The Standing Committee on Health received a presentation from the Western Cape Department of Health (WCDH) on its annual performance plan (APP) for 2019/2020. The Committee had asked the Department to expand its presentation to include information on the health landscape in the Western Province, as well as the challenges it faced, so that it could have a better understanding of the Department’s functions and services.
The Committee was told that the increase in the burden of disease in the province placed a great deal of pressure on the WCDH. At the same time, its budget had been cut drastically, and the need to provide an increase in services with limited resources was the main challenge for the Department. To address this problem, it was making an investment in the leadership of its structures, rationing non-essential services, and increasing the effectiveness of nurse-based care. It was also investing in community health, which would alleviate some of the pressures.
The Committee observed that red zones posed a safety risk for medical staff, and that interdepartmental cooperation and partnerships were needed to ensure the safety of officials so they were able to respond effectively to emergencies. Members questioned the outsourcing of laundry for linen, and requested a cost comparison between insourcing and outsourcing. Other concerns included the accessibility of health services for farm workers living in gated communities, and the impact of the closure of the GF Jooste Hospital in Manenberg. It was also recommended that the WCDH prioritise psychological treatment for staff under pressure, especially trauma surgeons
Annual Performance Plan (APP): Western Cape Department of Health (WCDH)
Dr Beth Engelbrecht, Head of Department: WCDH introduced the members of her delegation to the Committee. They were Dr B Vallabhjee, Chief Officer: Strategy; Mr Simon Kaye, Chief Financial Officer; and Dr L Angelotti du Toit, Chief Director: Infrastructure and Technical Management.
She said the purpose of the meeting was for the Committee to meet the WCDH representatives and familiarise themselves with the Department. The Department had been asked to extend the scope of the presentation beyond the APP so the Committee could gain more clarity on future Departmental plans. The focus of the presentation would be on the budget and its allocation.
She said the WCDH was under severe pressure from the burden of disease and fiscal constraints. Major challenges were the decrease in the budget, with an increase in the burden of disease and a growing population. The presentation would focus on how to balance these challenges. She added that the WCDH had achieved a clean audit for the past three years, and that it aimed at continuing this trend.
Dr Vallabhjee said the objective of the presentation was to describe the health landscape, the WCDH’s planning process, Healthcare 2030, the transformation strategy towards health sector reform, and finally the APP.
He described the service delivery environment as directly servicing 75% of the Western Cape population of 6.6 million people. Population growth was due to natural growth and migration. The Cape Town metro had eight sub-districts for which it was responsible, and there were 32 sub-districts in total. The service delivery platform had various levels. The first was community-based service, with care workers conducting visits and focusing on areas such as school health. The second was facility-based care, such as clinics and satellite clinics. District hospitals were the third level of service, tending to the first level of acute medical care in which specialists were placed. Regional hospitals offered the full package of care. The final level was tertiary training and central hospitals, such as Tygerberg Hospital. There were also specialised hospitals which focused on tuberculosis (TB) treatment, psychiatry, rehabilitation and dental care.
Dr Vallabhjee summarised the services offered by the WCDH as:
- Primary Health Care Services:
- 462 facilities in 32 sub-districts and six districts (five rural districts and eight sub-structures in the district of the Cape Town metro).
- Hospital Services:
- 33 district hospitals
- Five regional hospitals (including the level 2 services provided at the central (tertiary) hospitals)
- Six tuberculosis hospitals
- Four psychiatric hospitals
- One rehabilitation centre
- Two central (one tertiary) hospitals.
- Emergency Medical Services (EMS):
- 49 ambulance stations with 254 ambulances
- Forensic pathology services:
- 18 mortuaries and 41 response vehicles.
- Training for health care workers and professionals (in conjunction with universities).
- Regulation of private hospitals in the province.
The burden of disease had placed immense pressure on the health care system. A quadruple burden existed, comprised of non-communicable diseases, injuries stemming from interpersonal violence and car crashes, infectious diseases -- specifically TB and HIV – and mother and child health care.
Life expectancy in the Western Cape was 67.5 years, which was 2.5 years higher than the national average. The life expectancy of women was 70 years, compared to the national average of 67, while the life expectancy of men was 65 years in the Western Cape, which was 3.5 years higher than the national average of 61.5. The under five years of age mortality rate per 1 000 deaths was 20 in the Western Cape, compared to the national average of 33.
Dr Vallabhjee said the budget amounted to R24.8 billion, which had to fund eight programmes. The Department employed 31 549 people, of whom 93% were permanent staff. The workforce consisted 72% of women.
