MEC had engaged with the board to discuss alternative measures. An inaugural session had been held for the board, and strategic sessions would be organised.

The clinic committees were basically faced with the challenge of stipends not being paid. Discussions were being made over this issue, and the MEC had noted in her speech that the provision of stipends were under consideration for these committees.

With regard to the hospitals being converted to Community Health Clinics (CHCs), some experiences of unrest had been identified due to the misinterpretation of the conversion process. This was because some hospitals believed that the conversion was equivalent to a degrading them. It was for this reason that the Department had introduced road shows in order to enlighten the hospitals.

Dr Mbengashe reiterated that CHWs were part of the abnormal appointments, because their appointment did not fall within the 2007 structure of the Department. The CHWs consisted of people that volunteered to provide services within the community, and the Department supported such volunteers by providing some form of stipend for them. A comprehensive report had been provided to the Committee on the 6 305 CHWs in each district, as well as the services they provided. In this regard, the Department focused on home-based care, the lay-counsellors, care givers, and peer educators.

The ward-based outreach was a different programme, which was faced with some overlaps because some CHWs could have functional links to the ward-based team. However, the forms for CHWs and ward-based teams were different, and the nature of the Department’s relationship with these two categories was a voluntary, stipend-based type. The Department would be guided by NDoH on the final status of the CHWs.

As regards the provincialisation programme, the Department had entered into a well-designed contractual relationship with the local governments. Quite a number of issues had been identified in the provincialisation process, but most important was the issue of people changing their occupation specific dispensation (OSD). The OSD had introduced a new category, known as ‘operational manager’, unlike what had obtained in the old system where people were referred to as ‘sisters-in-charge’. The new system introduced requirements that the sisters-in-charge could not fulfil, and this had resulted in the dissatisfaction of most of sisters without specialities that could qualify them for the new category of operational manager. In resolving this issue, the Department proposed that acting leaders in clinics were transferred to handle the supervisory processes of managing the facilities. These people formed part of the 284 people who would manage the clinics. The people that had assisted the Department previously had been prioritised for this process.

In addressing the shortage of medicine, it was emphasised that medicines had to be ordered by clinics and hospitals before exhausting the available supply, otherwise such clinics would experience difficulties in ordering new medicines. Another challenge faced was the unavailability of medicines at the depot, even after orders had been placed. The difference in the packaging of medicines with which hospitals and patients were familiar, as against the actual medicines delivered, also constituted another challenge, mainly because manufacturers could decide to change their packaging. The Department was resolving this issue through the use of a programme introduced by the NDoH, known as ‘stock visibility’. The stock visibility programme came in the form of an application used for capturing stocks on a daily basis, as well as determining which medicines were available, and which were unavailable.

Defining the vacancy rate was a technical task because of the requirements of the baseline proffered by the National Treasury. The vacancy rate presented by the Department was a true reflection of what obtained within the Department. Being properly staffed meant that the right number of people for the right positions, with the right skills and levels of competences required for service delivery, should be provided to deliver quality service. All of this was determined by the patient load, number of skills needed, and the appropriate number of people. The new organogram had been able to identify facilities with  numbers in excess of those needed, as well as an insufficient number of people in some facilities. The new organogram would ensure that every facility had the number of people it needed.

Mr Kaye said that the bid committees were based on where the delegations took place. Any delegation under R500 000 took place within the facility or district, while those under R30 000 were on a quotation basis. Anything above R500 000 would be referred to the central head office, with an evaluation committee that dealt with all procurements up to R20 million. Any procurement above R20 million would be referred to a provincial structure which would assess such procurements. The challenges surrounding the specification of medical equipment had been resolved through the appointment of the chief director of hospital services as the chairperson of the specification committee.

The issue around employee benefit funding pertained to an issue raised in the previous year, where the Department had been faced with issues of accuracy and completeness. This was because it had allowed employees to make submissions on what they believed they were owed by the Department. The AG had proceeded to audit such claims and the Department had been unable to provide substantial documentation on them. In the current year, however, it had disclosed only validated claims with supporting documentation. The issue identified in the current year was around the data capturing of leave, an issue that had been picked up by the AG.

Irregular expenditure had been a challenge in terms of the qualifications. These had arisen as a result of the weaknesses identified within the SCM processes. The provincial treasury had identified this issue in 2010/11, and had funded the Department by about R120 million for a supply chain reform programme, resulting in the gradual strengthening of seven pillars within SCM. Out of the R212 million reported as irregular expenditure, R211.5 million had been for the previous year. The current year’s unregularised expenditure was R948 000 out of a budget of R19.9 billion. This showed a significant reduction in the amounts spent for document management.

In terms of recovery of losses or damages, Treasury Regulation 4914 specifically provided for recovery of irregular, fruitless and wasteful expenditure. With regards to regularisation, the Department faced a challenge with the completeness of the irregular expenditure, as the AG kept insisting that the amounts disclosed were incomplete. The Department had therefore gone back to review all its transactions from four years back and had come back with a total of R212 million. The Department would commence the next stage of regularising the expenditure after the AG had expressed satisfaction on the disclosure of the irregular expenditure.

Fruitless and wasteful expenditure were recovered from those liable in terms of the law, as determined by the state attorney.

With regard to the assistance provided to procurement officers, the Department’s primary function at head office was to ensure the existence of policies, oversight and outreach. An electronic procurement system had been developed as an outreach programme from the CFO’s office.

With regard to food and food security, he said that the suppliers were unwilling to take on the risk of committing to a contract that exceeded one month at a time, particularly because of food inflation. As noted earlier, anything below R30 000 would be dealt with on a quotation basis, while any procurement above R30 000 would be dealt with by the procurement committee. The quotation-based process took place at the facility, while the procurement committees were set within the district offices. The facilities therefore allowed themselves to do the work of protecting the food security at the local facilities, instead of sending them to the district offices.

With regard to the issue of insourcing versus outsourcing, all activities and programmes of the Department had to be carried out within the budget. The posts to be filled, and the various priority programmes, had to be filtered within the budget. The reality was that the province had lost a huge portion of its budget to the medium term expenditure framework (MTEF), and had also been allocated a smaller budget as a province. This issue affected insourcing and outsourcing. From an economic point of view, it was more reasonable to outsource than to insource. The Department was already considering the outsourcing of some programmes, such as food and security. The Nelson Mandela central hospital had been identified as operating a business model that was designed around outsourcing, and not insourcing. Another area that should be taken into consideration was with regard to who should be responsible for insourcing security.

Ms Campbell said that the Department had an annual recruitment plan with an improved post list, which was currently being filled in order to reduce the vacancy rate in the Department. In addition to this, there were ten Cuban specialists coming on board within the next month, to work in the Department.

She reiterated that abnormal appointments consisted of CHWs. Medical interns were appointed for one or two years, while other interns were appointed for one year. All appointments were made on a contract basis. Community service doctors and allied health professionals, non-clinical interns, and foreign doctors -- in terms the government to government agreement between Cuba and Indonesia -- were appointed on three-year contracts at a time. Sessional doctors and student nurses were also placed on contracts, and categorised as abnormal appointments. Any health professional above the age of 65 that still worked for the Department was appointed on a one-year contract at a time, as were the basic ambulance assistants that were busy with training.

With regard to the registrar programme, the Department currently had a total of 121 registrars and it would place advertisement for an additional 54 registrars very shortly.

She said that a facility should take the relevant documentation of an employee who resigned to the government employee pension fund (GEPF) offices to process the employee’s pension. The reviewed organogram provided for the insourcing of this process.

Mr Mlamli Tuswa, General Manager, ECDOH, said that the Department’s infrastructure backlog stood at R33 billion. The Eastern Cape had quite a number of medical facilities, even though not all of these facilities were in operation. The Department had no intention of building new facilities, but would rather repair and renovate the existing facilities within the province. The approach being adopted was to focus on the worst performing facilities, as well as the regions in which such facilities were located.

