The Public Service Commission (PSC) briefed the Committee on the outcome of its inspection to selected health facilities. The aim of the PSC inspection is to assess the quality of services to the public, the state of facilities and the conditions at service sites. The main objective of the inspection is to determine the availability/ adequacy of infrastructure, to assess the extent to which services are rendered to citizens and to assess compliance with the Batho Pele requirements. A summary was presented of the findings in the various provinces. Overall, the PSC had found that many of the buildings and infrastructure were dilapidated and old, needing to be replaced and refurbished urgently, and that medicines and patient folders were not secure or locked away. The staff vacancy rates in some of the hospitals - including doctor and nurses - was alarming, at around 46%, and the reasons given by the officials related to budgetary constraints and the moratorium that had been placed on further staff. The waiting period in most of the hospitals is long, the waiting area is not spacious enough for the patients, and in some facilities the nurses shared consulting rooms and in addition had to vacate the rooms and keep their patients waiting if a specialist doctor was visiting. The security situation in most of the facilities are up to standard. The lack of professional nurses hinders the operation of the mobile clinic in Phekolong. There was generally not a problem with obtaining medicines, but there was a problem in having sufficient working equipment such as monitors and special beds for maternity cases. Emergency medical services fell short of expectations.
The PSC had recommended that the Free State Department of Health should engage with the Department of Public Works, in order to address maintenance and provision of infrastructure, including carrying out repairs now and setting a schedule for routine maintenance in future. A mobile clinic operator was needed and it was recommended that a good retention strategy for staff was a priority, and that this should be tied into the performance contracts of the managers. For Eastern Cape, the PSC recommended a review and improvement of working conditions, as well as development of strategies for recruitment and retention of doctors, nurses and pharmacists. Commitment was needed on getting ambulances to service rural areas, and engagement was needed with Department of Public Works on the infrastructure. In North West, where the moratorium applied, it should be rescinded, and the provincial Department of Health was asked to reverse its embargo on purchase of health equipment and maintenance of facilities. Boreholes were needed at clinics. In KwaZulu Natal, PSC had asked that a norm for waiting times must be set and staff trained on professional ethics and complaints. In Limpopo, PSC recommended electronic filing systems, proper appointments and follow-up on cancelled appointments, proper storage of files, and availability of masks and gowns for visitors to the ICU ward.
Members expressed disappointment over the poor quality of the report, which they found thin and lacking in specifics. They asked what the various hospitals are doing to improve on some of the problems identified by the PSC, what had informed some of the recommendations of the PSC, why it had isolated only some of the problems in some provinces when surely the issues were more widespread, and expressed the view that the heads of departments could not be responsible for ensuring retention strategies when the problem of attracting staff was out of their control. They asked about the linkages and possible duplication of the work of the PSC and the Office of Health Standards Compliance, what methodology was used by the PSC. They questioned the comments on patient waiting times and what was meant by improving appointment systems in Limpopo. They asked about leadership challenges, the moratorium, what fast-tracking and follow up were done, how the hospitals were functioning, given the state of their equipment, and expressed dismay at comments on the vacancies and the ambulance services. The PSC clarified that this was a preliminary report, explained how it conducted the inspections and the Committee then called for a copy of the final consolidated report, once finalised.
Public health facilities inspections: Public Service Commission (PSC) briefing
Mr Kobus van der Merwe, Acting Deputy Director General, Public Service Commission, took the Committee through his briefing on the inspections that the Public Service Commission (PSC or the Commission) had performed on public health facilities. The initial slides outlined the objectives of the inspections, and facilities inspected (see attached presentation for details).
The facilities inspected in Eastern Cape were two district hospitals, namely Umlamli and Nompumelelo hospital.
In Free State, five facilities were inspected namely Phekolong clinic, Nelson Mandela Clinic, Manguang clinic, University Community Partnership and Dr J S Moroka Hospital.
In North West, six facilities were inspected: Manthe clinic, Dryhaarts clinic, Motlapaneng clinic, Makgareng clinic, Maganeng clinic and Taung hospital.
In KwaZulu Natal (KZN), nine facilities were inspected. They were Scottburgh Gateway clinic, Scottburg Clinic, Copesville Mason Clinic, Copesville Clinic, Kwacaluza Clinic, Umzinto Clinic, Philani Clinic, Dududu Clinic and Umbumbulu Clinic.
In Limpopo, only the Mankweng Hospital was inspected.
Condition of the premises inspected
Dr van der Merwe stated that there was a general lack of space for waiting area at most of the inspected facilities. The infrastructure at most of the sites inspected cannot accommodate the number of patients visiting the hospitals on a daily basis. Gateway, Copesville, Copesville, Mason and Umzinto, for example, could not accommodate patients.
Phekolong Clinic in Free State lacked consultation rooms. The nurses share a consultation room and take turns to consult with patients. The situation is exacerbated when a specialist visits the clinic – because patients wait even longer as the nurses give the consultation room to the visiting specialist before they can attend to other regular patients who are not scheduled to see the specialists.
