Western Cape Health Facility Boards and Committees Act: regulations & implementation progress

Meeting report

After the Chairperson had welcomed the Members, the Department of Health (DoH) team and other participants to the meeting, Ms D Gopie (ANC) objected strongly to the absence of the Member of the Executive Committee (MEC) and the Head of Department (HOD) of the DoH. She complained that it was unacceptable for them to be absent from such a crucial meeting. She had questions that she wanted to ask the MEC and the HOD directly. They were reported to have been caught up in an emergency in Robertson, and she asked for clarity on the emergency.

The Chairperson handed over to Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, Western Cape Government, to explain the absenteeism of the MEC and the HOD.

Dr Vallabhjee said he did not have details of the issue involved.

Western Cape Health Facility Boards and Committees Act: Presentation

Dr Vallabhjee said the purpose of the Act was to get to the primary health care services, which were the clinics, and to create board representation within the clinics in order to facilitate their daily operations, to build a relationship with the community, and to make sure that clinics got the necessary resources. The purpose of the Act was also to establish accountable primary health services and support them at the grassroots level through involving the community.

 

The Act provided for the establishment, functions and procedures of hospital boards and primary health care facility committees. This involved:

• the establishment of representative and accountable health facility boards and committees as statutory bodies;
• responsiveness of the management of health facilities to the community and the needs of patients and their families;
• community support for, and involvement in, health facilities and their programmes;
• responsible use of resources at health facility level; and
• that health facility boards and committees were provided with a basic set of clearly defined functions, which may be incrementally expanded in the public interest as the capacity of a board or committee increased

 

Regulations

The Act had been passed on 5 July 2016. The regulations had been published for comment on 20 April 2017, and the closing date had been 31 May 2017. The only comments received had been from the finance colleagues within the Department, pertaining to ensuring alignment with Public Finance Management Act (PFMA) prescripts with regard to the handling of funds. The regulations had been revised where relevant.

There were three sets of regulations, which covered financial governance, criteria and procedures to cluster facilities, and the process to call for nominations.

The financial governance regulations dealt with the following:

• Finance committee
• Annual financial statements
• Audit reports
• Asset management
• Loans, guarantees, leases and other commitments
• Trusts
• Investment of funds
• General financial matters
• Annual budget
• Expenditure management
• Banking and cash management
• Basic accounting records and related matters
• Procedures applicable to committees for expenditure, banking and cash management
• Traveling and other allowances
• Gifts, donations and sponsorships
• Unauthorised, irregular, fruitless and wasteful expenditure and management of losses and claims
• Financial misconduct
• Miscellaneous

 

The funds of a clinic committee had to be paid to, administered by, and accounted for by the Board.

 

The Board had to confirm the availability of funds before the clinic committee (CC) could commit an expenditure.

 

The Board made the payments on behalf of the CC.

 

The Department would re-imburse transport expenses for clinic committee meetings.

 

Dr Vallabhjee described the criteria for clustering primary health care facilities:

Where a Committee was established for a group of primary health care facilities contemplated in section 4(4)(b) of the Act, the Provincial Minister must determine the group by having regard to the geographic distance between the primary health care facilities, the size and distribution of the population served by the primary health care facility, and the service volume of the primary health care facility.

 

Before the Provincial Minister determines a group of primary health care facilities contemplated in section 4(4)(b) of the Act, he or she must request the recommendations of the district health managers in the health districts concerned, who must take into account the criteria specified in regulation 2(a) to (c), and duly consider the recommendations submitted in terms of paragraph (a) in accordance with regulation 2.

 

The procedure for the nomination of members for appointment to boards and committees was outlined.

 

Before appointing members to a Board or Committee in terms of section 5(1)(a) or 6(1)(b) of the Act, as the case may be, the Provincial Minister must  publish a notice in the Provincial Gazette, and publish or broadcast at least two invitations calling for nominations, by means of any one or more of the following media:

 

• a notice in a print publication in general circulation within the area in which the health facility or facilities concerned is or was situated, in the language most spoken in the area concerned;
• a notice in an electronic publication in general circulation within the area in which the health facility or facilities concerned is or was situated, in the language most spoken in the area concerned;
• an announcement on a radio station broadcasting within the area in which the health facility or facilities concerned is or was situated in the language most spoken in the area concerned; and

 

The Minister must also publish a notice on the website of the Western Cape Government, inviting bodies representative of the community or communities served by the relevant health facility or facilities to submit nominations for membership of the Board or Committee concerned within a period not less than 21 days of the date of the notice.

