The report of the Office of Health Standards Compliance (OHSC) featured prominently in the meeting, with the Committee wanting to find out what the various provincial departments were doing in response to the OHSC findings. The provincial Departments of Health of Mpumalanga, the Eastern Cape and Gauteng pointed out that the assessments had been carried out on the worst performing facilities in their regions, and that the findings did not necessarily reflect the position at all the facilities. They all confirmed, however, that they would intervene and address the issues raised in the OHSC report. Challenges that cut across the three departments included a shortage of funds, large sums of accruals, shortage of specialists, medical legal claims, inadequate repair and maintenance of infrastructure, and inefficient emergency medical services (EMS) systems.
For Mpumalanga, a major concern was the security situation, as there had been many cases where members of communities had attacked nurses during the night. The Mpumalanga Department of Health (MDOH) had intervened and unilaterally decided to deploy armed guards. Another challenge was that some people were bypassing primary health centres and going directly to hospitals, which prompted the Committee to ask why this was happening. Other issues raised included poor response times, the illegal dumping of medical waste, the cure rate for tuberculosis remaining static, the use of DDT to combat malaria, and the use of the centralised chronic medicine dispensing and distribution (CCMDD) system to assist in the distribution of chronic medicine.
Members told the MDOH of complaints they received about health services in the province. These included long waiting times at the hospitals, care givers who had been working in hospitals for over 20 years and were still being paid as little as R 3 000, the poor quality of food in certain hospitals, the negative manner in which the staff in hospitals, especially nurses, talked to patients, and the lack of privacy for people living with HIV AIDs, The Department was asked to respond to these complaints.
The Eastern Cape Department of Health (ECDOH) reported that it had 66 district hospitals offering 24-hour services. The province had the highest number of health facilities, but these were old facilities that were not designed for current needs. It had introduced a number of initiatives in high risk areas and as a result of the interventions, the incidence of tuberculosis (TB) had been decreasing in the province. All newly diagnosed TB patients were now provided with a National Health Laboratory Services (NHLS) lab track, which would assist in tracing TB patients moving from one facility to the other.
The Gauteng Department of Health (GDOH) touched on areas left out in a previous presentation. It said was taking lessons from Life Esidimeni, and had a risk register on issues it could pick up. It confirmed that the payment of Life Esidimeni claims would be from the Gauteng provincial government, and not necessarily from the GDOH. The Department reported that a mid-term review had indicated an increase in life expectancy, and that it was close to attaining a zero transmission of HIV/Aids from mother to child. Concerning following up on lost TB patients, community health workers were reported to be assisting in reducing TB defaulter rates. The national programme of registering citizens in preparation for the National Health Insurance (NHI) scheme would also help the GDOH, since there would be one database.
Mpumalanga Department of Health (MDOH)
The Chairperson began by stating that health was an emotive sector, and the Departments and the Committee had a responsibility to ensure people received health care services as outlined in the Constitution. The Committee had an oversight responsibility. She requested the Departments to be honest with the Committee on the challenges experienced on the ground.
Mr Gillion Mashego, Member of the Executive Committee (MEC): MDOH, said the Department had a responsibility to provide a longer and healthy life for all South Africans and to raise the life expectancy to at least 70 years. The security situation was currently not looking good. Members of the community had in many cases attacked nurses during the night. Community members in some cases fought each other and when injured, demanded to be given preference at the hospitals. He mentioned an incident where one of the doctors in one of the facilities had been attacked. The MDOH had made interventions and had unilaterally decided to deploy armed guards. It would in the meantime look at ways of providing better security at the facilities.
There was shortage of staff, and the current budget was not enough to engage new personnel. The MDOH had taken the matter up with the Premier and Treasury, and it had started advertising some posts. It had decided that money that should have been spent on overtime staff would instead be used to employ new staff. It was also seeking specialist staff members outside the Republic, and it was also looking at some of the South Africans who had been sent outside the country to study medicine. It had been sending a batch of 10 students outside the country to study, but the number had now increased to 28.
MDOH had in the past received complaints on emergency medical services (EMS). It was intervening and was currently doing an assessment of how many vehicles it had and how many the Department needed. It also had a system to monitor the movement and response time. It was planning to integrate its transport system with the EMS.
On infrastructure, the Department had inherited dilapidated structures and was busy with renovations, and was building some structures from the scratch. It was currently building four hospitals. It was using innovating building technology (IBT) to make it cheaper, and had built 28 IBT structures. Maintenance had previously not been taking place as it should have, so MDOH had set aside R25 million for the repair and maintenance of boilers, R28 million for the maintenance of other equipment such as generators, and R5 million for the drilling of boreholes. The Department of Public Works would assist MDOH to improve its infrastructure.
MDOH had built 87 out of a target of 287 primary health care (PHC) centres of ideal status, and the goal was to increase the number to 116. Its focus was more preventive than curative, and in order to achieve this goal, PHC outreach teams had been established. This would assist in reducing maternal and child mortality rates. Under the school health services, school learners were screened and learners with medical conditions were picked up and transferred to nearby PHC facilities and hospitals. A challenge identified was that some of the people were jumping from PHCs and going directly to hospitals. Another challenge was the long waiting time experienced at the hospitals.
