Deliberation on the Western Cape Government, Department of Health Annual Report for 2018/19 provided the challenges faced by the Department, including a budget cut, burdened staff members and limited resources. The Department reported having a clean audit outcome for 2018/19.
Members were concerned about the budget cut and the impact it has on service delivery; accessibility for cataract operations in the rural areas; the staff safety; and employment equity in relation to the appointment of Africans in managerial positions. In addition, community members raised questions about community engagement; the appointment of MPLs on clinic committees and hospital boards and the number of clinic committees; the closure of health facilities in Hout Bay during unrest; and when it will extend the Rural Health Service plan to other rural areas and poor communities.
Department of Health 2018/19 Annual Report
Dr Nomafrench Mbombo, Western Cape Health Minister of Health, noted that the Department had a difficult time and faced several challenges in the previous year such as budget cuts, influx of people as the Western Cape is the third most populated, and the disease profile. There were outbreaks, such as the listeriosis and crime outbreaks, and gender-based violence cases. Burdened staff and no increase in resources to appoint more staff. The department was able to maintain a clean financial audit and despite all challenges face by the department, staff members have been resilient, and she concluded by saying thank to all staff members.
Dr Beth Engelbrecht, Head of Department, pointed out that there are more people that have complex health conditions in the face of reducing resources. This is the fourth year in a row that the Department’s budget has been reduced and that the patient counts in the the population are increasing. Achieving improved health outcomes and a clean audit is not easy to do. She stated that the critical thing is to thank the leaders in the department and the staff at the forefront. The department is aware that the staff is burdened and overwhelmed and that the resources are limited. She concluded by encouraging the management team and the 32 000 staff members in the Department to continue the good work.
Discussion on Annual Report
Part A: General Information, pages 10-31
Ms L Botha (DA) thanked the Minister and the Head of Department (HOD) for the overview and extended her gratefulness to the HOD for always being accessible. She congratulated the Western Cape for having the best health outcomes out of all nine provinces in the country. She appreciated the progress in the performance of 7 591 cataract operations. She asked what constituted the 5 332 complaints that the Department had received, with regards to attitude. She asked how many of the 484 946 patients transported with emergency care services were from red zones where ambulances need police escorts.
Dr Engelbrecht stated that the Department managed 18.9 million patient contacts and of that number the Department only received 5 000 complaints. However, each feedback received by the Department is regarded as important to consider how to continually improve the system and provision of services. She agreed that attitude is one of the complaints that was raised and that it was something that the Department continually worked on. Attitude is a large percentage (23%) of the complaints received. However, at times compliments are received about staff attitudes. The critical thing is that the Department regards every feedback as positive, if need be the Department engages with the individuals involved. However, the context where this happens is important. There are staff who have been attacked or verbally abused by patients, and an environment that is conducive for both staff and patients is needed. On the patients being transported to the red zones identified as hotspot areas for crime, the Department did not keep record of that because the there was no information system for that specifically. The red zones were largely in the metropolitan area which plays a big role on how long it takes for the medics to reach the patients. The Department is willing to consider what can be done to make an improvement on that matter.
Ms R Windvogel (ANC) asked for a list of the hospitals affected by the challenges mentioned on page 10 of the report, the reasons and the steps taken to respond to those challenges. On the challenge of staff safety, she asked how many cases of attacks on personnel occurred during 2018/19, in which areas and how the Department planned to respond to the challenge.
Dr Mbombo responded that health does not start at the facility, the health system starts at home and that is why the Department has home-based healthcare workers; school health services; and even people who have not gone to health facilities are also part of the Department's responsibility, this is inclusive of the private system. The health system is made up of many systems. All facilities undergo a lot of pressures and these challenges are at times seasonal. The health system is expected to respond to any crisis or outbreak, and at times it is difficult for the budget to accommodate some of the unplanned challenges. On staff safety, in most areas it is not that the staff are directly targeted, but that the environment the facility is in poses danger to the staff. The Department can report the number of incidents that have been reported, but there are staff that operate in an environment where the violence within the communities poses a threat to them.
Dr Engelbrecht stated that safety is one of the most critical concerns for the Department. More than R300 million a year is spent on security services, but the Department found that there were 1 600 security incidents last year. How does society respond if it regards health services as belonging to society? The Department provides support to the staff when they experience safety concerns, but society needs to do the reflection.
