Hospitals: Western Cape & Gauteng Departments of Health

Meeting report

Western Cape Department of Health

Dr Mbombo, Member of the Executive Committee (MEC): Health, Western Cape, introduced the briefing on hospital services in the province by saying that unemployment, inequality and poverty probably impacted more on health than any other factor.

Dr Beth Engelbrecht, Head of Department (HOD): Health Department, said it was important to show leadership at every level, even at the lower levels. The Department’s long term vision was captured in Healthcare 2030, and the focus was on wellness not on illness. The goal behind the whole of society approach was to positively change the story of people in the Western Cape. To do so required safety, social services and education.

The Department remained under significant service pressure. It was doing the best it could with what it had. Violence had a massive impact on the life expectancy of men. One of the biggest pressures in the health system was the patient waiting times. The Mowbray Maternity Hospital was impacted largely by old infrastructure.

Dr Keith Cloete, Chief of Operations: Health Department, said that the leading natural causes of diseases in the Central Karoo area were very much diseases of poverty. There were many hospitals in the rural areas, but they were much smaller. Tygerberg hospital was the one which experienced the most pressure in the whole province because of its size and location, and the smaller hospitals connected to it.

The attacks on ambulances had been particularly worrying for the Department.

The Department was implementing electronic referral systems so they would be able to monitor patients better at the primary healthcare level.

Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, said that the Department had been working over the last few years to become a values-based organisation. There had been a focus on improving staff attitudes and the supporting work environment.

Dr Engelbrecht said that the Department was working on optimising service potential and the operational efficiency of medical equipment. Clinical engineering skills were extremely scarce skills, so clinic engineers had to work across the board.

In the Department’s budget, greater emphasis had been put on facility and infrastructure maintenance. All the strategies were to ensure that the Department could make the most out of what they had. The Department had made a conscious decision not to outsource the laundry services completely, as it was too sensitive an issue. It was working at reducing its linen losses.

The big challenge was that the Department had a maintenance backlog of R1 billion. For the 2017/18 financial year, 50.24% of the budget was allocated for maintenance. The Council for Scientific and Industrial Research (CSIR) had assessed Tygerberg Hospital and said it needsed to be replaced due to its physical condition, sustainability and functionality. Even after the Department had spent R700 million on Tygerberg hospital, the maintenance work was not visible as it had been spent on sewerage, water and gas lines. It would cost around R10 billion to replace the tertiary part of the hospital, and the province was motivating the National Department to assist financially.

Dr Vallabhjee said that the Department had recognised that information technology and information systems were very important, and had therefore developed a long-term vision for it. The systems they had implemented were not an end in themselves, but rather a means by which the Department could become more efficient. In the Province, they had a data centre and a unique identifier which could assist in tracking patients across the entire healthcare system.

Discussion

Ms E Wilson (DA) asked what the figures for wasteful and irregular expenditure were.

Dr Engelbrecht said that in 2016/17, the Department’s fruitless and wasteful expenditure had been R7 000. In the past year, they could not find anything. The Department had worked hard at reducing irregular expenditure to a point now where it was below the level of materiality.

Mr W Maphanga (ANC) asked how the Department was dealing with the Office of Health Standards Compliance’s (OHSC) findings in the Province. Were any changes being implemented?

Dr Mbombo said that the OHSC uses its own measurements, and they had not necessarily been a reflection of the whole system.

Dr Engelbrecht said that there were structures in place for accountability for finance and patient outcomes and the achievements of targets. There were also oversight visits done by senior management. Every hospital was required to take the OHSC’s reports very seriously. They were obliged to provide an improvement plan and were held accountable for the improvement processes they put in place. The OHSC also followed up on where the improvement plans had been implemented.

Mr Maphanga asked what the status of the oncology services in the Province was.

Dr Engelbrecht said that oncology started at the primary care level. The Department was looking at the whole spectrum of care and not only at the high end.

