North West Department of Health status report; Committee Reports: Provincial Hospital Services; KZN Oversight; with Deputy Minister

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12 September 2018
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The North West Department of Health said they had managed to achieve 63% of their performance targets, compared to the 60% achievement in the previous financial year. Challenges which had prevented them from achieving more of their targets were the labour unrest and industrial action that had taken place, the lack of resources in the form of staff and funds, as well as poor infrastructure. The financial section’s main feature was the accruals which were still owing by the Department, amounting to R992.4 million. They were planning on putting pressure on Treasury to provide them with additional funds.

One of the major concerns of Members was the use of Buthelezi ambulance services. The Committee wanted the NWDOH to justify why it had chosen to outsource their emergency medical services (EMS) and allow Buthelezi to perform one of their core responsibilities. They also expressed strong criticism of the hospital and clinic infrastructure in the province, which had not impressed them during oversight visits.

Other concerns were related to mother and child health care, with the Department being questioned about the high maternal mortality rate, and also why so many children were dying from diarrhoea. Members pointed to low levels of skill among staff, which was aggravated by staff shortages. These challenges would lead to an increased number of claims, and the Department did not have the budget to deal with them.

Meeting report

North West Department of Health (NWDOH)

Dr Magome Masike, Member of the Executive Committee (MEC): NWDOH, said that of the Department’s 102 indicators, 80 were due for reporting, of which 51 (63,8%) had achieved their targets. The major contributing challenges included the labour unrest and industrial action, as well as the shortage of resources, including manpower and funding.

Mr Kgosi Mothlabane, Deputy Director General: NWDOH, focused on the non-financial targets that had not been achieved. In 2017/2018, there were 91 indicators, of which 56 were achieved, and in 2018/2019, there were 80 indicators, of which 51 were achieved. In quarter one of the 2017/2018 financial year, 60% of the targets were achieved and in the first quarter of the 2018/2019 financial year, 63.75% of the indicators were achieved.

At the district hospital, the indicator for in-patient bed utilisation was not achieved. This was mainly due to a strike from February to May. Patients were often sent home, due to fear of the nurses not showing up for work. The target for expenditure per patient was missed, mainly due to accruals which the Department had to pay off. In the area of HIV/Aids, sexually-transmitted infections (STIs) and tuberculosis (TB), he listed the challenges as well as the remedial action planned by the Department. The target set out for the immunization of children under the age of one was not achieved, and this was due to the unavailability of BCG vaccine. The Department also had a programme for partnerships with general practitioners to refer pregnant women to the hospitals and clinics, after going to the general practitioners for their first consultation.

Maternal mortality was also worrisome to the Department, and they planned to make ensure that medical offers were upskilled so that they could deal with complications and prevent fatalities. The neonatal death rate was also worrisome, and one of the reasons for this was because pregnant women were not coming to the hospitals because of the strike.

Emergency Medical Services (EMS) had achieved only one of their targets. This could be attributed to the lack of staff. Licence discs had also expired, meaning that ambulances could not operate, thus increasing the response time. This was currently being fixed.

In Programme 6, Health Sciences & Training, the number of basic nurse students graduating had not achieved.  The students had not been successful with their assessments.

The percentage availability of essential medical supplies was also not achieved. This was due to the fact that the accounts had been frozen due to non-payment, so medical supplies were not being supplied to the Department.

Ms Bertha Maleka, Chief Financial Officer (CFO): NWDOH, said the Departmental spending for the first quarter of 2018/19 was R2.2 billion, which constituted 20.2% of the total annual allocation of R11.353 billion. Equitable share spending was at 20.7%, while conditional grants were at 18.1%. The quarterly target for revenue collection was R20 million, but the actual collection was R15.9 million (79,6%). All programmes except Programme 8 (health facilities management) had financially under-performed. She went through each programme, the spending and the accruals declared.

