Department of Health 2020/21 Annual Report

Health (WCPP)

17 November 2021
Chairperson: Ms W Philander (DA)
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Meeting Summary

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Western Cape Government Departments 2020/21 Annual Reports

In this meeting, the Committee considered the 2020/21 Annual Report of the Western Cape Department of Health.

In her opening remarks, the Minister reflected on the positive and negative aspects of the year under review, which had been dominated by the COVID-19 pandemic. Among the positive aspects were the lessons the Department had learned and the relationships it had forged with the private sector. Among the negative were the effects of the pandemic on society, the increased pressure on the healthcare sector, and the effects of disinformation and misinformation on the public’s trust in medical practitioners. She said that the Department had managed to continue to provide other essential care services even while responding to the COVID-19 pandemic, and it had also achieved a clean audit.

The Committee discussed the Department’s annual report section-by-section. Among other things, Members asked about vacancies, the use of contract workers, occupational health and safety, the representation of women and Africans on the staff, and the Department’s underspending in 2020/21. On service delivery matters, Members asked about the restructuring of healthcare facilities, the availability of emergency medical services, and the reintegration of provincial and municipal healthcare services. The discussion was long and sometimes emotional, and all participants expressed wholehearted gratitude to the province’s healthcare workers. 

Meeting report

The Chairperson led attendees in observing a moment of silence in honour of all healthcare workers, including those who had died.

Opening remarks by the Minister

Dr Nomafrench Mbombo, provincial Minister of Health, said that the annual report covered the period between 1 April 2020 and 31 March 2021 – a year which had been dominated by the COVID-19 pandemic. Much had changed in the country, especially during the hard lockdown. During the second wave of COVID-19 infections, many healthcare workers had been infected and died. Vaccinations had begun with the Sisonke project on 17 February and, and had been extended to senior citizens from 17 May. The events of the past year could be relayed in three categories: the good, the bad, and the ugly. 

She said that the bad was the effects on families and on all social spheres – gender-based violence, alcohol abuse and the unemployment rate had all risen during the year under review. It had been necessary to de-congregate the healthcare system to prioritise the pandemic, and many things in the Department of Health had to be done differently. Elective surgeries were delayed, hospital visits were limited, and hospital workers had to strike a balance between doing their jobs and providing emotional support to their patients. The third wave of infections had brought the hard task of deciding how to allocate a limited number of ventilators. Oxygen had been in very low supply nationally, and private and public hospitals had to lend each other oxygen when the one facility ran out. Many healthcare workers had died in the past year, and others – including the Department’s Chief Financial Officer – had retired.

The ugly truth was that, for the first time, people were questioning the health system and clinicians. When patients were diagnosed with something like diabetes, they trusted practitioners’ advice. But COVID-19 had brought a lot of scepticism among the public, and people from plumbers to security officials questioned the diagnosis and the recommended interventions. A lot of “fake news” was being spread, and people were perpetuating incorrect ideas. The pandemic had been heavily politicised by political parties, who used it as a “football” to attack one another. Personal protective equipment (PPE), needed for everyone, had been stolen, even though the healthcare system needed all the resources it could get.

The good in the pandemic was the lessons that had been learned. The Department had learned to do things differently. For the first time, there had been a good working relationship between the public sector and the private sector. When there was a shortage of critical care or intensive care unit (ICU) beds in the public sector, there was comfort in knowing that there would be available beds in the private sector. When private institutions could not take on any non-COVID-19 patients, they could go to public institutions, where beds would be available. There had been a lot of collaboration with civil society organisations, non-governmental organisations (NGOs), and contract workers, who had dispensed medicine packages for over two months. The Department relied on contract workers for screening and dispensing medications. It had also worked closely with the university, reaffirming the importance of evidence-based interventions. It had built a hospital in a month, and, using internal capacity, had created a centralised dashboard to record all COVID-19 cases. The period under review had demonstrated the agility of the health system. Across the province, all healthcare workers had been present and involved in the COVID-19 response – they had not stayed home, because they had wanted to help.

She said that, between the second wave and the third wave, the Department had realised that there were many interventions that could not be compromised on, despite the ongoing de-congregation of the health system. These included immunisations and HIV testing. The Department had also assisted the social sector with disability grants for medical personnel. The good news was that immunisation and other crucial packages, such as HIV testing and tuberculosis treatment, had never been suspended in the rural areas. Mobile clinic services were still rendered.