Mr Mashego reported on some of the positive indicators, and said that the number of children under five years with diarrhoea cases had improved, cervical cancer screening had improved, maternal and child deaths had reduced and there was availability of medicines in all the facilities. He added that MDOH was on course to handle all issues raised by the Auditor General on irregular expenditure and immovable assets. The plan for MDOH was to avoid a qualified opinion as it increased its controls.
Dr Savera Mohangi, Head of Department (HOD): MDOH, gave a budget summary and indicated that the Department had received a budget increase of R1.118 billion, or 10.2 %, of which R552 627 was from conditional grants and R565 494 from voted funds. The compensation of employees (COE) budget was 59.3% of the total allocation in 2018/2019, compared to the national benchmark of 62%. To increase access to health care services, the MDOH rendered health services through community-based facilities -- 81 mobile clinics, 228 clinics, 59 community health centres, 23 district hospitals, five tuberculosis (TB) specialised hospitals, three regional and two tertiary hospitals.
The TB cure rate was decreasing due to patients not producing sputum at the end of six months’ treatment, hence the need to continue counseling patients throughout treatment. There had been an outbreak of malaria in October 2017 which had accounted for 9 449 cases and 96 deaths.
She said that quality care was measured through compliance with the national core standards as set by the Office of Health Standards Compliance (OHSC), and none of the 33 hospitals was fully compliant with the standards. All hospitals were implementing quality improvement plans to address the identified gaps. She cautioned that self-assessments done by the MDOH may be biased, and to address the issue it would have the provincial departments rotating the districts and making assessments. The gaps that had been identified as common to all hospitals were:
- Clinical audits of each priority programme and health initiative were not conducted.
- Safety precautions that prevented harm in units where children were cared for, were not observed.
- Emergency trolleys were not standardized.
- Policies on handling emergency resuscitations were not available.
- The protocol on safe administration of medicines to patients was not available.
- Procedures for patients with special needs or with reduced mobility were not available.
- Staff-patient ratios were not in accordance with the approved staffing plan.
- Grounds and pathways were not well maintained, there was inadequate lightning, and no records were kept of inspections done.
Medical equipment at the MDOH was being procured on a two-year warranty basis, which speeded up procurement. Maintenance was in-house, with some done outside, although the Department still had a financial challenge with the maintenance of the equipment. It had outsourced the management of pharmaceuticals at the medical depot, and was in the process of installing a warehouse management system there. All the PHC facilities were reporting availability of medicines, using the stock visibility system. On medicines availability, MDOH had accruals for medicine of R373.7 million at the end of 2016/17, and R364.7 million for the year 2017/18. The shortage of drugs was attributed to the short-dated stock received from suppliers, supplier challenges and delayed payments due to cash flow problems. To avoid drugs expiring in the warehouse, no buffer stock was kept. In cases where a specific drug was not available, patients were given an alternative drug. The central chronic medicine dispensing and distribution (CCMDD) system had been piloted in the Gert Sibande District, and had now been rolled out to the other two districts.
Regarding human resources (HR), there were a few vacancies in top management. One of the Department’s priorities was to ensure it had a full team of executives, and all chief executive officer (CEO) posts had been filled, except for Lydenburg. Three vacant posts for chief financial officers (CFOs) should be finalised by July 2018. She also commented that there was a high staff turnover. For HR development, the Department was participating in the Nelson Mandela-Fidel Castro (NMFC) medical programme. There were also the 110 students sent to Russia, and the first group of four would be completing their studies in 2020. The total enrollment at the Mpumalanga Nursing College was 662 students for the four-year diploma programme, and a bursary system had been introduced at the nursing college.
She summarized the challenges in HR as:
- An outdated organogram.
- Shortages of staff, on which the MDOH had done some benchmarking with other provinces.
- Labour unrest.
- Safety-related challenges, where the MDOH had responded and contracted armed guards.
- Non-translation of the nurses to higher posts. A report on this issue was due on 30 June.
- Dr Mohangi also informed the Committee that the CEO of Themba Hospital had been reinstated. He had been given a warning and his suspension had been lifted.
There was a huge deficit on EMS, There was one communication centre per district, and in terms of response time, MDOH was not doing well. The situation could be attributed to a shortage of personnel and a shortage of ambulances. MDOH had appointed 96 emergency staff, and an additional 15 ambulances would be purchased this year. The number of obstetric ambulances had been increased to 24. Patient transport was to be integrated into the EMS. The Department had an EMS college, although it was currently not functional. On governance and leadership, it had a well-established audit and risk committee. It did not have an ethics management strategy and implementation plan. It had established a provincial misconduct committee and district financial misconduct and loss control committees. The responsibility of these committees was to investigate and report on all reported incidences of financial misconduct and losses suffered by the MDOH and make recommendations.
Regarding the under-spending on conditional grants, MDOH was strengthening the planning and monitoring of the grants. It had received a qualified audited report, and this could be attributed to the inadequate financial personnel over the medium-term expenditure framework (MTEF) period. It had intervened by placing qualified interns in the districts and hospitals .Accruals remained a challenge and it was reviewing, implementing and monitoring a strategy to collect money owed to the Department. It had also conducted reconciliation on funds to be surrendered to Treasury .The main accruals were in medicine, amounting to approximately R842 million.
The MDOH referral system was heavily reliant on Gauteng Province. The regional hospitals did not have a full complement of the eight core secondary systems. Although Ermelo Hospital provided eight core domains, the disciplines were headed mainly by Cuban doctors. MDOH was intervening to meet the challenge of patients bypassing PHC facilities by rotating community service health professionals in the PHC facilities. In order to address inadequate skills, it was increasing the pool of doctors by an additional five in the registrar programme, and was also entering into memorandums of understanding (MOUs) with academic institutions and other provinces.