Against a linear projection of 25%, the Department had spent 20% of its budget for community health centres in the first quarter, 22% of its budget for clinics, 23% for district hospitals, 21% for provincial hospitals and 23% for tertiary hospitals. It had spent 38% of the new or replaced infrastructure budget, but under conditional grants, had spent only 18.1% of the budget.

Revenue collection was below target by R4 million and this was attributed to labour unrest that had led to the late submission of the centralised accounts that were supposed to be sent to the funders.

Ms Jeanette Hunter, Administrator; NWDOH, presented on the community-based services, and said that the Department was doing well with school health services. The province had become the first to implement a policy on community health workers, as well as a policy to increase the stipend.

Environmental health in the province was non-existent, and poor waste management was a major problem that they were facing.

With regards to clinical services, 40% of their clinics were “ideal,” and 60% were in a poor condition, thus frustrating the staff who had to cope with adverse environments. Hospitals in the North West employed world class procedures, however, and this was due to the dedicated workers.

Emergency Medical Services (EMS) had been depleted in the North West, and they had had to outsource some of the services to companies like Buthelezi EMS. They were, however, in the process of establishing internal EMS units within the Department.

The service delivery platform was largely dependent on the referral system, which ensured that the correct steps were followed when moving from one hospital or clinic to another. In order for this to work properly, there needed to be an improvement in their transport services.

Infrastructure building and improvement needed funds, and the administrator planned to put pressure on Treasury by intentionally overspending.

The Department also planned to set up an external panel to deal with the labour unrest and facilitate communication between the Department and the labour unions.

The Department was gravely understaffed, leaving the health workers feeling overburdened. The Department required funds in order to fill the available vacancies, and they were working on it -- thjey were in the process of filling these posts

Another issue was that workers had not been paid for working overtime, due to the fact that they were working unauthorised overtime due to the shortage of staff. The Department needed Treasury to approve these payments.

Security guards had staged a walk out, followed by doctors and nurses who felt unsafe. This had been due to labour unrest among the security guards. Their contracts had ended over 18 months ago, and the Department was in the process of in-sourcing them.


Dr P Maesela (ANC) observed that in the previous year, the Department had more targets than they did this year. Even with the number of targets being halved, the Department was still not able to achieve even half of the targets for this year. There was something wrong with this -- the outputs were not very useful, to say the least.

He commented that the mortality rate for TB was high, while on the other hand, the Department had stated in their presentation there was a high success rates for curing TB. His question was why the TB mortality rate was so high, accepting that some patients with TB had HIV, He also wanted to know what was happening with mother and child care treatment in the Department’s system, because the presentation indicated that at one stage, they had a 100% mortality rate. Referring to the system in place, he said the most important component were the people, and with 4 220 vacancies not filled within the Department, maybe that was where the problem lay. If one did not have the people, then one was bound to fail.

When observing the causes of the labour unrest, he thought the Department was lucky that they still had people working for them. Performance management and development were non-existent, there was a shortage of staff, a lack of equipment and health facilities, poor infrastructure, overtime not paid and victimisation. With all of this in play, one was bound to have no-one working effectively, and then one could not succeed in delivering health services to the people.

He wanted to know why there was so much wastage, asserting that the Department seemed not to care about their resources. Why was the Department paying monthly maintenance for equipment that did not work, as this was fraud?  Were they still using Buthelezi EMS services?

Dr S Thembekwayo (EFF) asked how the Department investigated if the pregnant women had been informed about the agreement between general practitioners and the Department, that the women should be referred to hospitals. She noted that a special mention of Bojanala had been made in reference to combating malaria, and asked how the Department was working on tackling malaria in the whole province, as Bojanala was not the only district in North West.

She said there were reports of private contractors being used while over 40 brand new ambulances were standing idle, and she wanted to know what the latest report on this was. How much were the contracts for the Buthelezi EMS and Mediosa ambulances worth, how much had been overcharged and how much would be credited back to the Department? Lastly, what was the plan with regard to in-sourcing of the security services?

Ms E Wilson (DA) asked what the value of the medical claims were, what they had paid out in the last year, and what the cost of the legal fees, both paid and projected had been, as this had not been budgeted for.