She concluded that nobody would ever want to relive the 2020/21 year. Though it had brought people together and taught the government lessons, it had been a very difficult year. It was “amazing” that the Department had achieved a clean audit under these circumstances.

The Chairperson thanked Minister Mbombo for her open and extensive reflections.

Opening remarks by the Head of Department

Dr Keith Cloete, Head of the Western Cape Department of Health, said that it was a privilege for him to table the annual report for the first time as the Department’s accounting officer. The report reflected a “story of humanity.” He acknowledged Members, the Department’s management team, and its 34 000 staff members in the field. Adversity brought the best of humanity to the fore. The period under review had taught Department officials the importance of being kind and human, and the importance of taking seriously their job, which was to look out for others, especially for those who were most vulnerable. The health sector had reconnected to its purpose of serving the people of the Western Cape.

He welcomed the oversight of the Committee and other entities, including the Auditor-General, the Human Rights Commission, human rights groups, the Public Service Commission, and the Public Protector. In 2020/21, the Department had probably met with the Auditor-General more than anybody else. These institutions helped to keep the Department accountable, which increased the public’s trust and helped healthcare workers to be proud of their workplace. The Department aimed to have its patients feel proud to be served by the public health system. It had prepared its annual report on the basis of an ethical code, by which it aimed to serve selflessly and not for personal gain. 

Discussion: 2020/21 annual report

General comments and questions

Ms R Windvogel (ANC) apologised for being late – she was going through a difficult time due to the death of a colleague on the fourth floor.

She asked whether there were any decisions that the Minister would implement differently if she was given another chance.

She said that people were not adhering to physical distancing. Was there anything that the Department was doing to enforce the distancing measures? 

She asked about the risk of COVID-19 transmission in densely populated settlements. What engagements had the Minister had with human settlements departments on the densification of informal settlements? 

In reference to the last paragraph of page 15 of the report, she asked what the Minister and the Department had done to appreciate the dedication and self-sacrifice of nurses. Dr Cloete had mentioned that the Department wanted its staff to be proud to be associated with it. What was the salary range for nurses in the Western Cape? Did the Minister not think it was time to re-evaluate the nursing posts, and improve grading and salary levels? Many nurses had died at the beginning of the pandemic because the Department had failed to protect them. Members received a lot of complaints from nurses, who said that they were forced to report for duty even if they were exposed to COVID-19, and that there were delays in cleaning hospitals after someone tested positive for COVID-19. Did the Minister believe that the Department owed an apology to the families of those who had died? What would it take for the Department to build a wall of remembrance in honour of the front-line workers who had died fighting COVID-19?

   The Chairperson extended the Committee’s condolences and sympathies to the family of Ms Windvogel’s late colleague.

Mr R Allen (DA) commended the Minister and Dr Cloete for remaining unfazed in the face of adversity. It had been an extremely difficult year for many people. He commended everybody’s work over the last year, from the Minister and senior management right down to the lowest level. He had seen Dr Cloete on television, and heard him on the radio, many times. Communication had been necessary to ensure that members of the public felt safer, knew what was happening, and were equipped to deal with the COVID-19 pandemic. The Department had shared information adequately and openly. The audit outcome was also highly commendable. 

Ms L Botha (DA) acknowledged the Department’s 34 000 front-line workers. As somebody who had been personally affected by COVID-19, she wholeheartedly thanked the healthcare sector. She was glad that the opening remarks by the Minister and Dr Cloete had not been clinical and had come “from the heart.” They were the leadership that the healthcare workers needed and that the rest of the province needed. She commended the Department on the clean audit, and commended healthcare workers for going beyond rendering clinical services. The Department was accessible – when she called, it answered.

Responses

Minister Mbombo thanked Members for their words of support, which made a difference to the healthcare workers. 