Mr Maphanga asked how soon the Department envisaged the implementation of the strategies for improving patient experiences of care. Did it feel that the approach to improving staff attitudes would suffice, or should other be avenues explored? When would the review be available for Healthnet pickup points within the Metro? When would the electronic referral system start to function? How did the Department plan on mitigating the main challenges regarding the demand for higher wages?

Dr Engelbrecht said that when negotiations took place at the national level for salary increases, there was no link to the budget that the province received.

The Department had to work very hard to compromise between appointing more people and being able to afford increased wages. Staff safety, and particularly that of Emergency Medical Staff (EMS), was a major concern. There had been cases where staff Members had not been able to work efficiently due to post-traumatic stress

Mr T Nkonzo (ANC) asked for details on how the Department was eradicating wasteful expenditure.  What was the distribution of non-profit organisations (NPOs) and Community Care Workers (CCWs)?

Had anything been done which had justified the decline in attacks on ambulances from January? Had there been any convictions? A case had been taken to the Western Cape High Court to indicated that the impact of that type of crime transcended petty crime, due to its impact on society. There had now been three people who had been sentenced to 12 years in prison for stealing a cellphone, but it remained to be seen whether that would have an impact on attacks on ambulances.

Dr P Maesela (ANC) asked what people-centred care was. Does universal health coverage refer to the National Health Insurance (NHI) scheme?

Dr Mbombo said that universal health coverage was an international initiative which no one could rationally reject. The difference between universal health coverage and the NHI was about the funding methodology.

Dr Maesela asked if all clinics had clinic committees.

Dr Mbombo said that they now had provincial legislation which recognised all committees at healthcare facilities and hospitals.

Dr Maesela asked general progress in the Western Province, and why there was outsourcing, given the national policy focus on in-sourcing?

Dr Engelbrecht said that they had to look at how best to render services with the resources that they had.

Dr Maesela asked what transformation was like at the executive level.

Dr Enegelbrecht said that the Department recognised that transformation at the senior level was a challenge. There were other factors beyond the control of the provincial Health Department, such as the Department of Public Service and Administration (DPSA) requirements for promotion. The whole of government needed to assist in this regard. The Department was working hard to ensure that they could change its profile, however.

Ms S Kopane (DA) asked if CCWs were linked to healthcare facilities, and whether they were monitored by professional people.

Dr Mbombo said that CCWs in primary healthcare facilities were linked to the facilities. In some cases there were professional nurses who monitored CCWs.

Ms Kopane asked if the Department of Health was working with the provincial Department of Social Development (DSD) with respect to CCWs.

Dr Mbombo said that they did work with the DSD as part of the broader strategy for health delivery.

Ms Kopane asked for clarity as to the vacancy rate and its challenges.

Dr Engelbrecht said that the Department defined vacancy rates for posts based on those that it had funds for. A 4% rate was largely reflective of the turnover.

Ms R Adams (ANC) asked about the challenges of governance in the Department. How had it followed up on the Auditor General’s findings? How were infrastructure needs prioritised in the Province? How were the visits of CCWs being monitored?

Dr Engelbrecht said that as part of the Healthcare 2030 plan, they were looking at infrastructure.

Mr A Mahlalela (ANC) asked what the challenges in governance were. What was the Department doing about the governance challenges? How would it monitor the outcome of the strategies being put in place to enhance patients’ experience? What was the reason behind the difference in the internal assessment by the Department and the assessment by the OHSC, especially with respect to clinics in the Metro?

Dr Engelbbrecht said that when the full report was presented, they would be able to see the full extent of the difference between the Department’s internal assessment and the assessment of the OHSC.

Mr Mahlalela asked what the current situation was with regard to stock and system management at medical supply depots.

Dr Engelbrectht said that they had a very tight payment system to check that their payments were made within 30 days. They were working very hard to ensure there were no delays in payments caused by invoice issues

Mr Mahlalela asked what the share of the budget spent on primary health care (PHC) was.

Dr Engelbrecht said that PHC received 40% of the budget

Mr Mahlalela asked what the Department was doing to reduce pharmaceutical waste?

