The Portfolio Committee on Health met with Northern Cape (NC), Limpopo, Free State and KwaZulu-Natal (KZN) Departments of Health (DoH) to receive presentations on the status of their hospitals, after having received a briefing from the Accountant General on their budget allocations. The meeting also sought answers to questions based on the recent report from the Office of Health Standards Compliance (OHSC).
Highlights of the brief of the NC DoH included the reengineering process that had been focused on innovative ways to plan and re-align the budget, and the steps taken to reduce its accruals and capacitate the pharmaceutical section to ensure better service delivery. It also provided an overview of the health facilities, the status of care quality, medical equipment in each hospital, medicine management and availability, infrastructure planning and maintenance, progress on its human resources plan, challenges on emergency medical services and transportation, its governance and leadership, its financial systems, and delegations and referral systems.
The Committee expressed concern about the statistics in the OHSC report, and asked the DoH questions about issues involving its specialists; accruals; emergency service personnel; the status of ideal clinics, the district health system, primary health care (PHC) and the burden of disease; the functionality of its 14 hospital boards; and its referral system. The Committee requested it to forward detailed written reports on the Kimberley mental hospital challenges, its Central Chronic Medication Dispensing and Distribution (CCMDD), its Institute of Certified Records Managers (ICRM) accreditation of district hospitals, its disaster preparedness, and its responses on OHSC report and medico legal claims.
Limpopo DoH reported on its governance and leadership strategy, the district health system planning framework, its health care restructuring plans and its referral system. Other highlights included the its inability to cope with the burden of disease due to the unhealthy eating patterns of the community and the challenges of running 24-hour medical services, and the prevalence of diseases such as malaria and HIV/AIDS. There was a shortage of human resources, as it struggled to fill clinician and nursing personnel posts due to National Treasury (NT) under-funding. The chronic under-funding also resulted in equipment shortages, high pharmaceutical accruals, failure to upgrade infrastructure in facilities despite the higher number of patients being treated, a depletion of goods and services and an increased burden of medical-legal contingency liabilities. It asked for the Committee’s assistance to liaise with NT for the establishment of an academic hospital to resolve the issue of employing specialists in the Limpopo DoH.
The Committee again referred to the statistics in the OHSC report, and expressed their concern over surgery backlogs, cancer patients and the attitude of clinical and nursing staff. It asked the DoH questions about its use of DDT in combating malaria; vacant clinical and nursing posts; strategies to recruit specialists and registrars; and infrastructure in mental hospitals. The Committee mandated the Department to address the attitude of health workers at public hospitals, malnutrition in the province, and to follow up on patients’ complaints.
Both the Free State and KZN Departments said that the OHSC assessments had been done on a few poor facilities, and were not a representation of all the facilities. They both committed to correct the deficiencies that were identified in the report.
FSDOH reported that it had strengthened the household approach to promote access to health care, and had consequently reduced the number of people coming through the facilities. It had conducted its own self-assessment and found that out of 32 hospitals, only four had scores of 80 % and above. It would focus more on improving the worst performing facilities. It also confirmed that it was busy with the roll out of the central chronic medicine dispensing and distribution programme (CCMDD). It was unable to retain specialists due to the long process of filling posts. It had the State Information Technology Agency (SITA) providing the infrastructure network for the Department, although the progress had been slow. The TB defaulter rate was remaining high in Mangaung Metro, despite showing a decline in the other four districts.
The Committee advised FSDOH to avoid exorbitant costs, such as the use of private ambulances in public facilities. It criticised the inadequate stock of contraceptives, but was informed that contracts for contraceptives were done at the national level and at times when the demand was high, the suppliers were unable to deliver. The Department was commended by the Committee for being the only province that reflected on school health and the MomConnect programme.
KZNDOH reported that a new regional hospital, Pixley Ka Isaka Seme had been established and a new academic central hospital was still in the conceptual phase. There had been difficulty in attracting and retaining medical specialists at regional and tertiary hospitals in the rural areas and this had caused a strain on the KZNDOH referral system. It also reported that it had an aging fleet of ambulances and had a strategy to incrementally replace them The CCMDD had been rolled out in all 11 districts, and over 1.1 million patients had been enrolled in the programme. Financial delegations have been revised to empower the CEOs to procure up to a maximum of R 500 000 directly at institutional level, but the head office still did a lot of oversight. All hospitals have network connectivity, and attention had been given to all PHC sites to make provision for data-based connectivity services by the end of the 2018/19 financial year. There had been instability in top management due to the attrition of HODs, DDGs and CFOs. All of the posts had been advertised -- some more than three times.
The Committee welcomed the progress on oncology at KZNDOH, and commented that it could see an improvement in the Department, compared to the previous periods.
The Chairperson welcomed Members, the teams from the four provinces’ Departments of Health, and said the Committee’s major concern was that after receiving briefs from the Accountant General, it needed to receive detailed briefings on the status of the hospitals in each province. The Committee had received a report from the Office of Health Standards Compliance (OHSC), and would be asking questions about the hospitals, based on it.
Northern Cape DoH: Briefing
Ms Fufe Makaton, Member of the Executive Committee (MEC): Department of Health, NC, provided a broad political overview. She said the NC DoH had gone through a re-engineering process for the 2018/19 financial year. She had engaged the community and the DoH when she had joined in February 2018 and had observed that the staffing budget was inadequate, and that it had negatively impacted on service delivery in the Province. The reengineering process had focused on innovative ways to plan and re-align the budget. This had involved engagements with the Premier to reduce accruals that had negatively affected service delivery. The reengineering process had also identified the cost-saving drivers in the already tabled budget, and had capacitated the pharmaceutical section to ensure better service delivery.
Ms Thembi Mazibuko, Acting Head of Department (HOD): NC DoH, gave an overview of the health facilities in the province. These included 126 fixed primary health care clinics and 33 community health centres, 11 district hospitals, one specialised, one regional and one tertiary hospital respectively. She described the status of care quality, the medical equipment in each hospital, medicine management and availability, infrastructure planning and maintenance, progress on its human resources plan, challenges on emergency medical services and transportation, its governance and leadership, its financial systems and delegations and referral systems.