Regarding medico legal-claims and the management of litigation, the contingent liability as at 2017/18 was estimated at R7.6 billion. 158 cases to the value of R3.3 billion had been reported over allegations of cerebral palsy suffered by minor children. Mediation had proven to be flexible since it was initiated in the 2016/17 financial year. Through mediation, seven cases had been finalised and the MDOH had paid just under R2 million. Its intervention strategy was to conduct continuous training for health professionals so as to ensure patient safety.
MDOH had a risk management unit which identified and coordinated the management of departmental risks and fraud prevention.
There were 18 laundries in the 33 hospitals, and the objective was to have in-house laundries in all the hospitals. The plan was to establish an additional two laundries and to procure additional linen. MDOH had engaged the Department of Public Works (DPW) to penalise and terminate poor performance service providers charged with the maintenance of laundry equipment.
On security services, there had been an increase in community unrest, so the MDOH was creating awareness through community radio stations on the need to protect health facilities and staff.
It was using the patient electronic information system (PEIS).The system had information on a total of about 1.6 million patients. It had improved the patient file management process in PHC facilities through the implementation of the health patient registration system (HPRS).It had outsourced the management of health care risk waste. However, there had been non-compliance with national core standards on storage areas, and cases of illegal dumping, and it had engaged municipalities to monitor and penalise the culprits. All new facilities being built were also complying with national core standards with respect to storage of health care risk waste.
MDOH had adopted an infrastructure delivery management system (IDMS) as a vehicle for infrastructure planning, delivery and operations. 16 cooperatives had been appointed for sub-contracting work. The challenges experienced included insufficient budget for maintenance, poor performance of term contractors, and interrupted water supply.
TB management was being provided in five hospitals. The hospitals had support from various allied health workers, such as audiologists, occupational therapists, physiotherapists, social workers and radiologists. MDOH was decentralising the management of TB to the PHC centres. The TB cure rate had remained static, despite an emphasis on TB management in the province. It was also engaging the SA National Tuberculosis Association (SANTA) in order to procure the two TB hospitals from SANTA. In some instances, the cure rate was decreasing because it was using the world-based (WB) outreach team to assist in tracing defaulters. On the role of district health services (DHS) in strengthening the PHC centres, MDOH was working on establishing an additional 112 WB teams, although the budget remained a challenge. All newly constructed community health clinics (CHCs) were being built according to ideal clinic status, and R8 million had been set aside for infrastructure.
To provide mental health services, MDOH had only 106 beds against a minimum need of 1 214.
To combat malaria, it had appointed 330 temporary malaria spray operators to do indoor residual spraying. It was collaborating with neighboring countries by implementing the Mozambique, SA and Swaziland (MOSASWA) agreement on the management of malaria. 47 laboratory-confirmed listeriosis cases had been reported, with 12 deaths.
The Department was also experiencing a shortage of cataract surgeon’s and insufficient theatre time for eye operations. On AIDs and sexually transmitted infections (STIs), there had been a steady increase in HIV testing due to intensified community testing and a community campaign contributing to an increase in the medical circumcision rate. Immuniszation coverage of children under one year had increased from 80.2% in 2014/15, to 90.4% in 2017/18. MDOH was contracting non-profit organisations (NPOs), who in turn contract community health workers (CHWs). There were two sources of funding for the NPOs – the expande public works programme (EPWP) grant and the HIV AIDS grant. The main challenge for CHWs was the high illiteracy level, as programme was unable to attract qualified people because it was an informal source of employment. MDOH had benchmarked from KwaZulu Natal on the Operation Sukuma Sakhe and following the benchmark exercise, the Operation Vuka Sisebente (OVS) service delivery model had been launched in 2016.
MDOH participated through ward-based PHC outreach teams, whose major role played was to identify challenges during household visits and the referral of such cases to relevant departments.
Mr W Maphanga (ANC) said that the OHSC had reported to the Committee that most of the provinces’ Departments of Health had not improved their performance. He asked whether MDOH had met with the OHSC, and whether any changes were being implemented in response to their findings. He sought clarification on health care waste management, and wanted to know whether the Department complied with the Act (NEMA) and the National Environmental Management Waste Act (NEMWA). He also wanted to know whether there were tenders in place to deal with health care waste adequately. He asked why the malaria fatality rate was the only one that had increased, and what contingency plans MDOH had, now that weather conditions had become unpredictable. He also asked why Tonga Hospital had maintained a status quo of 70%. He sought clarification on the referral system, and asked whether the target of 1 April 2018 had been addressed.
Dr S Thembekwayo (EFF) referred to the MEC’s introduction, where mention had been made of patients jumping from clinics to hospitals, and asked whether there had been any efforts to discover what caused this. She wanted clarification on the unavailability of beds for patients who needed to be admitted, and gave the example of Evander Hospital, where patients were said to be sleeping on the floor, She wanted to know why this was so, as the Department had given the Committee information on usable beds and unusable beds. Regarding the suitability of candidates for key positions, she commented that MDOH had advertised several times, but had not been able to get suitable candidates, and said that the problem of unsuitability could last for years. If it continued to have a lot of vacant positions, it would not be able to run the province’s health operations. She asked what had happened to the previously employed security guards, and whether MDOH would be adding the armed guards to the security guards already in place, and whether these armed guards would be outsourced or in-sourced.