Dr Engelbrecht said that they were even monitoring where the waste was being handled. The Department of Environmental Affairs (DEA) was working with them on doing inspections.

The Chairperson asked from whom the Department was receiving medicine donations.

Dr Engelbrecht said that because of the shortfall of the HIV grant, the National Department had given them donations of stock that it had sourced. They regarded that as donations, but it did go to the patients.

The Chairperson asked for clarity around outsourcing.

He also asked what had happened in the case where a patient had gone missing and was found decomposed. 

Dr Engelbrecht said that the patient had a very advanced and incurable cancer. He had gone missing at Stellenbosch Hospital. The nurse had gone out for 15 minutes to fetch linen, and when she returned the patient was missing. They had called SAPS and searched the hospital, but no one had thought of looking in the ceiling, where the body was found.

The Chairperson wanted to know what was happening at the GF Jooste hospital in Manenburg. 

Dr Engelbrecht said that GF Jooste Hospital was a district hospital, and they were replacing it with a regional hospital due to the load of cases in that community. It would be the Klipfontein Regional Hospital. A site had been identified, and the business case had been submitted to the National Department of Health, and they were awaiting the final outcome. There have been engagements with relevant stakeholders.

The Chairperson asked if the Department thought that demolishing Tygerberg Hospital would be cost effective. Why had the Department moved from wanting to refurbish Tygerberg Hospital to wanting to demolish it?

She asked the Department about the allegation that they had stopped training nurses.

Dr Engelbrecht said that the non-training of nurses was absolutely not the case.

The Chairperson asked for clarity as to how the Department tracked patients using the unique tracking number.

Dr Engelbrecht said they had 14 years’ experience working with the unique patient identifier in the province. They had worked very closely with the National Department in developing the national system. 

Dr Maesela asked for more clarification on transformation.

Dr Engelbrecht said that at the senior management service (SMS) level, 8% of the province’s staff was black.  The Department looked at identifying mechanisms to expose candidates for transformation in order to push them through. Every vacancy was seen as an opportunity to contribute to transformation. An example of how they were handicapped by the national Department was that it was national policy that one could not become an SMS member, or even short-listed and interviewed, unless one had fiver years’ experience in a deputy director post. There were also people in the Department who had been serving for years, and that contributed to the Department’s profile. There was also a need to balance transformation with institutional memory and governance stability.

The Chairperson said that they would follow up the issues of transformation with the relevant parties.

The morning session was adjourned.

Gauteng Provincial Department of Health (GPDH)

The Chairperson said that she had been informed that GPDH did not have the presentation documents ready, and that Members had not been presented with copies of the documents. She requested that arrangements be made to print the hard copies and have the copies e-mailed to them.

Ms Kopane confirmed having received the document on e-mail, and that the document comprised 68 pages. She was of the opinion that GPDH was undermining their oversight authority and that it was not the first time it had come before the Committee ill-prepared. She said that on behalf of other Members of the DA, the party was not going to take part in the meeting.

Dr S Thembekwayo (EFF) added that should the meeting continue, then it would fail to include advice from the content advisors, and confirmed that the EFF would also not be taking part in the meeting.

Mr Mahlalela advised that the Committee should hear from the GPDH before taking a position on the matter.

Dr Gwen Ramokgopa, MEC: Gauteng Department of Health, responded on the failure to submit the documents on time. She said the GPDH had been made to understand that the presentation would be on the annual performance plan (APP) and the budget, the documents of which had already been tabled and were public documents. The impression by the GPDH had been that it was to present a high level summary. She apologised for the miscommunication, and requested that the GPDH be allowed to present, and the Committee could deliberate on what had been presented at a later date.

Mr Mahlalela said that the GPDH had not been asked to present on the APP, and the letter which had been sent to them had requested a presentation on specific areas. He added that the Committee should allow GPDH present, however, and the deliberations on what was presented could be done at a later date.

Members from the DA -- Ms Kopane and Ms Wilson -- left the meeting, as well as Dr Thembekwayo from the EFF. The GPDH was thereafter allowed to present.