With regard to the unavailability of medical equipment, the Department was adopting a new approach to resolving the problem, as opposed to the previous approach of buying equipment on the basis of need. It had entered into a framework contract, which was a contract with a longer timeframe. Nevertheless, such contracts were faced with challenges, such as the capacity of facilities to order against those contracts, and budget constraints at such facilities.

One of the implementing agents of the Department was the Coega Development Corporation. The Department acknowledged some of the concerns raised by the end users, in terms of the response received from Coega. It had therefore determined to refocus its maintenance portfolio strategy by dealing with it internally, instead of through Coega. It had also revised its service level agreement (SLA), and penalties could now be imposed.
Since the infrastructural challenges at the OR Tambo Hospital had been addressed, the Department was focusing on other areas, with the approach of carrying out repairs and renovation programmes.

The Department had a working relationship with the Department of Water and Sanitation, but the relationship was only at the level of complaints. The water services were predominantly a responsibility of the district or municipality, and/or a water board.

The initial approach designed to address the infrastructure challenges facing the Bambisana Hospital, was to carry out renovation and repair work, in collaboration with the NDoH. However, the assessment submitted to the Department revealed that there was virtually nothing to maintain at that facility. A new approach was then decided upon, which was to upgrade the hospital. A programme had been designed for this purpose, and an implementation plan had been sent in by the Department of Public Service and Administration (DPSA), which was now the current implementing agent of the Department on this project.

Dr Maduna acknowledged the fact that the Department was lagging behind in the number of clinics that had achieved IC status. However, its overall performance and provincial assessment in terms of the vital, essential and important elements, was not too bad, as it stood in third position among the other districts.
The Department used the ten components of the IC as a guide for where it should focus its attention. There had already been an indication of the measures that had been taken previously as far as the medicines supplies and laboratory services were concerned, the roll-out of the CCMDD project and the fact that facilities could order directly from the depot, as well as having programmes that would assist in picking up any irregularities in the facilities. The Department had also referred to the measures being taken from an HR perspective, by identifying facilities without leadership and providing facility managers for them. An explanation had also been given in terms of infrastructural interventions linked to medical equipment in the facilities. Efforts to deal with the health information management area had also been alluded to in the presentation. The NDoH was assisting the Department in dealing with the issues around the office of health standards compliance, in terms of aligning it with the IC programme.

Dr Terence Carter, DDG, NDoH said that the key issue around Bambisana Hospital was the delay in dealing with the issues facing it. The hospital was old and most of its facilities had deteriorated. It had poor ventilation in almost all of the facility, which posed a serious health and safety risk. A decision had been made for a new facility to be constructed, and the Coega Development Corporation had been appointed as the implementing agent for the rebuilding of this hospital. In the meantime, there was work to be done on the facility. The Development Bank of South Africa (DBSA) had carried out a conditional assessment of the facility, and it was expected that the outcome of such assessment would be presented to the NDoH on Friday. A project implementation plan had previously been presented to NDoH, but it was not satisfactory, and so the NDoH had asked for the plan to be redone. This implementation plan was also expected to be submitted alongside the conditional assessment plan of the building, after which the DBSA would ensure that an implementing agent was appointed and a professional service provider appointed to monitor the project. Funding was available, but the technical processes had to be completed before work could commence. The same process applied to the building of the new hospital.

Ms Jeanette Hunter, DDG: PHC, NDoH, said that the Compliance was regarded as the Department’s external auditor, as it was an independent body responsible for quality assurance in the health sector, while the relationship with the IC was an internal audit process. Beyond the audit process, the ECDoH had a responsibility to deal with the challenges or problems in the provinces. The IC process had been started as a proactive means for provinces to get their facilities in compliance with the Office of Health Standards requirements.

In finalising the CHW policy document, which was still a draft, it had been discovered that there were a myriad of stipends for various categories of workers. Guidance had been received from the DG and the HODs through the technical advisory committee of the NHC, that there was a need to harmonise this process to have one category of outreach worker for the Health Department. The delay in finalising the policy was because it focused largely on the working conditions and improved remuneration in terms of a stipend for workers, and it was necessary to ensure the existence of adequate funding for this purpose. Discussions on this issue were being held with Treasury, but Treasury was requesting detailed information on the qualifications and functions of these workers.

The MEC said that the Department had recorded a positive impact through its collaboration with the Cuban government for 20 years. There were 90 Cuban-trained doctors, of which 62 were already qualified, and 46 out of the 62 were in the Eastern Cape. Seminars had been held with them. They had gone on community outreaches in the province, and communities had been impressed by these outreaches.

Dr Mbengashe admitted that not enough advocacy had been done for the MomConnect programme. NDoH had supported the publicity of the programme, and indeed, more people should be aware of the programme. One of the advantages of MomConnect was the ability for a mother to say what aspect of the services she was satisfied with or not, and for the system to identify the mothers that had used the service previously. The Department would intensify its efforts to advertise the programme.

It had been noted that the 29 sub-districts were creating a problem. The MEC had therefore decided that the sub-districts be pulled back. The process of this change would be completed after the finalisation of the organogram in September.

The Chairperson asked the Department to look into further questions raised by the Members and report back to the Committee on the progress made. The Committee would still engage with the Department on the issue of infrastructure, as it remained one of the priority areas.

Free State Department of Health (FSDoH): Presentation
Dr Benny Malakoane, MEC, introduced the delegation from the Free State Department of Health (FSDoH), and outlined the chronology of the presentation.

Dr Sepele Matela, DDG: District Health Services and Strategic Health Programmes, FSDoH, opened the presentation with the Ideal Clinic (IC) report, saying the IC initiative had been introduced in 2013 by the NDoH to systematically address the deficiencies in PHC facilities and improve the quality of service rendered. A report would be given on the progress of the IC programme within the Free State Province, from the 2015/16 financial year to the current 2016/17 financial year. It would also address the expansion plan over the MTEF period, challenges, and quality improvement plans that were developed to achieve progress.

The Free State province had five districts, with 221 PHC facilities that rendered services to a population of 2.2 million uninsured people out of a total population of 2.7 million. The PHC facilities were distributed within all five districts in the following order: 73 PHC facilities in Thabo Mofutsanyana, 45 in Mangaung Metro, 43 in Lejweleputswa, 39 in Fezile Dabi, and 20 in Xhariep. It was expected that all PHCs would be ideal clinics by the end of the 2018/19 financial year.

According to the FSDoH annual performance plan (APP), a specific number of facilities would be enrolled into the IC programme over a three-year period. This process had started in 2015/16 with the enrolment of 100 PHC facilities. The target was to achieve IC status for all facilities by 2018/19. The Department’s scale-up plan was highlighted to show that 100 facilities were enrolled in 2015/16; 52 facilities in 2016/17; and 68 would be enrolled in 2017/18.

The definition of an ideal clinic was outlined. Ten components were developed to define the dashboard of an IC, by which the Department could measure its performance as far as IC was concerned. Various elements flowed out of these ten components, which were categorised into vital, essential, and important. However, the attainment of the vital element was critical to attainment of IC status, and they required immediate and full correction. They constituted elements that affected direct service delivery and clinical care to patients. Essential elements on the other hand were elements that required resolution within a given time period. They were processes and structural elements that indirectly affected the quality of clinical care given to patients. Important elements were those that required resolution within a given period of time. They also constituted processes and structural elements that affected the quality of the environment in which health care was given to patients. A categorisation was agreed upon by national consensus, to give weights to the three elements, and therefore score clinics in terms of silver, gold, platinum and diamond categories.

