Human resources & community health workers: Western Cape, KwaZulu Natal & Limpopo; Infrastructure projects; Financial management; Ideal Clinic Initiative

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

The Provincial Departments of Health in Western Cape, KwaZulu Natal and Limpopo presented updates to the Committee, briefing Members on matters ranging from personnel issues, particularly the attempts to use Community Health workers, financial management, supply chain, the developments on audits, accommodation and the move towards the Ideal Clinic. Members' questions were equally wide-ranging, asking officials to explain spending, address medical legal claims and explain the rumour that in a clinic at Bela-Bela a clinic was plagued by a resident snake which was unable to be removed.

The Western Cape Department of Health outlined he link between the poor economy and health of the individual and how this in turn exacerbated the position of the departments, leading to more focus on strengthening preventative healthcare. The population in the Western Cape was increasing and putting too much pressure on the budget, and working hours of practitioners had had to be reduced. The vacancy rate was linked directly to the vacant funded posts, with 36.5% of budget spent on personnel at the front line. Home Based Care Centres are to be strengthened and NPOs are used to align the centres, with a geographical spread that is trying to concentrate on rural areas. This Department had received  unqualified audits for 12 consecutive financial years. The Supply Chain Management had been decentralised. Challenges remained, particularly linked  to road safety injuries, socio-economic problems, alcohol-related problems, and safety challenges. The Department was trying to work well with strategic partners, including the police, private hospitals and surgeons. The Ideal Clinic initiative was adopted in April 2016 and teams were being  identified and trained, with assessments planned for December 2016. Clinics to be scaled up to Ideal Clinics by March 2017 were being identified.

The KwaZulu-Natal (KZN) Health Department reported that it had a strong emphasis on Community Care Givers. Although they were previously employed by NGOs, to assist with patients discharged from hospitals who still needed care at their homes, the Department had been funding them directly since 2010. They were provided with health promotion material and focus on health prevention over and above basic home nursing. The Health infrastructure was seen as critical to sustaining an efficient health care service, with a quality and condition to reflect the commitment and standards set by the Department to improve universal access to equitable healthcare delivery to all people in KwaZulu-Natal. The Department managed to spend around 98% of budget, although it had closed the BAS system early to prevent over-expenditure. The progress of the 204 potential clinics assessed in KwaZulu Natal was outlined, with three receiving silver status and four receiving gold status. There were still challenges with water and electricity, IT connectivity and budget constraints.

The Limpopo Health Department indirectly employs of the Community Health Care Workers, recruiting them through the NPOs, with funding being agreed formally and transferred in tranches after monitoring of their performance. Volunteers are paid a stipend. The compensation bill was rising although there were still vacancies. The Department was trying to avoid duplication and was engaging the unions to try to redirect some funding elsewhere, as well as stopping some outsourcing, although some capital equipment would then be required. Master Plans were being drawn to upgrade facilities. Service delivery was being delayed by long-drawn out disciplinary cases, and the Department was trying to improve on project management. This Department did receive a unqualified audit opinion in 2014/15, with matters of emphasis around fruitless and wasteful expenditure, irregular expenditure, and material impairment. For 2015/16 it received a qualified audit opinion, with qualifications on movable tangible capital and minor assets, accrued departmental revenue and employee costs and benefits. The Department was to embark on a comprehensive asset verification process and introduce and implement a quarterly asset count report, as well as reconcile registers with what it has on the system. There are some challenges with aging equipment and non-utilization of facilities. 248 public health center facilities would have to be upscale to meet the standards of the Ideal Clinic.

Members asked the Western Cape to explain the arrangements with the NPOs in the management of health workers, the reasons for delays in the Ideal Clinic, the gap in the reduction of working hours and how this would be addressed, and reasons for under-represent. KwaZulu Natal was asked to explain the benefits given to Community Care Givers,  whether there were plans in place to address the lack of capacity in SCM officials, time frames for completion of provincialisation of Ideal Clinics and the key senior management positions that remained unfilled. They wanted some clarity on the geographical or ward-based system in all provinces. Limpopo was asked to explain how many NPOs were contracted, and why Limpopo chose not to manage them directly.  Questions were asked around the high vacancy rate in mental health practitioners, and about the hospitals experiencing problems with the infrastructure and services. 

Meeting report

Provincial Department of Health briefings: Emphasis on human resources, Community Health, Ideal Clinic initiatives, audit and supply chain matters
Western Cape Presentation

Dr Beth Engelbrecht, Head of Department: Western Cape Health Department, gave a snapshot picture of the status of health in the province. She stated that 75% of the 6.3m population is uninsured. The population in the Western Cape is growing by 2.6% per annum. The R20bn budget also caters for the 31 300 staff members in the health sector. She highlighted there is a quadruple burden of disease. The HIV is most prevalent in the 24-35 age group in the Western Cape. The Prevention of Mother to Child PMTC and Anti Retroviral ART programmes are effective. TB has recorded the highest new infections but has got the highest cure rate in SA. The main risks are concurrent HIV and drug resistant TB.

