The Standing Committee on Health convened for a briefing by the Western Cape Department of Health on the Western Cape Health Facilities Board. The purpose of the meeting was to give a status update on the appointment of the clinic committees of the Western Cape, particularly to Section 5(2) of the Act, which refers to the appointment of members of the Provincial Parliament to Hospital Boards.
The Western Cape Department of Health considers community involvement on a global and local level, as a major player in health systems. The Department's long term vision for 2030, is aimed at functional statutory structures, since it is a key enabling mechanism for community involvement. The legislation to enable this has been put in place.
The Committee was taken through the structure of new facility boards and clinic committees, an overview of clinic committees and hospital facility boards, the appointment of clinic committees in the province, training and implementation challenges
The Cape Metropolitan Health Forum (CMHF) said the Department faces an uphill battle to get community support. It urged the Department to work with CMHF, as it has the expertise.
Members of the Committee noted dismay at the lack of progress, and took the Department to task for what the Committee perceived as a continuation of the same problems pre-Covid. Members were dismayed by the lack of functional clinic committees (less than half are functional in the province) and called for best practice to be shared. Members asked how the committees were utilised during the Covid pandemic, and what the value of it was, the scope of the hospital boards and what other measures were looked at to increase community engagement on functionality. Further questions probed monitoring evaluation and terms of reference for nomination.
The Department was called on to ensure all boards were functional and properly constituted, and should be up and running as quickly as possible. Locals are the eyes and ears of the community, and it should be looked at as a matter of urgency.
The Committee resolved to get the lists of all functioning and non-functioning hospital and clinic boards along with proposed information on the expiry of board terms, so the Committee can nominate a candidate. It was recommended that the Department should institute a monitoring and evaluation system.
Update on WCHFB implementation
The Western Cape Department of Health updated Members on the status of appointments to the WC Health Facilities Boards and clinic committees. It said Community Involvement in Health (CIH) is recognised globally and locally as a key ingredient to well performing health systems. CIH is part of the vision of Healthcare 2030 – and that functional statutory structures are a key enabling mechanism. The legislative framework (Western Cape Health Facility Boards and Committees Act, 2016 (Act 4 of 2016), and associated regulations, has been put in place.
The presentation then outlined the legislative framework and the provision it makes for clinic committees. The structure of the new facility boards and clinic committees were also outlined. Section 5(2) of the Act referred to the appointment of Members of the Provincial Parliament to hospital boards. The section said: In addition to the members appointed in terms of subsection (1) the Provincial Minister may appoint to a Board –
- A member of the Provincial Parliament, nominated by the parliamentary committee concerned with health matters; and
- One or more councillors of the municipal council for the municipal area in which the hospital is situated, nominated by the municipal council or a health-related committee of the municipal council
-The nomination of MPLs for Health Facility Boards needs to be submitted in writing from the Standing Committee on Health.
-The Standing Committee needs to decide on which MPLs are to serve on which boards and submit the minutes of the meeting thereof to the Minister’s office. Thereafter, the Minister can appoint the MPLs to the respective boards.
- However, it needs to be noted that MPLs can only be added to a board if there are more than 50% of the board members who are community members. This is because sub-section 5(3)(a) of the Act states that: “The members appointed in terms of subsection (1)(a) must constitute at least fifty per cent of the total number of members of the Board.” Thus, if the board currently only has 50% of members who are community members in terms of clause 5(1)(a) of the act, then adding an MPL would result in the board being invalid.
An overview of the status of hospital boards and clinic committees was provided. There should be a total of 155 functional Clinic Committees in WC. There are currently:
-Functional (properly constituted and actively functional: 65 (Metro: 26; Rural: 39)
-Constituted but not functional: 13 (Metro:4; Rural: 9)
-Not constituted and not functional: 77 (Metro:15; Rural: 62)
The overall purpose of the Board is to ensure accountability of the health facility management to the community and responsiveness to the needs of patients and their families. There should be a total of 45 functional Hospital Facility Boards in WC. There are currently:
-Functional: 33 (Metro:14; Rural: 19)
-Constituted but not functional: 4 (Metro: 3, Rural: 1)
-Not constituted and not functional: 8 (Metro: 2; Rural: 6)
Looking at the status on the appointment of clinic committees in the province, the majority of the term’s newly formed clinic committees of the new Act are due to expire at the end of June, July or August 2021. There are two groupings regarding the advertising processes for statutory bodies:
-Advertisement for Committee and Board members where the structures were previously NOT correctly constituted.
-Advertisements for replacement of Committee and Board members whose terms are expiring - will also consider re-appointment of CC members for second term where appropriate.