She said the Department indicated that it wanted to allocate each patient a special treatment supporter for HIV/Aids, STIs and TB control, and asked how these people would be paid, as the Department did not have the money to pay or assist them.

She found it shocking that one of the challenges was related to children under five years of age, who had died from diarrhoea due to the inadequate review of children with severe dehydration, and too much or too little of the incorrect type of fluid being prescribed in the ward. The remedial action here was to monitor the implementation of the recommended dosages. It was indicative that the staff did not know what they were doing, and this would lead to medical claims for which the Department had no budget. The same applied to women who died through obstetric haemorrhaging, where the remedial action was to follow up on facilities that were not conducting simulations of managing a patient with an obstetrics emergency. This indicated that the Department did not have the staff that could deal with an emergency.

Ms Wilson was also concerned with hypoxia (shortage of oxygen)and infections, as these were issues the hospitals should be able to manage. Facilities should be in place to manage hypoxia, and babies should not be getting infections in neonatal wards. The remedial action here was to follow up on personnel trained in neonatal resuscitation, which then raised the question on whether the staff had ever been assessed.

She had done an oversight at the Mafikeng Hospital,l and was not surprised that people were dying there, especially in the maternal and neonatal wards. One of the excuses used by the Department was that the Excelsior Nursing College was on a stay away, and nurses in the maternity ward in Mafikeng were also staying away. The staff must have been frantic and tired, because it was at Mafikeng Hospital where she had found mothers lying on the floor with their babies, mould on the walls, and a boiler that had not worked for months. It was these issues that would lead to medical claims in the long term, which they would not be able to pay for.

On the financial side, since the interest on rent and land had already reached 58% in only the first quarter, what was going to happen when the money ran out, because that would happen? The Department’s administrator had said they would overspend to put pressure on the Treasury, but this was an undesirable route as the country was currently bankrupt.

She recommended that since there were huge vacancies and no budget, the Department should channel some money from the Nelson Mandela/Fidel Castro programme, which was a priority for the Department, to employ the currently unemployed qualified doctors, in order to uplift its medical services. The priority should be the primary health care of South Africans, using that money to get doctors and specialists in, to equip the hospitals, and to provide the care needed by South African patients.

Ms S Kopane (DA) said that from the discussion, it was clear that there was a problem in the North West Health Department. Once that was acknowledged, only then could if be rectified.

She asked about the current relationship between the labour unions and the Department, and recalled that on 21 April she had visited Klerksdorp Hospital as well as the Khuma Clinic in Stilfontein, and had witnessed that even the nurses were joining the National Education, Health and Allied Workers Union (NEHAWU) protest at the hospital, leaving patients unattended. It was important going forward that the relationship between the labour unions and the Department was addressed. She wanted to know the implications of the strike and it affected the patients.

She said there were a significant number of accruals, and asked what the Department planned to do about this. Regarding the Buthelezi EMS services, she asserted that some of the ambulances operated by them were like taxis, and were not well equipped. Was the Department of an investigation being conducted by the National Treasury on this matter, which she had been informed about by the Minister of Health? She would also like to be provided with the helicopter EMS contract, the value of the helicopter and how long it had been operating. Lastly, she asked to be updated on the situation regarding the Head of Department. 

Mr T Nkonzo (ANC) referred to cataract surgeries, and said that one of the challenges was that appointments were being cancelled due to theatres not operating – what was being done to rectify this?  Were community health workers (CHWs) were provided with stipends, and if so, what were the terms of their contracts? What was the Department’s priority for the filling of vacancies? What did the Department mean when they said that the boards and clinic committees were functional, because other than attending meetings, the rest of the work that they were supposed to do was being done by the CEOs of the hospitals.

Mr A Mahlalela (ANC) sought clarification on the correctness of the achievements as reported, because there was no correlation between what was said to have been achieved and the expenditure. In Programme 2, for example, a 54% achievement had been reported, but they had spent only 20% of the budget and had an accrual of R355 million, meaning that they had not spent a single cent on accruals. He would like all the programmes to be explained in this regard. What intervention would the Department implement to deal with the problem of accruals? He would also like to know what the effects on businesses would be, especially small, medium and micro enterprises (SMMEs), due to the large amount of accruals still owing.