To Ms Windvogel’s first question, Minister Mbombo said that the COVID-19 pandemic had disrupted her initial “dream” for the Department. Following the 2019 elections, the DA had come in with a manifesto that it had wanted to implement across provincial government. Upon her appointment, she had had her own priorities, the most central of which was universal health coverage – that is, affordable, accessible, equitable, and high-quality healthcare services across the province, in line with the Ideal Clinic model. The province had promised the National Health Council (NHC) that it was possible to do National Health Insurance (NHI) differently, and had offered to pilot it in the Western Cape. The Eastern Cape and KwaZulu-Natal had also joined the pilot, and there had been high-level meetings. Plans had been in place, involving the private sector, employers, and others in social insurance. She had been “so excited” to implement those plans, and had now asked her team how the Department should go about resuscitating the plans. The NHI pilot might no longer be of great interest at the national level, but it still had to be done – universal health coverage was “the way to go” for the South African healthcare system. There was currently a two-tiered system, with most of the population uninsured. However, especially in the current economic circumstances, the public healthcare system would probably end up absorbing insured patients, too. For example, she was getting frustrated with the high costs that she had to pay for private healthcare services. She had ultimately decided that for something like ear irrigation, she would prefer to go to a nursing assistant at a public hospital than to a specialist who would cost thrice as much.

She said that, apart from universal health coverage, her vision for the Department also included community-orientated primary care. Healthcare was not just the business of the Department. Communities, civil society groups, and everybody else had to be on board. Under the principle of subsidiarity, community-oriented primary care had to be localised. In the Garden Route, the district management and its partners needed to “come up with something.” All districts had at least partly implemented it. The Department had met with all municipal councils on community-oriented primary care. Both local and national government had to be involved – it called for a whole-of-government approach. The Department of Social Development also needed to be involved, especially in the first 1 000 days of implementation. On the administrative side, the Department had already completed its management efficiency alignment project (MEAP). Previously, the system of accountability had been complicated, with the division between level-two regional hospitals in each district and level-one district hospitals in its sub-districts. For one example, there had been an alleged rape case at Paarl Hospital, and the district management had refused to intervene on the basis that it was a matter relating to a level-two hospital. Yet the case had also involved a family physician who reported to the district, not to the local hospital, and who had been doing rounds in another hospital. Integration could resolve many such issues and help provide more efficient care to the public. Following the restructuring, the hospitals would report to the district. The process was ongoing, and it had taken a very long time. However, the Department’s relationships with organised labour had improved during the COVID-19 pandemic.

To Ms Windvogel’s second question, Minister Mbombo said that non-pharmaceutical interventions like physical distancing were the first line of defence against COVID-19. However, although the Department could work on its communications strategy and recruit contract workers, people’s compliance with the interventions was generally outside the Department’s control. There was a need for other departments and sectors to collaborate and take responsibility. This was the case, for example, with the situation at schools and the situation in taxis – the Department had strongly opposed the decision to allow public transport to operate at high capacity, but it had been overruled. The COVID-19 pandemic was a societal issue, not a health issue. If the Department’s beds were occupied to 20% or 30%, it would recommend that there should be a curfew and stricter regulation of alcohol sales, in order to reduce the number of trauma cases. Whether these recommendations would be implemented was outside the Department’s control, but it made such recommendations based on the data.

To Ms Windvogel’s question about whether the Department had engaged with human settlements departments, she said that the Department had engaged with everybody. In the Western Cape government, there had been extended COVID-19 Cabinet meetings, involving the districts and mayors. There was an integrated hotspot strategy. Even the provincial Department of Economic Development and Tourism had been engaged on an issue at a Shoprite in Dunoon. The Department of Health had to engage widely, because it ultimately absorbed the impact of all social ills.

To Ms Windvogel’s question about recognising nurses, she said, the Department was responsible for human resources under the Public Service Act and the National Health Act, but some issues, salary determination among them, were national issues. When she was a nurse, she had belonged to a union, where she and others had fought against a pilot programme which required nurses to train for four years, only to end up with lower salaries than entry-level pharmacists. The unions had to fight for the nurses in collective bargaining forums. The occupation-specific dispensation had not been revised, and the unions had not objected. The provincial government could not itself do anything about salaries. However, the Department had implemented wellness programmes for staff during COVID-19. It had held webinars on mental health. 12 589 healthcare workers had been infected with COVID-19 cumulatively, and many had died. That had had a very big impact on the staff. COVID-19 would remain with everyone – especially in respect of mental state, inequality, and poverty.