Injuries are higher in the Western Cape than the global average. They account for 18% of SA burden of disease. The leading cause is substance abuse and road traffic accidents. Chronic disease account for 58% of SA deaths. This includes cardiovascular diseases, cancers, diabetes, and mental illnesses. 80% of mental disorders do not receive the required treatment. When it comes to maternal and child health, there is 90% antenatal coverage but 47% of deaths are avoidable. The leading causes of death are HIV/AIDS, hypertension, and pre-existing conditions. Neonatal deaths are prevalent and are due to poor breastfeeding, diarrhoea, pneumonia, and HIV.

Mrs A Aries, Chief Director in People Management,Western Cape Health Department, briefed the Committee on human resources with emphasis on community health workers. She said the Department has had an unqualified People Management audit for the past 12 years. For 2015/16 financial years, it received a clean audit. It has decentralised the management of People Management functions. CEOs have delegations for certain People Management functions.

The directorate responsible for Community Based Programmes manages the provision of Home and Community Based Care (HCBC) within the Department. This entails the procurement of HCBC service through open tendering and formal contracts with non-profit organisations (NPOs); management of contracts with NPOs who, in turn, have contracts with the Community Health Workers (CHWs) that they employ; and manage the budget allocated to CHWs. The service rendered by NPOs is co-ordinated at a decentralised level by the sub-district / district CBS manager.

The responsibility of the People Management to the CBS is to provide and manage the Expanded Public Works funding allocated to CBS from programme 6, procure the required training of service providers for the CHWs and manage the related contracts, assist with funding the logistical requirements of training from EPWP funding, and ensure that the details of the CHWs are captured on the central Public Works database, which reflects the number of work opportunities created.

As per HealthCare 2030, the HCBC includes a comprehensive integrated community based rehabilitation service, and it introduces the Rehabilitation Care Worker (RCW) supported by rehabilitation professionals to the HCBC and inter-mediate care platforms. The first 30 Rehabilitation Care Workers, selected from the level 4 CHW cadre, graduated from UCT in 2014 and are employed by NPOs.

(Figures were presented to illustrate the public health personnel, and remuneration of CHWs per level, and cost of CHWs and impact on budget if they are employed by the Department)

Dr L Angelettie-du Toit, Chief Director in Infrastructure, Western Cape Health Department, took the Committee through the infrastructure projects. Infrastructure priorities for the 2016/17 period are:  to strengthen and improve the Primary Health Care infrastructure in all districts with a specific focus on the metro, to modernise Emergency Centres at hospitals, to provide or upgrade Acute Psychiatric Units at hospitals, to focus on Maintenance and Fire Compliance at existing health facilities, and to improve efficiency, economy, and effectiveness of Procurement Strategies.

Concerning capacitation, she reported that the NT Circular of 13 March 2015 prescribes conditions for utilisation of Division of Revenue Act (DoRA) funding for infrastructure posts. Currently, 31 posts have been filled and funded out of HFRG. The scarcity of built environment, engineering and health technology skills remains a challenge. The Hub & Spoke Model developed for maintenance of infrastructure and clinical equipment enables improved efficiency, reduced costs and delays with repairs, and optimal use and distribution of scarce technical skills. The implementation of the Hub & Spoke contingent is upon budget availability.

Speaking to risks, she said the main problems were the under-expenditure of infrastructure budget, vandalism and theft, and fire outbreak. These would be mitigated, amongst other things, through the implementation of the Infrastructure Delivery Management System (IDMS), use of innovative procurement strategies, ensuring compliance with standardisation; installation of vandal-proof infrastructure including fixtures and fittings, improving security services; ensuring that design and construction of infrastructure is compliant, and establishing Health and Safety committees, appointing and training emergency representatives in accordance with the National Core Standards.

On challenges, she stated the infrastructure budget allocation has continuously been reduced over the past few years, and this necessitates the on-going reprioritisation of projects. Furthermore, inflation reduces the value of available funds, especially when that is combined with the negative Rand-Dollar and Rand-Euro exchange rate. There are also inconsistencies with the DoRA Grant Framework, and there is a lack of systems integration and interface.

(Figures were presented to illustrate budget and expenditure, projections per sub-programme, and performance-based incentive grant allocation)

Mr G Garrick, Director in Financial Administration, Western Cape Health Department, briefed the Members about issues that were raised by the Auditor-General and plans to address these concerns. For 12 years the Department has received an unqualified audit opinion with no material findings. Irregular expenditure is recurring though not serious. The emphasis of matter had no impact on the audit opinion. Material Contingent Liabilities were disclosed in respect of medical negligence claims. For the 2015/16 periods, there has been a 56% reduction in irregular expenditure. 75 recurring incidences totalled R1.88m.  R290m has been written off. The key driver is the conflict between an outdated means test and Public Health rising costs. All written-off amounts are handed over to debt collectors. As a result, R25.6m has been recovered via a debt collector in the current period.

(Figures were presented to illustrate accrued department revenue and contingent liability)

Mr Johan Jooste, Chief Director in Supply Chain Management, Western Cape Health Department, pointed out there are inefficiencies and efficiencies within the SCM system.  Inefficiencies are caused by the lack of integrated systems which create duplicated or inconsistent information and processes. Systems are not geared towards current SCM reform and there is a poor contract management for national contracts. Despite collaboration with the Department of Economic Development, Agriculture and Tourism, the Department still faces major issues regarding the implementation of local content.