As mentioned, 100 facilities had been enrolled into the IC programme in 2015/16, which was a contribution to the entire national enrolment target, the assessment of clinics and ultimate accreditation of facilities. However, the number of facilities to be assessed in the IC programme had been reduced by the NDoH. This had led to the assessment of 46 facilities out of the 100 enrolled facilities in 2015/16. A breakdown of the 46 assessed facilities was highlighted (see attached document). It should be noted that the ten facilities enrolled in Xhariep had been assessed. There were still 121 facilities that were yet to be enrolled.

The process of the IC assessment was as follows: teams were appointed in each of the 52 participating districts that were meant to constitute the core drivers of the assessment process within the provinces and districts. However, the cross-district peer review process brought in people from other provinces to conduct cross-peer reviews in other provinces. Although assessment was conducted internally, the IC assessment was conducted across provinces and districts. The Perfect Permanent Team for Ideal Clinic Realization and Maintenance (PPTICRM) team assessed each facility enrolled into the IC programme to determine the baseline. This was followed by an assessment by the district PPTICRM team to develop a quality improvement plan and monitor implementation of the programme. The assessment enabled the Department to develop quality improvement plans (QIPs), and facilities were scored against the IC dashboard. The peer review of the same facility by a cross district PPTICRM took place, after which the facilities were scored.

The peer review conducted in 2015/16 involved PPTICRM teams from the Northern Cape and KwaZulu-Natal provinces. The Free State Province had gone over to Mpumalanga.

A breakdown of the results of PPTICRM reviews in various districts were highlighted, starting with Mangaung metro, which was comprised of three sub-districts, namely Bloemfontein, Bostshabelo and Thaba Nchu. It was important for clinics to achieve a 100% score on the vital elements for them to qualify for IC status. The internal district results showed a lower percentage than the results from the PPTICRM assessment. Nevertheless, IC status was not achieved because the result was below 100%. In Lejweleputswa, some of the results of the internal assessment were higher than the peer review assessment. Other results from the remaining districts were highlighted (see attached document).

A summary of the progress made on ICs after a second reassessment in April 2016 showed that one out of the four facilities in Fezile Dabi scored platinum, four out of the 13 facilities in Thabo Mofustanyana scored platinum, while seven out of the ten facilities in Xhariep scored platinum. The total score showed that 22 of the 46 assessed facilities in the Free State scored platinum and gold. However, none of the facilities in Lejweleputswa and Mangaung metro scored either platinum or gold.

The internal assessment carried out showed that the best performing district in the Free State was Xhariep district. It was followed by Mangaung metro, despite the fact that it did not achieve IC status, but it had the second best result in terms of improvement of scores with the number of facilities. The worst performing district was Lejweleputswa. The best performing sub-district was Metsimaholo in the Sasolburg area. The second best performing sub-district was Botshabelo, while the worst perfoming sub-district was Setsoto in Thabo Mofutsanyana district.

There were a number of infrastructure projects that should have been operationalised at the end of the past financial year or beginning of the current financial year, as this affected the achievement of IC status. Most of the districts and sub-districts that had been identified as worst performing districts were those that were in the process of operationalising their brand new infrastructure, which would result in the need for a reassessment of these districts and sub-districts. The Department would request a reassessment of facilities in these districts from the NDoH.

In summary, 22 of the 46 enrolled facilities attained IC status, but diamond status was not reached -- only platinum and gold status was reached. Xhariep was the best performing district in the province, while Lejweleputswa was the worst performing district. The status determination results showed that the majority of the facilities in Mangaung metro were performing above 66%, but a better performance was needed.

Some of the challenges facing the province included poor infrastructure; human resources for health in terms of appointments of staff; insufficient budget for IC; and slow SCM processes to procure IC equipment.

The scale up plan of the province for 2016/17 was outlined. Thabo Mofustanyane was the pilot district, which should have been completely scaled up except for the challenges faced in terms of funding and infrastructure.

Some of the lessons learnt from the past financial year were the need to prioritise budgets for the IC programme, SCM processes for this programme, as well as carrying out a weekly monitoring of the IC progress.

The QIPs of the Department included cost analysis of IC requirements, allocation of budget for IC equipment from the equitable share; prioritization of procurement of IC medical equipment; centralisation of medical equipment; alignment of the Departmental infrastructure plan with ICs; and weekly monitoring of IC progress.

The costing of ICs for each district was outlined, and the infrastructure budget that would be needed to refurbish and maintain the ICs over the MTEF was also highlighted (see attached document).

Dr David Motau, HOD: FSDoH, presented on the HR status of the Department. A summary of the posts status showed that 17 680 posts had been filled, and the vacant posts were 3 760, which had resulted in a vacancy rate of 18%. 407 of the filled posts in the staff establishment were filled by community service officials. About R5.8 billion had been budgeted for compensation of employees for the current financial year. About R1.9 billion had been spent so far, with R124 million spent on commitments. The available budget was R3.9 billion.

The post status of Albert Nzula district hospital in Xhariep district was particularly highlighted, as it had recorded only three filled posts, and 194 vacant posts. The reason for this was because it was a new facility, and was yet to be commissioned. The process of appointing staff for this facility was already in progress. A detailed post status for regional hospitals and academic complexes was also given. The challenges of financial constraints being faced by the province also contributed to the difficulty in filling some of the vacant posts, and this impacted directly on training programmes to be carried out by universities, as well as on the joint staff establishment agreement that the Department had with universities.

The details of appointments that had taken place between April 2016 and July 2016 were outlined. Appointments into various occupational designations came in various categories such as permanent appointments, community service appointments, internships, sessional appointments and registrars. Overall, a total of 422 appointments had been effected.

For the period between April 2016 and July 2016, the Department had recorded 83 expired contracts, five deaths, five dismissals based on ill-health, 122 resignations and 122 retirements, resulting in an overall total of 337. Overtime expenditure had also been incurred during this period. About R12.7 million had been spent on normal overtime, while R77.4 million had been spent on fixed overtime. The vacancy rate had impacted on the overtime expenditure.

Feedback on the CHW progress report showed that implementation of new criteria for the CHW programme had started in September 2014. The criteria for admission included the possession of a matric certificate, proficiency in two languages (English and one local language), being a South African citizen aged between 21 and 55 years, as well as being physically fit to walk long distances. The CHWs were expected to work strictly in the community, and not in the facilities. This was in line with the PHC re-engineering.

In terms of stipend payments, nine non-governmental organisations (NGOs) had been awarded contracts to manage administration and HR issues of the cadres, including stipend payments, monitoring and supervision of activities for community-based services. The date of reporting by NGOs had been changed to facilitate timeous payment of stipends. 915 community care givers were receiving a stipend of R1 850 per month, according to the Ministerial determination. 594 CHWs were receiving R1 900 per month, while 104 enrolled nursing assistants and 44 enrolled nurses that provided clinical support to CHWs were receiving R3 000 per month. Stipend payments were made only after reports had been received on the work done.

The training plan for CHWs had been designed according to the need for coverage of family health teams in the wards. Training had commenced in the districts in 2011. 96 CHWs from Lejweleputswa had been trained in phase 1 in 2011, and were in the wards from 2011 to 2014. They had been coached by outreach team leaders (OTLs). Assessment on phase 1 had been carried out in 2014, and the results had shown that 36 CHWs were competent. These competent CHWs had then proceeded to phase 2 in 2014. In July 2015, 36 learners had commenced with the training for the qualification. 61 CHWs had failed the initial assessment, while 32 had been re-assessed in 2016. An additional 58 community care givers (CCGs) were trained in phase 1 in March 2016, to be assessed in December 2016. The training of 11 CCGs from Soutpan had been scheduled for November 2016 on the CHW programme. Four CCGs had been trained on HIV counselling and testing in March 2016. 11 CCGs would be trained on tuberculosis (TB) management in August 2016.

