City of Cape Town & Department of Health collaboration; District Health Plan

Meeting report

Opening Remarks

The Chairperson welcomed members of the Committee and delegates from City Health and the Western Cape Department of Health. Representing City Health was Dr Waarisa Fareed, Director, and Dr Paul Nkurunziza, Acting Manager: Specialised Health. From the Department of Health was Dr Gio Perez, Chief Director of Metro Health Services, Dr Nomafrench Mbombo, MEC for Western Cape Government Health (WCGH), Dr Beth Engelbrecht, Head of Department, and Dr K Cloete, Deputy Director-General: Chief of Operations.

Presentation

Dr Nkurunziza presented on behalf of City Health.

Background

The City of Cape Town delivers primary health care service, which comprises both environmental health & personal primary health care. These services are managed within 4 areas (Sub-divided in 8 sub-districts with legislated boundaries), via an extensive infrastructure of 16 Environmental Health offices, 70 clinics, 16 community day centres, 16 satellite clinics, 4 specialised services facilities and 5 mobile clinics. Personal primary health care is provided in partnership with the province, based on a service level agreement concluded with the Western Cape Government on an annual basis.

Services provided by City Health

The City provides services of environmental health, personal primary health care (clinic) services, specialised support services, outpatient substance abuse programmes, and other specialised services.

Discussion

Ms P Makeleni (ANC) asked for clarity on the difference in areas and the sub-district borders between the City of Cape Town and the Provincial Department.

Dr Nkurunziza apologised for the lack of clarity on the slides with respect to the boundaries. There were essentially four areas; North, East, Central and South. North consisted of the Northern sub-districts and the Western sub-districts with a little bit of Hout Bay. The South consisted of Mitchells Plain and the Southern sub-district. Hout Bay had been in the South but was moved to the North with the City’s new four area system. Central consisted of Tygerberg and Klipfontein. The East comprised Eastern sub-districts and Khayelitsha sub-districts. The Province had its own four sub-structures, but the East was the same for both sub-structures, with a little difference in that Mandalay, which was normally in the Mitchells Plain sub-district, lay in the Khayelitsha sub-district

Ms Makeleni referred to the staff norms. She asked if the service level agreement and the working conditions for staff members were the same across City Health and the province. Where the presentation referred to “community-based services team”, were those City of Cape Town staff or did they come from the community? Did the Community Care workers of the Province and the City of Cape Town undergo the same training, and did they have the same service level agreement? Ms Makeleni said that she was hoping to see what was contained in the service level agreement. She asked how the issues of overlapping infrastructure had been resolved. How effective was the collaboration between City Health and the Province and were there any challenges?  

Dr Nkurunziza said that with respect to the staff, the staff norms were determined by the services being rendered and the need. Different facilities would be staffed differently depending on what services they rendered. Community care workers were contracted by the Province. The City had an agreement with the provincial government. The content of the Service level agreements was quite broad. It defined their relationship with the City and the services which the Province and the City were expected to render. It also outlined the number of services the Province rendered per facility in the area.

Dr Nkurunziza stated that the main issue with respect to infrastructure was planning. There was a joint technical working group from the City and the Province on infrastructure. However, the question around the effectiveness of the collaboration between the City and the Province was not an easy question to answer. There were challenges where they worked together, and they had differences of opinion with respect to the interpretation of policy. Dr Nkurunziza said that he was, however, in no position to say how effective the collaboration had been.

Ms M Wenger (DA) asked about the service level agreements for the functions that the two entities were required to perform. Were they funded or only partly funded? If there needed to be more infrastructures, such as new clinics, who would cover the costs?

Dr Nkurunziza replied that, in terms of the service level agreement, the Province would fund HIV, TB and comprehensive services. The City also provided funds for those services because the Province did not cover the entire costs for those services. There was a shared contribution and commitment between the City and the Province to the service level agreement.  Dr Nkurunziza said that the City funded infrastructure for City facilities and the Province funded infrastructure for Provincial facilities.

Ms P Lekker (ANC) asked what the service level agreement entailed. How many environmental health practitioners were there, in which areas were they deployed and what challenges did they face? How did City Health measure improving healthy lifestyles with respect to the strategic goals set by the Department of Health? Were there any lessons to be taken from that? On the issue of specialised services, how many male clinics were there in the City of Cape Town and in which areas were they? Was mental health being funded optimally by the Province or was the City funding it? Were there any other stakeholders and partnerships with respect to mental health?