Since the specialist doctors referred to in the presentation were either Cuban or Ethiopian, she asked why South African doctors were not represented. What could be done to address the waiting time experienced in hospitals? She referred to complaints she had received from care givers who had been working in hospitals for over 20 years, and said they were still being paid R 3 000. She wanted to know whether that was the position. She also wanted MDOH to respond to complaints that the quality of food in some hospitals was bad, and the poor attitude of the staff in hospitals, especially nurses and the negative manner in which they talked to patients. She asked about allegations of a lack of privacy for people living with HIV AIDS, and why it took time for patients who were suffering to get taken for treatment in Pretoria. She had also received a complaint that from 1 January 2018, a new committed overtime had been implemented which had left out dentists. This had led to chief operating officers (COOs) cutting out dentists -- yet the dentists had never been consulted. She asked MDOH to respond to the complaint by the dentists.
Ms E Wilson (DA) said that the OHSC report on Mpumalanga had been bad, with 35% of the facilities said to be critically non-compliant. Not one entity in Mpumalanga had complied with the requirements. One of the biggest failures, according to the report, was management. The report indicated that instruments in the facilities were not sterilised, which was a priority. According to the report, there was no evidence that mobility and mortality in the facilities was being monitored, so she asked where MDOH got its mortality statistics from, given that there was no documentation. The Department had indicated that it had paid out R158 million on medical claims, and she wanted to know where that money had come from and whether it had been budgeted for. She commented that the Life Esidimeni claims may have to be paid by the provinces, because Gauteng could not pay for all of it, and asked if the province was making plans to pay for that. She also observed that because of accruals, MDOH was starting its financial year in the red, and in addition had irregular expenditure of approximately R3.3 billion. She commented that MDOH could not deliver medical care under such circumstances, and in the last year had regressed. She asked MDOH what it planned to do concerning referrals, since it was currently referring patients to Limpopo, but the facilities in Limpopo were also under pressure.
Mr T Nkonzo (ANC) wanted to know the controls being implemented to eradicate the irregular expenditure. According to the Minister of Finance, 8% of the budget was to be spent on maintenance. He asked what was being spent on maintenance and what maintenance policies were there. He asked how MDOH was dealing with contractors who did not deliver, and whether penalties were being applied, He wanted to know how chronic medicine was being distributed and if CCMD was being implemented. He sought clarification on the projected cost of medical legal claims, and asked MDOH to confirm which claims were prevalent.
Dr P Maesela (ANC) asked MDOH to go back and look at the OHSC’s and AG’s documents which could guide it to correct what it was doing wrong. He asked what had led to medicals accruals of R370 million, and what consequences were there for failing to pay on time. He asked for clarification on patients being given alternative drugs whenever there was a shortage. He commented that MDOH had a R7.5 billion contingency fund for litigation, and suggested that this money could instead be used to buy drugs. The MDOH did not have specialists because it did not train them, and in such situations, the equipment in the hospitals was not used because there were no specialists. He observed that MDOH was doing badly in terms of infrastructure maintenance, and cautioned that if it did not adopt a culture of maintenance, it would keep on demolishing what it builds.
The Chairperson commented that she would prefer it if the medical legal claims were categorised and the Committee was given information on whether these claims related to cases of cerebral palsy, missing records or any other claim. She said the Committee encouraged the in-sourcing of services. MDOH should be more specific on the contracts for services and where some contracts had been terminated, should give it reasons for the termination. She asked MDOH to confirm the numbers of trained Cuban doctors so that it was not reflected to mean that it was using Cuban nationals
MDOH responded that those hospitals that had continued under-performing and which had been singled out in the OHSC report did not have a full complement of management, but the issue of management had being looked at.
Regarding the 70% consistency and no improvement at the Tonga Hospital, MDOH had requested that it responds to the Committee in writing.
On the unavailability of beds, Evander was not using all the beds allocated to it. However, MDOH would look at all the hospitals and if need be, redistribute the beds.
MDOH agreed that it could not fully rely on foreign doctors. It was trying to train its own doctors so that it would be easy to retain them.
It was looking at the issue of waiting time at the hospitals in a bid to improve the situation at the facilities.
Regarding psychiatric patients who belonged to Mpumalanga and were being treated in Limpopo, MDOH confirmed that it had signed an MOU, but it would look further into the area.
On chronic medication and how it was distributed, the Department said that the CCBD system had started in the Sibande District. It had shops and pick-up points that had been registered to collect drugs, and the other two districts had joined afterwards.
Regarding medical equipment not being used, MDOH was trying to get into arrangements with universities that could assist with head hunting of specialists.
Mr Phaswa Mamogale, CFO: MDOH, responded on unauthorised expenditure and reported that investigations done in 2017/18 had managed to clear approximately R3 billion. MDOH had now awarded new tenders which were not irregular. Committees had been established to investigate irregular and fruitless expenditure. It had contract management in place for maintenance, and penalties were applied on non-performing contractors. In some instances, contracts were terminated. On whether MDOH budgeted 8% for maintenance, he said that it was unable to meet the required target because of financial constraints .
There were about 246 posts that were vacant, and MDOH was in the process of short listing to see if it could get the right candidates. It sometimes had to head hunt.