Dr Motau went on to present the infrastructure management report for the 2014/15 and 2015/16 financial years. A summary of funding for the 2015/16 MTEF period was highlighted. The funds were sourced from health facility revitalisation grant (HFRG), the infrastructure enhancement allocation (IEA), and the EPWP. In 2014/15, the adjusted budget was about R612 million, while the adjusted budget for 2015/16 was around R589 million. The budget for 2016/17 was R516 million.

In respect of the infrastructure project list for 2014/15, the summary of expenditure for the fourth quarter showed that 96% of the budget had been spent. The summary of expenditure for the fourth quarter of the 2015/16 financial year, however, showed that 95% of the budget had been spent. Underexpenditure was due to commitments on medical equipment orders for Trompsburg hospital and Pelonomi intensive care unit (ICU) that could not be cleared, due to the late delivery of medical equipment; COE due to the non-filling of vacancies; and invoices that were still being processed.

The human resource capacity of the Department in terms of DORA and voted funds was also highlighted. There were still 40 vacant posts to be filled in this regard.

The Department’s report responding to the findings and recommendations of the Portfolio Committee during its oversight visit to the province in June 2015, was presented. The Committee had visited Ikgomotseng Clinic in Soutpan, the medical depot and Pelonomi hospital. The Department was, however, asked to concentrate on the Ikgomotseng Clinic and the medical depot.

The Committee’s recommendations on the Ikgomotseng clinic had been for the Department to prioritise the issue of infrastructure and staff shortages; improve ambulance response time in order to curb instances of referred patients having to wait outside the facility to be transported; expansion of the clinic, since the clinic was too small and congested; address the challenges of payment and training of CHWs in order to ensure effective service delivery; create awareness on the MomConnect programme and register expectant mothers; and urgently address the boarder administrative failures in the Lejweleputswa district.
Progress was also reported on the recommendations given by the Committee on the medical depot, which included the need for the Department to address the staff shortages, and system bottlenecks hindering the procurement and supply of medicine. Progress reports were given on all these recommendations (see attached document).

Mr Molefi Motsie, CFO, FSDoH, presented the financial information of the department for the 2015/16 financial year. The total budget and total expenditure of the department from 2011/12 till 2015/16 financial year was highlighted, and it could be seen that it had been spending an average of 99% of its budget each year. The conflict between the compensation of employees (COE) and goods and services was pointed out. There had been an increase in COE, from 63% in 2011/12, to 65% of the total budget in 2016/17. The implication of this increment was a crowding out of goods and services. The COE had decreased by 1% due to the fiscal discipline that had been initiated during the 2014/15 financial year. The result of this was that service delivery pressures had emanated from the lack of appointment of personnel. In the current financial year, the Department had been instructed by the provincial treasury to reduce the COE by 0.05%, and this had increased the pressure on employee benefits from previous financial years.

The budget allocation for financial years was alluded to, noting that these budget allocations were projected at the start of financial years, and were subject to change during the course of the year. The actual budget allocation for goods and services in 2011/12 had been R1.7 billion. It had increased to R1.907 billion and R1.944 billion for 2012/13 and 2013/14 financial years respectively, after which it had been reduced to R1.7 billion in 2014/15, and subsequently increased to R2.4 billion in 2015/16. However, the inflation rate had affected the budget for goods and services. It was emphasised that the inflation rate affecting the health sector was different from the general inflation rates affecting the economy. The inflation rate in the health sector was around 9%. In essence, despite the fact that a nominal increase had been recorded in the budget, the inflation rate had impacted negatively on the purchasing power of the Department.

The increase in accruals also demonstrated the inadequacy of the budget allocation. Details of unauthorised expenditure for the periods between 2011/12 till 2015/16 financial years was highlighted with the comment that unauthorised expenditure represented the overshooting of the budget, which indicated that the Departmental budget was inadequate. Accruals referred to invoices that were yet to be paid at the end of a financial year. Despite the increase in the figures for accruals, the AG had given the Department a qualified audit, noting that the completeness of the accruals could not be determined.

The Department had spent 99% of its conditional grants in 2014/15, and 98.9% in 2015/16. On the other hand, it had spent 100% of its budget from equitable share payments in 2014/15, while 99.9% of the budget had been spent from equitable share payments in the 2015/16 financial year.

The Department had received a qualified audit opinion for the 2014/15 financial year in areas such as irregular expenditure, asset management and employee benefits. The qualifications and progress recorded on these areas were explained. The department had also received a qualified audit opinion for irregular expenditure, accrued revenue and commitments. Details of the qualifications and remedial action taken were explained in detail (see attached document). There were areas of emphasis that required immediate action in order to prevent such matters becoming qualification areas. Financial sustainability and payables constituted such areas. The qualification of these two areas was explained in detail, and the remedial action to be taken was also outlined, as were the amounts of unauthorised expenditure and accruals.

Regarding predetermined objectives, programme 2 was qualified because the AG could not verify 48% of its indicators. An unqualified opinion was received on programme 5, while a disclaimer was given on programme 7 in relation to the indicators of the medical depot.

Concerns had also been raised in relation to the annual financial statement, particularly on the misclassifications, which had been corrected during the audit process, and the R31 billion in unauthorised expenditure. Other areas of concern raised by the AG included the inability to pay suppliers within the stipulated 30 days, which reflected the challenges of cash management facing the province as a whole, and not just the Department of Health.

The Department said one measure to be taken included the finalisation of the audit action plan, which would be replicated in all facilities to ensure that the current findings were not repeated in the next financial year. The Department would embark on monthly monitoring of the implementation of resolutions and recommendations of the AG. An internal control unit had been established to conduct spot-checks on the implementation of the audit action plans. Consequence management would also be implemented to correct wrongdoings, and disciplinary action against some officials would also be instituted.

Ms Nelisiwe Phitsane, Chief Director: SCM and Asset Management, FSDoH emphasised that the SCM environment was a highly regulated one. The system should therefore be fair, equitable, transparent, competitive and cost effective. The regulatory framework of SCM was also highlighted, with emphasis on the Preferential Procurement Policy Framework (PPPF) Act No 5 of 2000 and the Broad-Based Black Economic Empowerment (BBBEE) Act of 2003. These addressed issues of the usage of procurement as a tool for development and transformation. Through the application of the principles of the PPPFA and BBBEE codes, the Department had been able to secure competitive prices. Also, 95% of contracts had been successfully awarded to businesses that were BBBEE-compliant, which were exempted micro enterprises (EMEs) and qualifying small enterprises (QSEs). At least 70% of the budget had been spent on advancing and promoting black businesses for economic transformation.

Some imperfections identified within the SCM systems included poor planning and ineffective implementation of procurement plans; a prolonged turnaround time in the procurement of goods, services and works; cost effectiveness and non-realisation of value for money; ineffective contract management; and shortage of human resources.
The department had developed various systems to address these imperfections. These systems included the establishment of a unit in SCM to evaluate SCM performance of every institution linked with procurement processes that were not in support of service delivery; usage of an evaluation tool to measure compliance to the five pillars of SCM without compromising on service delivery; development of a standard process flow charts with timelines; improvement in the turnaround time for acquisition of goods, services and works; as well as performance of market analysis and price check on wider selection of competitors in order to secure competitive and acceptable prices.

In terms of SCM systems efficiency, the development of the demand plans would be completed before the end of the current financial year or at the beginning of the new financial year. In essence, the development of the demand plans, which was informed by the annual performance plan (APP), would be completed in record time, as all plans had been approved, and acquisition plans had been developed and consolidated. The demand plans had also been consolidated to assist with the identification of common goods and services within the Department. The process of centralising the procurement of medical equipment had begun.

In terms of good SCM governance, officials in SCM signed the code of conduct on an annual basis. Other role players in the SCM processes and SCM committee members also signed declarations and confidentiality forms. In the event where non-compliance with the SCM code of conduct, or false declarations and non-confidentiality were discovered by the Department, it would report such matters to the fraud and corruption unit for further handling. SCM officials were rotated across various institutions as a means of boosting good governance within SCM.