Dr Ramokgopa began by highlighting a major achievement for the GPDH. An assessment had been done on the performance of the Gauteng provincial government, including the Department of Health, by independent panels and it had been discovered that life expectancy in Gauteng was on the increase. The success could be attributed to the control and management of HIV Aids.

She also addressed the issue of socio economic determinants of diseases, including crime, drugs and unemployment, which were key determinants of ill health. On crime, she informed Members that the casualty sections at the hospitals were usually over-burdened at mid-month and end-month when people had been paid. The incidence of crime contributed significantly to interpersonal violence and accidents which overflowed during these periods of the month. She also advised that drugs contributed heavily to adolescent mobility and mortality.

Though Esidemi had been an initiative of Mental Health, there were certain lessons which the Department had taken from the situation. These included the following:

• Realistic pricing of mental health carers -- the amount paid to non-governmental organisations (NGOs) to be reasonable in relation to patient care, so as not to compromise the quality of care;
• Risk assessment, thorough checking of NGOs’ capacity for licensing, type, and the number of patients that they could safely care for ;
• Adequate staffing for the care of mental health care patients;
• Policy decisions needed to be widely shared and discussed before implementation;
• Technical and clinical experts must be used where needed to ensure patient safety and care.

Other reflections by the GPDH included the monitoring and support of NGOs to assist them to meet minimum requirements for licensing. Some NGOs had had to be closed down where they did not meet the requirements and presented a risk to patients. She also pointed out that the GPDH wanted to ensure the Mental Health Review Board functioned as it was designated to by legislation in order to make the GPDH accountable. The health ombud had indicated that there had been undermining of board governance, and that the GPDH needed to monitor the mental health review boards to ensure core standard were complied with and maintained. There should also be a structure for consultations between the NGOs and the GPDH to avoid communication breakdowns. This would also include consultations with the family committees.

On external pressures, she said that Gauteng had the largest population and that the budget had not increased to meet the population growth, including high rates of immigration and urbanisation. There had also been a 5% increase in the demand for public health services because of the increase in the quality of care. The National Health Insurance (NHI) dispensation would assist, but the GPDH was the most affected by cash constraints. She gave a comparison with other provinces, and pointed out that Gauteng was the worst hit, as it had experienced cash depletion as early as September of every year. There was need to align budgets with cash so that there was continuity of services.

Previously, accruals had been building up by R2 billion every year since 2014/2015, but the GPDH had intervened and prioritised front line services, and the intervention had assisted in stabilising the accruals. It was not possible for any budget to carry this current burden of disease. The GPDH had an equivalent of about 10 epidemics at once including HIA/ Aids, tuberculosis (TB), maternal and neonatal heath, children’s health, diabetes, hypertension, inter-personal health, mental health, motor vehicle accidents, and cancer.

She also pointed out that there had been research in the Gauteng city region on the impact of inequities, and it had been discovered that Gauteng still accounted for a large number of people who had medical aid, although the number was decreasing.

Professor Mkhululi Lukhele. Acting HOD GPDH took Members through the internal challenges facing GPDH, which included the following:

• High turnover of leadership;
• Under-funding of the GDH;
• Rise in medical litigation;
• Ineffective decentralisation as a consequence of the cash constraints;
• Sub-optimal involvement of patients themselves, their families and stakeholders; and
• Poor labour relations. To deal with this, the GPDH had had a labour summit in the previous month.