She also highlighted NC DoH risk management profile, the state of its laundry services, its security services, its information communication technology (ICT), the status of its health care risk waste, and updates on tuberculosis and primary health care. She said that the 5% reduction in the Department’s budget allocation had led to a shortfall estimated at R1.8 billion. She also gave details of the employment and training curriculum of community health workers.
Ms E Wilson (DA) asked about the number and types of specialists in the province. She asked the MEC to confirm the kind of accruals she started the financial year with, and also requested updates on wasteful expenditure and medical legal cases.
Dr P Maesela (ANC) asked if the NC DoH had a chief financial officer (CFO). Why had R12.6 million been allocated for maintenance repairs in 2017/18? Did it have enough competent pharmacists and pharmaceutical centres? Did it have outdated medicines or stock-outs? He asked why it was taking long to repair its lifts and why it did not have outlined plans, with costs and time frames, on its maintenance projects. He sought clarity on why the NC DoH had 86 operational ambulances and 688 personnel. He wanted an update on respiratory diseases, an explanation of its process of referrals, and why it had a 49% high risk for obstetrics. Was laundry and security presently outsourced? What was the time frame to upgrade to in-sourcing?
Dr S Thembekwayo (EFF) observed that the OHSC report had identified that the leadership and corporate governance of NC DoH was at risk, so she asked the team to state the contingency plans to reduce the risks in this area by at least 50%. She expressed concern over how it recruited its leadership, because the OHSC report criticised the leadership in charge of clinicians for not having documented job descriptions for departmental and sectional heads. The OHSC report also indicated that medicine physical stock supply did not correspond to inventory stock, so she asked NC DoH to state the steps to curb the trend. The report also indicated that it either did not have disaster preparedness plans, or they were outdated. She expressed concern that the continued acting position designations affected staff performance. Why had a new contract been signed for outsourcing security in November 2017? She also asked the team to confirm if catering and gardening were still being outsourced?
Mr T Nkonzo (ANC) observed that eight of the 11 district hospitals provided 24-hour operating theatre access, and asked if these hospitals experienced challenges with referrals from regional hospitals. He asked how many lifts were being maintained. He wanted feedback on the functionality of the 14 hospital boards that had been appointed, and also asked about the time frame for the establishment of the review boards at mental hospitals.
The Chairperson asked the team how it would increase the number of emergency service personnel and how they would be trained. She asked about the status of ideal clinics and the district health system, and the challenges with self-referrals at the primary health care (PHC) level. She observed that 121 PHC structures had been appointed and asked about the integrated approach in place to ensure that the facilities were not clustered in one area. Were all 14 hospital boards functional? What were the timelines for establishing mental health review boards (MHRBs), particularly its training and induction time frames? Why did the Department not have information technology (IT) staff when unemployed graduates from institutions in close proximity were available? She asked the team to provide a breakdown of its burden of disease, particularly tuberculosis and mental health. She also asked which district hospital had attained Institute of Certified Records Managers (ICRM) accreditation. She asked the team to send detailed written reports on Kimberley mental hospital challenges, centralised chronic medication dispensing and distribution (CCMDD), ICRM accreditation of district hospitals, disaster preparedness, and responses on the OHSC report and medico legal claims.
Northern Cape DoH response
Ms Makaton committed to submitting the reports itemised by the Chairperson, and said that her team would visit the OHSC to address the complaints. The inspection report submitted had been for the 2016/17 financial year, but the DoH was awaiting the 2017/18 report, and she promised that there would be improvements on the governance issues itemised in the OHSC report. She had now been registered on the stock visibility register on drugs, so she would be able to monitor the stock as well. The earliest time frame for in-sourcing was February 2019. She had not indicated that she was already working with stakeholders on Emergency Medical Services (EMS) training -- the DoH had been able to convert some vehicles to ambulances, and this had allowed the province to employ more EMS staff and capacitate them as well. The report on ideal clinics had been completed and would be sent to the Committee. The recruitment of IT personnel had been suspended because they would be sourced after jointly completing the Department’s organisational structure with the Department of Public Service and Administration (DPSA). It had put plans in place to improve its EMS, and was compiling its mental health report which would be submitted to the Committee after it was completed in July 2018.
The Chairperson said she had asked for feedback on the mental health institution because there were challenges with the construction of the facility.
Mr Stephen Jonkers, HoD: DoH, said the confirmation of acting positions would be done after the organogram had been approved by the DPSA. The outsourced security appointed in September 2017 had been advertised in 2014, while all cleaning and laundry services were in-sourced. A task force team had been initiated to work on the R1.4 billion medical-legal claims, and it had made big strides in dealing with the cases. Some of the cases had been going on since 2014. Most were due to cerebral palsy. A lot of the cases were still in court, and the Department would provide detailed written reposes on the cases to the Committee.
Dr Dion Theys, Medical Director: DoH, gave the statistics of Health Professions Council of South Africa (HPCSA) registered doctors in the province. He said there were 30 specialists, of which 27 were in Kimberley hospital, and three in Upington. The Department had been struggling to fill the position of a lead specialist obstetrician and gynaecologist for some time. Although it did not have a lead specialist, the facilities undertook operations and babies were delivered. Statistics had shown a slight increase in cardiac arrest cases at Kimberley hospital, which was a tertiary hospital that offered referrals on cases that could not be treated without specialists. There was no lead cardiologist in the province, but as from 1 August 2018 a lead nephrologist would take up the registrar’s position. The DoH had an oncology specialist, two radiologists and one paediatrician. There were three specialists at the Dr Harry Surtie regional hospital, one general surgeon and two paediatricians. The DoH had a three-year maintenance contract in place with service providers, had regular routine maintenance on laundry facilities, and was currently running a fire fighting equipment maintenance programme. Maintenance activities also existed for the Department’s buildings and structures.
Mr Daniel Gaborone, CFO: DoH gave feedback on the accruals, and committed to send detailed reports to the Committee.
Ms Wilson asked for an update on medical claims.
Mr Mothuli Ntulelo, Director: Monitoring and Disaster Management, said the Department had 86 ambulances and 688 personnel because the personnel worked on a shift basis, and four shifts were maintained. EMS standards mandated that eight personnel be attached to one ambulance. The DoH needed about 120 ambulances, so it was working on increasing its EMS personnel to 960. It had a college in the province that trained students. It was presently seeking to be accredited to train 54 students and was planning to get accredited for two-year courses.