The Department had completed SCM processes with regard to infrastructure delivery and maintenance. The appointment of project managers had been finalised, but the Department was still in the process of appointing contractors to begin work on infrastructure delivery and maintenance.

Mr Volmink asked for an explanation for the massive increase in accruals, and what measures would be taken to mitigate the recurrence of such accruals. An explanation was also requested on the absence of a register for commitments, what consequences would follow from such an omission, and how the problem would be remedied.

Mr Khosa asked for an update on the vandalised clinic, and the plans in place to renovate it.  He wanted an explanation on the special type of inflation experienced by the Department and a list of the goods and services that were mostly affected by this inflation. Concerns were raised about the high vacancy rate in the SCM, as it could affect the efficiency of the unit in the long term.

Mr Mahlalela asked about the vacancy rate at both the clinical and administrative levels of the Department. He sought an accurate number of CHWs present in the province; reasons for outsourcing them; their conditions of service; who the CHWs were accountable to; how their performance was evaluated; and what their benefits, if any, were. He asked for clarification on the placement of ward-based task teams within the concept of re-engineering the PHC, how it was being managed differently from the ones already placed in the NGOs, the number of ward-based task teams that the province had, the number of wards that had been covered, as well as the number of those yet to be covered, and the projected time to cover such wards.
He also wanted to know about the events that had led to the Department’s state of financial unsustainability, and how that challenge would be resolved; the impact of SCM on financial sustainability; how the Department would be able to utilise additional funds without adequate personnel and capacity; reasons for the inability to build sufficient infrastructural capacity; an explanation on the delays in reconciling accruals since 2009, and steps to be taken in resolving these accruals without compromising on service delivery; clarification on whether the IC programme was an unfunded mandate; and an explanation on why the Department was funding acting positions instead of filling vacant positions with permanent staff.

Ms Ndaba asked for the Department’s turnaround strategy and plans with regards to the medical depot, including the advertisement of posts; whether the nine NGOs that had been contracted were from the disadvantaged areas of the province; the budget allocations for the nine NGOs; an explanation on whether enrolled nurses and enrolled assistant nurses were permanently employed, and the implication of having double jobs if these nurses were permanent employed, as well as clarification on whether the province had a surplus of nurses in the event that such nurses were not permanently employed; if the criteria for selecting CHWs had been in existence in previous years when these CHWs operated as cadres and on a voluntary basis without any remuneration, the effect of the criteria on cadres who volunteered without pay, and if the Department had any plans that in place to cater for these cadres.

The Chairperson expressed concern on issues around incompetent project managers, lack of proper contract management, as well as spending for unrelated purposes. No time frames had been set for the remedial actions proffered by the Department to address these issues. It was emphasised that the Free State was the weakest district, despite the fact that it was a pilot district.

FSDoH response
Mr Motsie admitted the accruals should reflect the actual figures recorded in the previous years against the current years. Accruals were derived from unpaid invoices at the end of a financial year. Some of the factors that could contribute to accruals were instances of a service being already rendered, without the receipt of an invoice for such service; matters of dispute with respect to already submitted invoices; as well as insufficiency of cash needed. It was not uncommon to find cases of services already rendered without immediate payment made for such services in the health sector. The Department agreed that the accruals should be managed. Efforts were already in place to manage the qualifications on accruals, as had been done in 2014/15 financial year, notwithstanding the fact the AG was satisfied with the accuracy of the figures of accruals.

Regarding the question raised on the inflation rate, different sectors of the economy faced different categories of inflation. The same applied to the health sector, as there were different standards used in determining the rate of inflation. Reference was made to a South African statistics report, issued in December 2012, to the effect that the weighted consumer price index (CPI) in the health sector was 11%. Recent research carried out in this regard showed that the current inflation rate in the health sector was around 9%. This inflation was caused by factors such as consumables, and the fees of professionals or specialists. The template received from the NDoH actually instructed FSDoH to calculate the inflation rate at 9%.

The issue of commitments had been resolved a while ago, and the Department was surprised that the registers of infrastructure projects had been audited in the financial year. It had been established that the Internal Reconsideration Mechanism (IRM) system used by the province had been modified at the beginning of the financial year. The Department had realised only at a later stage that the information inputted into the system was not credible, due to the transfer of information from the old system to the new version. Apart from the problem of the transition between systems, the project managers had also been incompetent and unable to foresee the problem at an early stage. A proposal had been made in the Department’s audit action plan, to introduce manual systems instead of relying solely on the IRM system.

Mr Motsie said the absence of timeframes for the audit action plan was because the presentation made to the Committee did not contain all the detailed information on most issues. There was an actual document on the Department’s audit action plan that outlined all the necessary requirements to be complied with. One of the approaches to be followed in the current financial year was the establishment of detective, preventive and monitoring mechanisms. A distribution of all the items in the audit action plan had been carried out to all facilities in the province.

The Chairperson expressed disappointment with the Department for not submitting all the relevant and vital information needed for a smooth process of engagement.

The MEC undertook to submit the document alluded to by the CFO, to the Committee secretary by Friday.

Dr Matela said the vandalised clinic had been set ablaze during a service delivery protest in November 2015. The Department had no budget within its infrastructure grant to deal with this unfortunate eventuality. Nonetheless, provision had been made from the district’s voted funds to carry out some repairs. Repairs were ongoing, but the clinic was still not operational. The infrastructure unit was aware of the situation, and would make adequate provision for renovations in the 2017/18 financial year. In the meantime, services had been redirected to the town clinics in Harrismith.

Dr Motau said that the existence of vacant posts was largely due to the financial constraints facing the Department. The directive of Treasury to reduce the COE by 0.05% was also adding to the financial pressures on the Department. The 18% vacancy rate was largely related to clinical posts. The exact figures would be forwarded to the Committee.

The MEC also undertook to submit a clearer explanation on the categories of vacant posts within the Department.

Mr Sipho Mtakati, DDG: Corporate Services, FSDoH, said that the Department recognised the challenge of paying acting allowances as opposed to filling up vacant posts. It was for this reason that 422 health officials had been appointed to fill vacant posts between April and July 2016.

Dr Matela clarified the acronyms and terminologies used in the presentation, for better understanding. Regarding the CHW programme, the Department had received a directive from the NDoH on its plans to embark on a PHC re-engineering strategy within the country. NDoH had outlined three streams of this re-engineering process to include the ward-based PHC outreach teams that comprised of CHWs, with a defined ratio of the number per household and number of wards that would have CHWs. It was later discovered that not all municipalities had made demands for CHWs or ward-based PHC outreach teams. The province initially anticipated 549 ward-based PHC outreach teams for 325 municipal wards. This was before a calculation had been done on the poverty index of the province. The province was now left with 315 municipal wards, traceable to the demarcation ward activities. The province had 98 ward-based PHC outreach teams, covering some wards within the province. The process embarked upon required a careful count of all the wards in the province, as well as the expected ratio. The criteria had then been revised to consider the poverty index and to target wards with the highest levels of poverty.

The details of the exact number of CHWs that existed in the province would be forwarded to the Committee. The CHW programme was funded through the Department’s HIV conditional grant, and this was the reason for contracting non-profit organisations (NPOs) and not absorbing the CHWs permanently, unlike what obtained in other provinces. It was engaging with other provinces and the NDoH to come up with a framework that would standardise the CHW and ward-based outreach programme across all nine provinces. Because the funds were sourced from the HIV conditional grant, a target had been set on the number of CHWs that could be recruited. A provincial target of recruiting 1 000 community care givers (CCGs) and 588 CHWs, had been set for the current financial year. The difference between CCGs and CHWs was in terms of the training CHWs were subjected to, according to the curriculum stipulated by the NDoH. Hence, the process commenced at the CCG stage, after which different phases would be passed before one qualified as a CHW. There were only 974 CCGs remaining out of the 1 000 targeted, as such recruitment processes were subject to resignations, deaths and other factors. 547 of the targeted 588 CHWs remained. The variance was due to several factors, including resignations, promotions, deaths and so on.