Ms A Bans (ANC) asked to know more about the plans for infrastructure projects: how many projects and in which areas; how many would address service pressures; how much money was being spent on them?
Dr Mbombo replied that there is document which has all the infrastructure projects at the different stages, where it is set according to the district, from A to Z.
Dr Engelbrecht added that page 129 of the Annual Report contains the details of the infrastructure programme.
Mr R Allen (DA) asked for better understanding of the scope and number of services that were provided through mobile clinics. He asked for more clarity on the initiatives undertaken to address the community related challenges.
Dr Gio Perez, Chief Director: Metro Health Services, replied that there are several different examples. He gave the example of the collaboration in the Vanguard area between the City of Cape Town Metro Police, the Department security staff and the Department of Basic Education, to create safe zones for the ambulances to access that community. The Department of Community Safety in the province also contributes to that initiative. The second example he referred to was the Klipfontein community as well as the engagement between the Police Forum and the police in Hanover Park and Gugulethu, where the challenges were taken up as community-wide interventions. In every area in the metro there is some level of engagement with the police service and the City of Cape Town Metro Police.
The Chairperson asked how regularly partners in rural areas are willing to work with the Department in rendering services to the communities.
Dr Mbombo replied that it was difficult to say how many, because it would be difficult to build proper infrastructure instead of mobile clinics in the villages, because most of the land is privately owned. There are however, partnerships in some areas, for which the Department did not have to pay, where the farm employers and other people assisted their communities and their employees to provide sub-services. In some cases, there could be a main clinic and satellite clinics which might have mobile clinics. She concluded that it was therefore difficult to know exactly what the scope is. The answer was the same in relation to the rendering of services to communities.
Dr Engelbrecht replied to the question about the extent to which the Department is working with the private sector to help create further reach into the community. There were examples in which farmers provide the primary services, or where the Department had worked with private companies who provided a mobile or fixed facility from where the Department’s staff could work. These are always linked to the primary health care facilities to ensure the data is always updated. She added that health is impacted by many factors, and it is not only about the rendering of services but also the prevention of illnesses in certain areas.
Ms Windvogel asked whether steps have been put in place to curb the identified challenges.
A Department official replied that the pressures are biggest in physical places such as certain hospitals that have more pressure than others. There are certain things that cause more pressures. It is a combination of a theme and a place. The theme and place show up at Tygerberg Hospital, more so than in other hospitals. As the management team, they must look at all the pressures and the places where those pressures are. The Department has formulated six important themes across all the areas. The first theme is the pressure on obstetrics services and natal services. The intervention has investigated the entire province to find out when babies are born, at which facilities, what the pressures are and so forth, pinpointing the specific places where the pressure is greater than other places. The second is the pressure on emergency sectors and the Department is about to go into recommendation on how to relieve the pressure from one centre to another. Linked to that is the pressure on emergency services. The other pressures are psychiatric patients, and the impact of violence on forensic pathology services. There is a detailed process for each pressure.
Dr Mbombo added that with individual pressures where it is urgent, the Department must act, and with others it might take longer.
Ms Bans asked how many clinic facility boards had been established and how many were outstanding. She asked what the Department is doing to mitigate the appointment of political members onto these boards which may risk them being the mouthpiece of political parties.
Dr Mbombo replied that all hospitals had hospital boards, where there might be one or two people that have resigned, and the Department would have to replace them, and for those whose terms are about to expire the positions are advertised. The new law suggests that the Department should approach the Standing Committee of Health in appointing a Member of the Provincial Legislature (MPL). After the 2016 law was put into operation, there have not been any appointments because the Department has placed a lot of focus on the clinic committee appointment. For the clinic committees, the ward councillor, according to the Act, are automatically appointed.
Ms Bans checked for clarity whether the Minister meant that all clinic committees are appointed, including in the rural areas.
Dr Mbombo replied that the boards are all appointed. The clinic committees are facing issues in relation to clustering, in which some clinics will function with the minimal number of the boards.
Ms N BakuBaku-Vos (ANC) asked if the Western Cape Health Department had done work in preparation for the NHI which seeks to accelerate universal health coverage.
Dr Engelbrecht replied that the main purpose for building the resilience of the health system is to take the partner [inaudible] into account. The partner works on increasing access, coverage, and quality. Access to primary healthcare is free and the Department also has a system where patients are assisted in terms of managing hospital accounts. The Department has been on a journey to universal health coverage for seven years and the NHI is also for the purpose of having universal health coverage.