Preparation for advertisement has begun. The advertisement will soon be placed in print media. The closing date for nominations will be six weeks from the date of placement of advertisement. In addition to being placed in the local papers, the advertisements will be put on the department website, Facebook pages and put on the notice boards of clinics and hospitals
- The interest amongst communities to volunteer has varied.
- The teething problems to get full functionality of committees (inadequate no. of members, lack of quorum for meetings etc)
- Challenges related to appointment of councillors to Clinic Committees
- In some instances, lack of remuneration seen as disincentive
- Training postponed in January due to the loss of our master trainer
- Also, Rural Health Services had requested the postponement of training due to the second COVID-19 wave
- Currently, CLOs are busy with community engagement around vaccination awareness
The Chairperson thanked the Chief Director for his commitment to restore the functionality of the various committee structures.
WCPP Legal Opinion
The Chairperson said Adv Romeo Maasdorp, Legal Advisor, Western Cape Provincial Parliament, submitted a legal opinion on the appointment of Members from the provincial legislature, to hospital and clinic boards, and asked him to report on this submission.
Adv Maasdorp said he thought Members received the legal opinion, and could therefore ask questions. Having listened to the Department’s presentation, he suggested one might want to benefit from the expertise of the provincial Department of Health's internal legal processes. If there was a difference of opinion the respective parties could debate those differences.
He asked for guidance from the Chairperson, and said he could give a summary, but felt the information provided was sufficient.
The Chairperson thanked Adv Maasdorp for his observations, and said it was important for the Committee to cover all angles, especially with all the relevant officials present. She said it might also be important for the benefit of the guests to have a brief legal summary.
Adv Maasdorp said his opinion is based on Section 52 of the Western Cape Constitution. He thought the Minister could use his discretion when it came to the appointing councillors to the various boards. The Act expressly provides for certain appointments. It relates to the number of people, and the various capacities served in communities, especially in areas of health.
Subsection two gives the Minister the power to appoint members to various health advisory bodies. Until the Minister exercises this function, the Committee has no role to play. It is the prerogative of the Minister, if one looks at the totality of the Act.
The Committee remains inactive until the onus shifts from the Minister to the Committee. It might be helpful if departmental officials could provide guidance on the intra-departmental dynamics, such as the manner in which the Minister exercised the power to activate.
Mr R Mackenzie (DA) said he looked at the minutes of 2018, as he had the privilege to serve in the legislature at this time. The relevant Act was passed in 2016, and yet the Act still creates problems. He asked if some of these challenges could not have been addressed, as it is exactly the same problems as mentioned in 2017. One can understand the impact of Covid, yet these are systemic problems identified prior to the outbreak.
Ms R Windvogel (ANC) said if she looked at page nine, only 65 clinic committees are functional. This is less than half. She noted dismay at this rate and called for best practices to be shared. She also asked for clarity on the number of functional and non functional committees.
Ms A Bans (ANC) said she shared Mr Mackenzie's concerns, and asked what the Department deemed as functional. She asked how the committees were utilised during the Covid pandemic, and what the value of it was; she also asked about the scope of the Boards, and wanted to know why Members were not remunerated; and how many provincial legislature members were appointed to these Boards.
Mr R Allen (DA) wanted more information on intentional grieving. He said it would be good to be briefed. He wanted to know if anything was done to get community members involved, besides the adverts which went out. He asked if the Department could establish if a lack of a Board or Committee impacted on performance.
The Chairperson noted disappointment at the lack of functionality. She asked what other measures were looked at to increase community engagement on functionality; and sought clarity on which month exactly the term of the Boards would end.
Dr Krish Vallabhjee, Chief Director: Strategy and Health Support, Western Cape Department of Health, said the Act created a lot of debate.
Regarding support measures to staff, he said virtual support sessions were held in the wake of the devastating impact of Covid19 on medical front line workers. The staff expressed gratitude to the Minister.
He recalled a project which would bring the various streams together, as local government level has capacity issues.
Adv Maasdorp said there would be a reason why the literal text of the Act gave the Minister discretion. What he picked up from Dr Vallabhjee was the nomination was given to the Minister, until such time when the Minister exercised the discretion. He spoke under correction, but in his view, if it was so urgent to exercise or not, it should be written as such in the Act. These Acts were deliberately written in a certain way. Until such time as the Minister exercised the function, the Committee had no role or responsibility to exercise, regarding any appointment of persons to any boards. This was the gist of his argument, if one looked at the totality of the Act and the drafted text. The Committee remained inactive and only started to activate once the Minister exercised her discretion.
Mr Mackenzie asked how the process would be taken forward to ensure these issues were corrected, and the clinical competence strengthened.
He called on Dr Vallabhjee to ensure all boards were functional and properly constituted, and should be up and running as quickly as possible. Locals are the eyes and ears of the community, and it should be looked at as a matter of urgency.