On protecting and recognising the sacrifices of staff, Dr Cloete said that the Department took the issue very seriously. He and the entire senior management had met with organised labour from the very first week of the COVID-19 outbreak. They had had an open conversation about staff’s anxieties, acknowledging that the pandemic should not be an issue of contestation between staff and management. One of the anxieties at the beginning of the pandemic, when not much was known about COVID-19, had been about PPE. That was a difficult conversation to have – it was difficult to prove that somebody had died after catching COVID-19 at a hospital, rather than in a taxi or elsewhere. The Department had engaged openly with its staff, and he doubted that any member of organised labour would say that the Department had not been honest and open in that regard. The anxiety around PPE had dissipated when people had realised that they could be infected anywhere. Nurses had started to worry that they were more exposed to COVID-19 in public spaces or at home than they were at work. It never became about blame, and labour and management had worked together. He had been interviewed after the first death of a nurse at Tygerberg, and the interviewer had said that the nurse’s family felt let down by the system. He had given an honest response: that what had happened to the nurse was shocking and painful for everybody.

He said that he thought the Department had done what it needed to do to protect its staff, to stabilise the PPE situation, and to reach an understanding with staff and navigate the staff’s anxieties. The management had “walked the journey.” As the pandemic progressed and the science evolved, the Department had moved from a physical protection approach to a new occupational health and safety policy. There was a technical committee, on which organised labour was represented, at which the Department worked out health and safety guidelines.

He said that the Department recognised the individuals who had died and the impact that their deaths had had on their families and communities. It would seriously consider Ms Windvogel’s proposal for a wall of remembrance. That would allow dignity and closure in acknowledging those who had died while serving their communities. Apart from symbolic recognition, the Department had taken a collective decision to give every staff member two days of leave. The staff had appreciated that gesture.

Part A: General information (pages 9-25)

The Chairperson tabled Part A of the Department’s annual report and invited Members to discuss it.

Ms Botha asked whether the behavioural change campaign (see page 15) had been successful. If it had, what lessons had been learned from it? She commended the Department for incurring no unauthorised fruitless and wasteful expenditure (page 19). Finally, she asked how the number of vacancies (page 26) had affected the Department’s operations over the period under review.

Ms N Bakubaku-Vos (ANC) asked whether there was likely to be a fourth wave of COVID-19 infections before the end of the year (page 16), and whether measures were in place to respond to it. She believed that the best weapon against COVID-19 was vaccination. What progress had there been on the vaccination drive? Were there enough doses of the vaccine? Had any expired, or were any set to expire soon? What as the plan to get more people vaccinated?

She noted that of the Department’s 33 615 employees, 65% were health professionals and 35% were administrative staff (page 16). How had the number of employees been affected by the extensive cuts to employee compensation budgets that were being implemented across the Western Cape? How had the number varied between 2014 and 2021? Moreover, 11% of the staff were not employed permanently. How many of those were seasonal workers? How much did the Department spend on permanent staff and on seasonal workers? She also wanted a breakdown of the positions occupied by the 13% of employees who were white. How many Africans occupied senior management and top management positions?

She asked how much of the Department’s expenditure on the infrastructure response to COVID-19 had been spent on long-term solutions in the healthcare system. Why were there still people sleeping on the floor in Khayelitsha District Hospital and others? How had the overall expenditure improved rural health? How had COVID-19 affected the maintenance of healthcare facilities, especially old ones like Tyberberg Hospital and Groote Schuur Hospital?

The Chairperson reminded Members only to ask questions pertaining to the 2020/21 financial year.

Mr Allen said that the Department reported 9.6 million primary care contacts in the year under review (page 16). However, he assumed that this figure double-counted people who had had multiple contacts. How many people had used primary care? 558 732 patients had been transported (page 16). What was the average waiting time for the period under view?

He noted that 89% of Department staff were permanent staff (page 16). How did this permanent capacity compare with that of other health departments across the country? Also, could the Department explain whether and how it provided assistance to other provincial health departments?

Ms A Bans (ANC) asked about the under-expenditure of R250 million recorded on page 18. How could the Department justify this under-expenditure in such a difficult year? Would the unspent funds rollover to the current financial year? Where over-expenditure was the result of theft (page 19), what had been stolen, and in which hospitals?

She noted the reference in the report to the Department’s strategic plan for 2019 to 2024 (page 19), and asked whether the Department could tell Members the “gist” of the plan.