Mr Jooste described some of the efficiencies in the system as follows:

- Accounting Officer’s System introduced 2 years ago
- Delegations: allow for decentralised procurement
- Demand Management: planning introduced for all decentralised buying institutions
- Sourcing Pipeline: it highlights all planned formal procurement processes for an 18-month period
- Centralised procurement processes for Laundry and Security Services

Some of the measures implemented to address SCM imperfections and improve Contract Management included: :

- Implementation of the the Demand Management Planning and Procurement Plans
- Regular training interventions
- Monthly SCM Forums: Departmental and provincial (via PT)
- Contract Registers have been introduced on SharePoint
- Development of a specification library for equipment specifications
- PPFA and BBBEE Regulations are used as a driver for development and transformation through procurement

Dr Engelbrecht talked about progress and challenges on implementing the Ideal Clinic Initiative. She reported that the Western Cape formally adopted the Ideal Clinic Initiative in April 2016. PPTICRM teams are being identified and trained. PPTICRM assessments are planned for completion by end of December 2016. Peer Review assessments are planned for completion by end of February 2017. The Western Cape is currently identifying the clinics for scale-up, to achieve the Ideal Clinic status by March 2017.

227 facilities in the Western Cape have completed their status determinations. Of the elements assessed, 56% were assessed as “yes”, 31% as “no”, and 13% as “partial”. The Western Cape has six health districts. The Central Karoo has done the best to date, but their numbers are very small. Overall, the Western Cape facilities did best in Information Management and HR, and are worst in partners and stakeholders, and infrastructure.

Remaining challenges and critical matters were then outlined. The main concern is the  relationship of the Ideal Clinic to national Core Standards and alignment, specifically, whether PHC facilities are required to conduct annual NCS self assessments. The IC elements are ambiguous and “not applicable”. Some elements do not apply to very small clinics. Connectivity in some facilities results in data capturing challenges. There is no specific person yet identified at National Department of Health (NDOH) to assist the Western Cape.

In her conclusion she stated that the buy-in from the services has been good, and good progress has been made because the Western Cape started one year after the other eight provinces and has “caught up”. The Western Cape Provincial Department has received excellent co-operation and assistance from the National Department.

KwaZulu-Natal Presentation
Dr Sifiso Mtshali, Head of Department, KZN Health Department enlightened the Committee about the human resource activities of his Department, with a special emphasis on Community Care Givers (CCGs). Community Care Givers (CCGs) are community members who provide basic health services within their communities. CCGs were previously employed by NGOs due to the demand in the escalating numbers of patients discharged from hospitals needing care at their homes. In 2010 the KZN Department of Health took a decision to terminate contracts with the NGOs and opted to fund the CCGs directly. CCGs are provided with health promotion material, and they focus on health prevention over and above basic home nursing. Each CCG is allocated 60 households in a Ward and is required to visit 3-5 households per day. Each CCG is linked to a clinic/health facility within the catchment area.

The CCGs; responsibilities include the following tasks:
- Conduct environmental health assessment (health & hygiene issues)
- Assessment of family health cards.
- Treatment adherence.
- Data collection (immunisation and health status)
- Submit reports to health facility for interventions.
- Participate in Operation Sukuma Sakhe (OSS)

1 456 CCGs have been provided with career opportunities within the following work streams:

576 Trained as Nutritional Advisors
820 Trained as Enrolled Nurse
60 Trained as Health Promoter’s Assistant

On completion of training, the former CCGs are now fully employed. He further noted that challenges are compounded by ineffective supervision, reporting lines, expectations of CCGs and their status in relation to stipends and full-time employment, and shortage of vehicles to support the teams.

Mr Bongi Gcaba, Infrastructure Manager,  KZN Health Department, stated that Health Infrastructure remains the visible interface between the Department and the public at large, and is a critical aspect for sustainable and efficient healthcare service delivery. The quality and condition of facilities must echo the commitment and standards set by the Department to improve universal access to equitable healthcare delivery to all people in KwaZulu-Natal.

In 2015/2016 a number of events or situations happened which were not planned for and which would continue to have an impact on not only budgets but also on planning, which necessitated a review of the 2016/2017 plan. These events / situations included:
Implementation of Load-shedding by Eskom: KZN-DOH is focusing on ensuring that all hospitals and 24-hour facilities have sufficient back-up power.
Impact of the drought: participating in the War room and working with municipalities to manage water systems and provisioning of boreholes, working with facilities to manage, supply and maintain water wise plumbing and fittings, implementing a programme to install rain water tanks to harvest rainwater and improving facilities storage capacities including elevated 72-hour supply tanks.
Severe storms: severe storms experienced in the last years impacted greatly on facilities, for example, in Townhill Hospital where storm repairs had to be done twice.

The Health Infrastructure Programme of the Department was allocated a budget of R1.552 billion for 2015/16 and R 1.583 billion for the 2016/17 financial years. Because of the high reduction of an Equitable Share allocation, almost all projects were transferred to the Infrastructure Grant. Infrastructure Development has for the last five years managed to spend the budget successfully, and the management of the budget has been improving year on year.