Ms Windvogel asked what population is being referred to in relation to the 91.5% of citizens in the Western Cape that have access to healthcare within 30 minutes of their residences. What is the Department doing about the people in the rural areas who do not have this kind of access, because mobile clinics are not the ideal solution.
Dr Mbombo replied that this was data the Department received from the National Department of Health in terms of the access and coverage. The Department might get a one-day mobile clinic for a farming area, which is part of a satellite and a satellite is part of a main facility. Ideally the truck is always there on the one designated day and can be expected to arrive. However, each area has dedicated health workers. There are also patients who require level two healthcare and need to be seen by a specialist. The Department makes provision to transport them from their homes. There are also areas where there are very few patients, however, services are still rendered.
Part B: Performance Information, Pages 34 – 134
Ms Botha asked how many staff members were redeployed to the Saldanha Clinic.
Dr Engelbrecht replied that the Diazville Clinic was destroyed during protests and so its total staff had to move to the Saldanha Clinic, it was about 16 people.
Ms Windvogel asked about the increased caseload based on the year-on-year admission rate and what the chances were of the crisis re-occurring. She asked which facilities were closed due to increased protests and civil unrest; how long those facilities were closed for, and how many times were the clinics temporarily closed and the reasons for their closure.
Dr Engelbrecht replied that the section referred to forensic pathology services. Those were all the patients that die of unnatural deaths that were being sent to forensic pathology mortuaries. Violence in the communities had been significant which impacts on the number of unnatural deaths. She noted that it cannot be guaranteed that the violence would not occur. The Department is the recipient of the people who are injured from the incidents of violence. The backlog occurs because forensic pathology services is only a public service, so the Department cannot buy out the private sector. What the Department has done is to consider the extent and capacity, despite the financial challenges, of whether there could be more forensic pathology offices with a specialist, because the specialist must do the final scientific report. The Department has done good work to pull people from the rural areas to help in that manner. Societal changes are needed for the Department to change the situation. Protest actions often happen in the rural areas and in the metropolitan. The Department must ensure staff safety and that is why there is temporary closure of a health facility, for a period of two or three days, it depends on the context and the situation. In all the situations, the Department will work with SAPS and the Local Municipality to consider the best way of dealing with the matter. However, the Department does ensure to plan when there is a need for chronic medication. Hout Bay has been particularly under pressure in the past few years and often has to close and that is always because of protest action.
Dr Perez added that he gets a monthly report from all the managers. There would have been instances where health facilities have closed for several hours due protest action becoming a problem. It varies across months and areas. No facilities in the rural areas have been closed for more than a few hours at a time. In the metropolitan, protest action can become a chronic issue and staff members start taking strain in specific areas where there is repeat protest action on a regular basis. Hout Bay is an example of such an area.
Ms Botha asked if the Department was involved in the aftercare of patients treated for substance abuse. She asked how many patients had been admitted, went through the programme but did not complete and then were readmitted.
Dr Engelbrecht replied that the Department has indicated the impact that substance abuse has had on the emergency sector and especially the psychiatric services. An inter sectoral approach is required to reduce this burden. The Department works with the Department of Social Development in terms of the aftercare of those patients. The Department has readmissions for psychosis or psychiatric conditions and is trying to put in place an approach to ensure the maintenance of a record of the patients that come in more frequently. The Department also has specialists go to the homes of those frequent visitors to venture ways of ensuring that the patients do not relapse.
Mr Allen asked what steps the Department was taking to pre-empt the budget cuts to ensure that services continue what measure the Department was taking to address the budget constraints.
Dr Engelbrecht repeated that this was the fourth year that the Department faced budget cuts and has put in approaches and mechanisms on how to deal with those matters. In doing so, there are things that need to be done, the first is that the Department must be careful about the decisions on where to appointment of staff, because the staff cost is about 60% - 63 % of the budget. The rest of the budget is based on goods and services, looking at the most economical way for the Department to get goods and services. In that case, the Department negotiates to ensure that it gets the best contracts to negotiate the best prices for those goods and services. The Department is in continuous conversation with the national colleagues on the prospects of where the budgets are going, and in continuous communication with the treasury as well. The Department makes a strong case to prevent budget cuts. These are difficult conversations and decisions, but the Department tries as best at possible to start early to ensure that it responds positively.
Ms Bans asked for the details of the transgressions that the Department took.