The Chairperson requested that the reports on EMS should contain statistics that reflected age, gender, race and category of staff.
The MEC asked the Chairperson to provide a timeframe for presenting written reports to the Committee. She said National Treasury had sent a memo on accruals that had included queries on irregular and wasteful expenditure to her office, and committed to give the Committee feedback on the memo.
The Chairperson remarked that she was pleased with the first impression she had received on health services in the Province. She recalled that she had communicated the case of an accident patient and the MEC had acted swiftly to give the patient a referral, because the facilities to treat the patient were not available where the accident had occurred. She said the MEC still needed to sort out issues of dirty institutions, time wastage and an environment that was not conducive to healing at the hospitals. People complained about the attitude of porters, general assistants and cleaners.
She advised the MEC to work on its EMS because it was not the only province that had bad roads and long distances. It needed to address the issues of the medical legal claims and improve on its HR management.
Limpopo DoH: Briefing
Dr Phophi Ramathuba, MEC: Health, Limpopo, referred to the Department’s governance and leadership, the district health system (DHS) planning framework, its health care restructuring plans and its referral system. She said that clinicians in the province could not cope with the burden of disease due to the unhealthy eating patterns and the challenges of running 24-hour medical services, because the province initially had four-roomed houses that could not accommodate lots of clinicians and nursing personnel. Limpopo was also challenged by a shortage of human resources, as it struggled to fill clinical and nursing posts. National Treasury (NT) did not understand that the DoH had to appoint more nurses to assist with treating patients.
A security alliance had worked in areas where Traditional Councils had assisted with securing hospitals in the province. The attitude of nursing staff could change with training, because they were presently overburdened with the roles of cleaners and health registration personnel. An analysis of the value of additional doctors in Limpopo had made its leadership decide that it was better to post doctors to district hospitals, rather than employ them at the national hospitals.
She gave an update on the referral system, and said that there had been an increase in the unnatural deaths of people in the age range of 15 to 59 as a result of diabetes and hypertension. She attributed these unnatural deaths to unhealthy eating patterns and the lack of exercise in the community. Hospital CEOs were now called to account for maternal deaths. Although there had been a reduction in deaths due to malaria, there were still challenges in malaria management because of DDT shortages.
The challenges in the Department were the budget deficit, unsuitable policies, and inappropriate staffing, which limited the critical clinical personnel due to limited funding from NT. Limpopo needed an academic hospital that would attract specialists to address complicated cases. Total maternal deaths in the Province had reduced from 225 in 2014 to 185 in 2017, and a state of the art mental hospital had been commissioned in Ledwaba, Limpopo. She said pharmaceutical medicine delivery and management models did not address each other, so she appealed to the Committee to intervene on malaria drugs, because it was a sole-sourced item. Also, most of the pharmaceutical depots obtained drugs through transversal tenders controlled by NT, so NT should give the Limpopo DoH the difference on the drugs’ quoted prices, because it facilitated the supplementary contracts.
Limpopo DoH was challenged with speciality medical equipment. Presently, oncology and renal dialysis equipment was outsourced through public private partnerships. The 45-minute target on EMS and patient transport was a challenge due to bad roads and long distances within the Province. Ambulance thefts had been addressed through the installation of tracking devices, but some ambulances had been destroyed by the community during protests. The key HR interventions were restructuring, prioritising and rationalisation and filling of its critical core and non-core positions such as cleaners, ward attendants and porters to improve service delivery.
Mr Justice Mudau, CFO: Limpopo DoH, said that the Department’s year-on-year equitable share allocation had been slightly reduced in 2018/19 compared with 2017/18. To accommodate the slight increase in compensation of employees (COE) allocations, there had been a reduction in allocations for goods and services, transfers and subsidies, and payment for capital assets. The chronic under-funding had resulted in a shortage of specialist services, equipment shortages, high pharmaceutical accruals, a failure to upgrade infrastructure in facilities despite a higher number of patients being treated, a depletion of goods and services and an increased burden of medical-legal contingency liability. Despite these challenges, Limpopo DoH had developed a turnaround strategy approved by the executive committee (EXCO), which involved reducing the medical-legal contingency liability.
Ms Wilson expressed concern over the use of DDT to combat malaria, because the Stockholm Convention had banned its use. She was also concerned about the surgery backlogs and the fact that cancer patients had to wait for 12 months to be referred because there were no oncologists. She asked for an update on challenges due to seizures and delivery during births. She corrected a purported reference of the MEC to a statement that HIV and AIDS was a black man’s disease, and said that it affected all races. She was worried by the OHCS report that the Giani training centre was disgusting, and people were leaving. The transportation of patients in emergency conditions were inadequate and Limpopo did not have disaster management in place, despite the fact that it shared borders with a country which had issued an alert on cholera. She also expressed concern about the attitude of clinical and nursing personnel, and attributed this to the increase in medical legal contingency liability. The increase in the mortality of young people could be attributed to malnutrition and starvation, not necessarily the unhealthy eating habits as mentioned by the MEC, because 60% of the Limpopo community survived on grants.
Mr Nkonzo asked the team to state the strategies to fill the vacant clinical and nursing posts, and to provide action plans and timelines to resolve the challenges of the Limpopo DoH.
Dr Thembekwayo said the OHSC report on patients’ rights and dignity had indicated that the average domain score was less than 50%. It had mentioned that patients were not treated in a caring and respectable manner because there were no records. The Limpopo DoH also did not have patient satisfactory surveys on clinics and hospitals, so the Committee could not ascertain if the patients were being treated in a satisfactory manner. The OHSC report on patients’ rights and dignity average domain score on continuity of care was 26%. This was evidenced by the fact that the files of patients transferred to other hospitals did not have referral letters. Also the average domain score on complaints management was 34%, which showed that patients were not monitored correctly. She also expressed concern over patients’ waiting time and waiting areas. The food services’ average domain score was 45% and one of the hospitals served only “pap” (porridge) without any accompaniment. She asked why security was still outsourced, and asked for timeframes on in-sourcing. She asked if cleaning, gardening and catering was still being outsourced and the timeframes for in-sourcing these services.