During the 2015/16 financial periods, the Department performed well. It achieved a total expenditure of R 1.5154 billion and the percentage spent was 98% against 100% of time lapsed. The main reason why the achievement is not reflected as 100% was due to the Department closing the BAS system early to prevent over-expenditure by the Department programmes as a whole. Any instances of under-expenditure were due to the early closure of the BAS system of the Department and all invoices were not paid at end of March 2016.
(Figures and pictures were presented to illustrate completed projects, projects in planning, budget and expenditure, and expenditure per programme)

He also stated risks were around budget, project procurement and supply chain, and performance of implementing agents. Because of continuous reduction in the Equitable Share option, many projects have been placed on hold or are being delayed. The delays of these projects would vary from one to more than two years.

He said that SCM processes have been done mostly without input by KZN-DOH and this resulted in delays of the appointment of PSPs by KZN-Department of Public Works (DOPW) , due to long drawn out SCM processes, and the quality and experience of PSPs appointed by KZN-DOPW. Many had no or limited experience in planning and management of Health projects. As a consequence, the KZN-DOH continues with monthly meetings with KZN-DOPW. From 2016/17, the KZN-DOH would be represented on the SCM committees of KZN-DOPW, and the new Standards of Procurement to be implemented in 2016/2017 would also assist in improved SCM processes.

Implementing agents had failed to perform to a satisfactory level, and this had, over the last few years, resulted in a high number of cancelled projects, many liquidations, long delays both prior to construction and during construction, as variations are not dealt with expeditiously, and massive cost increases due to delays and additional costs due to cancelled projects. In order to mitigate these risks, the Department has undertaken to hold ad-hoc meetings to resolve gaps in reporting. An effort has been made to update the Project Management Information System (PMIS), and there has been some development of improved Reporting proformas  by KZN-DOH, and holding of monthly report back meetings.

In wrapping up his infrastructure presentation, he said in the last years the KZN-DOH infrastructure unit worked hard to improve and this is showing results in the budget management and overall achievements. Capacity is being increased in the unit and the unit is working with KZN-DOPW to ensure that its capacity is sufficient. The infrastructure unit is aiming to place infrastructure development and management back into Provincial Government hands. The infrastructure unit is meeting regularly with KZN-DOPW to improve corporative governance. The improved capacity of the infrastructure unit allows KZN-DOH to ensure a sustainable Health Service Platform while moving away from constructing new facilities to well maintained, optimally utilised and sustainable existing facilities going forward.

Mr Sihle Mkhize, Acting Chief Financial Officer,KZN Health Department, stated that the Department received a qualified opinion for 2015/16. The qualification was a result of movable tangible capital assets and minor assets, irregular expenditure, and compensation of employees - commuted overtime allowance. The Auditor-General (AG)  was unable to obtain sufficient and appropriate audit evidence that the management had properly valued and fully accounted for movable tangible capital assets and minor assets disclosed in Note 39 of the Financial Statements. Also the AG was unable to determine whether any adjustment relating to movable tangible assets stated at R2.84 billion (compared to the 2015: R2.29 billion) and minor assets stated at R665 million (2015: R450.91 million)   in note 39 to the financial statements was necessary.

In its action plans, the Department would, amongst other things, complete physical asset verifications and establish if the asset cost can be obtained from historical costs of similar assets, review all assets reflected at cost in the annual report figures to ensure that the appropriate value and voucher is assigned to the asset, and perform a complete review of the FAR for the consistent application of the fair value methodology and the appropriateness of the fair values. The Department is also going to conduct a physical asset verification exercise to ensure all assets are accounted for and accurate population of complete asset barcodes, descriptions, serial numbers, makes, models, IT stock numbers, conditions, VIN numbers and location information.

On irregular expenditure, the Department did not disclose all irregular expenditure. There was  non-adherence to procurement legislation due to breakdowns in internal controls over SCM. Consequently, the AG was unable to determine the full extent of the irregular expenditure stated at R410 billion (2015: R3.17 billion) in note 31 to the financial statements as it was impracticable to do so. The Department now plans to initiate processes for the retrieval of all unsuccessful bids received for existing provincial contracts and file as per Archives Act, and to engage Provincial Treasury on Standard Process and Policy for the retention period for bids received but not awarded. The Technical support services is going to review all bids prior to presentation  to ensure all documents are filed and the processes followed are compliant.

He outlined the position on compensation of employees, the commuted overtime worked was not supported by reliable evidence for payment of services rendered as well as contracts. The policy on attendance registers would be reviewed to ensure that all staff (inclusive of doctors) sign a register. Provision would also be made as to how attendance at night should be recorded for doctors in this policy. The Departmental Policy on Commuted Overtime would be reviewed and CEOs, Medical Managers and HR Managers would be work-shopped on the revised Policy.

With regard to compliance with legislation, effective steps were not taken to prevent fruitless and wasteful expenditure of R 5.12 million as disclosed in Note 32 of the Financial Statements, in contravention of section 38(1)(c)(ii) of the PFMA and Treasury Regulation 9.1.1.Now all officials responsible for incurring fruitless and wasteful expenditure would be referred to the Department’s Financial Misconduct Committee for sanction.

Mr Mkhize also talked about the Supply Chain Management and Procurement issues that need to be improved. Audit Improvement Plans are to be developed, and plans are to streamline Demand Management processes in order to identify and implement improved sourcing methods guided by leading practices in strategic sourcing. Standard Operating Procedures (SOPs) have been finalised and training has been given to all institutional management teams. As part of the Department’s Strategic sourcing processes, all contracts advertised are awarded in an equitable manner with emphasis on SMMEs – utilised as a tool in development and transformation.

