The Western Cape Department of Health briefed the Western Cape Provincial Parliament’s Standing Committee on Community Development on its quarterly performance reports for the period October-December 2017 and January-March 2018. For both quarter 3 and quarter 4 the Department underperformed significantly on indicators for Health Facilities Management and Emergency Medical Services. The Department noted, however, that the targets for these two indictors were very small and the overall performance of the Department should not be judged solely on these two indicators. The Department said often too much focus is put on what goes wrong while those things that go right far outweigh it. For the annual performance indicators, the Department achieved a total of 121 out of 150 which is 81% its targets, partially achieved 27 targets which is 18%, and did not achieve 2 which is 1 % of its total targets.
The Department still faces problems with the forensic pathological services due to the lack of staff. The Department is working with academic institutions to get more students to pursue careers in the forensic pathological services and are also using bursaries to attract new interns into their services. The Department said that the work environment in pathology is not particularly appealing to students wishing to go into the health profession.
The Department did not achieve its target on its health technology budget spent. Underperformances by consulting groups and problems with contractors have caused a total under-expenditure on maintenance and capital expenditure of R 53 million. The Provincial Health Department is currently working with the Department of Transport and Public Works to address issues with backlogs in infrastructure problems.
Members of the Committee raised particular concerns over the backlogs in the forensic pathology services. They urged the Department to address the issue by advertising careers in the pathology services to students in high school. Members were also concerned over the challenges in infrastructure and maintenance and cited the problem of under-expenditure as an ongoing problem for years in the Department. Members of the Committee expressed concern over bed occupancy rates and the negative public image of Khayelitsha Hospital.
Draft reports of the Visits to the Swartland District Hospital on 12 June 2018 and to the Salt River Mortuary on 8 May 2018 were adopted.
Committee minutes for 22 May 2018 were adopted.
The Chairperson welcomed members of the Standing Committee and the Delegation from the Western Cape Department of Health. The Delegation included Dr Beth Engelbrecht- Head of Department, Dr Nomafrench Mbombo- MEC for Health; Ms Lesley Shand- DD: Information Management; Dr David Pienaar- Public Health Specialist; Dr Laura Angeletti Du Toit- CD: Infrastructure and Technical Management; and Dr Krish Vallabhjee- CD: Special Health Services.
Dr Beth Engelbrecht said that they would focus on the Annual part of the presentation. In the Department’s Annual Performance Plan was a total of 150 indicators of which 15 are new indicators developed by the National Department of Health. This usually has an impact on developing systems and very often it comes so late that it has an impact on their ability to set proper targets.
Briefing by Provincial Department of Health
Ms Lesley Shand gave the presentation. Quarter 3 had 119 indicators that were relevant for that quarter of which 81% were achieved. Of those indicators, 5 were not achieved and 18 were partially achieved. Emergency Medical Services, EMS, and Health Facilities Management are the two programmes where they are underperforming whereas they are achieving all their targets for the Administration indicator.
2017-18 Annual – indicator performance vs APP targets
Of the 150 Annual Indicators 121 were achieved, partially achieved 27, and not achieved 2. 81% of their Annual targets were achieved.
2017-18 Annual – Highlights/Achievements
Ms Shand went through the list:
- Improved cultural entropy levels
- Unqualified audit
- >90% of facilities have broadband access
- >80% of hospitals achieved > 75% compliance with the National Core Standards
- 98% of complaints resolved
- 93% of complaints resolved within 25 working days
- On average hospitals are 86% occupied with average length of stay within 5% of target
- 89% of fixed clinics conducted Ideal Clinic status determinations by Perfect Team for Ideal Clinic Realisation and Maintenance (PPTICRM)
- PHC utilisation within target
- Expenditure per patient day equivalent within target for all programmes
- Maternal mortality rate lower than last year; Antenatal visits before 20 weeks above target
- TB drug sensitive and MDR treatment success rate above target
- Clients remaining on ART (including TB/HIV coinfected) and antenatal clients started on ART above target
- HIV tests performed above target
- Immunisations generally above target
- Bursaries awarded and intern intakes generally above target
2017-18 Annual – underperformance Programme 2
- Not achieved
Ms Shand said the one indicator where they did not achieve their target was severe acute malnutrition case fatality rate. There are several reasons why they did not achieve this target. One was that the number of cases admitted halved, but the acuity of the patients admitted increased resulting in more deaths. The second issue is their target was set based on a previous definition. In the past, they only looked at patients whose primary diagnosis was malnutrition and this year they started looking at all patients who are malnourished.