Dr Maesela asked for updates on the mission hospital and the strategies to recruit specialists and registrars into the Limpopo DoH. He asked the team to state strategies to upgrade its infrastructure to enable it cope with the increased number of patients, and its strategy to address the shortage of clinical and nursing personnel.
Limpopo DoH response
The Limpopo DoH acknowledged the report of OHSC in its infancy, because such surveys had not been done before. Although the report considered a three year sample size of 17%, and had looked at the worst performing hospitals in the province, the Department had taken note of the complaints and was committed to making improvements. The Committee should note that the report had indicated that provinces like the Western Cape (WC), which had better systems, had shown no improvements, which indicated that greater challenges existed. Also, the OHSC reports showed that there was attrition in urban provinces like the WC, although it was more apparent in rural provinces like Limpopo.
The Limpopo DoH had the drugs, but they were not being distributed and this would be addressed. The report had raised concerns on the attitude of clinical and nursing personnel, but they behaved behave better when they were in private hospitals, and the DoH would also address this. The OHSC report had shown that provinces like Limpopo that did not have teaching hospitals had oncology challenges. The province had only one oncologist, but the DoH had signed contracts with private hospitals to alleviate the oncology challenges.
The Department had noted the complaints of ill-treatment in district hospitals, but requested detailed information from the Member to ensure that it could handle the situation. It had a complaints box that was opened jointly with the management of hospitals, but it also received SMS’s that were not detailed, so detailed reports from the Members would go a long way to addressing complaints. A lot of patients bypassed out-patient care because the PHC facilities were not enough. Each CEO would account for PHCs under their control.
The interventions on the turnaround strategies were explained. The posts of senior clinical and nursing personnel were been filled by restructuring, as mentioned by the MEC. The DoH had started electronic filing to curb the problem of the space needed to house the files. New categories of food service aids, supervisors and managers were being introduced to create employment opportunities in the community. A dietician position had been added to the new organogram. Ideal clinics would address patients’ experience of care through the surveys that would be conducted.
It was not advisable to employ registrars if clinical and nursing staff had not been employed. The, DoH had therefore sought the assistance of NT to build central hospitals, and academic hospitals would be next in the drive to build clinical and nursing capacity. The infrastructure in place did not allow the Department to fulfil targets on child and adolescent psychiatry, so they were presently accommodated in the adult section.
Dr Ntsie Kgaphole, Head of Department (HoD) said the team had noted the names of personnel who had been complained about, and the necessary action would be taken. The action plans for revamping the Department would be shared with the Committee after presenting it to the EXCO. Postings were being prioritised, and doctors who had completed their internships were being posted to areas where they were needed most. Equipment maintenance had been awarded to service providers. Local authorities had given a piece of land for a Musina hospital, so the national DoH was addressing its establishment.
Dr Ramathuba said the team had a strong Facebook and Twitter presence, so it responded to accident communications by involving EMS personnel. Acting employees were placed on probation for 100 days and were made permanent after they had turned things around. The Bela Bela clinic structure had not being handed over to the Department because there was a contention between the Department of Public Works and the contractor.
Musina Hospital was part of the National Health Insurance (NHI) challenge because it had few facilities, but despite this, it had recorded zero maternal deaths. She had to give an award to the midwives at the hospital that had delivered triplets safely and without complications for a patient that had come from across the border, without even knowing the patient’s medical history.
She agreed that poverty contributed to malnutrition and disease, so the team had created the dietician post to assist the community to eat properly and exercise. The older generation did not die early from diseases like diabetes, because they ate right, and grew beans and vegetables. The new generation, however, ate junk food and did not exercise, so they died early as a result of diseases such as diabetes.
Malaria had increased when DDT was banned, but the World Health Organisation (WHO) had exempted DDT for use in public health. The WHO’s position was that DDT was banned in agricultural use, and this position could be forwarded to the Committee. The other product used to substitute DDT had led to more deaths, because the female anopheles mosquito had developed resistance to it.
She corrected the impression that she had said AIDS was a black man’s disease. The City Press had had to issue a retraction on their earlier story. Her contention had been that HIV/AIDS was prevalent amongst the black race, but the funding was with whites. Black people lived in poverty and engaged in sleeping with older men, which was why HIV/AIDS was prevalent amongst them. There were no white home-based carers or lay workers, so if HIV/AIDS was to be addressed, funding should be placed where it was needed.
The Chairperson said the country needed to sit down together to address certain issues by speaking about them to ensure that people were healthy and embraced healthy eating habits. The DoH needed to address the attitude of health workers at public hospitals, because when the same health worker worked in a private hospital, he/she behaved better. Malnutrition needed to be addressed. The older generation ate right and exercised, so they did not die early, while the younger generation received grants, did not eat right or exercise, so the burden of disease was high and they died earlier. She asked the MEC to give her numbers so that the Committee could follow-up on complaints.
The OHSC report of 2016/17 had been informative, and the Committee was awaiting the 2017/18 report. She informed the MEC that the only weakness in Limpopo’s brief had been that it had referred to issues that it had dealt with before, but had not informed the Committee of the progress it had made in resolving the issues. She requested that the Limpopo DoH submit written reports within 14 days on areas where the Committee needed more information.
Free State DoH: Briefing
Dr David Motau, HOD: FSDOH, said that at a time when health was under strain, the Department used the district health system based on PHC principles. PHC services were rendered through different settings within the communities, such as households and schools. Hospital services were provided through 25 district hospitals, four regional hospitals, one specialised psychiatric hospital, one tertiary hospital and one central hospital. EMS was crucial in ensuring consistent accessibility of the different levels of health care through the referral system. Comprehensive priority health programs were rendered across all the levels of the health care system, and included HIV/AIDS, maternal, TB, child and women’s health, as well as communicable and non-communicable diseases.
To promote access to health care, FSDOH had strengthened the household approach. In this way, it had been able to reduce the number of people coming through the facilities. He informed the Committee that there was proper alignment of other districts when it came to access of health care, except for Mangaung metropolitan hospital. On access to antenatal care, FSDOH was doing well except for the small Xhariep district.