Concerning progress and challenges on the Ideal Clinic Initiative, of the 204 facilities assessed in KZN, three facilities received Silver status and four facilities received Gold status. The Ncotshane Clinic scored 87% as the best performing facility in KZN. The Umlazi D Clinic scored 17% - the lowest performing facility. Challenges are around water and electricity back-up systems in rural areas, Information Technology (IT) Network connectivity challenges in the rural facilities, and budgetary constraints for clinic maintenance.

The KZN Province has included the Ideal Clinic Realisation Programme in the Service Delivery Improvement Plan (SDIP). Improvement plans are in place to ensure compliance with the ICRMP.

Limpopo Provincial Department of Health Presentation
Mr Justice Mudau, Acting Chief Financial Officer, Limpopo Health Department, briefed the Committee about the human resources with emphasis on community health workers. He said the Department is an indirect employer of the Community Health Care Workers (CHCW). The CHCWs are recruited through the Non Profit Organisations (NPOs) that are funded by the Department. The NPOs are funded through a 3-year cycle and Service Level Agreements (SLAs) are signed annually with successful NPOs and funds are transferred to them in tranches. The NPOs submit reports quarterly to the funder (DOH) and DOH, in turn, monitors the NPOs before the transfer of each successive tranche. The NPOs pay volunteers a stipend regulated through the ministerial determination that the Department of Labour passes every year.

This Department received an unqualified audit opinion during 2014/15, and matters of emphasis raised by the AG were on fruitless and wasteful expenditure, irregular expenditure, and material impairment. In correcting fruitless and wasteful expenditure, the Department plans, amongst other things, to enforce the delivery of invoices at a central point within the finance section and to enforce a compliance checklist to ensure that relevant laws and regulations are complied with before transactions are processed. An Irregular Expenditure Committee has been established to adjudicate on non-compliance. Contracts for key commodities have been concluded, and workshops are continuously held to capacitate officials.

In addressing material impairment matters, the Department has enlisted the services of two collection agencies to collect on behalf of the Department, as the payment rate affects the impairment of Accrued Departmental Revenue. The Department is currently reviewing its Impairment Policy to benchmark it against other departments.

For the 2015/16 financial period, the Department received a qualified audit opinion with the qualifications relating to: movable tangible capital and minor assets, accrued departmental revenue, and employee costs and benefits. In order to rectify the issues the AG raised, the Department is going to embark on a comprehensive asset verification process and introduce and implement a quarterly asset count report. It also plans to reconcile the registers of patients visiting the hospitals and those captured on the system. There would be monthly monitoring of completeness and accuracy of patient visit and billing. It will assess amounts that would not be recoverable and engage Treasury in the process of writing-off. The commuted overtime policy that has been developed has been implemented with effect from April 2016. Leave forms are to be filed chronologically, and there would be monthly reconciliations of attendance registers with leave records to investigate any exceptions.

On Programmes 2 (District Health Services) and 5 (Central and tertiary hospitals), the AG found an unqualified conclusion on the usefulness of information. The Department plans to improve on record keeping, strengthening performance reviews at district level and facility level, and strengthen monthly verifications of data.

With regard to Supply Chain Management, Mr Mudau stated the Department has enforced compliance, with the development of procurement plans by all institutions within the Department. It has advertised and awarded contracts for strategic commodities. The Department has further revised the existing SCM delegations to give powers to CEOs. There will be a signing of code of good conduct by SCM Practitioners and Bid Adjudication Committees, and screening of suppliers to mitigate conflict of interest.

(Figures were shown to illustrate the Health Infrastructure budget and expenditure, allocation per Implementing Agent, and a list of projects to start construction in 2016/17)

He stated infrastructure challenges are around ageing and inappropriate “not fit for purpose” infrastructure and equipment, non-utilisation of facilities after practical completion, limited capital and maintenance budgets versus the needs, and lack of term contracts: maintenance, equipment and furniture. He said these could be resolved if the Department could be sensitive that the end-user requirements should be guided and entrenched in policy and legislation – and not design for end-user preferences; that each proposed project should be accompanied by how it is going to be resourced, particularly on the health service providers and operational budget, to revisit the work undertaken by the Task Team on health care funding, and update data and cost estimates; and consider alternative implementing agents to assist in programme management.

He added that the way forward is to participate in existing term contracts and begin with the maintenance term contracts; build relationship with internal critical stakeholders “buy-in by all”, from project identification, prioritisation, and end-user requirements; and communicate more appropriately and effectively.

Dr Kgapola, Acting Head of Department, Limpopo Health Department, enlightened the Committee about progress and challenges around the implementation of the Ideal Clinic Initiative. This Department has identified 248 Public Health Centre (PHC) facilities that need to be scaled up to meet the standards of the Ideal Clinic for the current financial year. The Department is ranked third (57%) together with the Eastern Cape in terms of overall Ideal Clinic progress for the 2016/17 financial years.

The Sekhukhune District is ranked ninth among the best performing districts in the country at 66%. The Mopani District is the lowest performing district in the country with 36%. The Motupa Clinic is ranked as the second lowest performing in the country, with 17%.