On the dentist issue, the Department had consulted clinical managers and conducted a workshop, and had asked the dentists to submit evidence that the dentists worked overtime, but they could not provide the evidence. The Public Service Commission (PSC) had investigated the matter and had also requested information from the dentists, which was not produced. He confirmed that where dentists worked beyond normal time, MDOH paid for ordinary overtime, and not committed overtime.
Dr Mohangi responded on the findings of the OHSC, and said that there were specific institutions that were assessed which were poor performing, and they should not be seen as a reflection of all the institutions.
The challenges in respect of malaria were in those areas bordering Limpopo and Mozambique, and MDOH was now ensuring it synchronized the spraying.
Previously the MDOH had had guards, but they were not armed. The armed guards were additional. She confirmed that security was an outsourced function.
The complaints about the quality of food in some hospitals concerned three weeks when staff members were on strike.
Regarding caregivers earning R3 000, she responded that those might be CHWs, since MDOH did not have volunteers.
The Department compiled and had information on mortality and morbidity rates in the facilities. It had manual registers which were thereafter entered into the national health information system (NHIS). She said that MDOH did not budget for medical legal claims, but paid for it by decreasing goods and services expenditure. She added that it would not be able to pay for Life Esidimeni claims, and had not received information on whether it would be required to pay.
Mr Mashego said the MDOH would go back to the facilities referred to in the OHSC report and correct those areas needing attention. He commented that Free State province was in-sourcing, and MDOH would send a team to benchmark there. It would also go through the reports of the AG and the OHSC and look at ways to improve service delivery. He asked Members to direct complaints received to him and said both the MDOH and the Committee could deal with the issues. He agreed that the infrastructure was not good and that the Department was still correcting errors of the past. It knew the challenges and would work hard to ensure it had clinics that were of ideal status.
The Chairperson said that the National Health Act, sec 25, provided that the executive heads must carry out a visit to the facilities. The Committee was required to check that what the Department was doing was being done in line with what was expected of them. The Committee would appreciate getting the written responses on the feedback requested. She also asked MDOH to respond in writing concerning a PHC centre which had been closed.
Eastern Cape Department of Health (ECDOH)
Dr Thobile Mbengashe, HOD: ECDOH, began by giving an overview of the province. The Eastern cape was spread over 168 966 square kilometers, and two-thirds of the population was under 30 years of age. 12.6% was under five years old. The province had eight health districts, six municipal districts and two metros. It was primarily a rural province, and that had a bearing on the people who sought services from the ECDOH. The poverty rate stood at 52.7 %. Communicable diseases like TB and HIV were the leading causes of mortality. Non-communicable diseases like heart disease and diabetes were also common causes of mortality. Maternal and child mortality rates remained high. During 2017/18, a total of 16.4 million visits had taken place at EC health facilities. There were 66 district hospitals offering 24-hour services. The National Health Insurance (NHI) envisaged outreach programmes, including integrated school programmes.
The province had the highest number of health facilities, but these were old and not designed for current needs. The referral system adopted was a bottom up and top down system, which was referrals between facilities, and referrals down to the community health facilities. Two major systems of EMS were in place -- one was the response in major urban areas, and the other in rural areas. The two systems were less than satisfactory, but ECDOH was doing better in the urban areas. On the availability of EMS services, ECDOH did not have 416 ambulances on the road -- it only had a 254 patient transport system. It had 2 185 EMS staff, which was not the right number. Challenges in the EMS included geographical coverage and terrain, uneven salary scales when people moved from a local municipality to the province, poor infrastructure for EMS, and scarcity of EMS skills. The action plans in these areas included the recruitment of 100 additional accident emergency assistants (AEAs) by 31 March 2019, and training and upgrading of 96 basic ambulance assistants (BAAs). ECDOH also planned to implement the EMS regulations and to appoint a task team to advise on the regulations.
The Department had strengthened its use of electronic inventory management systems on pharmaceuticals and medicine. Improved access to medicine was achieved through CCMD. Expenditure on non-contracted medicines and surgicals by the end of the first quarter had been R101 million, of which 51% was for medicine and 49% for surgicals. The planned intervention by ECDOH was to expand the use of stock visibility and Rx Solution, the prescription assistance programme, and to introduce a new warehouse management system for the pharmaceuticals depots. It also planned to train nurses on good stock management.
The province was divided into four regions with four forensic pathology (FP) centres. The challenges experienced in these centres included a shortage of Forensic pathology officers, an increase in the number of unknown bodies, a shortage of dissecting mortuaries in the province, non-availability of x-ray facilities, and a shortage of forensic pathology specialists to cover the full spectrum of the services. The ECDOH followed a 90-90-90 strategy on the management of TB and HIV. The ECDOH had done a number of initiatives in the high risk areas and as a result of the interventions, the incidence of TB had been decreasing. The TB treatment success rate for smear positives had increased from 83% in 2014 to 86% in 2016. In 2014, ECDOH had 6.7% of TB patients lost and requiring follow-up per district. All newly diagnosed TB patients were now provided with a National Health Laboratory Services (NHLS) lab track, which would assist in tracing TB patients moving from one facility to the other.
The province had four psychiatric hospitals and three mental units. The challenges in these facilities included few mental health specialists, and funding the gap for infrastructure requirements to develop psychiatric services.