Regarding the legislative planning framework, the WCDH was busy planning for the new term for the next five years in conjunction with national and global frameworks. Global policy frameworks which were being taking into consideration included the sustainable development goals (SDGs). National frameworks included the National Development Plan (NDP), specifically chapter ten and the National Health Insurance (NHI) scheme. There might be amendments to the plan. The previous five-year plan had focused on good governance, and health and wellness.
He explained that Health Care 2030 was not a statutory requirement, but was a project by the Department which formed part of its long-term plans. He did not want to dwell much on the topic, and said that it was available on the WCDH’s website. The expanded vision statement for Health Care 2030 was:
- A quality experience in a world class, public health service;
- A focus on motivating the population to take responsibility for their health;
- To shift focus from illness to wellness;
- To achieve among the best health outcomes in the world.
These objectives could be described through a description of what health care would look like for patients and staff. This was summarised in the core values of Health Care 2030, where the values were stated as caring, innovation, accountability, integrity, responsiveness, respect and competence.
Health Care 2030 was not focused just on improving the health care service, but was built on a philosophy of community engagement and intersectoral work.
The Department’s transformation strategy was based on various assumptions, which took into account the external environment in which it was situated. Budgets had been decreasing in real terms, and the WCDH had seen the continuation of a complex and stressed environment. Climate change had posed a problem, in which the drought-induced “Day Zero,” increasing wild fires and energy concerns were affecting health care. Illness had also become more complex, as people no longer were diagnosed with a single illness, but many, which complicated services. The transformation strategy was aimed at dealing with all of these problems. This strategy was built on service-driven priorities. Good governance (internal and external), culture change and dispersed leadership and technology and innovation were also important in bridging these problems.
The approach the WCDH had chosen for universal health care (UHC) was based on a three-pronged approach. The first was that health system strengthening was the basis towards improving UHC. The second was focusing on policy responses, to ensure that coherent policy decisions were taken. The third was a bottom-up approach to UHC, which meant interpreting where the WCDH was currently. The way in which services were rendered also needed to change. This would require bending the curve of disease coming at the WCDH, dampening the demand on its services and redesigning the service delivery models and platform.
Dr Vallabhjee said the APP consisted of eight programmes. These were:
- District Health Services. This had various sub-programs such as clinics, complaint resolution, district hospitals, and health care services for HIV/Aids, sexually transmitted infections (STIs) and TB. This programme also focused on improving the continuation rate for people who start anti-retroviral (ARV) treatment but did not finish. The Department estimated this as 40%. This meant that only 60% of people completed chronic illness treatments.
- Emergency Medical Services.
- Provincial hospitals.
- Central hospital services. This programme had sub-programmes which focused on tertiary education hospitals and Red Cross hospitals.
- WCDH bursaries and internships for health sciences training.
- Health care support services, such as laundry and energy provision.
- Health facilities management, to ensure that service points were kept up to date with technology.
Dr Vallabhjee told the Committee that health was a complex issue. Health should be viewed not only as a consumption issue in the budget, but also as part of the economic sector, with broader functions such as employment creation and ensuring a healthy work force. The health sector ensured that goods and services budgets were spent, and also trained professionals and graduates.
Mr G Bosman (DA) asked what type of public/ private partnerships the WCDH was considering. He also asked what the sentiment amongst the private sector was, particularly from the private hospitals.
Ms L Botha (DA) asked why the Department gathered so much negative criticism in the media, despite working very hard. Had there been an increase in staff to undergoing psychological support and treatment due to the nature of their work?
Ms A Bans (ANC) said that staff stress was visible. She asked what the plan was to help staff, as resources were in decline and pressure levels were increasing. Why had the WCDH outsourced its laundry and linen instead of saving via insourcing?
Mr R Allen (DA) asked the Department to expand on the “pressures” referred to in the presentation. What had they meant by “compromising service outcomes?” What ideas were in place to help the WCDH deal with the increasing demand for services? He referred to an incident within a red zone environment in Manenberg, and said that an ambulance had taken 35 minutes to reach a civilian in need. In red zones, ambulances were often escorted by the South African Police Service (SAPS), but there was no formal agreement in place for this arrangement. This limited the responsiveness of services. He asked if the WCDH and SAPS had a more practical way of handling the situation?
Ms R Windvogel (ANC) said the Department had mentioned training community members as health care workers, and asked how many health care workers they had and if they were going to be incorporated into government? She asked Dr Nomafrench Mbombo, Member of the Executive Council (MEC) for Health, about the closing of the GF Jooste Hospital in Manenberg, despite the Department facing capacity problems. This would add more pressure on to the Mitchells Plain services. How was the Department going to fix this?