When it comes to challenges, he noted that developmental partners in districts are not fully involved on the Ideal Clinic project. There are insufficient funds and delays from the SCM processes. There is no compliance to patient record content adhering to the Integrated Clinical Service Model Prescripts. Filing and archiving compliance is only at 9% due to insufficient space. Signage from the main road to the facility is available for only 12% of the facilities. 64% of the PHC facilities experience physical space and routine maintenance challenges. 48% of redundant and non-functional equipment at these facilities has not been removed, and 8% of these PHC facilities have functional back-up electrical supply. Available protocols and guidelines have been implemented at only 30% of these facilities.

Western Cape Presentation
Dr P Maesela (ANC) wanted to know what the arrangements are with the NPOs in the management of health workers and why the Department is not taking over the administration of the health workers. Also, he asked what strategies are in place to address the scarcity of built environment engineers and technologists. He further enquired why the Ideal Clinic programme was adopted after three years after it has been implemented nationally.

Dr N Mbombo stated the NPOs are not private and are part of the health system. Some of the NGOs have been in existence before 1994. The Department is creating an enabling environment to make sure everything dovetails and is integrated.

Dr Engelbrecht, on the scarcity of built environment engineers and technologists, explained that the Department had a bursary scheme called Sakhisizwe. Their graduates came from the Cape Peninsula University of Technology, University of Cape Town and University of Stellenbosch, and went on to complete the built environment programmes. They have been absorbed into the system, especially those who were registered with the professional bodies. The only problem encountered was around quantity surveying students from the CPUT who had not been accredited by the professional body and now had to go through other avenues to get accredited. The Department is trying to attract such students, and they are provided with the necessary training for accreditation. However, it is difficult to match the salaries offered by the private sector.

Dr Engelbrecht spoke to why the deal Clinic was adopted late. This programme is a description of how a clinic should function because it is part of a system. Hospitals and clinics have to comply with certain standards. The Department had to make sure that other essentials, like nurses and medication are available. Some of the things required in the Ideal Clinic are things the Department has identified before and implemented.

Dr Mbombo also added that the Western Cape health outcomes are far better than in other provinces. The Department is not at its peak yet but it is trying its best. In every clinic there is a clinical health practitioner and  how to address the problem of waiting is very important. The  Department aims to be patient-centred.

Mr H Volmink (DA) wanted to find out if the gap left by the reduction of working hours of health practitioners would be addressed adequately.

Dr Engelbrecht explained that the hours have not been reduced. It is only the shifts they work that have been re-arranged because their salaries depend on the number of hours they work.

Dr Mbombo further indicated there has been an increase in population and doctors cannot work for 30 hours continuously. There is huge pressure for them, especially in emergency, paediatrics, and maternity. By 1 January 2017 everything is expected to be implemented and completed.

Mr A Shaik-Emam (NFP), asked how far the Department was in making temporary health workers contracts permanent. He enquired what the Department was doing with regard to other departments, in terms of health education through the media, particularly on alcohol abuse. He wanted to find out what plans are in place to address the problem that the Cape Metro has the worst run clinics. He asked how many of the 500 officials that have been found to be corrupt are from the Health Department. He wanted to know how many young people get infected on a daily basis with Aids. He asked for clarity on the R182m spent on medical claims.

Dr Engelbrecht spoke to the permanent contracts and pointed out that this programme is still part of the health system. The health workers have been hired to fill part of the system and it all depends on the muscle of the Treasury, and one has also to look at the skills they possess. That is why the Department had a summit and tried to find out how to address these matters. They do not have to feel they are cheap workers or practitioners. There is a retraining programme in place and work is in progress.

Dr Tracey Naledi, Chief Director of Health Programmes, Western Cape Health Department, spoke to publicising health education through the media, and explained the Department is responsible for Strategic Goal 3 which looks into the health of families, young children, and communities. Strategic Goal 3 is led by the Health Department and is supported by the Departments of Social Development, Community Safety, and Transport. The process is being tested in the Drakenstein District to see how the integrated development model is working. Every six months there is a door-to-door survey and matters are reviewed every three months. The Department is consulting on a policy paper on how to deal with alcohol abuse. Pilots are being done in the Drakenstein District, LaGuNya (Langa, Gugulethu, and Nyanga), and Khayelitsha. The Department is working with communities and informal shebeens in trying to reduce alcohol abuse. It is also working with mobile units of the neighbourhood watches in these communities. Brief interventional motivations are being done. Such programmes are aimed at educating the communities about alcohol consumption by pregnant mothers.

Dr Mbombo heard the comment  about the worst run clinic in the Cape Metro, but said that he would have preferred to see evidence. The Department is not perfect and it does not dismiss things but people need to bring evidence so that problems could be addressed. That is why the Complaints System had been put in place to address such problems.

Dr Engelbrecht heard the comment on corrupt officials and and said that there were three whose matters were being looked into. In regard to HIV and young girls, she said the focus is on the prevention. The Wallacedene clinic and other Community Day Centres are focusing on the prevention programmes.

Dr Engelbrecht spoke to medical legal claims,and  explained that, globally, medical services are associated with risks and legal claims. The Department has two people who work with the legal advisors of the Department on medical claims. Patients are given all the support they need. There are cases that are before the court, and others are just notifications. Those that are before the court are cases where the Department is trying to find solutions. The Department has quality approaches for the staff so that it knows the right thing to do. There is also a system in place to listen to complaints, so that they are addressed immediately. A committee of three members has been appointed to look into these matters. The members are not employees of the Department. There have been Treasury approvals to top up money or reduce the money that is paid out to patients, as needed.