Dr Nkurunziza said that he could not say off the top of his head how many environmental health practitioners there were. He said that they were inadequate for the norms required. The norm was 1 per 10 000 members of the population. He estimated that City Health had 1 per 23 000. The City was looking to bridge that gap by creating additional posts. The environmental health practitioners were involved in both the formal and the informal sectors. One of the key performance indicators for environmental health practitioners was to visit informal settlements on a weekly basis to identify risks to health as well as monitoring food and water in both the formal and informal sectors in society. The insufficient number of environmental health practitioners to cover the area was one of the challenges. The other challenges included security risks in certain areas, issues with legislation and the increasing burden of work.

Dr Nkurunziza explained that measuring health was quite difficult. City Health was looking at the infant mortality rate, which had been dropping for many years, the average lifespan, which had been increasing, HIV transmission from mother to child, and the number of children born to adolescent mothers which had also decreased over the last few years. Dr Nkurunziza added that there were three male clinics. Dr Nkurunziza said that the question on mental health funding should be answered by the Province.

Dr Nkurunziza said the Adult PACK protocol empowered practitioners and nurses to some degree in screening and managing mental health conditions, although, not at the level of a psychiatrist or a specialist. That was funded by whoever was rendering it. Nurses, psychiatrists and psychologists were not part of the City’s services.

Mr Nkurunziza said that when City Health was informed to present to the Committee, officials were not told it had anything to do with provincialisation. He had not prepared anything on that topic.

Ms D Gopie (ANC) asked how ordinary members of the community knew which services belonged to the City and which services belonged to the Province. When did the Province decide to take over a particular service and when was it decided to leave a service to the City?

Dr Nkurunziza said that they would not want people to know who was offering which services to whom. He said that the goal was that there should be integrated personal primary healthcare in almost all facilities. The facilities were, however, clearly marked so that complaints could be sent to the relevant body. Shared facilities might, however, face problems. The City and the Province were striving to render the same services.

Mr D Mitchell (DA) asked how many professional staff were currently in that directorate.

Dr Fareed said City Health had 1853 professional staff members. She noted that City Health was not a directorate but a department. Social services, which City Health fell under, was a directorate.

The Chairperson asked where the substance abuse programmes were located. What was the current number of vacancies in City Health and what was the timeline to fulfil those? Were the specialised services for sex workers in the operational parts of the facility? What did the numbers look like in respect of complaints and compliments for the 2017/18 financial year? What were the challenges with the electronic appointment system that the City would be introducing?

Dr Nkurunziza said that the substance abuse programme was active in six facilities. There was one facility per sub-district, but they were spread across the four areas. They were attached to primary healthcare facilities. The vacancy rate was 7%.

Dr Fareed said that they usually had a six-month turnaround time. She noted that they have a high attrition of nurses because they generally go over to the private sector or work internationally.

Dr Nkurunziza said that the specialised service for sex workers was managed by sensitised people to avoid discrimination. Not all staff in all facilities were buying into the electronic appointment system. There were also issues with respect to absenteeism of patients on the day of an appointment. He said they wanted to start rolling out the system from 1 July 2018.

Dr Fareed added that City Health was embarking on change management with the current manual system so that when the electronic system was launched, they would be able to break down many of the challenges. City Health was committed to keeping the appointment system to prevent queuing and to increase accessibility to health.

The Chairperson asked about the timeline for implementation.

Dr Nkurunziza replied that on 1 July it would be piloted for a period of two months. Then it would roll out over the remainder of the financial year. City Health expected that the electronic system would be in all facilities by the end of June 2019.

Ms Makeleni asked how the service level agreements and the collaboration were physically monitored. How often was the service level agreement reviewed? In the past two years, when the agreements were reviewed were there any major issues? How ready was the City to implement the National Health Insurance (NHI) scheme? Ms Makeleni asked for clarity over what informed the sub-district divisions. What was the City doing to compensate for the fact that the funds being transferred from the Province were not sufficient for the total costs of services rendered?