She asked the Department to prepare a report for the Committee on the public-private partnership mentioned at the bottom of page 19. That report should include the comments that the Department had received from the National Treasury, and the response that the Department had sent. When would the building project commence?

Mr M Xego (EFF) asked how advanced the Tygerberg Hospital project was (page 19), and what possible obstacles there were to its implementation. 

On the Department’s vacancies (page 26), he asked how long the vacancies had existed and whether there was a plan in place to fill them. Did the vacancies not hinder service delivery?

Ms Windvogel asked where the facilities referred to on page 20 would be built. Were there plans to build more such facilities in remote places? In the Karoo, for example, patients spent time on the floors while waiting for ambulances.

She asked whether there was a risk that COVID-19 would spread in mortuaries where the corpses of COVID-19 patients were kept (page 20). What measures were in place to mitigate the risk?

She asked how the shortage of forensic personnel in the Western Cape was going to be addressed.  

The Chairperson asked about the R99 million in Programme 1 mentioned on page 18. The bulk of that amount was linked to administration. What were the causes of that figure? Did that include elective health services?

Responses on Part A

Minister Mbombo said that behavioural changes began with the public and staff. At the beginning of the pandemic, little had been known about COVID-19. It had begun with screening and testing, and now also included getting people ready for vaccination. Many approaches had to be combined. The Department especially targeted the misinformed and uninformed. The behavioural change programme had also involved community healthcare, going door-to-door with healthcare workers, and the Red Dot taxi service. The Department advised people to maintain physical distancing and propagated the “three C’s” – avoiding closed spaces, crowded spaces, and close-contact settings. Behavioural change interventions had to adapt as the science evolved and more information became available. Interventions were tailored to the localised contact – a different approach was called for in Khayelitsha than in the central Karoo, and the Department had to understand the context and the setting. Teams in each area had a tailor-made message. 

In response to Mr Xego and Ms Botha’s questions about the Department organogram, Dr Cloete said that some vacancies were deliberate, because the Department had realigned its operations. From 1 April, the organisational structure had been streamlined, becoming more efficient and more effective. The supply chain management, finance, people management, and infrastructure units now all reported to the Chief Financial Officer. A head of finance had been appointed, completing the Chief Financial Officer's team, which now had a head for each unit. One deputy director-general post had also been removed.

To Ms Bakubaku-Vos, he said that details on the COVID-19 fourth wave and vaccination programme would be released soon. The Department had learned from the previous waves, and was currently working with scientists and policy structures to prepare a fourth-wave preparedness plan. The plan would be submitted to the national Department of Health on Friday, and the plans would be discussed at the NHC over the next two weeks. The Department was not working in isolation – its fourth-wave plan was just one element of the country’s overall fourth-wave plan and COVID-19 response.

On the number of permanent personnel, he said that health departments naturally had contract posts – a lot of what the Department did was train people. The 11% of staff who were not permanent were appointed on contract. Medical interns and community service doctors were appointed on contract. Registrars in any speciality were appointed on four-year contracts. The Department had more permanent capacity and stability than other provincial health departments. It had added more contract posts due to COVID-19 and the vaccination rollout, increasing the number of employees – by the third wave, 2 000 employees had been added. When personnel’s contracts ended, the Department tried to find a place to absorb them permanently.

He said that the Department took diversity and employment equity seriously. There was proof – although from outside the current reporting period – that the proportion of black employees in the senior staff had increased.

On infrastructure, he said that the COVID-19 pandemic had interrupted all the Department’s initial plans, including on such things as universal health coverage. The Department had had to erect tents, which it had done quickly. It had set up an 850-bed hospital at the Cape Town International Convention Centre, though that had since been decommissioned. It had prepared the Mitchell’s Plain Hospital of Hope, which would be available for use if necessary during the fourth wave. The Department also had a broader infrastructure strategy, but the pandemic had hindered its ability to carry out its infrastructure plans during the period under review – some had had to be postponed. For example, the work on the forensic pathology unit had been delayed until the current financial year. The Department had learned to do things differently and to work with the infrastructure experts. However, the healthcare system was premised on the necessity of operating no matter what infrastructure was available. On any given weekend, a combination of factors could lead to a facility being overwhelmed with alcohol-related cases, regardless of what infrastructure had been prepared. The Department also had to facilitate the movement of patients between facilities, to ensure their dignity – if there was a lot of pressure at one facility, patients should be moved somewhere else.