Dr Mbengashe also reported on the Tower Hospital investigation. The Department had conducted its own internal investigations and a report on the findings had been submitted to the Minister’s office. The CEO had been placed on special leave, and the ECDOH had instituted disciplinary proceedings on implicated staff. The medical officer who was alleged to have altered medical notes had been reported to the Health Professionals Council of South Africa (HPCSA). The issue around the kitchen and isolation wards had been dealt with and ECDOH would proceed to look at the conditions in other mental institutions.
Facilities in the rural areas had had difficulty in dealing with medical waste. The challenge had been in the mixing of ordinary waste with medical waste. The Department was looking at programme priorities for
waste management, which were as follows:
- Establishment of health care waste committees in all facilities.
- Training of pharmacists on the management of pharmaceutical waste.
- Training in the use of waste generators.
- Facilitating the appointment of waste collectors.
- Monitoring the segregation and containerisation of waste.
Mr Simon Kaye, CFO: ECDOH reported that 99.7 % of the adjusted budget had been spent and that goods and services had been overspent by R23.9 million. Roll overs requested from treasury included equitable share (ES) roll overs and conditional grant roll overs. For the 2016/17 year, the ECDOH had retained an unqualified audit opinion. It had R1.1 billion worth of medico legal claims against it. It had spent R433.5 million on legal fees. The Department was implementing a multi-pronged medico legal strategy, focusing on administrative, legal, clinical and mediation interventions. The Department was also making progress in the defence of medico legal claims, as well as interventions to root out corrupt elements. Some of the strategies adopted included the packaging of electronic management, early intervention to strengthen the capacity of medical defence, and the creation of a medico legal trust. It had also appointed a consortium of legal practitioners to assist the state attorney with defence.
Ms N Mavuso, Deputy Director General (DDG): Human Resource and Corporate Services, reported that the macro structure had been approved by the MEC in March 2018 after concurrence by the office of the Premier (OTP) and the Ministry of Public Service and Administration (MPSA), and that it had been rolled out since April 2018. The organizational reform had made provision for a strong district and hospital management team. The number of approved non-clinical posts was 394. The ECDOH had appointed five senior managers, four of whom were women. It had exceeded the employment equity target of 50:50 at the senior management service (SMS) level. The executive management team had been appointed. 84 % of SMS posts were filled. The overall vacancy rate in the Department stood at 9.5 %. Of the total 772 PHC facilities in the ECDOH, 582 had approved clinic committees.
Mr Mlamli Tuswa, General Manager: Infrastructure, reported that ECDOH had allocated funds of not less than R500 million for maintaining day to day facilities. Life support equipment was all centrally handled. ECDOH was looking for competent contractors who could maintain this equipment. The intention was to have an internal capacity once the call duration was over. Through an internal contracting arrangement, the Department would move away from reactive maintenance to scheduled maintenance. He took Members through infrastructure plans for mental health units, including Madwaleni, St Barnabas Hospital, Holy Cross Hospital, Cecelia Makiwane Hospital, Komane Hospital, Tower Hospital, Elizabeth Donkin Hospital and PE Provincial Hospital.
Dr Mbengashe asked the Committee to note that the health services were under pressure because of the demand for health services, coupled with the impact of medico legal claims.
Ms Wilson commented that the OHSC report indicated that the ECDOH performance was one of the poorest, and that this was reflected in what was seen in the claims. Having accruals of R214 million was a hard way to start the year. She asked whether those were just medical accruals and if so, she wanted confirmation on the figures of the other accruals. She asked how many specialists ECDOH had, the areas of specialty and what the shortage was and how the shortage of specialists affected the surgery backlog. There had been an OHSC finding irregular and fruitless expenditure which had stated that most of the facilities were non-compliant, and she asked ECDOH to respond to this. Did the ECDOH have any information on the media reports saying that the Life Esidimeni claim amount was to be split between the provinces.
Mr Maphanga, wanted clarification on the scarcity of EMS personnel, and whether there was a target number. He also noted that the ECDOH had few mental specialists, and asked what was being done to ensure the province was served. He also wanted to know whether the two forensic pathologists for East London had been appointed.
Dr Thembekwayo referred to the OHCS report, which stated that the average sub-domain score for pharmaceutical services was low, pharmacies were not functional, medicine and supplies were not procured as required, and stock control systems were not in place. She asked why the ECDOH was planning to expand the use of stock visibility before dealing first with the identified anomalies. The OHSC report on health emergency and disaster had given the ECDOH a score as low as 14 %, and she wanted to know what mechanisms it had for disasters. Security services, garden services, cleaning services were all outsourced -- why the Department not in-sourcing? The province had scored 18% on staff welfare, so how did the ECDOH intend to make improvements on staff wellness? She added that she was impressed with the presented plan of the “journey to operational excellence,” and said it could help improve efficiency.
Dr Maesela commented that the report was vague, with no information given on under-expenditure and conditional grants, and also no costs were attached to the infrastructure for clinics. He asked whether the new clinics and new staff accommodation were ideal, or if the Department was just replacing the clinics, and wanted to know whether it had the NHI in mind. He also asked if the audit report for the 2017/18 financial year was out.
Mr Nkonzo sought more information on the 66 district hospitals offering 24-hour services—what the spread of these hospitals was, and whether the number could be increased. He also asked for specifics on whether the ECDOH was collaborating with other departments, such as transport.