A target of 116 enrolled nursing assistants had been set, and 114 of such nurses remained. The number of enrolled nurses was 33. The enrolled nurses were also funded through the HIV conditional grant. The nurses did not operate two jobs at the same time. It was pointed out that this category of nurses was not in the employ of the Department on a full-time basis. The enrolled nurses and nursing assistants formed part of the ward-based PHC outreach team, and provided support to the CCGs and CHWs in the province. The issue of absorbing these categories of staff permanently into the Department would require the achievement of a national consensus.

A document that spoke to the conditions of service of CHWs and CCGs was under way. Nevertheless, the province had put in measures to ensure good conditions of service for them, such as provision of uniforms to identify different cadres, working shoes, kits, and even cars for the teams. About 46 cars had been invested into these programmes, and had been given to the outreach leaders. Spaces had been created within the clinics for them to work, and stationery had also been provided to assist them with data capturing.

Regarding the relationship between CHWs and ward-based PHC teams, he reiterated that the transition process that most volunteers went through to become CHWs was already infused into the ward-based PHC outreach teams. In other words, the CHWs were a component of ward-based PHC outreach teams, as it was expected for the province to have one CHW covering 350 households. The Free State, therefore, had experienced a category of transition of volunteers to professionalised CHWs, as part of the ward-based outreach teams.

With regards to the cases of cadres not meeting the new admission criteria, he said that all cadres were given an opportunity to undergo training, after which tests were conducted, and some of them had failed repeatedly. The Department had sought advice on the exit strategy that should be adopted for the categories of people who consistently failed the test. The performance of CHWs was evaluated quarterly on the basis of the work they do in the catchment clinics. The NGOs were also assessed to ensure that they met the laid down criteria.

The nine NGOs contracted in the Free State were all sourced from previously disadvantaged areas, and their performances were also scrutinised by the Department.

The concept of the IC had emanated from the Operation Phakisa initiative, which had not necessarily been directed towards health but was aimed at achieving big, fast results in the economic sectors. The health sector, therefore, had adopted the objectives of Operation Phakisa for the IC programme. The IC strategy was not necessarily a project, as it had always been a goal of the Department. The IC programme only conceptualised its overall goal. No special funds had been allocated to the realisation of this programme, and the financial constraints constituted a major challenge in achieving IC status for most clinics in the province. The Department had had to derive funding from its voted funds to implement the IC strategy.

However, the NHI pilot district had received seed funding in form of the NHI direct grant, with direct stipulations for the use of the funding as provided in the business plan.

Mr Mahlalela noted that some of the responses given by the Department were problematic because of the comparisons made with other provinces.

Ms Hunter spoke on the finances for the IC programme. The IC programme was a continuous quality improvement programme. The 184 elements were not new. Before provinces were properly constituted, there had been a white paper on the transformation of health services. The IC elements did not only speak to the facilities, but also provided for what should take place at the outreach level.
The reason for re-engineering a continuous quality improvement programme to identify specific issues, was because of the 2012 baseline results that showed only psychiatric hospitals were meeting the baseline standards in the Free State. Many facilities had been in a dire state at the time. The way forward to resolving the challenge of funds for the IC programme was for the provinces to work with the ten treasuries to engage with National Treasury, or motivate for the funding of the package. With regard to the implementation of ICs, it had been agreed that clinics who motivated for an IC would take on the existing supervisors and existing quality assurance workers.

The Chairperson emphasised that the process of engaging with all provinces was aimed at correcting a system that had disadvantaged the people of South Africa. The Department was asked to submit written responses to other questions raised by Members of the Committee.

Northern Cape Department of Health (NCDoH): Presentation
Mr Lebogang Motlhaping, MEC: NCDoH said quite a number of policy shifts had been recorded in the past three years, including the improvement of quality health care services through the IC programme; the introduction of the Office of Health Standards and Compliance; the introduction of ward-based outreach services, school health services, and district clinical specialist teams, which could all be referred to as an unfunded mandate. The Department had therefore been expected to reprioritise both financial and human resources to ensure that all programmes were achieved. The presentation would address some of the challenges facing the Department, including the need for strengthening the financial systems.

Ms Elizabeth Botes, HOD, NCDoH, presented on the HR status in the province, saying that the Northern Cape executive council had taken a decision for all departments to cap their headcounts without impeding on critical and frontline service delivery posts, which implied an approval of all critical and frontline service delivery posts by the Premier’s office, through consultation with the provincial treasury. The reason for this was that departments were expected to remain with the medium-term compensation budget limit approved by the executive council, in accordance with the promulgated budget.

As at 8 August 2016, the Department’s HR status showed that it had a reduction of 53 clinical posts when compared with the previous financial year, while four additional non-clinical posts had been filled in the current financial year. Overall, the total staff establishment was 6 735. The Department had more clinical posts than non-clinical. The reduction in the number of posts referred to posts that it was struggling to retain, such as the specialists types.

A Personnel Administration System (Persal) clean up had commenced, in line with the directives of the executive council, where all appointments had been adjusted on the system. As at 1 July 2016, there were 488 appointments that were out of adjustments, which meant that such appointments were not linked with approved posts. However, by 1 August 2016, these out of adjustment posts had been allocated to funded valid posts within the establishment. A total of 1 616 vacant unfunded posts had been abolished. These posts were mainly support posts, rather than critical service delivery posts. Based on the reprioritisation strategy of the Department, a total of 704 critical and frontline service delivery posts had been prioritised for filling.

The Department’s vacancies in terms of critical human capital were highlighted, showing that there were 477 vacant posts for health professionals, and 227 vacancies for administration and support.

The Department had trained a total of 205 students across all five districts of the province, in the Cuban programme. Some of the students were still undergoing training. However, the Department had produced 33 doctors who were currently working within the province, from the Cuban programme.
As at the end of July 2016, 159 students had been trained in various fields, compared to the total of 218 students trained in the 2015/16 financial year.

He said that the NCDoH had worked with different CHWs, ranging from home-based caregivers to TB tracer teams, peer educators, lay counsellors and retired nurses that served as team leaders for the ward-based outreach teams. Although there had been an outcry for the absorption of CHWs, the Department was faced with the challenge of budget constraints. The projected budget for absorbing the current number of 2 592 CHWs at level three, was R485 million. The Department would therefore require the assistance of the NDoH in developing a strategy to employ or absorb these CHWs.

A breakdown of the CHWs in all five districts of the province, and the NGOs from which they had been sourced, was highlighted. The 2 592 CHWs had been sourced from 30 NGOs, and 56 nurses had been retired. Based on the funding difficulties and budgetary pressures facing the Department, the absorption of CHWs was a difficult process to embark on at the moment. For the foreseeable future, these CHWs would be employed through the NGOs. A stipend of R2 500 per month was paid to CHWs, resulting in a budget of about R97 million per annum spent on them.

The ward-based outreach service was comprised of a critical output of CHWs, and was in line with the change of scope from home-based care to ward-based care, to deliver comprehensive ward-based services. The ward-based outreach services conducted household assessments, provided health information, supported chronic patients, and assisted with CCMDD processes in certain areas. All 38 wards in Pixley Ka Seme district were covered with ward-based teams. The majority of them had received training up to phase 2 and captured their data electronically.