He was concerned that the main reason being cited for the underperformance of the Department was the strike. It did not make sense for the strike to be blamed for the underperformance, when in some areas the Department over-performed (a 63% performance in the first quarter of 2018/2019, compared to the 60% achievement in the first quarter of 2017/2018). There was no consistency or correlation.

He commented that TB was a leading cause of death not only in South Africa, but around the world, and was interested to establish how much budget the Department had allocated for TB.

He advised the administrator, who had stated that the Department might overspend to put pressure on the Treasury, that under the new Audit Act this would be considered unlawful. Furthermore, when one overspent, it was Parliament that had to authorise this over-expenditure, and not Treasury.

He wanted to know why EMS had been privatised. What did the Department need to address that could not be addressed internally?  What was the total cost of the Buthelezi services, and was this decision was economical compared to in-sourcing from the Department?

Ms R Adams (ANC) asked how the Department managed to meet their daily expenditure requirements, and for an explanation of what “special treatment supporters” were.

Department’s response

Mr B Redlinghys, Director: EMS, NWDOH, said that that the 40 ambulances procured by the Department were all currently in use. The R1.6 million a month helicopter contract with Buthelezi would end at the end of this month. The inter-facility transfer contract which had started in April 2016, would end in March 2019. The Department had limited the scope of Buthelezi, however, allowing them to transport only priority 1 patients (extreme emergencies), with authority form the Department. They were also inspecting the ambulances and personnel used by Buthelezi. The Department was also establishing an EMS advisory committee, as well as an EMS licensing authority. They were in the process of developing a single communication centre for the whole province and were looking into developing a planned patient transport service which would be used to ensure that they did not burden the ambulance services. The Department was also getting another 40 ambulances, and were in the process of getting more staff.

The Chairperson enquired about the Buthelezi investigation, and would like to know what the Department was doing about this

Mr Redlinghys replied that the Department would check the qualifications of the staff working for Buthelezi, as well as inspect the vehicles to ensure that they were correctly equipped. 

Mr Johan de Klerk, Infrastructure Delivery Management System (IDMS) Adviser: NWDOH, said the reasons for the accruals being so high was that they had procured contractors without looking at the available money as well as the cash flow projections. They had underspent on some projects and some projects had finished early, and so they had been pressed by some contractors to pay them once the projects were finished. He added that they would probably still have accruals next year.

Ms Maleka also spoke about the accruals. Accruals amounted to R992.4 million, but it was important to note when they ended the financial year of 2017/2018, there had been an underspending of R296 million, so in real terms, the accruals amounted to R696 million, compared to the accruals of R750 million for the previous financial year. To date, the Department had paid 83% of the accruals, which was R823 million. The strategy for dealing with the accruals was that they were currently reviewing most of their contracts to do a cost-benefit analysis, and also to determine the value for money. They were also developing a price catalogue to ensure that when they got quotations, they were not just accepting any price given to them. They were implementing an invoice tracking system to ensure that invoices were paid within 30 days.

With infrastructure projects, they were improving the specifications to ensure that they did not incur any variation orders going forward. They were aligning their procurement plans to the annual performance plan, as well as the budget. They would ensure that every submission submitted to the Departmental bid adjudication committee was accompanied with confirmation that there was enough money in the budget.

The Department was also overspending on patient expenditure, because they were paying for the accruals as well the expenditure for the current financial year. With the interest and rent, the challenge was the payment of Telkom invoices. Telkom charged interest seven days after they invoiced, but in government it took up to thirty days to pay after receiving an invoice.  They were in a process of engaging with Telkom to ensure that the interest was reversed and paid back to the Department.