- Partially achieved
14 partially targets were partially achieved. The ART Retention in care after 12 months and after 48 months was only partially achieved. This is due to the social conditions and economic influences on the more vulnerable population which has an impact on the retention in care. It is very difficult to get permanent addresses and accurate contact information of these patients to try to track them and keep them in care when they do not come in for their visits.
The target for Medical male circumcision was also partially achieved. Improved from last year, but still under target. The improvement can be attributed to the assistance of Non-Profit Organisations, NPOs, which they have used to assist the Department. Societal influences and stigma attached to this impact on how well they can do.
In terms of TB, the three indicators where they did not achieve are affected by socio-economic status and substance abuse in the community. Approximately one third of all their TB patients are also HIV positive which places them at a much higher risk of death even if they are on ART.
For the mother postnatal visit within 6 days, mothers do not always return for care or they return after six days.
The Department also underachieved on diarrhoea and pneumonia case fatality rates. This is because of the nature of these indicators that deaths cannot be predicted with 100% accuracy. There was also a decline in the overall admissions which is a positive, but it did have an impact on the outcome of the target.
For the Grade 1 school learners screened and the HPV 1st dose, the Department underperformed slightly on these two indicators which was due mainly to Ad Hoc campaigns which were introduced during the year to deal with things like measles. The staff who would normally do the school screening visits or the HPV campaigns were diverted to assist with the Ad Hoc campaigns.
The underperformance of the cataract surgery rate can be attributed to equipment shortages and staff shortages at certain points during the year.
Ms Shand said the underperformances in the delivery rates from 10 to 19 years in facilities and the neonatal death rate in facilities is attributed to a change in the definitions. Previously deliveries were measured from 10 to 18 years and the neonatal changed from 0 to 7 days, to 0 to 28 days.
2017-18 Annual – underperformance Programme 3,4,5,6,7,8
- Not achieved
The percentage of Programme 8 health budget spent was not achieved. The over expenditure can be attributed to health technology equipment expenditure. Additional project allocations were made to mitigate projected under-expenditure in infrastructure. There were also occasional changes in expenditure timeframes as a result of either earlier or later practical completion of projects. The Department also had under expenditure on maintenance and capital infrastructure which balanced out the over-expenditure on the technology budget. There was however an under expenditure of R 53 million.
- Partially achieved
The target of EMS response under 15 minutes was affected by prolonged staff ill health, which included Post Traumatic Stress Disorder from increased attacks on EMS over recent months. This tended to reduce the Department’s capacity to deliver services. The EMS inter-facility transfer rates were affected by Red Zones because of the attacks, EMS staff have to wait for SAPS escorts to accompany them.
The inpatient bed utilisation rate in TB hospitals was slightly below target. This was mainly due to the policy of decentralising of TB management and has resulted in patients having shorter admissions to hospitals.
The target for the number of bursaries awarded for scarce skills categories was below target. This was due mainly to students not meeting the minimum entry requirements at the HEIs, failures, and the Department had to use some of the funding to fund relief staff to cover staff on training. The target for the intake of forensic pathology services (FPS) assistant interns is an ongoing problem. The Department has difficulty recruiting FPS assistant in interns due to entrance requirements and the nature of the work environment.
The Department did not fully achieve its target for the percentage reduction in energy consumption at hospitals. Due to the drought this year the focus was shifted to saving water and less focus was on saving electricity.
Mr D Mitchell (DA) asked if it is possible for the Committee to receive a list of NPOs involved in the male circumcision campaign, particular those in the Central Karoo/Eden district.
Dr Engelbrecht said they would send a list of the NPOs to the Committee.
Mr Mitchell asked in which hospitals the backlogs are with respect to cataract surgery. Did the cataract surgeries done on Mandela day help to increase the performance of the cataract surgery rate?
Dr Engelbrecht said they do have backlogs. The Department sets its target according to the World Health Organisation (WHO) vision 2020 standards. Last year the Department did 40 cataract surgery cases on Mandela day and this year they did 95. The one limitation is that cataract surgeries require an ophthalmologist, an anaesthetist and a particular microscope. The Department has high volume extract theatres and they can do up to 40 cases a day if they really push it. Going forward, the Department plans on having high volume extract theatres in regional hospitals.
Mr Mitchell asked if the Department can shed some light on the agreement between the forensic pathology services in Salt River and CPUT. The waiting lists are at Tygerberg, Groote Schuur, Eerste river etc.
Dr Engelbrecht said CPUT is offering a stream in forensic pathology and they are working with CPUT to get more students into the field.