 

Progress and Implementation of the Act:

 

Concurrence was requested from the Provincial Ministers of Finance and local government, as per the prescripts of the Act. Concurrence was granted on 30 August 2017 by the Minister of Finance and on 9 October 2017 by the Minister of Local Government. The regulations were signed off by Minister in latter half of November 2017. The Act and its Regulations came into effect on 7 December 2017. As part of the proclamation process, health facilities requiring a committee were designated at the same time, as per the relevant prescripts.

 

Once the Act and its Regulations came into effect, the Minister was empowered to cluster facilities, which was signed off on the 1 January 2018. District management applied their minds to the clustering of clinics. The criteria considered included the geographic distance between facilities, the size and distribution of the population served, and the service volume of the primary health care (PHC) facility.

 

Advertisements calling for nominations were placed in all the required media across the province in January and February. The closing dates were set for 28 February for rural facilities and 9 March for City of Cape Town facilities. The feedback was that the period for nominations should be extended to allow for more nominations, so the Minister had extended the closing date for nominations to 15 May.

 

There were concerns about the nomination form, which had been revised and made more user friendly. A communication had been sent out to all who attended the Health Summit in March, and to non-profit organisations (NPOs) on the Department’s database. The revised form was also available on the Departmental website, and messages had been put out on social media.

 

The nomination form that the Act uses is for the nomination of members of the boards and facilatators.

 

To process the nominations, district management will collate all the applications, assess them against criteria in the Act and Regulations, apply the vetting process for security clearance, and then provide a set of recommendations and a full list of nominations to the Minister, who would make the final appointments. The district Offices would communicate the outcome to the applicants.

 

Capacitating clinic committees

 

WCG Health had engaged the Networking HIV/AIDS Community of South Africa (NACOSA) as the training provider. As a non-governmental organisation (NGO), NACOSA was best positioned.  It was funded via the Global Fund, with a remit for community systems strengthening. It was developing course content following a co-production process via stakeholder engagement. There would be a one-day induction and orientation programme for all health facility boards and clinic committee clusters in 2018/19, followed by more substantial training. The training would also be piloted at sites in five rural districts.

 

The one-day induction and orientation programme would cover topics such as what health governance was, PHC facility governance structures, the recruitment process for clinic committee members, roles and responsibilities, interacting with members of the community, monitoring and evaluation, and general administrative guidelines.

 

Resources provided would be a pocket handbook, a “Guide for Primary Health Care Facility Governance Structure Members,” and a resource manual for capacity strengthening of health governance structures in South Africa, covering areas such as understanding the community, health in context, financial management (including procurement processes), advocacy, lobbying and networking.  The training programme for capacity strengthening of health governance structures would span two to four days.

 

Dr Vallabhjee concluded by saying the Department was glad to have finally arrived at having a formal statutory framework in place. This was a big achievement, notwithstanding the length of time it had taken. The Department recognised that the intent of this legislation was to have formal mechanisms and processes to encourage and allow for community involvement in health services development. It wanted to hear the voices of communities and wanted to encourage active participation, and this legislation gave formal legitimacy to these structures.

 

Discussion

Ms P Lekker (ANC) asked for clarity on the concurrence from the document, as well as giving effect to the Act. She also asked about the distribution of the nomination form, and how the Department could trust that its message would be heard through social media coverage posters, because people in the rural areas lacked access to the internet and social media. She also wanted to know more about the nomination process.

Dr Vallabhjee described the training context associated with the induction and orientation, which involved encouragement for community participation in health services. There were challenges, particularly those related to finances.

Mr D Mitchell (DA) had asked for specifications defining what were rural and what were urban districts.