Dr M Tlhojane,, Acting Director: Corporate Services, said the Department had developed tools for the clinic board committees, and these tools were in line with the manual for ideal clinics. From time to time, they conducted workshops on their roles and responsibilities. They were also in partnership with the North West University to offer courses on monitoring and evaluation so that they could perform their responsibilities. They had also requested the district chief directors to discuss the functionality of all health governance structures at their monthly meetings. The priority for filling vacancies was on primary healthcare and hospitals.

Mr Motlhabane responded to questions related to service delivery. With TB, there were two areas that were being measured -- the ordinary TB treatment success rate, and the multidrug-resistant TB treatment success rate, where their indicators were not the same. When it stated that the TB had been cured, it meant that they had made sure that they had taken the last sputum sample to ensure the TB was completely gone. He added that many of the TB deaths were due to a combination of diseases, such as having TB as well as HIV/Aids.  

The maternal mortality rate at the moment was 126 per 100 000. They were holding maternal mortality forums where clinical managers, nurses and people in maternity were looking at the causes and how these deaths could be prevented. They had also given general practitioners forms so that they could report on all pregnant women who came to visit them on their first visit, so that the Department could be aware of this. They had mother and child coordinators in each sub-district to facilitate this.

On the issue of malaria, North West province, unlike other provinces, did not have a malaria problem as such, as it was found only in certain areas during the rainy seasons. That was why a special mention of Bojanala had been made. In the affected areas, the environmental health practitioners in the area did routine spraying and surveillance of malaria mosquitoes, particularly during the month of November.

A specific TB treatment supporter was someone who was trained, whether it be a community health worker or a family member of the infected patient, and was able to administer treatment specifically for the patient they were dealing with.

The challenge with the cataract surgeries had been the strike. That was why some of the surgeries had been disrupted and had not taken place on schedule.

On the issue of non-communicable diseases, there were programmes being implemented, including “obesity week,” as well as “walk for health” programmes.

Ms Hunter acknowledged that it was indeed fraud to be paying off equipment that did not work, and that it was fraudulent to have procured equipment that did not work in the first place. The chief procurement officer was investigating this issue, as well as the Buthelezi issue. The Buthelezi contract could not be ended as they needed leverage over Buthelezi, as Buthelezi owes the Department money. Without the contract, Buthelezi would probably never pay back the money. The in-sourcing of security guards was currently in the works.

On the issue of the money running out, the administrator said that they were in constant communication with the Treasury, but accruals were bound to happen again this financial year.

The Provincial Bargaining Chamber was operational again, and issues between the labour unions and the Department were being dealt with via this route.

Dr Masike said the Department was aware of the four non-communicable diseases that had been devastating the province -- cardiac conditions, chronic pulmonary diseases, cancer and diabetes. With cardiac diseases, they aimed to prevent, diagnose, treat and control it. They were also in a private-public partnership with Netcare, where they were able to treat cardiac patients, and no longer needed to send them to Gauteng hospitals.

He also mentioned the work done by board members, mentioning how they brought medical workers who worked long hours, food to say thank you for all their hard work. They also bought children in the hospitals presents for Christmas. During the strike, it was the board members who were updating the MEC on the day-to-day happenings.

On the issue of BCG and other drugs, the Department did not necessarily have control over the situation. BCG was not available in the country because the manufacturer could not cope with the demand. However, they had a contingency plan to ensure that children below the age of one year, received their BCG vaccinations.

Outsourcing EMS, and having inter-facility transfer contracts, was a way to combat maternal mortality, as this would ensure quicker and more efficient transfers from one hospital or clinic to a district hospital where they could be assisted.

The MEC also did follow-ups in the hospitals where there were problems, and they had made progress on this.

Fraud cases, and any other cases the Department were dealing with, had been reported to the police, and the MEC communicated directly with the Minister of Police, Mr Bheki Cele. The Hawks were also pursuing other cases that had been reported.

Mr Joe Phaahla, Deputy Minister of Health, ended off by stating that what was lacking was support for the administratorfrom the national Department of Health. The administrator must be assisted in pointing out problem areas that needed work.

The meeting was adjourned.

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