Members of the Committee heard a briefing by the Western Cape Department of Health on the roll out of an electronic filing system to improve reliability of information on reported performance; the User Asset Management Plan (U-AMP) including all associated costs and challenges relating to the upgrading and eradication of ageing infrastructure; a mechanism to avoid the future recurrence of debts written off due to salary overpayments and discussion on challenges regarding the recovery of funds from former employees.
Top of the agenda was an explanation by the Department regarding a query by the Auditor General of South Africa on the Department’s recorded achievement involving the number of immunisations on the indicator: “Dtap-IPV/Hpv 3 – Measles first dose drop-out rate”. The Department had asked and obtained permission from the National Department of Health (NDOH) that the indicator be dropped from the Annual Performance Plan (APP) as it did not add value and could not be logically interpreted. However, Members struggled to understand why the indicator had been included in the first place if it was not important. They wanted assurances that measures were in place to prevent children falling through the cracks and being deprived of crucial early immunisation.
To guard more effectively against the above scenario, the Department informed the Committee that it had developed and piloted the next phase of an integrated electronic reporting system which would combine the old stationery system and the Primary Health Care Information System (PHCIS). Among other benefits, the new system would make clinical audits easier.
The Department had also asked that another indicator, “Mother postnatal visit within six days rate” be made more flexible since a health facility visit by a mother even after six days post delivery of a baby still had the desired effect. Deliberations on how this flexibility could be expressed in the new indicator did not reach finality and the Committee left the matter in the Department’s hands for further consultation.
A presentation by the Department on its annual User Asset Management Plan (U-AMP) was so alarming to Members that it was decided discussion be shelved for a later time after the Committee Members had had their written questions answered in detail by the Department.
The Chairperson welcomed everyone. The meeting had been the result of a concern raised in an earlier interaction during which a Member of the Committee, Ms C Beerwinkel (ANC), had drawn attention to the decentralised nature of the Department’s manual filing system.
The electronic filing system
Dr Beth Engelbrecht, HOD, Department, Western Cape Government Health (WCGH) told the Committee that that National department of Health (NDOH) approval had been requested and obtained to remove the indicator titled “Dtap-IPV/Hpv3-measles first dose drop-out rate”, as it did not add value. She assured the Committee that the indicator was still monitored operationally and that as the roll-out of the integrated stationery and Primary Health Care Information System (PHCIS) system progressed, electronic reporting system rules would become reality resulting in more accurate data and evidence.
Another indicator; “Mother postnatal visit within six days” had also been misstated, due to postnatal visits after six days also being reported on, but not captured as an achievement within the six day period. During the performance review process later in the year, the Department would approach the NDOH to allow more flexibility in how this indicator could be defined.
Ms Beerwinkel asked for clarity on how badly affected reporting had been on the drop-out rate of babies immunised for measles and why the Department was still using the old manual paper-based system if the electronic system was already available.
Mr S Tyatyam (ANC) said removing the performance target did not remove the actual problem of ensuring that children were appropriately immunised, and he was not satisfied with the Department’s explanation of how this would be done. The Department seemed to be only concerned with the AG’s finding rather than addressing the issue of children not being immunised. He was worried that this could be reduced to a tick-box exercise. He asked how long it would take for the Department to switch onto a fully electronic information management system.
Ms M Maseko (DA) wanted to know how different the reporting system for measles was from the one for Tuberculosis (TB), and why had the former run into reporting problems. How was the budget arrived at if the information was not accurate? She asked the Department to take the Committee through the process of recording of information in order to find out what had actually led to the discrepancies in reporting.
In response, Dr Engelbrecht said immunisation for measles was an everyday activity at all public health institutions and that information was recorded in real time. However, the removal of the Dtap-IPV/Hpv3 immunisation indicator from the Annual Performance Plan (APP) had been done for purely technical reasons because the process of capturing the data was so complex that only a single mistake could have the effect of statistically undermining the impact of usually up to 14 million actually recorded immunisations, thus failing to add value and even leading to unnecessary negative findings against the Department. The amendment did not mean that less immunisation had occurred but accounted for variations in the venue and the times at which immunisations took place.