The infrastructure report of the Department revealed that 17.6% of the budget had been spent in the first quarter of 2016/17, as opposed to the projected expenditure of 25% from the health facility revitalisation grant (HRFG). The deviation in expenditure was as a result of the payments for the mental health hospital project, amounting to R56 million as at July 2016 -- an amount which could not be paid by the Department due to challenges, including the withholding of approval by NDoH to pay from the HRFG. The Department was in the process of resolving its challenges with the both national and provincial treasuries, and with the NDoH.

The completed project of the new De Aar Hospital had been handed over to the Department, and was ready for operationalisation, provided that some form of funding was received. Other completed projects included the upgrade of a 36-bed mental health unit, which would be ready for operationalisation by October 2016, to commemorate Mental Health Month; accommodation of 25 state patients currently in correctional facilities; upgrading of the EMS station at Calvina; and the provision of fencing and guard houses for clinics, hospitals and community health centers (CHCs).

With regard to the status of the new mental health hospital, he said the hospital had reached 87% of physical completion. Current activities on the project included specialised work, such as flooring, painting, heating and ventilation, electrical and landscaping. The projected completed date was July 2017.

A detailed report on other infrastructure projects in the province and their various stages was highlighted. Most of the infrastructure projects focused on filling the gaps identified in achieving the ideal clinic (IC) status and timelines by the National Health Council.

The financial management report of the Department was centred on the audit outcomes, as requested by the Committee. It had received a qualified audit opinion, with emphasis on issues such as movable, tangible and intangible assets; accruals and payables; accrued departmental revenue; commitments; irregular expenditure; and SCM, procurement and compliance. The leadership of the Department had experienced a change through the transfer of personnel from various offices to specifically address the issues around the audit outcomes and other service delivery matters. Progress had been made in reducing the number of qualifying paragraphs from eight to five.

The IC initiative was the primary intervention towards readiness for the NHI scheme. The Department was working towards achieving ideal status in all clinics within the province, in compliance with the directive for all clinics to be ideal by March 2018. This process had commenced in 2015/16 financial year, which meant that the Department had three years to achieve IC status. There were 36 facilities in the NHI pilot district of Northern Cape that had been targeted to reach the IC status by 31 March 2017, as well as 30 other facilities in other districts.

A baseline assessment had been conducted on all facilities within the Province, and the result obtained had been 56% of ideal status for all 164 facilities. The province was currently pursuing quick wins related to various elements.

Three facilities -- Ethembeni (Prieska), Marydale and Hopetown clinics -- out of the 36 facilities in the NHI pilot site had achieved IC status. Nine more facilities had already attained over 70%. Of the additional 30 facilities in other districts, Alexander Bay clinic and Alexander Bay CHC had attained IC status in the previous year. However, a new requirement relating to paediatrics had been introduced in the current year, which was still to be attained. Overall, 29 out of the 66 facilities had attained above 70% of IC status.

The challenges faced in achieving IC status included inadequate budget, lack of vital equipment, infrastructural challenges, HR challenges, and challenges with security services. Measures had been developed to address these challenges.

Other complementing initiatives that could be linked to the IC initiative to further assist with improved patient experience at the clinic were highlighted. The first was the CCMMDD programme, where almost 10 000 patients had been enrolled at the Pixley Ka Seme district to facilitate quick and easy delivery of medication to patients. The roll out of this programme to other districts had also commenced. The health patient registration system was another complementing initiative, which was designed to address patient flow, filing, appointments and improved information. This system had been rolled out in Pixley Ka Seme, while the roll out to other districts was in process. The effect of these initiatives included an improved patient flow; a reduced number of patients needing to visit facilities for chronic disease management; shorter waiting times; improved patient satisfaction; less medicine stock-outs due to the introduction of the stock visibility system (SVS); the integration of clinics within a network of services; and less congestion of clinics.

The MEC concluded the presentation by saying that the province was doing its best to close all the gaps in the Department. It was opened to advice and suggestions from the Committee on measures that could be taken to realise a long and healthy life for all, easy access to facilities, and ensuring an improved experience for all patients. He expressed optimism on the Department’s ability to produce more positive reports in the future.

Ms Ndaba commended the NCDoH on the progress made so far. However, she wanted to know what the implications were of the 1 616 CHW posts that had been abolished; the total budget for training interventions for 2014/15 financial year; and the reasons for employing CHWs through NGOs and not directly.

Mr Volmink spoke to the abolition of non-critical posts, and said that all posts within the health sector were critical. He wanted to know if any exercise had been carried out to determine the critical and non-critical posts within the Department to assist with mapping out necessary human resources. Based on the background that the Northern Cape was a vast province, having remote facilities, large areas of land, and hard to reach facilities, it was important to ensure that people with critical conditions could be attended to within a short duration, using the EMS. Air ambulances played a major role in this regard. Mr Volmink said that he had posed some questions to the Minister earlier in the year on the province’s air ambulance services, which included the details of the expenditure, whether third parties were being used, and if services were operational. The responses received had been unsatisfactory, and this had resulted in follow-up questions. The Minister had alluded to the fact that responses had been based on the feedback received from Northern Cape itself. No data could be sourced for air ambulances in the 2012/2013 financial year, despite the fact that huge amounts had been allocated for this purpose. Some responses to the questions posed were also contradictory. The Department was therefore asked to clarify the contradictory issues and provide responses to the same questions posed to the Minister.

Mr Khosa wanted to know if the employment of CHWs through NGOs was a conditional requirement; if the Department had future plans to employ the CHWs on permanent basis; if the CHWs were manageable in light of the expansiveness of the province; the mode of transportation for CHWs to certain remote areas; if all completed projects of the Department were functional; the availability of human resources and equipment for completed infrastructural projects; if services were currently being rendered by the completed facilities to the communities; if measures had been put in place to ensure a non-recurrence of unauthorised expenditure, and what such measures were; how the Department would ensure payments within the required period of 30 days, and the previous challenges in achieving payments and the turnaround strategy going forward; and what the overall percentage of ICs had been implemented in the current year.

Dr Maesela wanted to know if there were posts within the Department that were funded by international donors and if so, what the percentage of such posts were, and how the absorption of such posts would affect the budget of the Department in future; the implication of the 1 616 abolished posts on the achievement of quality health care services within the province; what the mobility of CHWs were within the province; what changes were responsible for the struggles experienced by health facilities to reach the platinum goal in the NHI facilities; what support was given to facilities to assist them in reaching the platinum rating; to what extent the vacancy rate affected clinical initiatives; the number of targeted facilities which had facility managers to drive the implementation of the IC initiative; what impact the moratorium on employment had on the quality of service in the health facilities, especially because of the vacancies for 477 health professionals and 247 support staff; and why most of the infrastructural projects of the Department were at the planning stage at the same time.

Mr Mahlalela wanted to know how the Department monitored the performance of CHWs, since they were employed through NGOs, the cost implications of employing CHWs through NGOs, the conditions of service, and benefits that accrued to them; the number of wards that already had ward-based teams, and the arrangements for such ward-based teams; what efforts had been put in place to resolve the leadership issues at senior management level that had contributed to the qualification status of the Department’s audit outcomes; measures put in place to address inadequacies for poor management, as well as consequences for transgressions; if vacancies in key management positions were being addressed; what forms of cost-containment measures would be adopted to address the issue of accruals in the health sector, that would not compromise service delivery; and where money would be sourced to pay for outstanding accruals.

NCDoH response
Ms Shouneez Wookey, CFO: NCDoH, said that the Department’s training budget was R21 million, while the bursary budget was R22 million, resulting in a total of R43 million for training and bursaries.
With regard to unauthorised expenditure, the Department acknowledged that the existence of legacy accruals and a continuous shortage of cash flow had culminated in the recurrence of irregular and unauthorised expenditure. The AG had noted that the problem was with leadership, and it had therefore embarked on an enforcement of internal controls to ensure that each department was held accountable for its budget allocations.