Ms Bans recalled asking a very specific question about how many councillors were appointed, and how many are still in the pipeline waiting to be appointed.
She noted dismay with the direction of the Committee discussion, which seemed to focus more on the legal issues. She thanked Mr Mackenzie for his input, as he could help to iron out some issues the presenter might have missed. She also asked for a definition of a functioning committee.
Ms Windvogel asked if there was a proper monitoring and evaluation system in place for clinics and hospitals boards, and if not, if due consideration was given to implement such a plan.
The Chairperson asked which month exactly the term of the boards would end.
Dr Vallabhjee said he picked up on what Adv Maasdorp said, and he will engage the Minister and maybe the Minister can offer relevant clarity.
He asked if he could furnish information on how many councillors were appointed at a later stage.
He said the Department has a database of all properly constituted committees, as well as the dysfunctional ones.
There was a determination to establish where the dysfunction lay.
The Department spoke to districts and appealed to it to appoint local residents as the focal point for these boards.
The local residents are very important as the Department needs the locals to follow up and engage with community structures. This was difficult to do from head office. Locally appointed people at sub-district level are crucial, as people know the local environment and can engage and ensure functionality. He was dismayed by the budget constraints, and welcomed the support from Members to be nominated to these boards. The Department would like to deepen the relationship with the committee. The Department will amplify its work through social media and ministerial roadshows. He liked Ms Windvogel's idea of using the best model. This is a great way to determine functionality.
All the councillors were appointed on the same day between the months of June and August therefore those three months were mentioned. There is also a process underway to reappoint councillors.
It was a struggle making these councils work. It is an ongoing process. At no point did the Minister say every board was functional. In some instances councillors might be appointed, but the Council itself might not be effective. It was a struggle to get community members involved in the constitution the Department, then to realise the application and nomination process must be reviewed. The necessary change was made.
Dr Douglas Newman-Valentine, Head of Ministry, said most hospital boards in the province have Members of Provincial Legislatures (MPLs).
The Minister did not effect any appointments with the new term and the new Act, as no nominations from the Committee were forthcoming.
The functionality of boards were monitored on a weekly basis from within the Ministry.
The boards had its value. Victoria Hospital Board secured a R2 million donation toward Covid19, as well as Karl Bremer, which instituted a staff support programme.
The Department coordinated various Whatsapp groups which sought to bring together the various spheres, such as district, and so forth. Best practices are shared here.
Ms Bans said she took note of Dr Newman-Valetine’s comments around no appointments made under the new Act. She felt it was important for the Committee to be involved.
She also asked to be briefed on the terms of reference used for the nomination, or appointments of Members to facility boards.
Ms Windvogel said her question was not answered. She wanted clarity on how the monitoring took place, and said many facilities were in dire straits, and hardly functioned, if at all.
Dr Valabhjee reiterated his earliest comment about the Department’s monitoring system being in place. The challenge he highlighted centred around the lack of capacity at local level.
Dr Newman-Valentine said he will furnish the Committee with the terms of reference.
Cape Metropolitan Health Forum input
Chairperson of the Cape Metropolitan Health Forum supported Mr Mackenzie's proposals. She said she received complaints from clinic boards from Macassar to Cape South, and referred complaints to the Department. She also said she was in possession of ministerial communication about non functioning boards cited as functional.
Input by the public
Another representative from civil society said during a meeting with Dr Cloete (Western Cape Head of department of Health) last year, Dr Cloete promised to work on clinic committees, together with the Cape Metropolitan Health Forum (CMHF), and to see what worked. He said the Department was well aware of the excellent working relationship which existed with the Department and CMHF.
Due to mistrust by community members, the Department continued to face an uphill battle to get community support. He urged the Department to work with CMHF, as it had the expertise. Budget cuts should not be the determining factor, and voluntary work requires no money. CMHF is ready to set up these structures, and calls on the Department to engage and visit communities.
Mr Mackenzie said the Committee should get the lists of all functioning and non-functioning hospital and clinic boards. He proposed information on the expiry of board terms, so the Committee can nominate a candidate. He also wanted the Department to get the attendance register.
Ms Bans wanted more information on the terms of reference which governs the appointment of MPLs.
Ms Windvogel asked the same question.
Mr Mackenzie explained how the process of nomination works.
The Department should provide a list of all boards, properly constituted but not functional.
Mr G Bosman (DA) said there must be engagement with the Whip's office to include other Members as well. He also wanted an attendance audit.
Ms Windvogel recommended the Department should institute a monitoring and evaluation system.
The Committee adopted its Report on a site visit from 28-29 October 2020.
The Committee also adopted its June 2020 - October 2020 Quarterly Report.
The Committee programme was adopted.
The Chairperson thanked Members and the meeting was adjourned.
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