FSDOH had conducted its own self-assessment on the quality of health care, and had found that most of the facilities performed below 80 % -- out of 32 hospitals, only four had scores of 80% and above. The Department would focus more on improving the worst performing facilities. On the overall performance of ideal clinics during 2017/18 year, it had improved slightly in terms of numbers, but it was not where it wanted to be. On patient safety/clinical governance and clinical care, FSDOH was committed to focusing on facilities that were not doing well. The medical equipment acquisition plan had been developed and a bid for various equipment had been concluded in 2016. The contracts awarded included the maintenance plan for a period of five years. Redundant and obsolete equipment in the facilities had been identified, collected and put in a central place in preparation for disposal.
Dr Motau took Members through the audit findings on the management of pharmaceuticals. The Auditor General of South Africa (AGSA) had previously expressed a qualified opinion on accounts payable due to differences between supplier statements and accounting records of the trading account .Pharmaceuticals were procured, warehoused and distributed from the medical depot, which was licensed with the NDOH and Medicines Control Council (MCC) until 2021. Health facilities were allocated budgets with which they procured their own medicines from the depot. FSDOH was busy with the roll out of CCMDD process. Challenges in the process include external pick up point (PUP) contracts being signed late, patients losing interest, rejected/script renewals and the change to new service providers which affected new enrolments.
He reported on the progress in addressing AGSA’s findings, and the interventions which the Department had implemented:
- Improved turnaround time for payment of claims to improve cash flow;
- Vacant posts filled – four pharmacists have been added to the team;
- Depot Treasury task team had submitted its report;
- Depot licensed and registered with MCC/NDOH and the South African Pharmacy Council (SAPC). The licence expires in 2021;
- No progress on the acquisition of IT infrastructure and equipment for Rx solution;
- Implementation of a Stock Visibility System (SVS) in 94 % of the facilities;
- Pharmaceutical and Therapeutic Committees (PTCs) were running, but the challenges at the district level were the shortage of staff and inept attitude among the staff.
He gave a breakdown of the medicine availability per hospital and the medicine availability at level 2 and 3 hospitals.
On Human Resources FSDOH had a total staff establishment of 21 617, but only 17 151 had been filled, so there were 4 466 vacant posts -- a vacancy rate of 20.66 %. In 2017/18, 1 744 had left because of retirement, attrition and resignations. It had been unable to retain specialists due to the long process of filling posts. Submissions needed to be approved by Treasury, and the process may take from two to six months. Posts not filled within six months were abolished, as per Department of Public Service and Administration (DPSA) guidelines. The medical training platform for FSDOH was at Universitas Hospital, FSDOH had signed an MOU and there were joint appointments between the University of Free State (UFS) and FSDOH. All four regional hospitals were accredited by HPCSA as training platforms for medical interns.
The one psychiatric hospital had total staff of 730, and the key positions at the hospital were psychologists, psychiatrists and nurses .The Department was revising the HR plan for 2018/19-2020/21.Organisational development had commenced with the restructuring of the staff establishment. Performance was managed in terms of the Performance Development and Management System (PDMS) policy. Recognition of improved qualifications had been implemented since 2013. Overtime requests were approved prior to working and there was strict adherence to 30% of the official’s basic salary. In-sourcing of kitchen staff in Bongani, Manapo and Free State Psychiatric Complex (FSPC) hospitals would be completed by the end of July 2018. In-sourcing of security staff in Bongani, Mofumahadi, and Manapo Mopeli would also be completed by the end of July. There had been an improvement in governance and leadership, and the Department was working on the challenges.
FSDOH had two financial systems that addressed patient information and revenue collection:
- A sourced system, which provides patient information, clinical information and billing of patients;
- A Patient Archiving and Documentation System (PADS), developed in-house, which is used for admission and billing of patients.
All institutions and district offices had access to financial systems. The Department required a full complement of administrative personnel in order to effectively administer daily activities. Officials that were operating the systems were trained by provincial Treasury prior to commencement of their duties. The reliability and credibility of the PADS system was still not adequate, since system crashed and recovery was difficult due to lack of support. Budgetary control on the procurement of pharmaceuticals was still not effective, since it was done manually. FSDOH had the State Information Technology Agency (SITA) providing the infrastructure network for the Department, SITA had been requested to assist, but progress had been slow.
Dr Motau referred to the Department’s budgeting process, and gave an example of conflict with Treasury over the compensation of employees (COE). In spite of a Treasury instruction for COE to be reduced by 0.05% in 2016/17, COE had been increasing from 63 % in 2011 /12 to 66 % in 2017/18, leading to a crowding out of goods and services.
FSDOH had been working hard and after 13 years it had been able to get an unqualified opinion from the AG. The total irregular expenditure for 2016/17 had been R4.416 billion. Investigation was progressing currently, and more than R1 billion of irregular expenditure was expected to be finalised in 2017/18.
It had a plan to incrementally train EMS personnel to a level where these personnel needed to be in terms of the regulations. It needed 274 ambulances, and would be adding 15 more ambulances in this financial year. On aero medical services, a total of 60 hours were available to be used for flying with patients or specialists, and unused flying hours were carried over to the next month. The aero medical service was used for intensive care unit (ICU) transfers, major incidents and outreach programmes.
Provincial EMS capacity had been improved, and a total of 1 498 officials had been trained. Dedicated PHC ambulances had been introduced at some clinics to improve the waiting time for referrals.
One strategic risks identified for 2017/18 was the contingent liability of R1.9 billion for medical negligence claims. Dr Motau informed the Committee that the Department had uncovered a scam involving employees and lawyers sifting through patients’ files to identify possible negligence claims. It was developing a strategy to mitigate all the risks.
On Laundry services, linen availability was monitored and 73 % average availability had been attained during 2017/18. Key challenges included aged equipment, shortage of staff and poor implementation of linen management procedures in the laundries and health services.
Iintegrated security systems had been installed at Pelonomi tertiary hospital, Boitumelo regional hospital and Sinorita Ntlabathi District Hospital. The in-sourcing process would be completed by the end of July 2018.
FSDOH had two directorates dedicated to the Priority 3 of the NDP and the implementation of the eHealth strategy, the IT support directorate and the information management directorate. All 33 hospitals had connectivity. The Department was currently rolling out high speed broadband and additional funding of R28 million had been allocated to help improve IT infrastructure connectivity. In collaboration with SITA, FSDOH would implement a provincial virtual private network to improve connectivity between all facilities.