Dr Nomafrench Mbombo, MEC for Health, WCPP, also emphasised this, saying that it was not possible to do all immunisations at the same time and place. She however assured the Committee that the system had other inbuilt mechanisms to report, measure and address the drop-out rate of the immunisation process. Once drop-out cases are identified through the system, the Department actually went out to children’s homes to find out why children had missed the deadlines and where possible administered the vaccinations. Furthermore, every child who came into the public health facility for whatever reason was routinely checked for any discrepancies in the regime of vaccination. This was part of the Integrated Management of Childhood Illnesses (IMCI).
Dr Engelbrecht also added that the HIV/Aids programme had the potential to play a role in reducing the drop-out rate in measles vaccinations.
Ms Beerwinkel asked what measure had been put in place to ensure that no child fell through the cracks.
Mr Tyatyam repeated his question on the timeline on the replacement of the manual system by an electronic one.
Dr Engelbrecht emphasised that the reporting of measles vaccination was still part of the Department’s APP save for only the particular Dtap-IPV/Hpv3 vaccination. In reply to Mr Tyatyam’s question, she said the electronic system was not yet fully in place; however there were already areas where it had started operating.
Mr Ian De Vega, Manager: Information Management, WCGH, stated that a fully operational system depended on a good supply of electricity, broadband access or connectivity. Full connectivity was a ten year process and the WCGH project was only three years in the making.
Ms Beerwinkel asked what was being done about mothers who, although aware of the dates on the child’s clinic card, still did not come in for immunisations.
Dr Engelbrecht replied that should a child miss a deadline for a particular vaccination, home-based carers are sent out to bring the mother to the clinic for a session and to find out what the situation was. A related matter was the request by the Department that it be given flexibility in defining the indicator relating to a mother’s “postnatal visit within six days”, which is part of the APP. As it stood, the indicator did not take into consideration that a visit made after the six day period still had the same desired effect.
The Chairperson asked what was meant by this flexibility and what the approach of other provinces was on this issue.
Ms Maseko asked the Department to explain what the significance of the six days was.
Dr Mbombo said the period was not only part of the national health guidelines but also international best practice to check that everything was going well between mother and child post delivery. However, in practical and performance audit terms it was not necessary to restrict the number of days to six as this was only the ideal.
Mr Tyatyam was not clear about this. Why did the AG make a fuss about it if the six days was not mandatory?
Ms Maseko also wanted to know if it was at the insistence of the AG or the Department that the indicator be put in, and why was it an issue now and not before?
Ms Beerwinkel asked if the Department had its own cut-off period in mind and how many days that might be.
Dr Mbombo said her view was that the indicator was an impractical expectation from NDOH. The socio-economic profile of those using the public health system should make it obvious that it was not feasible for poverty stricken mothers to spend money on public transport to hospitals unless it was absolutely necessary to do so, and besides, cultural beliefs also played a part in defeating the purpose of the indicator – in African culture it was not good for a newborn to be exposed to the evil luck of strangers during the sensitive first days of life.
Mr B Joseph (EFF) proposed that six days be the minimum period and the cut-off be 12 days.
Dr Engelbrecht accepted the proposal with the proviso that further deliberation with the Department’s child and maternal health experts be undertaken.
Ms Leslie Shand, Manager: Information Management, WCGH, told the Committee that a review of NDOH’s targets would be taking place in June 2018 and submissions would be made with regard to the matter, with the expectation that a change could only be made next year.
The User Asset Management Plan (U-AMP)
Dr Laura Angeletti du Toit, Chief Director: Facilities and Infrastructure Management, WCGH, said the plan was prepared annually in compliance with the Government Immovable Asset Management Act (GIAMA), as well as the Division of Revenue Act (DORA). The plan was a strategic mechanism and some of its purposes included:
- identifying, presenting and prioritising the WCGH’s infrastructure needs in support of implementation of the Strategic Plan, Healthcare 2030 and the Healthcare Acute Hospital Plan
- ensuring that the greatest health care needs in the Province are addressed as the highest priorities, whilst ensuring that optimum cost efficiency and affordability were achieved
- providing an indication of anticipated expenditure per programme, sub-programme and per project over the life cycle of the facility.