Ms P Lekker (ANC) asked the reasons for not achieving the target for Ideal clinic statuses and how many were supposed to be done.
Dr Engelbrecht said that it is a new indicator that was set in the annual performance plan. The target was 268 clinics and the Department did 239, the achievement was 89.2%. of clinics assessed
Ms Lekker asked for clarity around “socio-economic” conditions being a reason for the underperformances of certain targets.
Dr Engelbrecht said that it is important to recognise that higher levels of deprivation means that the burden of disease is greater.
Ms Lekker asked if the Department is trying to address the shortages in staff to do administrative work electronically.
Dr Mbombo responded that in terms of the legislation they still have to keep hardcopies of files for 5 years. So, they have to do both electronically and on paper.
Ms Lekker referred to the partially achieved target of forensic pathology services (FPS) assistant interns. She asked that since one of the reasons for that is students not meeting the minimum entry requirements, if the Department is trying to do an outreach to the various institutions during orientation periods.
Dr Engelbrecht said that the minimum entrance requirements is down to the subject choices made by learners. Learners need to have done Mathematics, Biology, Science and English as a minimum. The work environment of forensic pathologists is not for everyone and often students do not want to work in such an environment. The Department does advertise for the career path and recruit, but a lot of students choose not to pursue a career in that field.
Ms P Makeleni (ANC) asked the Department to explain why they did not achieve their target for the pneumonia case fertility rate.
Dr Engelbrecht said it is very difficult to predict with accuracy how many children will die of pneumonia.
Ms Makeleni asked if the Department would provide a list of those hospitals which are sitting with a bed occupancy rate of 100% and above and how the Department plans to address this issue.
Dr Engelbrecht said they can provide that list to the Committee. Tygerberg Hospital for example has 1300 beds and these beds are distributed across various wards. Some of these wards may be 130% full and others may be 80% full. Judging a hospital’s performance based on bed occupancy rate can be misleading. Hospitals in the metro areas are more affected by higher bed occupancy rates. One response might be to build more hospitals. The other response will be to address the reasons why hospitals are filled up by addressing the burden of diseases and the causes for people needing to be hospitalised.
Ms Makeleni asked what is the exact figure for the maternal mortality rate.
Dr Engelbrecht said that the figure went from 59 per 100 000 last year to 57 per 100 000 now. The Province closest to the Western Cape has double the maternal mortality rate and the Department has actually reduced the maternal mortality rate.
Ms Makeleni asked what the reason is behind changing the measurement to 0 to 28 days for the neonatal death rate in facilities.
Dr Engelbrecht replied that the National Department of Health changes the measurement.
Ms Makeleni asked if the Department could indicate in which areas they have to deal with severe acute malnutrition.
Dr Pienaar said areas associated with malnutrition are areas of poverty and migration.
Ms Makeleni asked why the target for the expenditure PDE (TB Hospitals) was partially achieved.
Dr Engelbrecht said they had less patient day equivalents which means they had less beds that were full but they still have the overhead costs and the fixed costs.
Ms Makeleni asked for clarity around the partially achieved target of the “percentage of programme 8 capital infrastructure budget spent (excluding maintenance)” and whether the Department can send the Committee a list of where this occurred.
Dr Angeletti Du Toit said one of the Hospitals is Victoria emergency centre. The problem there was with the appointment of a new structural engineer and the Department had to wait for the new design of the emergency centre. The Valkenberg revitalisation was affected by the underperformance of the entire consulting team and the Department of Public Work had to fire all of them. They had to start over again with a new consulting team.
Mr B Kivedo (DA) asked for clarification around acute malnutrition; how it is related to other diseases as well as how prevalent it is.
Dr Pienaar said it is very difficult to predict with single digit accuracy, based on the previous year’s statistics, how many patients will die of malnutrition and the related disease. Often children are hospitalised with malnutrition and diarrhoea or pneumonia and diarrhoea at the same time. Previously they would use clinical judgment to establish the main cause of death but now what they do is count all diseases for children and use it in their statistics. This results in cases where a child has two diseases and that child’s cause of death falls in two disease categories. District six CDC was also delayed by 12 months due to issues with contractors and consultants.
Mr Kivedo asked why there is social stigma attached to medical male circumcision.
Dr Pienaar said that the Department is trying to provide social marketing for young men to commit themselves to a surgical procedure. This is very difficult and the Department struggles with getting prospective patients to the clinic on the day of the procedure.
Mr Kivedo asked for clarification around the electronic tool used to identify and engage with TB patients.