Health care waste management was outsourced. Buhle Waste was servicing four health districts, while Ecocycle Waste was servicing Xhariep district. The pricing structure was charged per kg, and the service providers were monitored on a quarterly basis. On monitoring of health care risk waste (HCRW) one of the findings was that one of the service providers had not adhered to the conditions of contract. FSDOH had intervened and was monitoring the service provider through environmental health practitioners who were appointed as waste management control officers.
On Infrastructure planning, FSDOH carried out capital projects and also did upgrades and refurbishment of previous projects. He provided a list of free state Infrastructure projects completed and operational and FSDOH Infrastructure projects currently in planning and under construction. As a result of the execution of facility maintenance processes, recent improvements had been made and contractors had been appointed who would do maintenance and refurbishment work in the five districts of the province.
The districts had created hubs to support facilities with minor maintenance issues, and staffing of the artisans was under review. A maintenance call centre had been established by the DPW. FSDOH would develop similar call centre by the end of July.
TB prevalence was estimated to be 10% of the total population. The defaulter rate remained high in Mangaung Metro, despite showing a decline in the other four districts.
PHC had been strengthened by the implementation of NHI processes, with five streams of PHC re-engineering, ward-based outreach teams (WBOTs), district clinical specialist teams (DCSTs) and contracting of private general practitioners. However, Mangaung metro was still struggling. The challenges to the district health system in strengthening primary health care included the following:
- Inability to recruit and appoint fully fledged DSCTs;
- Shortage of school health teams;
- Medical equipment and aging infrastructure affecting compliance to service standards and ideal clinic status.
The number of CHWs trained to date was 1 452, but there was a group that had been trained but was not competent, and FSDOH was working on a strategy to exit them. There were two master trainers for the whole province. All enrolled nurses who were not on the Personnel Administration System (Persal) were contracted through non-profit organisations (NPOs), and they were therefore paid by NPOs on a monthly basis.
The Free State executive council, led by the Premier, had visited KZN to establish partnership relationships. The council had resolved, in line with Operation Hlasela, to incorporate the principles of SukumaSakhe .The process to establish war rooms in various municipalities had started and the district offices were involved. There was resounding political support, evidenced by the involvement of the executive authority in activities such as:
- Back to care initiatives;
- Healthy life style exercises;
- Public debates on various issues related to legislation to reduce trans fatty acids and salt in processed food;
- Regulation of foods sold during school hours;
- Issues relating to therecent emergence of listeriosis and rabies.
Ms Wilson asked for an update on the number of specialists in the province – how many FSDOH had against what it needed. She asked for an update on oncology and what the approximate waiting time was, from diagnosis to actual treatment. Regarding medical claims, what was being claimed against FSDOH, and the nature of the claims? She referred to the OHSC report and while she understood that the facilities assessed were a small percentage of the facilities, those facilities assessed were performing very badly and the FSDOH was sitting with a crisis, with major failings in leadership and governance. The accruals were disconcerting, with only 40% going to goods and services and 60% to COE. It was concerning that FSDOH could not deliver on goods and services. She wanted to know what was happening to the people involved in the irregular expenditure -- whether there was consequential management. The condition of pre-hospital emergency medical services in the province was alarming, the incidence of TB was still high, and critical district specialist positions were vacant.
Dr Thembekwayo referred to the OHSC findings and said that even though only the worst case scenarios were used, inspection and re-inspection had been done at some of these facilities to confirm the position. For clinical support services and pharmaceutical services, the average score from the report was above 50 %, but the report listed some of the deficiencies, and one shortcoming was that a delivery schedule for medicine and medical supplies was not available. From that finding in the report, she said that there was a correlation between the OHSC report and the presentation from FSDOH, which stated that pharmaceuticals’ availability across various pharmacies and the depot was difficult to determine and manage centrally. She wanted to know why there was difficulty at the depot. On clinical efficiency management, she requested FSDOH to take note of its deficiencies and work to overcome them. On disaster preparedness, it had scored below 20 %, and she wanted to know why disaster management plans were not available. On communication and public relations, the OHSC report stated that there was staff dissatisfaction, and she wanted to know why the staff was not considered in matters pertaining to them. The report indicated that security services were a key challenge, as most of the clinics were without security staff. It had also indicated that toilets and bathrooms were not cleaned. She asked whether cleaning services were in-sourced or outsourced. The OHSC report had also found that the procedure for the procurement of food was not available. She asked FSDOH to respond to the findings.
Mr Nkonzo asked what the latest Auditor General’s report had said. He wanted more details on the challenges of security services and infrastructure. He commented that the presentation on medical availability at the depots as at 31 May 2018 was not so bad, and requested FSDOH to give the Committee an assurance or a plan of what it was going to do to maintain that situation. He observed that availability of contraceptives was at 56%, and said that there was need for further improvement. He commented on the 4 800 vacant posts and asked which of those posts needed to be filled immediately, and whether there were any critical posts not filled. On the in-sourcing of services, he commended the province for what it was doing and said that FSDOH was the only province that had a report which told the Committee the action plan on in-sourcing. He also commended the Department for the training of officials before commencement of duties. On the EMS, he asked why FSDOH had approved the purchase of only 15 ambulances against a shortfall of 144 ambulances.
Dr Maesela said that out of 32 hospitals, only four had performed above 80%. Facilities that were in remote areas were not working well, yet the services were needed more in those areas. He wanted to know why the rate of vacancies was high, and why there was a challenge in recruiting medical specialists. On FSDOH not complying with legal and regulatory requirements, he said that this should not be up for discussion, and that it had a responsibility to abide by the regulations. He asked whether ICT was outsourced or in-sourced. What was it was doing to reduce COE, despite the Treasury directive? The presentation indicated that there were facilities with private ambulances, but he advised FSDOH not to spend money on exorbitant costs such as private ambulances. He added that all the Department’s identified ten risks could be dealt with, and that it must prioritise and deal with them.