The Department had centralised its procurement process to the provincial office; delegations had been provided for districts and hospitals with very small amounts, but the centralised procurement system would enable bulk buying and bulk discounts, while spending was also being managed for the distribution of goods and services. The budget control measures put in place included a pre-approval system, where budgets were allocated and each manager would be given his budget per care centre. The budget unit would check to see if funds were available before any spending could occur within that budget allocation. A requisition would then be submitted, quotations would be requested, and the cost of goods would be considered before the budget was approved.

The issue of payments made in excess of 30 days remained a challenge. A request had been made to the provincial Treasury for a cash advance to sort out outstanding payments. The control measure put in place to resolve this issue was the development of a tracking system that monitored requisitions from the date such requisitions were received in the Department’s supply chain unit, as well as staff efficiency. Staff efficiency was tracked from the date requisitions were received till the date the quotations were requested, the date of the issuance of orders, the date of delivery of goods, the date when the invoice was received, after which satisfaction with the delivery of goods would be confirmed. Service directives would then be issued to staff to inform them of the number of days within which invoices should be paid, in a bid to control the actual amount of payments within 30 days. The big challenge was in getting Treasury to believe that the cash advance would assist in clearing payments outstanding for longer than 30 days, and in effect, be able to manage the system.

Ms Botes said that the intention of the Department was not to cut costs at the expense of quality service delivery at the clinics and hospitals. An example of cost-containment measures could be found in sifting through the contractual obligations of the Department. This was exemplary in issues of housing leases where, for instance, the Department had been able to pick up 56 housing leases in Upington, of which the rent for five of those houses, ranging between R5 000 and R14 000 per month, had been paid by the Department, but the houses were vacant. The Department had paid at provincial and district level for the same houses. It was in such areas that cost-containment measures would be implemented to reduce wastage and gather money to pay out the accruals.

The Department said that 60% of its projects were currently on site. Out of that percentage, there were legal projects that were taking a bigger chunk of the 2016/17 budget. The planning processes alluded to in the presentation would be finalised shortly, and the procurement stages would commence shortly. The projects would overlap into the next financial year.

Ms Lindiwe Nyati-Mokotso, Chief Director: Health Programmes: NCDoH, said that the Department was guided by a document released from the Department of Labour and a ministerial determination in stipulating the conditions of service of CHWs, as it related to leave that could be taken, as well as their uniforms. The CHWs were currently being paid a stipend of R2 500 per month, and bonuses were awarded to them at the end of the year. With regard to the issues around permanent employment of CHWs, the Department was waiting for the NDoH to finalise the draft policy of 2015 regarding the ward-based outreach teams. However, the province had considered the cost implications of absorbing the CHWs, and decided upon the guidance of the NDoH. The CHWs worked currently within households and areas where they themselves resided. It was only the NGOs that would not be situated in the areas where the care givers worked. The NGOs reported to the clinics on a daily basis to sign the register, as a requirement for monitoring. The Department also ensured that the NGOs submitted a quarterly report on the activities of the CHWs before the stipends could be transferred to the NGOs. NGOs were also requested to submit bank statements before the stipends could be transferred. Payments were made by the NGOs into the bank accounts of the CHWs, and not directly, in order to access all bank statements required for documentation at the Department.
She said that the Department battled with insufficient team leaders in the province. NGOs were given an amount of money to assist with travel expenses for training. There were 38 teams in the NHI pilot district of the province, and the Department was trying to roll out these teams even as they continued with their training in the new syllabus, so that they could complete phase 1 and 2 and qualify as mid-level workers. The Department would therefore have a cadre of mid-level workers by the time the policy document was finalised by the NDoH.

Ms Mariette Eckard, Project Manager, NCDoH, said that three out of the 164 facilities had reached IC status, amounting to 2.5%. Some facilities only needed vital equipment to retain their IC status. In the previous financial year, the average percentage for targeted clinics was 78%. There was a challenge with getting the vital equipment that those facilities needed to attain the IC status. While the Department was in the process of identifying the needs of the facilities and beginning the purchase of needed equipment, rapid improvement was envisaged within the entire process. The average percentage in the Pixley Ka Seme district was currently at 66% for all the clinics. The NHI grant was being used to purchase some of the vital equipment for clinics in this district. Other funding avenues would be looked into for the purchase of vital equipment for clinics in other districts.

One of the major commitments of the Department was focused on addressing the issue of facility managers. The idea was to ensure the appointment of facility managers in all health facilities.

Ms Ntende Mazibuko, Chief Director: District Health Services, NCDoH said that the Department had been faced with a situation where all districts had presented their submissions on the permanent appointment of operational managers. In facilities where there had been attrition, the expenditure on COE revealed that there was only a little room to include additional expenditure to the COE budget, especially with regard to the filling of critical posts. 477 of the 704 posts sifted by the Department were for the clinical services. The submissions for such posts had been completed and forwarded to Treasury for consideration, in line with the moratorium. In other words, while there was the burden of moving budgets around for the COE and identifying areas of inefficiencies within the Department, it would look into recovering wasted funds and thereafter direct such funds to the critical needs. The operational managers and critical clinical posts would be accommodated as a result of this exercise.

With regard to reasons for not using the Workload Indicator of Staffing Needs (WISN) to determine the critical and non-critical posts within the Department and whether the exercise had been undertaken, she said that the exercise had been undertaken within the province, but not all facilities had been completed. However, the majority of facilities had conducted the exercise according to the normative guidelines provided to all provinces by the NDoH. The province had been unable to comply with the WISN norms at the moment.

Addressing the issue of reports of blood running from the hospitals into the streets, she pointed out that the alleged report had been corrected. The true situation was that the volume of autopsies conducted in the mortuary at the time had resulted in an overflow of the drainage system, but it had been bloody water and not blood itself. The overflow had not been into the street, but into an internal road behind the mortuary within the compound of the hospital,. The problem had been addressed immediately in the days that followed.

Ms Botes said that the abolishment of posts in the Department did not equate to a total disappearance of posts. There was an organogram that outlined the establishment in accordance with the personnel and salary administration system (PERSAL). National Treasury and the Department of Public Service and Administration (DPSA) were joint custodians of this system. In terms of a public service and administration directive, only funded and vacant posts must be reflected in the post establishment, as per PERSAL. In other words, all unfunded and vacant posts should not be reflected. As soon as funds were available to fund a post, the post would be recreated in the establishment. In the current instance, the Department had a huge vacancy rate that would technically have resulted in an inaccurate reflection on its vacancy rate, especially because the majority of the posts culminating in the vacancy rate would have been the unfunded vacant posts. It was for this reason that the 1 616 vacant posts had been removed from the Department. Of the 1 616 posts, 704 constituted critical posts.

Mr Motlhaping referred to the air ambulance service, and said that service providers normally charged an availability fee. The HOD and the rest of the team had been instructed to identify service providers that would be available as and when needed in order to avoid incidents of payment for planes that were not used.

He saidthat some of the housing lease contracts had been terminated as a control measure, to avoid wasteful expenditure in the Department.

Regarding consequences for maladministration within the Department, he said that the past MEC had appointed a team to investigate alleged incidents of maladministration in the province, and a report would be received shortly on the findings of the task team. Some officials were currently on suspension and were undergoing the appropriate disciplinary process.

Mr Volmink reiterated his question on the operation of air ambulances within the province at the moment.

The Department said it had been a participant in an RT contract until it was recently terminated by National Treasury. This situation affected not only the Northern Cape, but also other provinces. National Treasury had advised provinces to make use of the deviation procedure for air ambulance services.

The Chairperson concluded the meeting by urging the Department to continually update the Committee on any progress made. A time would be scheduled for an oversight visit to the province. The issue of bloody water running through the street spoke to the issue of maintenance. The Committee hoped that such maintenance issues had been addressed fully.

The meeting was adjourned.


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