Ms M Gillion (ANC) wanted to know if training would be possible over weekends. She felt this could not really work, because many people used weekends for their personal activities, so no one would be attending. Was there a set training curriculum programme? What was the timeline for NACOSA to do the training? What was NACOSO, and what do they do? The Department should not come to the Committee without explaining the organisation to Members. Why was it awarded this tender?

Mr Kiewiets, Department of Health, said the objective was to get as wide coverage as possible across the entire province. Whether the training would cover two or four days had not yet been decided, but the right balance was needed. The Department would have to establish when it suited people to attend training -- it did not have to be at weekends. There would be three rural areas and three in the metros.

He said the Department could make information on NACOSA available. It had awarded the tender to NACOSA because it did not have to go for a new organisation, as it had been used previously.

The Chairperson asked about the boards’ role in the financial management of the clinics.

Dr Vallabhjee said that the funds would qualify for tax exemption. The Department would monitor as it went along. The boards would have to manage all financial concerns. Clinics would need to go the boards for funds, and ask for confirmation.

Ms Lekker asked who would be responsible for paying the auditing fees. How many clinics on average would the boards be responsible for?

Ms Gopie said that the form that was criticised at the summit had been fixed, but how would it be distributed to people who were interested, such as those in Worcester or those with no emails? When would a decision be finalised?

Ms Gillion asked whether informal and formal settlements been taken in consideration where the geographical location of facilities was concerned. Were these clinics going to be separated from the Department of Health, and governed by the City of Cape Town? Had consideration been given to involving different political parties, who could address community issues in specific areas?

Dr Vallabhjee said that the Department did not get involved in political party issues. There had been a number of consultations with the City of Cape Town on how the Department had made its decisions.

Ms Gopie complained that the meeting was being undermined by the absence of the Minister, because Dr Vallabhjee could not answer all the political questions. The Committee needed clear answers, should have its time wasted. It needed identification of what were rural areas. She had questions that she wanted to ask the MEC regarding the misuse of power. Could one trust the MEC not to make political appointments? The MEC should be present at this meeting.

Ms Lekker said that four days of training would be too much for people away from home, and suggested bringing in people from rural areas for training, and then sending them back to conduct training in their communities. She added she was not satisfied with only three rural and metro sites.

Dr Vallabhjee said the training programme was only a pilot. The Department was still going to look at each case and see what could be suitable for the people involved. There would be a media programme to support the orientation. The Department would consider a “train the trainer” programme.

Ms Lekker said the Department had to ensure that the voices of the communities were heard at all times, to make sure that the clinic committees were sufficiently competent. She had a major problem when it came to lack of planning for outsourcing, such as appointing a service provider instead of training people that would be there permanently, otherwise it was a waste of money. She would be very interested in hearing from volunteers who knew what was happening among the communities. If one considered this piece of legislation, how did one ensure that politics was not involved with those people who were working in the community? They should be serving the community for the love of it. 

Mr Mitchell asked if he could experience the orientation when it took place.

Ms Lekker said the ANC was not aware of the process, which she suspected was not open, transparent and fair. Could that letter be provided to the Committee, so Members could see the contents and who it was addressed to?

Ms Gillion said that people were not aware of the process. Consultations had not lasted for even a month. It did not work like that when working with communities. All the rural areas behind the mountain were not aware of the processes.  Every opinion of the community should matter. The concern was that the recommendations were not even featured in the regulations, because the process mattered. The Committee needed to have a serious meeting with the Health Department, which should come and account in a proper manner.

Ms Gopie said the current relationship between the Department and the Committee was not clear. There had not been a tender process, and a budget had not been outlined, which was a slap in the face for Members. With regard to NACOSA, the Committee did not want training that was not accredited. Did the community just have to accept that NACOSA would be the provider?

Dr Vallabhjee responded that NACOSA had a long history of working with communities. The Department wanted to pilot, reflect and learn as time went by, which was why it did not have a fully detailed programme now. It was mindful of the lack of rural access to the internet.

The clinics made the decisions on the nominations. The Department would provide details for those who wanted to attend the orientation. The form had been distributed electronically. Section six provided the information on the councillors, as written in the Act. The process had been dealt with politically. A letter had been written to the relevant structures, giving the background on the Act.

The meeting was adjourned.