The building of Dr JS Moroka Hospital requires urgent refurbishing. The hospital has old and run-down buildings with cracked floors and a leaking roof in the registry where patient files are kept.
Clinics such as Umzinto and Copesville do not have enough space for patient files and storage of medication. Copesville was found to have boxes of medication and other material stacked against the walls in the clinic due to insufficient space.
In Mankweng the infrastructure appeared to be fairly maintained.
Masks and gowns were not available for inspection team when inspecting the ICU ward in Mankweng Hospital.
Most of the equipment in Taung Hospital in North West is old and needs to be replaced urgently. The staff of the hospital informed the PSC that lack of budget is a challenge to the maintenance of this equipment.
Other challenges faced by the health facilities included shortage of vital organ monitoring equipment. The specialised beds in the maternity ward are very old and cannot recline to accommodate expectant mothers.
Adequate measures were in place at most of the health facilities inspected.
Human resources constraints
Shortage of staff, especially doctors and professional nurses, was a challenge for most of the facilities inspected. Umlamli Hospital had a total vacancy rate of 48%. The hospital has a total of nine posts for doctors but only one post is filled. Taung Hospital is currently also operating with a 48% vacancy rate and positions cannot be filled due to a moratorium on the filling of positions that has been in place since 2014, imposed by the Department of Health (DoH).
Another challenge raised by staff was that when doctors resign or retire, the vacancies are not filled. The shortage of staff is further exacerbated by the exodus of health officials who are now resigning and retiring in order to safeguard their pensions, due to the introduction of new pension laws. Absenteeism by nursing staff was also raised as a problem in Mbumlulu Clinic which serves approximately 300 patients per day.
The mobile clinic at Phekolong has not been operational since November 2015 due to lack of staff.
Availability of medicines
Umzinto and Copesville clinic reported occasional shortage of chronic medication. However, in most of the inspected facilities availability of medication was not a challenge.
Emergency medical services (EMS)
In most of the inspected facilities there was a general concern about the length of time it takes for the EMS central office to dispatch ambulances. In Taung Hospital only two ambulances were operational and four were sent for mechanical repairs.
Patients' waiting times
There was a general concern in most of the facilities inspected about unreasonable waiting times before patients were attended to. In some cases, the patients were not attended to at all, and thus had to reschedule the appointments.
The PSC set out its recommendations for each of the provinces. In Free State, the recommendation was that the Free State Department of Health should engage with the Department of Public Works, in order to develop and implement strategies that can assist with the maintenance and provision of infrastructure. Respective district offices should ensure that major infrastructure repairs are carried out as planned and that routine maintenance of infrastructure is conducted regularly. The Free State Department of Health should prioritise the appointment of a mobile clinic operator at the Phekolong clinic. The Free State Department of Health should prioritise the development of a retention strategy to retain medical doctors, pharmacists and professional nurses who terminate their employment to join the private sector. Retention targets should form part of performance contracts of District and Hospital manager.
In respect of the Eastern Cape, the PSC recommended that the provincial Department of Health (ECDoH) should improve working conditions of medical professionals and develop a strategy for recruitment and retention of doctors, professional nurses and pharmacists. ECDoH should develop a strategy to address the limited provision of ambulances in Umlamli and Nompumelelo hospitals and get them to commit to how they intend to service the rural areas where these hospitals are situated. ECDoH should engage with the Department of Public Works in order to address the identified infrastructural challenges. Particular attention should be paid to the replacement and refurbishment of the hospitals' boilers, generators and air conditioning systems.
PSC recommends that the provincial administration in North West should rescind the moratorium on the filling of funded vacant positions in order to ensure that quality services are rendered. The provincial Department of Health should rescind the total embargo on the purchase of health equipment and maintenance of the health facilities. The water supply boreholes should be erected at Maganeng, Matlapaneng and Manthe clinics.
PSC recommends that the Department of Health in KZN must pronounce an ideal norm on waiting times. Administrative staff members must be duly inducted on professional ethics within the health sector. The Department of Health in KZN should develop and improve on the efficient management of complaints procedures.
The PSC then recommended that in Limpopo, an electronic filing system should be introduced to ensure appointments, and to eliminate delays in obtaining patient files. Sufficient storage should be provided for files in an appropriate room, and sufficient masks and gowns should be made available for visitors in the ICU ward. A system to assist patients whose appointments were cut off the previous day should be introduced to avoid the same problems recurring on the next day.
Dr W James (DA) asked if there was a duplication of roles between the Public Service Commission and Health Standards Compliance authority. He wondered how thorough and reliable is the methodology used by the PSC for its inspection?
Mr T Khoza (ANC) said that the PSC only appeared to have made recommendations to one province that it must develop its retention strategy, and queried if this then meant that other provinces have developed their retention and recruitment strategy satisfactorily. He asked what advice is given to provinces to aid and ease the challenge of retention strategy, and what were the main reasons for the shortage of staff; was this linked to lack of skill in the country, or budgetary constraints; he also wanted to know then what recommendations were being given? He asked for an indication of the main reasons why patients were having to wait for so long, and the reasons for the different system of equipment procurement, since some provinces were using a centralised system and others were using decentralised systems. Again, he wanted to know exactly what the PSC was doing to assist.