Dr Mbombo also added that the Western Cape litigation is not higher than that of other provinces. In most cases, some patients need to be given an opportunity to share their stories, not to sue. Western Cape did not say that they may not sue.

Mr A Mahlalela (ANC) wanted to know about the number of community health workers employed by the province. He further enquired about the number of wards that are covered by the health workers, especially in rural areas. Lastly, he asked what the budget is for infrastructure maintenance.

Dr Engelbrecht spoke to the number of community health workers, and elaborated that these numbers are between 3000 and 3800 and they are supported through the NPOs. The aim is to improve the health outcomes and, therefore, they are key in this regard. The Department also has community based workers in its system, who are hired through the NPOs. The NPOs are taken through a rigorous training for management and accountability.

Dr Mbombo, responding to the question on wards served by health workers, explained that clinics do not service one ward, but planning is done according to geographic needs and health workers are attached to the nearest health institution or clinic. They form part of strengthening the health system.

Dr Engelbrecht stated that the infrastructure budget maintenance is around R385m. Most of the money goes to maintenance.

Mr T Khoza (ANC) wanted to know what the reasons are for under-expenditure in infrastructure.

Dr Engelbrecht explained there were contractual issues with a hospital that was being upgraded and the Department of Public Works had to cancel the contract. The infrastructure development needs are determined by the growing population.

The Chairperson enquired why the Department has put the CACs under the City Council instead of the Department, and asked why there are too many health sub-districts.

Dr Engelbrecht said that it is an unfunded mandate for the Council to administer clinics. All those clinics have been put under the province already. The issue is unfolding but not concluded. It is being looked at by the Mayor.

Dr Mbombo answered that sub-districts are there to strengthen the health system. Their model is the same as in a municipality. In each sub-district, there is a hospital. The district hospital has its own COO, who works with the MAYCO. The metro is divided into sub-districts and sub-councils.

KwaZulu-Natal Presentation
Mr Khoza asked what benefits do Community Care Givers get besides the stipends. Also, he wanted to know if there are plans in place to address the lack of capacity in SCM officials. He wanted to find out about interventions that would be given to the Ideal Clinic in Umlazi D, seeing that its performance is the lowest.

The MEC noted that Community Care Givers get a 2-year contract. Others have been career-pathed to become nurses and food advisors, and are full-time employees. The challenge is only from nurses that have been unemployed. The Care Givers have done so much, and it is morally correct to career-path them.

Dr Mtshali, Head of Department said that the Department was currently building capacity in the SCM unit. Internal training was developed and rolled out last year and they have also involved the help of National Treasury. In the last report it was indicated that letters would be sent to the CFOs and CEOs, calling them to account on financial management issues that have been neglected or not given thorough consideration.

The MEC spoke to the Umlazi D Ideal Clinic and explained that the challenge is with the managers who are running the clinics. The consumables are supplied by the Department but the salaries are not provided by the Department. It is a question of whether the Department would pay the salaries when it takes them over, but the issue is still under discussion. The Community Care Givers report about what is happening on the wards. The Health Department has benefited greatly from the work of ward councillors in trying to detect who does not get treatment and who needs aids or special assistance.

Mr Mahlalela wanted to find out about timeframes for the completion of the provincialisation of the Ideal Clinics. He wanted to know what the status quo is regarding key senior management positions that are not filled. He asked how different the Ward Based Teams are from the Community Care Givers in terms of the work they are performing, accountability, or duplication.

Dr Mtshali said that discussions were held on the provincialisation of the Ideal Clinics, and identified where to start. The plan is to start with other municipalities and end with eThekwini. The completion would not happen this year because of funds committed already. Work is in progress.

The MEC answered the question on  unfilled key senior positions, and stated that the new position of CFO was being challenged, but the Department would now be going to shortlist and get the right candidate. The Department is still discussing how to incentivise administrative doctors rather than specialists.

Dr Mtshali explained there is no duplication in terms of work between Ward Based Teams and Community Care Givers,. The Community Care Givers have been in the Wards Based Teams. The challenges exist when it comes to specialist clinical teams. It is easy to find family physicians but more difficult to get anaesthetists. There is no problem with the nurses.

Mr Volmink asked for clarity on under-expenditure and irregular expenditure in infrastructure.

Dr Mtshali elaborated there were projects that were not getting off the ground but were being planned. The Department started to prioritise facilities that needed urgent interventions. As a result, some projects had to be put on hold because money had to be prioritised. In regard to  irregular expenditure, most infrastructure projects are done in-house. Others get outsourced. Some matters had been audited by the Independent Development Trust (IDT) but the Department could not get the documents it wanted  back and it had to release the figures. There was currently an asset management structure that looks at their shortcomings. The Department would be embarking on quality reviews.

Limpopo Presentation
Mr Mahlalela asked how many NPOs dealing with Community Health Workers have been contracted and what the rationale is for appointing the NPOs as opposed to the Department to manage them directly, and enquired how the Ward Based Outreach Teams related to the NPOs. He commented that the Department has not reported on progress concerning infrastructure because during a visit to Musina Hospital it was concluded it was not habitable. He said he was disappointed by the audit outcome. It showed regression, and he asked if it would improve next time.