He also took Members through the top 20 risk factors the GPDH was facing, which formed part of the risk dashboard. The risks were as follows:

• Inadequate access to quality health services for mental health patients;
• Increase in maternal, new born, infant, child morbidity/ mortality;
• High death rate due to an increase in the number of HIV and TB infections;
• Inadequate resourcing of the Primary Health Care (PHC) reengineering programme. Gauteng was doctor-centric, and the GPDH still had to work on the community to start embracing primary health care;
• Serious adverse events;
• Poor quality of essential medical services’ referral/call system due to incorrect usage of the system;
• Shortages in pharmaceutical supplies;
• Ageing infrastructure and health technology;
• Non-adherence to prescripts;
• Lack of standardised information technology (IT) platforms to enable the provision of quality health care;
• Delays/late payments to suppliers (30 day payment period);
• Inadequate human capital management;
• Inability of supply chain management;
• Financial losses due to litigation;
• Inability to achieve medium term expenditure framework (MTEF) revenue collection targets. The GPDH was second in the province in terms of revenue collection, but it aimed to improve more on that;
• Fraud and corruption was still high;
• Fruitless and wasteful expenditure;
• Irregular expenditure; and
• Inability to function in the event of disaster.

He took Members through a graph comparing PHC headcounts for the years 2016/2017 and 2017/2018, which showed that there had been an increase of about 20 000 over the two years. The increase had been similar for out-patients.

On complaints management, there had been an increase in meeting the target, and currently complaints were managed within 25 days.

The TB default rate was high, especially in Sedibeng and Tshwane, and the GPDH had sent people to these areas to track the defaulters. There had been a slight dip in respect of access to medicine because some of the suppliers had not been able to provide the medicine, but patients had still got treatment, although it had been at a higher cost.

Dr Lukhele gave an overview of the ICT projects which comprised the Health Information System (HIS). The Payment Clearing and Settlement (PAC) system had proved to be helpful, and the major challenge facing ICT infrastructure was the shortage of funds.

On infrastructure, one strategy for improving finances had been to hold off on new projects. There were, however, some completed projects and other new projects which were under construction. The 2018/2019 priority was to upgrade hospitals to level 3 for Occupational Health and Safety (OHS). The GPDH was engaging the Department of Infrastructure Development (DID).

The GPDH had five laundry services, some of which were based at the hospitals. The DID helped with the maintenance of the laundries, and the GPDH was working to improve the 52% efficiency of the laundry services.

Ms Kabelo Lehloenya: Chief Financial Officer (CFO): GPDH, said that patient care was usually put at risk by accruals. Previously accruals had been going up by R2 billion every year, but the GPDH had been able at arrest the growth. Based on the recommendation of the intervention task team (ITT), the GPDH had received R1.5 billion from the Gauteng provincial treasury to settle accruals for the 2018/19 financial year. It had been able to deal with the accruals by paying off all those it owed R10 million or less, which comprised the small, medium and micro enterprises (SMMEs). There were, however, those who had not been paid because the invoices had been received but had not yet been matched. It had also engaged the big suppliers -- about 39 of them -- and had committed to pay these suppliers within 24 months. This would cut across three financial years. Should any other resources become available then GPDH would be able to pay the suppliers sooner. The provincial treasury had so far given the GPDH R4.8 billion to settle accruals.

The GPDH reported on a cash-based system and not on an accrual basis, and had a target of spending 1/12 of the allocated funds, which translated to around 8.3%, every month. However, it had spent 9% in the month of April 2018 because of the accruals.  If GPDH were to exclude accruals, then cash payments had been 6%, which was impressive because it reflected controls within the Department. A financial intelligence tool was being developed which would ensure that what was reported was what had been incurred in the course of the month, in comparison to the cash availability. Central and tertiary hospitals were the main budget consumers.

On compliance, the GPDH was fencing the budget to restrict it to current year needs, and was working on making payments within 30 days of receipt of invoices, as demanded by the Public Finance Management Act (PFMA).

On the medico legal payment status, the GPDH had made payments of R125 million in the current year. There were various mechanisms it would put in place to deal with this, as the Minister had made it clear that the Department should not disadvantage patients because of paying claims.

On improvements in the financial system, she said that previously GPDH had been requesting three quotations. It was, however, coming up with a method of standardising prices. It was also improving and converting requests for quotation (RFQs) to suppliers to contract, which would enable it to review contracts and control prices.

There was a committed team looking into the area of irregular expenditure. This was being done together with the South African Institute of Chartered Accountants (SAICA). The GPDH was also doing away with month to month contracts which were not cost efficient. In terms of inventory management, if an item was not in the plan then it would not be bought.