Mr H Volmink (DA) asked if there were sufficient numbers of emergency services personnel, and whether they were adequately trained. He asked what were the main challenges around the moratorium, and what were the leadership challenges. He also wanted to know what recommendation was given by the PSC to these challenges.
Ms C Ndaba (ANC) asked what the staff in KZN did that made the PSC make such a recommendation and what kind of unprofessional behaviour the PSC considered that had informed the recommendation. She was also interested to know what the PSC would do when departments did not follow its recommendation, and whether it had any method of fast-tracking or follow up on its recommendations to departments.
Ms L James (DA) said that the Committee should follow up on the report and recommendations made by the Commission.
Dr P Maesela (ANC) asked the response of the province or staff of the facilities inspected after the report has been given to them. Had the staff given any reasons, and were they appreciative of the recommendations to be made by the Commission?
Ms D Senokoanyane (ANC) noted the report that most of the medical equipment was old or not working, and wondered then how the hospitals were operating or functioning. She asked what was the response of the staff or officials of the Hospital with regard to improving on the functionality of the equipment, and what exactly was the task of the people named in the report who were supposed to be maintaining the equipment. She commented that the 48% vacancy rate is alarming, and she did not think the moratorium could be solely to blame for this. She further commented that the shortage of ambulances to service the hospitals is a big challenge and should be looked into. She was not happy to hear that there was rescheduling of patient appointments, and thought that the PSC should have been making a strong recommendation that more primary health care nurses or officials should be trained, because this is a major challenge. She commented also that the presentation had indicated that across all provinces, retention of staff seemed to be a common problem. However, she thought that adding a retention strategy as part of the performance contracts would not be fair, as the moratorium was a national decision and cannot be rescinded by the province. The unavailability of ICU masks and gowns is a matter of irresponsibility.
Mr A Mahlalela (ANC) asked about the relationship between the Office of Health Standards Compliance (OHSC) and the PSC and whether they shared information or cooperated. He asked when the inspections were done. He asked for more detail on the Commission's remarks that patients are turned away and appointments rescheduled. He asked if there was a national norm for waiting periods and why KZN seemed to announce its own.
The Chairperson commented that there is no date on the report showing when the inspections were conducted. The quality of the report was poor, thin and did not meet the expectations of the Committee.
Ms Sellinah Nkosi, PSC Commissioner, said that the inspection was done in August and September. The consolidated report has not been finalised. The reason for this presentation is to enable the Commission to get more from the input from the Committee, which will strengthen the final report. She added that there is also a province-specific report. The Commission has a protocol for conducting inspections. An inspection by the Commission is not a research project, because it goes into matters much more deeply when conducting research. She described this exercise as a “dip-stick inspection” when the PSC would look at the most glaring challenges and share its findings with the executive authorities or the departments. There are common elements that the Commission looks into, but this would not stop it from investigating in other areas. The essence of the presentation to the Committee was to enable the Committee to then engage with the various national and provincial departments on what had been identified.
She explained that when the clinics closed at around 16:30 it had been found that from 15:00 the workers would start to pack up, and would turn away any patients who clearly would not be seen before 16:30. However, the point was that they were doing this without taking their names or arranging for them to come in and be seen first on another day.
She noted that the PSC and the OHSC had a close relationship, and the PSC will also brief the Minister of Health on the outcome of its inspection. Follow up mechanisms and a tracking of the recommendations would also take place.
The PSC would be recommending the training of primary health care nurses to help in the mobile clinics.
She noted the comments about the staff retention. She said that the staff had, during interviews, particularly cited the moratorium as the reason for their difficulties. This was an issue that the PSC felt should be taken up with the Minister of Health as it appeared to be a national problem. The PSC had furthermore proposed a retention strategy for the clinics.
Detailed reports on the particular behaviour of staff were in the specific province report. The PSC would be sending a consolidated report to the Committee. In addition, the PSC engaged with departments before publishing the reports.
Dr van der Merwe noted that the mandate of the PSC was to deal with service delivery in the public sector. The functions of the Commission are enshrined in sections 196 (e) and also 195 of the Constitution. The measurement and methodology used by the Commission is reliable.
Dr James noted the comments and asked that the comprehensive and detailed report should be sent to the Committee.
Mr Justice Kgoedi, Director: Support, PSC, agreed that the Commission would identify problems and make sure that they were solved.
Ms Nkosi apologised that this report had not met the expectations of the Committee, and repeated that the comprehensive report should set out far more
Ms Senokoanyane recommended that the PSC should, in asking its questions, explore the answers more deeply. Some information can be misleading and needs further enquiry. She reiterated that the current report was of poor quality.
The Chairperson repeated that the comprehensive report should be sent to the Committee, and suggested that if the Commission was not ready to present the full report by this meeting, it should rather have asked for the meeting to be rescheduled.
The meeting was adjourned.