Mr Justice Mudau, on Community Health Workers and NPOs, explained that this is historical. Before 1994 there were NGOs that were raising funds that were managed by the churches. Even in the new dispensation, these NGOs are still doing this work. Now the international funders are saying there is a new government that has to fund the NGOs. The administrative costs of these funds go to the middleman and that is why you find that the caregivers get paid very late. The Department is deliberating on whether it should not start administering these funds by itself. For instance, one NGO was found to have only R700 000 in its account but it could not be seen where the other money went to . Another one was found to have bought a Jeep Cherokee, and the Department had to cancel the contract and refer the matter to the National Prosecuting Authority and Asset Forfeiture Unit.
The NPOs add value but there are a lot of challenges within the value chain. The NPOs help the Department to trace those who are defaulting on medication. They are looking how, nationally, they could formally employ these community health workers. It is difficult to leave some of them out because their school education differed. Some have been career-pathed and are professional nurses, especially in rural areas. He also noted that retired nurses are beginning to go to the Social Development Department to register NPOs. Such mushrooming businesses should be discouraged

The MEC added that when these NPOs are opened, it is easy to appoint unemployed graduates and school dropouts. But when they have to be absorbed into the health system, it becomes difficult to leave others outside, especially those who have been with the NPOs for a long time. The issue of criteria poses serious challenges.

Mr Mudau spoke about infrastructure progress. He said the dates for advertising the projects are reflected in the presentation document. The Committee could go through these dates and decide when it wants to come and monitor progress. He spoke to the disappointing audit outcome, and explained the Department is confident that during 2016/17 it would manage again to get an unqualified opinion. During the 2014/15 audit, the team had a good relationship with the AG team. With the new AG team, the Department has to up its standards. The asset verification was done and it was found that some assets were not found, only to discover they were shifted to other units. But when the AG team was shown these assets, it refused to cooperate. The same applied to the question of leave with the new AG team. The Department had tried to tell the AG that the documents were not found because they had not yet been captured on its system due to some complications from the side of the Department, but when they did show the AG team the leave documents, there was a refusal to engage. However, the Department's new audit employee has felt that the AG has been unfair and had asked the AG to withdraw those paragraphs that put the Department in a bad light. The Department is still going to deal with matters of emphasis.

Dr W James (DA) remarked that he fully supports the expansion of medical education. There is a need to plan and look at migration patterns. It is better to also look at the disease originating from these rural areas than focusing on retention strategies. Doctors want to work in rural areas but did have to take into account practicalities such as schools available for their children.

Mr Volmink wanted to know how is the Department is going to address the vacancy rate in mental health, and he asked what happened to the hospital that had to stop its operations because electrical problems. He further asked for clarity on the irregular expenditure which amounted to R215m.

Dr Kgapola admitted that the vacancy rate is very high. The challenge is that the Department recruits and funds students, but when they finish their studies, they do not want to join the Department and some do not even want to go back to the province, especially to work in rural areas. The Department is winning in its effort to trace them so that they pay its money back. Concerning the hospital with electrical problems, he said the matter has been attended to. There is the general electrical supply. The only thing that is not there is the alternative electrical supply. Irregular expenditure was the result of contracts concluded by Public Works Department.

The MEC commented that the issue of psychiatrists is a crisis in the entire country. It is even worse in rural areas. She said when the graduates finish their studies, they come up with all sorts of excuses on why they do not want to work in rural areas. The Department is of the opinion that if they study and train in a rural area, it is possible they would stay. The Department is working on ways of recovering the state money and incentivise those who are willing to work in rural areas. She said there are plans to do a study to find out if a person who studies in a rural area would be able to also work in a rural area in order to see if they would be advocates of the environment that produced them.

Dr Maesela enquired if the Department was buying land to build houses or just buying houses for accommodation. He also asked for clarity on the upgrading of bulk water storage.

Dr Kgapola said the Department was procuring flats and houses within the towns. In the process, the Department is also building townhouses for its staff. The accommodation is mainly for doctors, nurses, dieticians. With regard to the bulk water storage, he indicated that the Water and Sanitation Department has given the Department its own contract. The Department has its own budget and engineers to monitor its own projects. The municipality has been asked to help the Department with water supply in that local hospital.

The Chairperson asked for an update on the medical legal litigation of the Department. She also asked for clarity about a clinic that had been completed in Bela-Bela, where apparently a snake lived in the floor that could not be removed.

The MEC answered that in respect of medical litigation Limpopo was not doing well in comparison to other provinces. If the Department had state of the art facilities, it would not be sued in courts. The Minister is finalising the issue of attempting to use an arbitrator without going to court. Professionals are arrogant and that results in the Department being sued because they lack empathy and humility.

Dr Kgapola said that the snake matter was unfortunate and that the contractor produced shoddy work. The Department is attending to this matter.

The MEC remarked that the academic hospital that is being built in Limpopo is going to improve the image of the province, especially when considering the investment that is going to be made there. For South Africa to improve the number of doctors in the country and province, it welcomed the establishment of the Sefako Makgathe University. The Committee must assist the province in making sure the university produces the best candidates to do research and work in the rural areas of Limpopo. The province has committed R10m to fund 59 students. Already retired academics had started giving their skills and experience to the new university because they want to see the project happening.

The meeting was adjourned.

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