Dr Pienaar said that the majority of patients diagnosed with TB are monitored on a paper system. This paper system delays the ability of the Department to recognise electronically by at least 3 months when a patient has been diagnosed with TB. With the electronic system it will be easier and quicker to monitor TB diagnosis and patients.
Ms D Gopie (ANC) cited the underspending of R53 million as a recurring problem. She asked if the Department had done any research on this and if the Department has a plan to address it.
Dr Angeletti Du Toit said that the problem is multifaceted. The responsibility of infrastructure falls under many stakeholders. The Department of Public Works is the WCGH’s preferred implementing Department and they are responsible for all the capital infrastructure projects as well as scheduled maintenance projects. The capacity of the Department of Public Works is getting better and the WCGH’s relationship with them is improving. Agreeing on the roles and responsibilities of the two Departments is key in addressing the infrastructure delivery problems.
Ms Gopie asked for clarification around the average length of stay in Tygerberg Hospital and the overcrowding in the ICU.
The Chairperson asked what the relationship between the Provincial Health Department and the Department of Transport and Public Works is like.
Dr Engelbrecht said that between the Provincial Health Department and the Department of Transport and Public work they are putting a range of steps in place to improve the relationship. The two HODs from the Departments have agreed to work together and collaborate to improve the relationship and achieve a shared vision.
Ms Lekker said that the Department only focuses on post-matric qualifications. The problem stems from high schools in the Western Cape, and one of the problems is mathematical literacy as a subject. The Department needs to go to schools and address the problems there via outreach programmes. Having more interns at pathology service centres would alleviate the backlog.
Dr Mbombo said that there are 10 categories of health professionals in the health system. Pathology may not be the ideal choice for those students who which to pursue a career as a health professional.
Ms Lekker interjected and said the MEC is not addressing the question directly.
The Chairperson said Ms Lekker should give the MEC an opportunity to finish her response.
Dr Mbombo said that the issue is not about subject choices since all health professions require Maths and Science, but the challenge is making a career in pathology more appealing to prospective students.
Dr Mbombo departed the room.
Dr Engelbrecht said that she takes the passionate plea by the member. They do outreach programmes to schools and do tell students what subjects they need to do. Perhaps they need to focus more on learners in grade 9 before they have made their subject choices. The Department had a target of 10 interns and they only achieved 9. She apologised if the Department did not respond fully.
Ms Lekker said that many people working in the public health sector are not benefitting from the venture to the electronic system.
Dr Engelbrecht said only Khayelitsha, Mitchells Plain, one ward in Tygerberg Hospital, has electronic content management. They do not have that in all their Hospitals.
The Chairperson asked if the bursaries awarded to interns was for learners coming into the field or for individuals working in the medical profession.
Dr Engelbrecht replied that bursaries were to attract individuals into the system. Not all of them would feel that the work environment would suite them.
Ms Makeleni said there had been a lot of coverage in social media of Khayelitsha Hospital over bed occupancy other issues. When the Committee visited Khayelitsha Hospital they did not see any of those issues. She asked what the problem is.
Dr Engelbrecht said that Khayelitsha Hospital is in a very good state and the infrastructure is still in a good condition. The hospital has been very well maintained. Sometimes mentally ill patients and patients in the emergency centre choose to sit on the floor and sometimes it is better for them to sit on the floor. Members of the public may take photos of that and it gets circulated on social media for a long time after that. She spoke to the Hospital Board and they are very satisfied with the performance of the hospital.
The Chairperson thanked the Department for their presentation and their time.
Ms Lekker asked if they could request a list of consultants that were used on projects which were delayed.
Ms Makeleni recommended that they invite someone from the Khayelitsha Hospital to inform the Committee on some of the challenges they face from the community.
Ms Gopie recommended that the Department review the ways they recruit and attract forensic pathologists and interns.
Mr Mitchell requested a list of NPOs involved in the male circumcision campaign.
Mr Kivedo said he would like more information on how many patients have been deemed untraceable due to a change in address or contact information. Also, what the role of healthcare workers is in such a case.
Ms Lekker noted her disappointment that Dr Mbombo did not respond adequately to her questions.
The Chairperson said Ms Lekker should have allowed Dr Mbombo to finish her responses before addressing the issue.
Adoption of Committee Minutes
The Minutes of Committee meeting held on 22 May 2018 were adopted without amendments.
Draft Report of visit to the Salt River Mortuary on 8 May 2018
The draft report was adopted without amendments.
Draft Report of the Visit to the Swartland District Hospital on 12 June 2018
The draft report was adopted without amendments.
The meeting was adjourned.
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