The Chairperson asked FSDOH to clarify the matter of private ambulances being used in public facilities, and the cost of such services. She said that FSDOH was the only province that had reflected the medical legal claims and given the categories. It was also the only province that had reflected on school health and MomConnect. She noted, however, that it had not specified the districts. She asked if FSDOH had engaged the Department of Basic Education, and if these programmes had a bearing on matric results. She asked whether it could look at CHWs and consider those that had the capacity to be trained further. She also asked it to provide the ages of the CHWs who were not passing the exams. She asked why FSDOH was silent on its relations with labour unions and also asked for an overview of Manapo hospital.
Ms Montseng Tsiu, MEC: FSDOH, responded on enrolled nurses who were on stipends and their capacity to be trained further, and clarified that FSDOH had been referring to community care givers (CCGs). Some did not have a matric qualification, and the Department was looking to see if it could absorb them as cleaners. The CCGs that were being trained were those with a matric qualification. She also confirmed that FSDOH had a plan to absorb enrolled nurses in the Department.
Dr Motou responded on the question of the status of Manapo hospital. It had realised that there was a problem of leadership at the facility, and had overhauled the management and made sure systems were in place. The hospital was now running properly. FSDOH would be training some of the Cuban students at that facility. He agreed that there was a problem with leadership and governance. For orthopedics, the OHSC report said there was a risk, and the FSDOH was working on an improvement plan to get its house in order. Regarding the number of specialists across the province, he asked to present the figures to the Committee in writing. He informed the Committee that he had in the previous day signed the appointment of spinal specialist.
On the status of oncology patients, he responded that the Department had 400 patients awaiting radiation treatment, and that the radiation must be done by September 2018. FSDOH had two machines but one had expired, so it was going to explore leasing a machine to deal with oncology.
On litigation, the medical legal claims were approximately R2 billion, and the claims range from medical negligence to cerebral palsy -- the details would be provided to the Committee in writing. The FSDOH would also provide a report on how it was dealing with the OHSC report.
Regarding the budget, he confirmed that the COE was crowding out the funds available for goods and services. The COE was influenced by labour agreements and issues around conditions of service. The challenge of the COE was going to continue until FSDOH had the requisite skills in its facilities. FSDOH would work with the universities, to see how they could assist. The universities could also assist with issues of outreach.
In response to the OHSC report, he said that FSDOH had delivery schedules in place. He agreed that the inability to fill posts was affecting performance. It had made a point of appointing managers who would lead the districts, and with training and monitoring it should be able to improve. He confirmed that disaster management plans were there. Communication with staff was key and FSDOH would make sure it did that. He confirmed that there was a challenge of safety and security across the facilities.
He responded that there was a moratorium on the province, where FSDOH filled only clinical posts and not critical posts. It was not appointing drivers, armed guards and cleaners. On contraceptives, he agreed that the figure was low and informed Members that the contracts for the contraceptives were done at the national level, and at the time when the demand was high and the suppliers were unable to deliver, FSDOH had ended up being given permission to buy out.
On the irregular expenditure, there had been consequence management, but he pointed out that the expenditure went back to 2009 and that some of the people to hold accountable were no longer in the system.
FSDOH would provide details on the in-sourcing of services to the Committee in writing. The IT systems were not integrated, and he asked the Committee to intervene to have the matter with SITA resolved.
He agreed that FSDOH had to adhere to legal and regulatory requirements. He confirmed that FSDOH had a strong relationship with the labour unions, and that there had been no strike in a long time.
Ms Tsiu thanked the Committee, and said that the engagement had assisted FSDOH to know which issues need more focus.
The Chairperson asked FSDOH to include an update on infrastructure in the written report. She added that there should be no distinction between clinical and critical posts, and that every person in a facility counted. She confirmed that the Committee would assist and engage Treasury. She also emphasised the importance of communication
KwaZulu-Natal DoH: Briefing
Dr Sibongiseni Dhlomo, MEC: KZNDOH, said challenges in the health sector needed constant attention by innovative leadership. The Department required the support of the Committee on the funding for health. Whenever KZNDOH was in need for funds, the response given was that it must prioritise to avoid overexpenditure. The areas that eventually suffered in most cases included the EMS, staffing and infrastructure. KZNDOH had a proposal for a minimum staff establishment and was working to strengthen contract management in order to reduce irregular expenditure. The plan was to go back to the basics, where health institutions provided comfort.
Dr Musa Gumede, HOD: KZNDOH, said that the province had a total population of about 11 million people, with 10 municipalities, one metropolitan municipality and 54 local municipalities. Life expectancy for males was 57.8 years, whereas for females it was 63.5 years.
On patients’ rights and access to care, he said that services were provided in each of the districts. KZNDOH had one central hospital, three tertiary hospitals, regional hospitals, district hospitals and specialised hospitals. It had proposed a number of new hospitals to increase access. A new regional hospital, Pixley Ka Isaka Seme had been established, and a new academic central hospital was still in the conceptual phase.
Difficulty in attracting and retaining medical specialists at regional and tertiary hospitals in the rural areas had posed a challenge for the referral system. KZNDOH had an aging fleet of ambulances and had a strategy to incrementally replace the ambulances. There were 75 EMS bases and 12 communication centres, one provincial health operations centre,which was computerised, and 2 588 paramedics were employed in the province. A major challenge for the EMS was the manual booking system and problematic IT links.
On complaints management, KZNDOH had rolled out the implementation of the national guideline to manage complaints, and the resolution of complaints within 25 working days had improved from 56 % to 75 %. It had picked up the negative attitude of health care personnel and the long waiting time for service, and it was dealing with poor standards of care. It was also using media, especially radio, to promote patients’ rights. He added that missing patient records contributed to insufficient information when attending to medical negligence cases.
On clinical governance, only two hospitals did not have appointed hospital board in place, and mental health review boards had been appointed in four districts. The Department was reviewing all district health councils. Following the municipal elections in 2016, all DHCs that were in place had had to be dissolved, as new members had come into the district.