Ms B Arries, Chief Director, stated that this a question that needed to be discussed later.
Ms BakuBaku-Vos asked which NGOs the Department was working with and if this meant that all Community Health Workers (CHWs) are now earning R3 500 a month. She asked for more information on the terminations and appointment.
Dr Engelbrecht agreed that all the CHWs earned R3 500 a month and that is the money is transferred to the NGOs and then paid to the workers. She replied that the terminations were H Burger and KA Jeens who terminated their services, and T Tladi was transferred to a different department.
Ms BakuBaku-Vos asked for details of the hospitals that could not achieve the performance target and the reasons for this and what the Department has done to address this. She also asked which hospital could not conclude the self-assessment within the reporting period and why. What structures had been adopted to address the challenges listed under comment on deviations (that is, incorrect patient contact details, movement of patients, and gangsterism and violence continue to impact negatively on the follow up of patients who have missed appointments for ART). In the Metro, the City of Cape Town has reported that suboptimal infrastructure and staffing cannot meet demands of caring for an ever-increasing cohort of patients on antiretroviral therapy (ART).
Dr Engelbrecht replied that the Department is working with the Office of Health Standards Compliance (OHSC) which is in the process of finalising the tools by which they will do the evaluation of health services. Two hospitals did not achieve the 75% and more on National Core Standards self-assessment rate.
Dr Perez stated that for the hospitals achieving more than 75% on the self-assessment, there are two parts to this. There are 33 district hospitals and the intention is that they must do self-assessments, then it is checked how many score more than 75%. One of the hospitals that could not do the self-assessment was because it burned down. The details for the other two hospitals with less than 75% can be made available.
Dr Perez said that many of the reasons are stated about the challenges in tracking patients on ART. Treatment is started and one wants to ensure that after 12 months the patient is still on treatment, and 48 months means four years later the patient is still on treatment. The Department has a recording system and the ability to check 12 months later or four years later are influenced by factors such as relocation. There are a range of factors that need to be considered. However, multiple systems are being put in place to track patients. The Department is also working on multiple partners in this area.
Ms Windvogel asked if the number of patients sleeping on the floor and on chairs in the district hospitals are looked at when the inpatient bed utilisation rate is considered, if this indicates that the inpatient utilisation rates are increasing and what is being done about this.
Dr Engelbrecht replied that often this is found, especially in the emergency centres, that patients wait for long periods of time and that they find it more comfortable to be on the floor. Once a patient is admitted, the number of patients admitted are taken as the top part of the indicator and the bottom part is the number of beds. In other emergency centres you find that a decision has already been made to admit a patient, but there are no beds available for the patient, because of extreme congestion.
Mr Allen stated that there seems to be a 50% difference between the planned and the achieved target for school health screening. The comment under Deviation states: “The school health screening package is provided according to needs”. He asked if the need is so high that it cannot be reached.
Dr Perez replied that the school health data is a technical data recording issue. The Department received an unqualified audit due to the recording of the school health data, therefore this was a resolution reached with the Auditor General, and not that the screening was not done. The Department holds that screening happens according to the need of the child rather than doing a complete screening when a child only needs a portion of it, the Auditor General disagreed with that. The data that is presented indicates that the Department is doing data for full screening and not according to partial screening.
Dr Mbombo added that every child in the rural areas will receive screening at least once a month. Some services might not be granted by the Department directly but there are other teams that provide support.
Part C: Governance, Pages 135 – 149
The Chairperson said this section would be dealt with by Standing Committee on Public Account (SCOPA).
Part D: Human Resource Management, Pages 152 -207
Ms BakuBaku-Vos asked what strategies are put in place to include the number of Africans in management. She asked if the note that the "biggest unintentional casualty is the human and caring factor" in the service also refers to staff attitudes and if so, how the Department had addressed the matter.
Dr Mbombo replied that with HR it becomes an emotive issue in relation to diversity. The Department has acknowledged that it is moving very slowly with regards to race, but that it is worth noting some of the strides that have been made. The Department has more females than any other department and the majority of them are Coloured females, which reflects the Western Cape demographic. She acknowledged that a reason might be that people stay longer in their senior management positions and that more must be done in terms of recruiting more Africans.
Ms Windvogel asked about plans to improve the staff response rate on the staff satisfaction survey as 7 379 responses were received (23.6% response rate). She asked why satisfaction is decreasing compared to the last survey.