The presentation highlighted the current condition of state health facilities and the estimated maintenance backlog thereof in the Western Cape. Of the 331 state owned facilities, 52% were in good condition and 37% were in fair condition. By contrast only 28% of leased facilities were in good condition, while 55% were fair. The estimated value of buildings in 2018/19 was R45 billion and the total estimated maintenance backlog at the end of March 2018 stood at R1 billion. The backlog of estimated value of capital infrastructure (new buildings, replacements, renovations and upgrading) was R27 billion in 2018/19.
Primary challenges in the planning, delivery and maintenance of existing infrastructure included continually shrinking budget allocations; and budget cuts leading to postponement of projects and capacity constraints at the Provincial Public Works Department resulting in under-expenditure of the infrastructure budget. The impacts of the above had resulted in some of the following:
- Increase in the maintenance backlog which already stood at over R1 billion
- Slow delivery of primary health care facilities
- Delays for the Metro Hospital Replacement Programme (Helderberg, Klipfontein, Tygerberg hospitals)
- Ageing medical equipment with insufficient funding for replacement, increasing the risk of future service interruption/disruption and shutdown
The Department had come up with a number of strategies to prevent the above including:
- increased focus on maintenance
- reducing spends on capital projects
- A hub and spoke maintenance approach
- Alternative construction methods for healthcare facilities
- An integrated asset maintenance and management system
- continued partnerships with donor organisations
At the suggestion of the Chairperson, the Committee decided the presentation had raised several worrying matters and there was not enough time to deal competently with the matter. The Chairperson instructed that members write down questions and comments and those is submitted to the Department.
Recovery of debt in respect of salary overpayments
According to the Chairperson the matter had arisen from a query by Mr Tyatyam during a discussion on the Department’s last Annual Report.
Ms Bernadette Aries Chief Director: People Management, WCGH, took the meeting through a presentation which outlined reasons for salary overpayments; mechanisms in place to mitigate the phenomenon and disciplinary action taken.
Ms Aries said the above could have occurred in a number of ways including as a result of overpayments on basic salary; leave gratuity; commuted overtime; service bonuses; allowances and others. Mechanisms in place included regular sample testing; ongoing training of Human Resources staff; dissemination of procedural manuals; deduction of Departmental debt from employee pension benefits and a debt management policy. However there was a need for more mechanisms such as auditing of leave files; development and updating of policies; and monthly reports on leave without pay. Disciplinary action would be taken with regard to employees knowingly receiving payment they were not entitled to and instances where overpayment occurred due to negligence
Mr Tyatyam said he was more interested in the person who “pressed enter “, thus initiating the overpayment in the first place. How officials were made accountable by the Department for their lapses?
Dr Mbombo said the majority of cases occurred during the salary adjustment of nurses, especially upon completion of qualifications on the Occupation Specific Dispensation (OSD). Some nurses got paid for qualifications obtained without having first worked in the particular field of specialisation, as required by the regulations; while others got paid while still working at a general level although they had qualified for an advanced level. There was lot of ignorance amongst nurses on these matters and Dr Mbombo’s view was that information sessions on OSD should be held with groups of nurses in this regard.
Dr Engelbrecht agreed that at around R1 million a year, the debt was a substantial amount of money to lose, but she pointed out that given a wage bill of R14 billion, it was not a crisis.
Ms Beerwinkel said she felt compelled to say that the service rendered by the Department employees at public hospitals left a bitter taste despite attempts by the leadership to sugar coat the state of health services in the province.
Mr Joseph said employees should be encouraged to study and better themselves. He also felt that more training was needed to strengthen the competencies of Human Resources staff at the Department.
Dr Engelbrecht said she had noted the comment by Ms Beerwinkel but she also pointed out that every time she visited hospitals she came away humbled by the dedication and humanity of the staff. She encouraged Members to give feedback and information to her on all instances of wrongdoing or corruption or ill-treatment of the public in any health facility in the Western Cape. As for overpayment, she assured the Committee that all possible mitigation strategies were being carried out to ensure that the debt is eliminated.
The meeting was adjourned.