Mr M Xego (EFF) said that one of the problems experienced by ambulances was the vast distances they had to cover. What was the plan to overcome this challenge in order to be more responsive in cases of emergency? He added that the WCDH’s statistics on complaints and satisfaction did not seem right, as he had experienced many complaints and dissatisfaction on the ground. This was at odds with the APP report. He asserted that people on the ground were not happy with the service they received.
Dr Mbombo said that Universal Health Care (UHC) was an international approach which was practised in various countries, but had not yet been implemented in South Africa. The NHI scheme was a vehicle through which UHC was to be implemented. The WCDH was working in partnership with the Eastern Cape and KwaZulu-Natal Departments of Health. It was responsible for the licensing of private hospitals, which fostered a relationship of engagement between the public and private sector. However, there was no legislation which ensured accountability for private clinical outcomes. In contrast, the WCDH was responsible for the health of all the citizens in the province.
The Minister then addressed the question of negative press in the media. She pointed out that a department like Basic Education, for instance, was responsible for pupils only during school hours. Over weekends, after school and during the holidays, the schools were not liable for the wellbeing of students. However, when it came to the WCDH, it was responsible for the wellbeing of everyone at all times. This ranged from the unborn child to the 100-year-old “auntie” -- and even the deceased. The WCDH also had to be responsive 24 hours a day, seven days a week and 365 days a year -- their responsibility never stops. This responsibility and constant need to be providing services were what added pressure to the WCDH, which resulted in negative media coverage.
The WCDH also faced many complex issues as patients, especially children under the age of five, visited the clinics more than once. The twenty minutes allocated per consultation needed to be efficient, as the burden of diseases was increasing. Patients no longer visited with one illness, but had many simultaneously which translated into a larger amount of work and tests to be done per patient. The Department acknowledged the concerns in the media, and was focused on improving its responses. Sections within the Department needed to communicate more with patients, and ambulances should notify patients if they could not make it within 15 minutes.
Dr Mbombo said that the Life Esidimeni situation could have happened in any province due to the sheer pressure on the health system in South Africa. The WCDH wanted to appoint more staff, but could not due to fiscal constraints. She commented that the health sector had lost R9bn during the latest budget cuts, and that this was going to increase. Provincial budgets had also been cut, which also had an impact. The WCDH needed R1.3 billion to function, but had only R925 million available. Patients were increasing in numbers, and poverty was complicating the burden of disease.
On the topic of psychological support, she said that a project “Caring for the Carers” was under way for staff such as trauma surgeons, and that different departments had different days on which they received support. Service rationing had also been taking place in cases where patients did not have a strong chance of survival. These decisions were based on medical decisions by specialists. She explained that when someone was brain dead, a call had to be made, as the care spent on keeping the patient alive could be spent on someone with a better chance of surviving. Another example was kidney dialysis -- if people needed to receive dialysis but had many other illnesses which made survival and recovery unlikely, they were not put on dialysis. These interventions were not unique to South Africa, but happened internationally.
People in rural areas waited longer for ambulances due to challenges such as not having access to the houses of workers on farms. Ambulances also faced challenges such as the safety of paramedics in areas identified as red zones. A specific threat was the shootings in Manenberg. The City of Cape Town had a safety plan in place with the WCDH, and community watchers tip off ambulances when shootings are going to happen. A strategy used in red zones or inaccessible areas for ambulances, was training and empowerment of citizens. Members of communities were trained in first aid.
She said that UHC would focus on the integration of service. In the UHC system, there should be different kinds of service providers. She commented that most service providers were male dominated in terms of ownership, but a focus was being put on non-government organisations (NGOs), which were mostly run by women, to empower them so they could create a system where they appointed each other, also resulting in job creation. There was also a ward-based community health programme which the WCDH was running, which focused on grass roots empowerment and community collaboration.
Service delivery needed to consist of various types of staff -- specialists, nurses and general health care workers. The WCDH used a system where people were not appointed to certain positions, but were rather offered a one-year contract. This included the outsourcing of the laundry and the use of NGOs.
The Minister said that the GF Jooste Hospital had been closed because the building was a safety hazard to patients and staff. It had been used as an old age home, prior to it becoming a hospital. No women’s and children’s services had been offered at the hospital, which meant that people still had to travel to other hospitals. This was also one of the reasons why it had been demolished. The WCDH had decided to build another hospital. The GF Jooste hospital had originally been a level one hospital, which had 100 beds, while a level two hospital had 500 beds. The building of a new hospital would see an upgrade from a level one to a level two. A new site was currently being chosen and the WCDH was in contact with the Department of Public Works.
The Chairperson raised a quick question, asking how much money had been reserved for NHI purposes. She also questioned what the Department anticipated the impact of budget cuts would be on services across the province.