Dr Nkurunziza said he would not be able to answer the question on physical monitoring. City Health measures performances based on quarterly data and targets. The service level agreement is reviewed on an annual basis. There are a number of challenges and differences of opinion with regards to the content of the service level agreements and the expectations. If the NHI started the following day, City Health would not be ready. Part of the process, though, was working towards the ideal clinic.

The Chairperson asked if the City could speak to the shortfall in funds in terms of percentages.

Dr Fareed said the City contributed 60% and the Province contributed 40%.

Dr Nkurunziza said the shortfall did have an impact, not only on the City, but also on the Province. City Health would love to employ more staff and render more services.

The Chairperson asked how City Health supported care workers with their challenges.

Dr Nkurunziza said that healthcare workers faced challenges of security even in their facilities. Environmental health practitioners were deployed throughout the City. On average there were two officers per sub-district. The challenges they faced in informal versus formal settlements were different, but they rendered the same services.

Dr Fareed said that in that year they have had about 6000 complaints that have come through and they sometimes come with compliments as well. Each complaint was investigated, and City Health contacted every complainant. Staff had a turnaround time of 23 days and they had a target of turning around 90% of complaints in that period.

Ms Gopie asked if the complaints were in different languages.

Dr Fareed said that if a complaint came in a different language, it was translated.

Ms Makeleni asked if there was accommodation for people who wished to make a complaint in their own language.

Mr Mitchell said that Mr Makeleni was asking if the actual complaint form was available in all languages.

Dr Fareed said she would have to get back to the Committee on that, but she thought it was available in three languages.

The Chairperson asked what the patients mainly complained about.

Dr Fareed said that the majority of their complaints were about rodents and waste disposal.

Ms Lekker wanted to know what exactly the issues were the City was facing with the National Health Insurance system.

Dr Nkurunziza said infrastructure was the main challenge with the implementation of the NHI, as well as staff shortages.

The Chairperson asked how many healthcare personnel had requested support from the EAP programme. Were there any patterns of absenteeism in healthcare facilities?

Dr Nkurunziza said he could not, at that moment speak, to the numbers of staff who had requested support.

The City had a target of 5% absenteeism and, for a long time, City Health had achieved that target.

The City of Cape Town had divided the City into four areas. Those four areas were along sub-council boundaries. City Health had no influence on the division into areas.

Presentation by the Western Cape Department of Health

Dr Gio Perez made a presentation to the Committee on behalf of the Department. Dr K Cloete presented on the rural districts.

Mortality: All districts

Dr Perez said the best place to live in the province was probably the Overberg area where the mortality rate was lowest in 2013. The Central Karoo area had the highest mortality rate at 945 deaths in 2013. Mortality rates were generally coming down.

Demographics: Cape Town

Dr Perez said the Department served just over 4.1 million people for the 2018/2019 year. Of that population, 76.6% were uninsured. He said the important thing to note was that the population dependant on the public sector was higher than the uninsured population because many patients on medical aid also used the public sector.

Cape Metro BOD

The Mortality rate for HIV and TB has been decreasing well. Dr Perez said that the gains being made in HIV and TB treatment were being offset by interpersonal violence and, to a lesser extent, chronic diseases of lifestyle.

Service Continuum

Dr Perez said that primary healthcare was part of a continuum of services that the Department provided.

Primary Health Care (PHC) Facilities: Metropole

Areas where there was little coverage such as at the Southern peninsula, up the West Coast between Blouberg and Atlantis, and certain parts of the farmlands in the East were areas where the population tended to be very small.

PHC Facilities Service Delivery Platform: Metropole

Smaller facilities tended to be City facilities and larger facilities tended to be Provincial facilities. Where there was an overlap, they worked together to provide a range of facilities.

PHC Headcounts: Metropole

Dr Perez said they currently had just under 10 million patient interactions per year. Two thirds of that was in Provincial facilities and one third was in City Health facilities.

PHC & CBS Headcounts: Relative contributions

Dr Perez said that their facilities were becoming increasingly saturated. They were looking at other means of seeing patients and actually trying to see patients closer to their homes. The CBS headcount was largely patients being seen by community health workers outside of their facilities.

Collaboration

Dr Perez said collaboration was more difficult in joint facilities and in facilities that were close to one another. Patients often became confused when they had to move from one system run by the City to another run by the Province and vice versa.

Basic Package of Care

Dr Perez said the basic package of care was part of an ideal clinic initiative. That was essentially focused on readiness for NHI.