Ms Arries replied that the volume of cases that the staff deal with and the pressures they experience affect them and the Department has a wellness program to support them. On staff satisfaction, one must be aware of the caseload pressure the staff are faced with. The Department is trying to acknowledge that staff are stressed as well as looking at how change and creating input into the system can provide them with support. The survey, which happens every second year, gives the staff an opportunity to voice their opinions. The response rate decreased between 2016 and 2018, therefore, the Department must find better ways to reach the staff. However, from those responses the Department can address the positive and negative areas.
Ms Bans asked what the reasons were for not adding clinic technologists, how many sessional pharmacists the Department employed and how much it spent on this. She asked why there are few Africans in the Department's top management and what plans exist to increase the numbers of Africans. What jobs are foreign nationals doing?
Dr Engelbrecht replied that if there is an urgent need, there is a way in which the person is added to provide the service. On use of foreign nationals and the type of skills, it is often clinical services where the Department cannot recruit for that vocation, but that is a small number.
Ms Bans asked for an indication of the exact number. She asked what the reason was for not filling critical vacancies.
Ms Aries replied that there are 100 people employed for this period for scarce skills. The Department has an agreement with other African countries and elsewhere, where individuals are employed on a contract to provide the services. It is made clear that they are employed in specific areas, and in most cases, on a temporary basis. With regards to the vacancy rate, the Department looks at where the critical need is for appointment. And the money is allocated where the need is.
Ms Botha asked if any of the people whose contracts expired have been absorbed into other recruitment. She asked if the sick leave patterns are monitored for "pay-day leave".
Ms Aries replied that the Department’s medical interns, registrars and admin interns form the large group of people on contract for training purposes. The Department does consider recruitment from that group; the Department can recruit some but not all the people.
Dr Engelbrecht replied about the profile of the management service and what the department is doing to improve African representation. There has been a slight increase in the number of African people in the current year. It is important to look at the figures at a Director level (level 13). There are often excellent candidates that can be shortlisted. However, one of the requirements from the public administration service is they must be a Deputy Director for five years, so we cannot shortlist that person even if they are brilliant. That is one of the areas that the Department has recognised as a challenge and it is trying to put in more people as Deputy Director, so that they may be able to apply for the Director position. The Department must ensure that the environment in which the staff are working is comfortable and that they feel they can excel. There are several opportunities provided for Africans to reach the SMS level. The Department also looks at the professional categories that need massive numbers. The Department does monitor the sick leave pattern, because it is known that some staff regard sick leave as a right. The authority and responsibility to monitor the patterns for unplanned leave have been delegated to local managers.
Ms Botha asked if one could assume there was a pattern of "pay-day and the day after pay-day leave".
Dr Engelbrecht replied that it was a slight possibility. It is a small number of days taken for sick leave and 84.4% is with medical certification.
Ms BakuBaku-Vos asked if African people do not apply or if they do not have the qualifications to be senior management staff (SMS). She agreed and was happy that most staff in the Department are female, however, she did not understand the reason for the small percentage of African individuals.
Dr Engelbrecht stated that in her previous response she did indicate the various mechanisms that the Department was putting on place. The number of SMS members in the Department is 65 of a staff complement of 32 000. This is a very small number of people and the Minister has indicated that several of them have been in the Department for an extensive number of years. To address this the Department was doing various thing such as the provision of bursaries, the Department invests a lot in leadership positions. There is a list of about 19 strategies that include bursaries and skills development.
Dr Mbombo added that in terms of the Department’s organisational structure, it is important to put out a call first because more doctors and nurses are need. There are also several other positions which are not enlisted because they are appointed by the universities. In some instances, there are African CEOs who are, however, not at the SMS level.
The Chairperson asked how the influence of safety and the budget impact the demand on services and would it be influenced in a centralised health system.
Dr Mbombo replied that for the past three years millions of Rands had been lost. The national sector has also lost billions of Rands in assets. When calculations are made, there are already financial constraints. If it is R1.3 billion, that is the total budget for three major district hospitals. If the budget is cut by that amount, the Department might have to close them down, but that does not mean the patients will disappear, they will go elsewhere. Maintenance must be done to keep up. For the Western Cape, the reputational damage is already there. The Department is in a situation in which they do not know how the staff is coping. The number of staff available in proportion to the challenges faced, does not correlate. There needs to be more staff, but the Department cannot spend more than the designated budget on the staff component. The health system in South Africa is in distress. The entire system is suffering due to various external factors.