The Chairperson commented that she was surprised that a project at the Elizabeth Donkin Hospital was yet to be completed after more than five years.. She had noted that the ECDOH was the only province that had talked of a solution on medico legal claims. She also wanted to find out the position at Nelson Mandela Hospital, where the catering was outsourced.
Ms Helen Sauls-August, MEC: ECDOH responded to the queries on the OHSC report, and reminded Members that the OHSC had made an assessment of 70% of the worst performing hospitals over the last three years.
Regarding the gravel roads which made it difficult for EMS operations, a sum of money had been put aside by the Department of Transport to prioritise high priority facilities, but thus far not a lot had been done.
Mr Kaye said that the Nelson Mandela Hospital did work on an outsourced service model, as the in-sourcing was more expensive and the financial predicament did not assist. The ECDOH had suffered budget reductions and as much as it would like to insource, the money was not there.
On whether the audit report for the financial year 2017/18 was out, he said that the AG was on site and would report by 31 July. The indications at the moment were that it was still unqualified.
Dr Mbengashe responded on the question about , and said that most of the hospitals had in-sourced services, and what was mainly being outsourced was security. There had been discussion on how to deal with the cost of security.
He said all new clinics were being built to achieve ideal clinic status. He confirmed that ECDOH would provide a list of 24-hour clinics to the Committee in writing.
Dr L Matiwane, Chief Director: Hospital Services, said that ECDOH had a clear targeted number of EMS personnel it required -- 10 for each ambulance -- and that it was training for those numbers. It had not appointed the two forensic pathologists for East London and Mthatha hospitals. It had 10 specialists for psychiatry services, however.
Mr Tuswa confirmed that the clinics were fully compliant and met the ‘ideal’ standards. The ECDOH would submit the cost of the psychiatric units to the Committee in writing.
Dr Mbengashe responded on the question of stock visibility. The reason why ECDOH was expanding stock visibility was to target clinics, and for that it needed to have a system that resided in the clinics. He had not yet read the OHCS report itself, but confirmed that disaster management was done at a facility level and that the provincial disaster plan was there. ECDOH would work with the facilities to ensure the facilities knew what to do when it comes to disasters.
On EMS staff, he agreed that they needed support. The 92 posts not filled were in relation to grant posts, but for the others, ECDOH was able to meet the targets because there were no barriers.
The Chairperson advised ECDOH to put all issues requested by the Members in writing. She added that EMS were under serious threat and that the Committee would follow up with the NDOH regarding the Elizabeth Donkin project and the Nelson Mandela Hospital. The Committee needed information from the Departments to be able to understand what the situation was.
Gauteng Provincial Department of Health (GDOH)
The Chairperson asked GDOH to zero in on the areas not covered during the previous presentation.
Prof Mkhululi Lukhele, Acting Head: GDOH, began by informing the Committee that GDOH had a procurement plan on medical equipment and the monitoring of assets to ensure the assets were maintained throughout their lifespan. On pharmaceutical and laboratory services as at the end of March 2018, 410 075 patients had been enrolled on the CCMDD programme, against a target of 270 000.There had also been an in-house development of the MSD on-line system, which was an electronic ordering portal and document management system.
On governance and leadership, he confirmed that governance structures were in place, hospital boards had been appointed and the GDOH was piloting clinical governance structures. It had started a process of skills assessment and coaching. It was on course to stabilise accruals. The conditional grants it received from the NDOH continue to decreased, this was causing a big strain on its operations.
On the referral system, he said that GDOH had fivedistricts, and the O R Tambo clinic in Johannesburg health district was being refurbished to accommodate 24-hour services. The out-patient headcount came mostly through the district hospitals. The GDOH still had unreferred patients, and a number of the patients were referred in line with what was usually expected. The in-patient transfers happened more at the central hospitals.
For security services, the GDOH employed a hybrid approach, with the biggest portion being outsourced. Hospitals had partial technology security systems. The Department currently spent R60 million monthly on contracted security services.
The Department had a total of 754 CHW teams covering the five districts, with team leaders who were well trained. He also took Members through how many visits were done by the CHWs per household. 8 720 CHWs had been contracted. On the “War Room” sukuma sakhe approach, the province had adopted the deliverology methodology to fast track citizen experience.
Dr Gwen Ramokgopa, MEC: GDOH said that the Department was taking lessons from Life Esidimeni, and had a risk register on issues it could pick up. The payment of Life Esidimeni claims would be from Gauteng, and not necessarily from the Department of Health. The provincial government had considered going to Treasury.
The GDOH approach was to build on the NHI, There was a mid-term review which indicated an increase in life expectancy, and GDOH was close to attaining zero transmission of HIV/Aids from mother to child. It had identified maternal and neonatal area as key area of focus, as it was an area that contributed to medical legal cases. There had been an objective survey in the province on quality of life, and the GDOH received a high score. Another survey would be done before end of the term.
GDOH acknowledged that it needed to strengthen its governance. The Department’s recovery plan also responded to the accrual situation. On governance and stewardship towards the NHI, the problem was that most of the functions were centralised. She added that there had been a panic that GDOH did not have funds, but it did have funds and a budget of R46 billion, but the demand was high.
She had recently done an unannounced visit to one of the facilities and had discovered that one unit had been expanded from 32 cots to 64 cots -- but the staff number had remained the same. GDOH had no moratorium on posts, but would fill only critical posts. There had been an outcry from the universities that the GDOH was reducing the funds that went to higher education and that it had not trained 1 000 nurses, as only 700 had been trained. This had been done so that the GDOH could prioritise services.