All CEOs at level 13 and above were subjected to a competency assessment process prior to appointment. The vacant CEO posts were all in the process of recruitment. 75% of all hospitals had conducted self-assessment on national core standards. On the management of pharmaceuticals and medicines availability, the Provincial Pharmaceutical Supply depot coordinated demand management and forecasting, acquisition management, warehousing and logistics, safe disposal of pharmaceutical waste and transaction management. The department was using the electronic stock management system, and the stock visibility system (SVS) allowed it to know when stock was low. The OHSC had measured processes, not stock, and KZNDOH was not short on stock. Anti-retroviral medicines stock was moved between facilities to meet patient needs. On expired medicine the department would roll out Rx Solution to all clinics to better manage the pharmaceutical stock at clinics. It had also installed back up generators to some clinics as an NHI initiative, to assist in preventing the damage of cold chain pharmaceuticals. The appointment of pharmacists’ assistants had also been factored into the minimum staff establishment for clinics. The Central Chronic Medicine Dispensing and Distribution Programe (CCMDD) had been rolled out in all 11 districts, and over 1.1 million patients had been enrolled on the CCMDD programme. He confirmed that there were challenges in the depot, but the new method of delivering drugs directly to facilities and to patients would assist.
On medical equipment, previously KZNDOH had no service level agreements with original equipment manufacturers (OEMs). The Department had entered into service level agreements with the OEMs or their agents for life support equipment. It was also looking at improving technicians to ensure it had people with skills to deal with assets. Financial delegations had been revised to empower the CEOs to procure up to a maximum of R500 000 directly at institutional level, but the head office still did a lot of oversight.
On ICT Interventions, all hospitals had network connectivity. Focus had been given to all PHC sites to make provision for data-based connectivity services -- internet, intranet, email -- by the end of the 2018/19 financial year.
On the state of the district health system in strengthening primary health care, KZN leadership and governance, 10 of the 11 districts had a permanent full time district director with the remaining district director post (King Cetshwayo district) in the process of recruitment. In an effort to further improve local health service co-ordination and accountability, the Department was exploring the implementation of a sub-district model. The adoption of community health workers into full time employment was negotiated at national level, but the province had included all community care givers on PERSAL.
He gave a report on the progress towards adoption of Operation Sukuma Sakhe (OSS) and said that the Department had appointed a focal person who was responsible for monitoring the programme.
On oversight and leadership there had been instability in top management due to the attrition of HODs, DDGs and CFOs. All of the posts had been advertised -- some more than three times. KZNDOH had aligned the performance agreements of all SMS members and CEOs with the strategic and operational plans. It was looking at the organograms to assess whether it could deploy some people from head office.
The Department had a provincial task team to assist it in undertaking internal control assessments. The team had commenced in February 2018.There was an audit log which it was following and it needed to work and build capacity of internal controls. The Department had fully fledged and functional risk management committee (RMC) headed by the HOD. Each hospital had an operational risk register and the Department had a consolidated risk register. One if the top ten strategic risks identified was the unauthorised doctors working outside the public sector. On operational management, a lot of posts had not been filled, and KZN had deliberately decided to increase its funding to train specialists.
Ms Wilson commented on the shortage of EMS vehicles, and advised that if KZNDOH did not have disaster plans in place, it would face a lot of legal claims. The negative attitude of health care personnel needed a lot of work. She also asked if the Department could look further into the issue of missing patient records, as it could have a link with the high number of medical legal claims. She wanted to know what was being done concerning the BCG vaccines for TB, and who the supplier was. She commented that drugs were valuable, and if there was no stock count, KZNDOH would not know if the drugs were there. With 63 % of the budget going to COE, KZNDOH would not be able to deliver appropriate medical services. The R7 billion maintenance backlog was massive and the infrastructure would fail. She asked the Department if it could specify which specialists were part of the 395 available, and if it could clarify the surgery backlogs at the hospitals. She commented that there was a shortcoming in the organisational structure -- the HOD was working in an acting capacity, and the supply chain manager had also been out since 2011. She welcomed the progress on oncology and commented that previously a lot of people had died because of negligence.
Dr Thembekwayo said that the OHSC report had been taken from the worst performing clinics in the hospitals and could thus not be generalised. However, re-inspection had been done by the OHSC, with no improvement. She requested KZNDOH not to forget the worst scenario cases. On patients’ rights, the average score from the OHSC report was 61%, and the deficiencies noted were that minutes of patients survey satisfaction reports were not available, staff satisfaction surveys were not conducted, there were no ablution facilities for disabled persons in the hospitals, and a disaster management plan was not available. She advised KZNDOH to go back and address the issues raised.
Dr Maesela commented that contradictions were an indicative of development, and thanked KZNDOH for the turnaround.
Dr Dhlomo said that the Human Rights Commission (HRC) had recently commended KZNDOH for the work it did, and despite disputes it would go on to provide services to the people. On EMS, he said that an ambulance costs approximately R1 million, and KZNDOH needed to purchase 500 ambulances. Once it bought them, it had to allocate them to the hospitals and replace them every 12 months, and these costs placed huge pressure on the budget. He added that there were no stock outs in the clinics, the system adopted was transparent, and KZNDIH encouraged the CEOs to visit the clinics.
Dr Gumede commented on the scarcity of skills. KZNDOH was testing what the NHI would require, and it wanted the R100 million given to be used to strengthen the system instead of having to outsource. It had a plan to replace the ambulances in tranches and identify districts that had fewer numbers. The Department had taken note of the worst performing facilities and would go to each of them and correct the issues. He confirmed that BCG 1 was a challenge, but when the stock was available, the facilities usually contacted the people.
Mr Phumelele Shezi, Acting CFO: KZNDOH, commented on the irregular expenditure. The Department had a treasury intervention team who assisted in preventing irregular expenditure by strengthening controls. It had devised a turnaround strategy. The supply chain management was run on a manual system, so if one lost a requisition, the whole transaction became irregular. The intervention team would assist it to procure an electronic system. The financial misconduct team had been reconstituted. On accruals, it had a burden of unpaid invoices. It had, however, been able to produce a saving plan through proper market research and strengthening of supply chain management.
Ms Wilson asked KZNDOH to advise the Committee in writing how much the medical claims were.
The Chairperson commented that there had ben an improvement in the KZNDOH report compared to their last presentation. It was good to start by first acknowledging that there was a challenge. She agreed with other Members that there was a difference in comparison to the previous time the KZNDOH had presented to the Committee.
The meeting was adjourned.
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 3
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 6
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 1
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 2
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 3
- Hospitals: Northern Cape, Limpopo, Free State, KZN Departments of Health 4
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