Maternal Care

Dr Perez said the City was currently extending its Antenatal and Postnatal care services.

Dr Perez said that officials of the City and the Province did work well together but they had different conditions of service and different ways of doing business. Patients often had difficulty navigating the system due to that. The Department spent about R 3. 2 Billion on personal primary healthcare in Cape Town and according to the last district health expenditure review about R 774 million of that came from the City. Due to their different budgeting systems, if the City added in some of their management costs, that figure became bigger. They had 4 800 staff at primary healthcare level. Provincial staff members were struggling with interpersonal violence and they struggled to get staff in and out of hotspots. Sometimes they had to close facilities because of gang violence.

District Aspirations as per DHP

Dr Perez said the district health plan had a three-year cycle and was a joint district health plan.

Rural District Health

Dr K Cloete presented that part of the Presentation.

Dr Cloete said that the Overberg district was the one district where HIV was not among the top ten causes of death. He said that within each district one would find local nuances. For instance, in the West Coast district the migrant population has a big impact on their services.

Discussion

Ms Makeleni said that for the mortality rate for 2013 did not tell Members much about what was currently happening.

Dr Mbombo said generally one would always find that data was around three years behind. It was due to certain methods in biostatistics.

Ms Makeleni was curious as to the real figures and not the percentages in the Cape Metro BOD.

Dr Perez said he took the point and would provide the actual numbers.

Ms Makeleni asked how far the city of Cape Town was on the digitalisation programme of the Province.

Dr Perez replied that there were certain aspects of the service which were closer to being fully digitised than others. There were other challenges that they were struggling with, such as manual registers.

Ms Makeleni asked if the City and the Province were facing any litigation together.

Dr Perez was not aware of any litigations faced by the City and the Province together. What sometimes happened was that patients sued the City instead of the Province and vice versa. Those lawsuits were then just passed on to the relevant party.

Ms Gopie asked for more information around specialised services and what that entailed.

Dr Perez said that the specialised clinics were mainly dental clinics, youth clinics, male clinics and two reproductive clinics.

Ms Gopie asked if health departments in rural areas encouraged gardening.

Dr Cloete reported that the Department had a long history of gardening initiatives, mainly for nutrition programmes. Over the years they had realised that what the Department spent on that programmes was not as impactful as it was when managed by other parties whose business was in gardening.

Ms Gopie asked if there were any plans to put treatment facilities in rural areas for patients who had to travel from rural areas to the Metro area for treatment.

Dr Cloete said they have healthcare pickup points throughout the province and there were vehicles to pick patients up and take them to the metro for treatment. There were, however, initiatives in place to get specialised services closer to patients in rural areas.

Ms Wenger commended the decline in deaths from HIV and TB in the Metro.

Dr Mbombo said that the briefing had been about personal primary healthcare. Within the whole primary healthcare services there was community and home-based community care services, and there was personal primary healthcare which was facility-based. The other package in primary healthcare included school health as part of the whole package. She said that when planning the Department took into consideration where facilities were, and patients were referred accordingly. The Department also used demographics, trends and other statistics to plan for the health system.

Ms Gopie asked if the school healthcare programme existed in all schools, or just in certain schools.

Dr Mbombo said the Department was focusing on primary schools.

Dr Perez added that the programme was governed by an integrated school health policy. That was an agreement between the Department of Health and the Department of Education. The first point of call was at the school itself because there should be a school-based support team at every school. There was collaboration between the Department of Health and the Department of Education to conduct a screening programme which was largely on the teeth and the eyes. It was not at every school but at schools agreed upon by the Department of Health and the Department of Education. In the past there had been a focus on shifting more support to schools in the lower quintiles. Now there was a more nuanced approach and children in need at all schools were identified. The Department was currently covering about 20% of the schools in the province and that needed to be shifted up.

Consideration and Adoption of Draft Minutes of 17 April 2018

The Committee addressed the minutes of 17 April 2018.

There was some discussion about whether the minutes should read that the Committee raised a concern or that a Member raised a concern. The Chairperson said the Committee Coordinator should check what had been said.

The Chairperson noted that the minutes stated that some of the questions of the Committee had not been answered. Again, it was a Member who had asked, not the Committee.

The Minutes were adopted with the changes.

The meeting was adjourned.