On OHSC report, the GDOH acknowledged that although it had performed better, the facilities identified were the least performing. It had noted the recommendations and would push these facilities.
Ms Wilson referred to the OHSC report which indicated that GDOH had scored 19 % in the area of oversight and accountability. She remarked that there was a huge problem in risk management and ineffective leadership, and the GDOH started its financial years with a serious deficit attributed to accruals. She cautioned that health services could not be delivered for all with the accruals in place. She wanted confirmation on what the figures for irregular and fruitless expenditure were, and a breakdown of the specialists in the facilities and what impact the shortage of specialists had on surgery backlogs.
Dr Maesela wanted to know what the GDOH was doing about the community partnership team effort incapability, saying such efforts could not be compensated through funds. He commented that there was a lack of a multi-level disciplinary approach in dealing with the problem of standards. The accruals were an albatross, and the GDOH needed help from whatever source.
Dr Thembekwayo commented on the OHSC finding on pharmaceutical services, and said the average score given was 63%. Some of the deficiencies highlighted were that there was no evidence that stock taking had been done for medicine and medicine supplies, and procedure manuals and terms of agreement outlining the supply of documents were not available. She also noted that different committees met quarterly, whereas the council met only once a year. She asked whether it was possible for the council to meet twice a year for sustainability, and to also keep them informed.
The OHSC score on communication and public relations was 48%. The staff satisfaction survey showed that the staff felt they were not able to participate in decision making. She advised that staff members should be considered in order to reduce strikes. Staff dissatisfaction also had an impact on health emergencies and disasters, and on staff wellness. There was no evidence that staff participated in staff initiatives. She wanted to know how the GDOH was dealing with the OHSC findings.
Mr Nkonzo wanted clarification on CHWs and their stipends, and whether there was a desire to increase them to the minimum wage. He also sought more information on the deliverology of the service intervention unit.
Mr Maphanga asked what was being done to aid in the tracing of TB defaulters and whether the correct information was captured in the hospitals.
The Chairperson asked how the Nelson Mandela children’s home was helping the GDOH. She also said that the Committee would have preferred if the information on “wage shock” was specific, indicating the sectors most affected, whether the administrative or clinical side.
Dr Ramokgopa confirmed that the GDOH would provide a breakdown of specialists to the Committee in writing. On the surgery backlog, she informed the Committee that she had visited one of the orthopaedic departments, and had talked to patient, and had realised that the same patients sometimes registered in three or more different hospitals. She confirmed that GDOH would look more into this area. It agreed that the organizational effectiveness was weakened with centralisation, but believed the approach currently adopted would assist in stabilisation.
Gauteng experienced cash depletion by September every year, yet the patient load continued. GDOH was trying to stabilise organizational recovery. It had a letter from the Wits School of Medicine, and together both parties were looking at how best the country could prioritise areas where there was pressure. The NHI’s universal coverage had a strong component of preventive medicine which would assist.
In response to the possibility of the Council meeting more than once a year, she responded that through the provincial health forum, GDOH had community engagements in between. In October 2017, it had had a summit with the stakeholders, and it had also had a labor summit four weeks ago.
On preparedness for disaster, she said that was a matter of following up on protocols. GDOH was prioritising the housing of security.
On the community health worker stipend issue, the challenge was that the provinces did not have adequate funding, and that it paid the CHWs through a paymaster.
On deliverology, the GDOH was benchmarking against the Western Cape. It was a service improvement intervention programme, and included improving the patient’s experience. She added that CHWs would help in reducing TB defaulter rates. The national program of registering citizens as preparing for NHI would also help, as there would be one database.
She confirmed that the Nelson Mandela children’s hospital was a state-aided facility with specialists in pediatrics. GDOH had to recruit specialists, who were students, but the specialists were supervised by the doctors who trained them, establishing a clinical governance system that could rotate. The facility was being utilized -- it was a national asset, and the GDOH was also looking at that mode of governance to replicate in other hospitals.
On the staff complement, she noted that the wage shock was mainly as a result of the occupational specific dispensation (OSD), and the increases in goods and services had not kept up with OSD.GDOH would provide a list on the wage shock as experienced in different sectors, whether administrative or the clinic sectors.
Ms Kabelo Lehloenya, CFO: GDOH confirmed that the amount on fruitless and wasteful expenditure had been R22.8 million for 2017/18, and that the R443 million had been from other years. The GDOH had a plan to regulariae irregular expenditure, and it was looking at consignment stock and month to month contracts. R1.5 billion had been given to GDOH to settle accruals, and there was a strategy to ensure that the current year’s budget was ring-fenced to settle current year expenses. It had a plan to stop accumulating accruals.
Prof Lukheleadded that GDOH was ensuring that each facility was run as a business unit to ensure there was no wasteful expenditure. On pharmacy issues, the OHSC had not found evidence that there was no stock taking -- staff members had taken stock but had not documented it, and GDOH would work to correct that. It had identified communication as the weakest link, and would take action to improve on that.
The Chairperson commented that the process was empowering to all, and she hoped that as the decentralisation of services to the districts was happening, the managers at the district level were empowered. This would assist in preventing labour disruptions and also empower communities. She commented that only Mpumalanga had raised the issue of health workers being assaulted by communities.
The meeting was adjourned
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