Dr Engelbrecht stated that the Minister was explaining the benefit of local decision-making at the district level. Whatever system is developed in the country must be at a place where there can be decision-making locally and a response to the needs of the public. The Department finds that at a national level there are decisions made about other departments, but not about Health. Decisions must be context specific and must be made in the best interest of the patients. That is why the Department focuses on decentralisation to ensure the continuity of care and access for patients.
Ms Bans asked what kind of grievances had been lodged.
Ms Aries replied that people lodge grievances about their salaries, job level, outcome of performance assessment, recruitment and selection. Those are the type of grievances the Department deals with.
The Chairperson said that it would be dealt with by SCOPA.
Public Hearing: Round 1
A community member asked for clarity on the Community Oriented Primary Care (COPC) as it relates to the community-based services that are currently rendered through the Department; where the 20 learner sites are in the province; and if there was any documentation on how the sites were identified, by whom and for whom. Is there an indication of whether the senior management positions held by females are decision-making positions? How did the sales of capital assets take place, was it through tenure or auction? On the Western Cape Rehabilitation Centre (WCRC), if the Department knew that the contract was going to come to an end, was there not enough time to put new measures in place to ensure it is renewed? On the Belhar site, is there any progress and what is the community’s role in it? On Rural Health Services (RHS), if the adolescent project was funded by the Global Fund, how does this impact the adolescents, and is there any alternative form of care for adolescents in the rural community? Is the process around cataract removals only a public private partnership process or is there a package of care for the rural communities on essential services? Has the Department addressed transformation and how transformation relates to community involvement?
Dr Engelbrecht replied that there are 19 learning sites, of which four are in the metro and 16 are in the rural areas. The selection was made based on where the population is biggest. These are critical learning sites where the communities are the primary care. The primary care is a change of focus targeted at penetrating into people’s homes where the service can extend to support families. The COPC is not only about health, but also addresses related social aspects.
Dr Perez stated that there are technical reports from the rural areas. The management is reflecting on the learning from the 16 rural sites and the four sites in the metro. One of the key factors is to connect the community-based services with the facility-based services to get better outcomes for the population. There needs to be deliberation on how to land some of the learnings in a better way by looking at community engagement. However, there are critical reports that reflect on the learning sites.
Dr Engelbrecht stated that the 65 senior management in the Department carried all the responsibility for the 32 000 staff members as well as the population. For an individual to reach the level of being an SMS member or director, there are requirements that need to be met. The position is about decision-making and making delegations on finances, people and services. Everyone in those positions, including females, make those kinds of decisions.
Dr Mbombo added that on the COPC, the Department would have to go back to the basics and in real terms be able to involve the community, including the civil society structures.
A Department official replied that there are government structures throughout the system to which sales are referred to. There are different methodologies of disposing of assets and auctioning is one of those. The Department was in the process of awarding a new service provider that is expected to come in the following year.
Dr Engelbrecht added that the Department had started on the new tender process 18 months before the contract expired due to the complicated nature of the matter. The question about the Belhar site is linked to Tygerberg hospital and there will be a new Tygerberg Regional Hospital that will be based in Belhar. The site has been identified where there is a lot of human settlement, and the Department has been allowed access to the site for the new hospital.
A Department official added that in the previous year the human settlement fund had formed a development in which they created electricity, water and sewage connections that would be part of the hospital. The Department is now working on the clinical brief and the technical brief. Once completed, they will be submitted to the National Department of Health for confirmation.
Dr Engelbrecht stated that the community is involved in such processes is that the way that the Department responds is to indicate that the plan is to have a regional hospital that would be part of the Tygerberg facility.
On the youth and the Global Fund, Dr Perez replied that a learning site intervention is being initiated. It works with two high schools and look at increased HIV testing in those schools, the community and youth in those areas. A lot of the work was done to mobilise people to be involved with HIV testing. The money has been ceased, but the activities are still ongoing. The activities are being absorbed for the broader youth development strategy for that area. This is leverage of the relationship between different departments in the government.
Dr Engelbrecht replied that there is package of service providers for cataract removal and depending on the complexity of the procedure that must be done there are more specifics at a central place. Cataract removal happens in various hospitals in the rural areas, it does not happen at the clinic level, because it is a specialised capacity. It is available, however because of the complexity of the cases, patients must be transported for the service. The Department does have a transformation journey. This has been a three-year process, in which service transformation ensures access to services. The COPC is also part of the service transformation. The Department does however recognise that it is an area that needs to be worked on.