The financial intelligence tool alluded to earlier would help the institutions to become accountable. The approach adopted was that entities were not allowed to spend more than what they had.

Services for health care waste management were outsourced to three companies, and these companies had been selected in an equitable manner. One of the companies, Buhle Waste, was a black-owned company, while another was Seane Medical Waste, which was an SME company. Both companies had been doing good work. The Department spends about R91 million per annum on waste management, and generates about 4.7 million kg of waste each year. The collected waste is removed and treated at a private approved treated plant.

The GPDH spends about 60 % of its budget on salaries. For the current year, the amount spent on salaries was 57.5%, which translated to around R 26 billion. This was primarily because of the wage shock and employment surge. The implementation of the OSD and generous above inflation wage increases over the last decade had seen a wage shock in the health sector. The cost of a full time equivalent (FTE) employee had increased by an average of 10.6%. The headcounts had also increased, and the Department had added 25 000 employees over the decade. Money had had to be taken away from essential services to fund the cost of employment. She gave an example of last year, after the medium term adjustment budget, where R1.1 billion had been taken away to fund the cost of employment.

Professor Lukhele said that the Department was investigating irregular expenditure, There had been a slow purchase of medical equipment because the bidding committee was not sitting regularly. It was currently outsourcing security, but it would do a security analysis to consider other options. as it had been discovered that the money paid to the security companies was not paid to the workers.

The GPDH had four central hospitals and was sharing some of the workers with the universities. It was engaging the universities and work was in progress to finalise multilateral and bilateral memorandums of agreement (MOAs).

The intervention task team had discovered a bloated team in the central office and a decision had been made to send some of the workers to the frontline. The GPDH was also working to include women and persons with disabilities in the Department, and to make appointments on a permanent basis. It had paid performance-based pay progressions to employees on salary levels 1 to 12 in December 2017. On 8 May 2017, it had tabled options to the unions on the intended payment of performance bonuses.

The Department had 30 clinics providing 24 hour services, it was aiming to increase the number to 33. On contracting of community health workers, it had not been able to absorb them because of finances. It had, however, been paying them through Smart Purse Solutions, which had been effective.

On governance and leadership, the GPDH had been looking at the clinics’ governance structure and the goal was to decentralise through five districts so that each district was able to handle its delegation. A task team had been established to oversee the decentralisation.

Dr Ramokgopa said that the recovery plan for the GPDH would consist of the following areas:

• Reshaping the operations design and governance and stewardship for improved service delivery;
• Drive uniformity of performance and modernise information management and use for integrated decision making;
• Prudent fiscal discipline across all facilities;
• Strengthen human resources; and
• Strengthen clinical and non-clinical service outputs and outcomes.

She stressed that the GPDH did not have a moratorium on posts and that it would prioritise critical posts. The majority of workers were patient-based, and the Department had decided that those who had performed above level four or five required recognition. It was difficult to justify not giving bonuses to other employees, but the GPDH had to prioritise the main areas. It was also not complaining about OSD, but there should be an equivalent increase in the budget. National grants to Gauteng had also been on the decline. She confirmed that she had been having meetings with the vice chancellors to see how the budget for the Department of Higher Education could assist in the training of health professionals.

The GPDH welcomed the State Liability Amendment Act, since it would provide interim relief, but the budget should not come from the money set aside for patients

Mr Mahlalela thanked the GDH for the presentation, but pointed out that the following areas had not been extensively covered:

• Pharmaceutical management system;
• Planned patient transport;
• Referral system;
• Medical equipment;
• Medicine availability; and
• Governance and leadership.

The Chairperson commented that the challenges experienced earlier in the afternoon could have been avoided. She reminded the GPDH that she was always available and that should it feel that the time given to them to prepare had not been adequate, they could always have asked for the meeting to be rescheduled. She confirmed that a communication would be made to the GPDH on when the deliberations on what had been presented would be done.

The meeting was adjourned.