Dr Engelbrecht said that when people went to public hospitals, they complained because their experience did not meet their expectations -- they expected private care services, such as those at the mediclinics, from state hospitals. This was not realistic, and was a constant issue which the Department had to deal with.
Looking ahead, the WCDH had to balance services with fiscal constraint. The goal was to keep services going, keep staff committed and deal with patients’ expectations. It was in communication with many other departments, such as Sport, Arts and Culture, to cope with certain issues such as sport-related violence. However, communities also needed to take ownership for their health.
She said the Department focused on leadership training where people were able to help other people. Leadership training in the Department was also very important so that health professionals could help patients more efficiently. The burden of disease was a big problem, however. Clinics complained of waves of poverty and illness. These clinics were often situated in red zones where the most care was needed. She concluded by saying that problems of safety for their personnel remained a challenge/
Ms Windvogel said that she was a ‘plaas meisie’ (farm girl). The APP had mentioned a 91.5% access rate to services. She asked if farm workers were included in this figure, as they still received limited services. They stayed in gated communities which had limited access to government services. The improvements made by government, such as public roads and services, were not seen on farms. Government services reached only 60% or less of farm workers.
Dr Mbombo responded that education and health were the two services needed most by these workers. Health impacted on all aspects of their lives. Due to farm workers living on farms, which were private property, government had limited access to providing direct services to them. The WCDH had established health net points, which was a provincial initiative to increase access of health services to farm workers. She said that this depended on partnerships with municipalities, churches and farmers. Informal arrangements had also been made in cases where patients needed to be fetched from their homes. However, the availability of services and accessibility to services was not the same. Primary care included treatment by doctors. The approach that the Department had was nurse-driven, and supported by doctors. In some areas, physical clinics had been built with farmers making land available. In other areas, mobile clinics had been used. In some communities, such as in Grabouw, clinic hours had been extended.
The Chairperson thanked the delegation, which left the meeting. There was a short adjournment.
Committee resolutions and adoption of minutes
Ms Bans said she felt that her questions had not been answered, specifically the question on outsourcing. She asked for insourcing to be added to the Committee’s recommendations for discussion. This should be formally answered by the WCDH in writing.
Mr Allen said he would like to visit the learning sites close to his ward in Manenberg and Hanover Park, and wanted to know who the contact persons for these learning sites were.
Ms Botha said that she supported Ms Bans request to find out more about the laundry services. She wanted the Department to do a cost comparison between the insourcing and outsourcing of linen. She asked that the Committee also schedule time for oversight visits.
Mr Allen said that he was biased in his choice of sites, but that the Committee did not have to visit them and that they could go to any site.
Ms Windvogel agreed that oversight needed to be done.
The Chairperson the Committee to consider and adopt the minutes of the meeting of 4 June.
Ms Botha said that the minutes were fine and could be adopted.
Mr Allen seconded, and the minutes were adopted.
The Chairperson asked Members to consider the forthcoming Committee programme. She said that the next engagement would be on 7 August.
Ms Botha asked if oversight could be done on that day.
The Chairperson asked for agreement from the Committee, and said that the oversight would take place during their weekly slot. She asked for recommendations for site visits.
Ms Botha said that due to time constraints and other meeting commitments for Members in the afternoon, the sites should be chosen wisely.
Ms Bans agreed, and said she had another committee meeting scheduled for 7 August at 14h00.
The procedural officer said that they would be back at 13h30, and that the engagement would be scheduled to fit into this timeframe.
The Chairperson asked if they were going to visit the learning sites proposed by Mr Allen. She asked Members to make proposals for 14 and 21 August. She added that 2 September would be a constituency week, and that meetings thereafter would fall on 11 and 18 September. The Committee also had to consider a bill in October. Members needed to consider their commitments outside of the Committee before making recommendations.
Ms Botha proposed that on 14 August the Committee visit the forensic pathology services, and the programmes run that under these services.
The Chairperson asked the procedural officer to schedule this.
Ms Botha said that the WCDH had opened a new pathology laboratory, and she asked for oversight of the site. The Education Committee was busy drafting an invitation to the Health Committee to join them in a visit to the Red Cross Hospital on 10 September. She asked if the 10 September visit could be swapped for the Health Committee’s meeting on 11 September.
The Chairperson said a decision would be made after an invitation had been received. On 14 August, the Committee would visit the pathology laboratories and a briefing by the WCDH on the services offered should be incorporated in the visit.
She added that the Office of Health Standards and Compliance had sent a communication about a visit to the Committee to take place during October 2019. These visits were done nationally, where the national minister embarked on provincial outreaches. More details would be provided to the Committee in due course.
The meeting was adjourned.