A community member asked what will happen about the budget cuts to communities and the provision of chronic medication.
Dr Engelbrecht replied that the budget had been cut because the budget allocation to the Department decreased from the previous year. This means that at a national level, the amount of money for the provinces has been reduced. Due to this, the Department must consider what the priority is in terms of allocating money. For chronic medication, the national tender for certain medications is handled by National Treasury. There was a hiccup, nationally, and unfortunately the Department is on the receiving end. The Department does ensure regular communication with the public about distribution and tries to be as responsible as possible to ensure that the medication does reach communities.
Dr Perez added that there is a marker that tracks how many items are in stock at the Centralised Chronic Medicines Centre and a vehicle is allocated to transport the essential medication.
A community member asked how the Department manages to achieve releasing property and providing shuttles amidst the budget constraints, but yet the Department closes Hout Bay day hospitals. The community of Hout Bay was not consulted when the hospitals were closed. If the Department does not have funding why is it going to court to prove that it provides health care?
Dr Engelbrecht replied that there had been unrest in the Hout Bay community that affected staff and that the well being of the staff is the Department’s highest priority. Measures need to be put in place to ensure that the staff are in an environment that they feel is safe for them. Not all decisions are taken by the management in the Department and that it depends on the level of authority that is required for a decision. In this case, there is a local sub-structures director and a sub-district manager in the space to make decisions. However, the Department is very aware of the situation. There are steps taken to ensure that the space is accessible, and that the staff are working in a space where they feel that their safety is not at risk. Those are the considerations that the Department has going forward.
A community member asked how many of the staff that were dismissed for misconduct had scarce skills – how is a nurse that has worked for 20 years with a scarce skill dismissed?
Dr Engelbrecht stated that the Department follows due process on labour and is audited by the Department of Public Service and Administration as well as the Public Service Commission that checks in with the Department’s HR processes when there are any disciplinary processes. The process of fairness to the staff is there and the Department works with the unions and members of the staff’s representatives.
Dr Mbombo added that the case was as old as 2015 and that different stakeholders had met with the Department. There are about 113 cases of dismissal and it would be unfair to only address one case.
A community member asked when the Department is planning to extend the Rural Health Service plan to other rural areas and poor communities. Empilisweni Clinic faces a challenge of lack of services.
Dr Engelbrecht replied that Transnet provides a service in which one of their trains is used throughout the country to deliver healthcare services. Like Empilisweni Clinic, many clinics in the rural areas close at 16h00. The Department will see if these hours can be extended. There are however, home based community workers that go to the patients’ homes as an extension of the Department.
Dr Mbombo added that there are four main clinics with satellites. She acknowledged that there were challenges and the planning must be based on whether the population is increasing, but of priority is the extension of the clinic. The Department must consider how to ensure that sub-services are provided.
Public Hearing: Round 2
A community member asked what a community-oriented approach entailed. The challenges that the sites face are the role of the community and the community needs to play their role of engagement. She expressed the worry that the Department decides based on the needs of the community, and that the community has no input. “Where are the clinic committees?” It should be an indication to the portfolio committee, that plays a critical constitutional oversight role, that something needs to be done about community involvement. The portfolio committee needs to protect the communities with their role of ensuring community participation. She asked where the four CPOC sites are in the metro, whom of the hospital board are on the sites, whom of the clinic committees are on the sites; and if the community should not be playing a role in the integrated role of rendering services to the communities.
She acknowledged the challenge on the performance of post mortems and asked if the turn-around time had improved and how the families were being notified of the outcomes of the results, once the post mortem examination has been done. She also asked if the quality assurance residential facilities have a grip on the need of mental health services. Whether the Department is aware of the minimum conditions of service and what burden was placed on the facilities during this time. Whether there were any recommendations based on the results of the Clients Satisfaction Survey and if they were implemented. She asked where the Ideal Clinics were in the metro or the province, if the Clinic Committees were not fully appointed. The Hospital Facilities Boards Act does not make mention of members of provincial legislatures (MPLs) in the composition of local facility boards and asked how this Act relates to the Western Cape Health Facility Boards and Committees Act, 2016 and the power that MPLs have on the hospital boards. She asked if there was a report on the First 1000 Days Initiative and if there was a change in behaviour from parents on the immunisation of children under 5 years of age. Are children under 5 years tracked? How does the Department respond to the staff seeking care? How are folder transfers done from one facility to another? Why are there still many children under the age of 5 years that die from pneumonia?
A community member stated that when there was protest action in Du Noon there was access to the facility area and that the manager of the facility engaged with protest leaders, there was no threat. Therefore, why is staff safety a concern at the facilities in Hout Bay but there is not a concern in Du Noon. There has only been four protest actions in Hout Bay in the past three years. The Department must be honest. The closure of the facilities is not due to unrest but because of the Department’s failure to build the public clinic that the HOD referred to. The Department is using this to fast-track the development of the polyclinic and combining two facilities to the disadvantage of the community. If the Department is serious about the engagements, they must be willing to hear what the community has to say. The money from the Department must be used more effectively.
A community member asked how the Department addresses employment equity in the employment of African nurses and individuals at management level in rural areas, because of language barriers.
A community member stated that nurses, especially in clinics, experience a lot of stress which at times leads them to psychiatric clinics and sometimes managers also add to the stress of the staff members. She asked what the Department was going to do about the staff members at the clinics. The quality of services given to patients is reduced because of the caseload and lack of time.
Dr Mbombo replied that the community starts from the people that have been serviced, considering that the Department would not be able to engage with all 6.7 million of the people that are being serviced. The Hospital Act makes a provision that 50% of the clinic committees and hospital boards are community members. Those are the individuals who represent the voices of communities. The legislation has changed, because previously it did not include clinic committees, but does now. As it is the first time that the Department engages COPCs, they are experiencing hiccups; however they learn from those challenges. In addition, there are requirements for the ministry office appointments. The people of reference are the ones in the committees and they are representatives of the communities. Section 2(a) of Facility Board Act contains the clause about the appointment of MPLs in committees. The MPLs are not part of the Clinic Committees but can form part of the board, but they will only be appointed if they meet all the requirements. These individuals must be nominated because it gives them an obligation to respond to the structure that nominated them.
Dr Engelbrecht stated that the Department is aware that the staff is under tremendous pressure and is suffering moral injury, and that is why the Department is investing millions of Rands to support staff when they have post-traumatic stress disorder. The staff’s wellbeing is the Department’s utmost priority. The case overload on staff is recognised. She had a full report on the training of clinic committees and programmes have been tested and ensured to reflect the Western Cape communities. The turnaround time for the post mortems has decreased and the staff consistently engage with the families on the progress of the post mortem examination. There are non-governmental organisations that are explicitly contracted to render mental health services in the communities and funding is then transferred to those organisations to ensure the rendering of services. The staff satisfaction survey is replied to the same way that the Department responds to the Ideal Clinic findings. There is a quality improvement plan for all the findings to see how the Department can improve. The staff satisfaction survey is a good way to receive feedback.
Dr Perez stated that the Department regards the First 100 Days Initiative to be an important programme. This programme is being done in collaboration with other sectors to get the best health outcome for mothers and children, and there are four learning sites for these. From this initiative, there are many things that the Department is learning, such as how to have an involved programme for everyone. What the Department tries to address is how to ensure that community members are involved in such programmes. The Department expected 6 000 cases of pneumonia but reported more than 14 600 cases. Therefore, the Department is now reporting pneumonia cases more accurately and this has to do with the ICD-10 coding which allows for the recognition of more cases. This is therefore a positive thing, but children dying of pneumonia is still an issue so when working with primary health care, these are the things that should surface to reduce these cases.
Dr Engelbrecht explained the folders remain in the facilities that they are in, they do not transfer with the patient. The Department intends to start using electronic systems which creates access to the folders, as well as electronic discharge. This is still work in progress. The Department has been looking, for over seven years, at which sites are available in the Hout Bay area to have a large enough site for a community day centre for the community. The best has been found and engagement with the City of Cape Town has taken place, however the process is taking longer than what has been anticipated.
Dr Perez added that protest action and violence in the surrounding areas amounted to a total of seven occasions and only two resulted in complete closure of the facility and the remaining five were with service interruptions. Other alternatives are being explored, the process is evolving, and communication will be made.
The Chairperson encouraged the members of the community to work hand in hand with the Department to solve these issues. She thanked the Minister, HOD, the Department delegation and the community members and adjourned the meeting.
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