He said that the Department was passionate about learning, including learning how to do medicine differently, how to care for patients differently, and how to care for them better. It wanted to reform the way that it made decisions, delivered services, and worked with others. With what it had learned, it hoped to deliver the Minister’s dream of universal health coverage.

He said that Mr Allen’s question about the 9.6 million primary care contacts was astute. The COVID-19 dashboard was possible because the Department had a provincial data centre, which did not only work with aggregate data. It attained specific data using unique patient identifier numbers which were attached to each patient. The patients’ identities were, of course, well protected.

Dr Cloete said that the waiting times for transport services were covered in the next section of the report.

He said that National Treasury and national Department of Health had done an analysis of employee compensation expenditure across the provinces, looking at how much money each provincial department spent on personnel. In per capita terms, the Western Cape spent the least on employee compensation. It was one of the most efficient departments, because in per capita terms it spent less on permanent staff, but it also had the highest variation across different kinds of staff. The Western Cape had more psychiatrists, cardiologists, and other specialists than any other provinces. Other departments had approached him, and he would be meeting with representatives of the Limpopo and Gauteng departments to share insights on how to attain this kind of efficiency.

He told the Chairperson that the details of the R99 million figure could be found on page 37.

He said that the strategic plan was summarised on page 35, providing the strategic objectives. Among the Department’s concerns were life expectancy, maternal mortality, infant mortality, and viral load suppression among HIV and tuberculosis patients. It was also looking at the functioning of the health care system, with such objectives as clean audits. The plan was generally oriented towards the goal of universal health coverage.

To Ms Windvogel’s question about the new facilities, he said that the context was emergency medical services (EMS) transferring people between different intermediate care facilities as required when there was pressure on a given facility. Beds had been added in virtually every rural district, along with infrastructure adjustments, to accommodate COVID-19 patients in the district hospitals. Bed spaces had been renovated and upgraded, and access to oxygen had been improved. He was proud that rural hospitals had been able to accommodate all patients or, if they reached capacity, EMS had been able to move the patients to different facilities.  

To Ms Windvogel’s question about corpses, he said that understanding of COVID-19 and the transmission of COVID-19 had evolved over time. Initially, it had been thought that COVID-19 could be transmitted when someone touched a corpse, but it was now clear that, because corpses did not breathe, they did not contribute to airborne transmission. Forensic pathologists under the Department followed very clear precautions, including wearing gloves and using two bags for each corpse. He thought that the risk of corpses spreading the virus was very low.

Mr Simon Kaye, Chief Financial Officer, Western Cape Department of Health, said that the Department had underspent because it had not initially known what the COVID-19 response was going to look like and how much it was going to cost. It had received funding based on its best estimates, and those had turned out to be slight over-estimates. It had received a third budget adjustment in March, coming out of the second wave of COVID-19 infections, when it had not known how much budget would be required for the third wave. In the end, the Department had saved about R220 million of the COVID-19 funding allocated to it. That money would be used to cover its response to the fourth wave. That was fortunate, because little budget had been allocated in the current financial year. The Department also had rollovers of funds for projects which were continuing in the current year. The Department’s culture was such that it did not spend money on things that it did not need, which meant that it had a good relationship with Treasury and could ask for rollovers. The country’s fiscal situation did not current look positive, so the Department had been conservative in spending its budget.

He said that there would always be theft and losses in an organisation of the Department’s size. Sanctions had been applied and people had been dismissed where appropriate. The details of the cases were in Part D of the annual report. The Department required ethical conduct of its personnel.

On the Tygerberg Hospital project, he said that part of the service redesign involved looking at general specialists’ services, especially services in regional hospitals in the Cape Town metro. One could not look at the Tygerberg public-private partnership in isolation from other Department projects. Tygerberg had to split into two hospitals, one of which would be Belhar and the other of which would be the current teaching hospital, but rebuilt. This would not be cheap. The project would cost between R9 billion and R10 billion, and the province could not afford the requisite capital investment, so funding was ultimately the problem. Under the public-private partnership, somebody else would provide the building and the capital, and the Department would be able to repay the partner through savings acquired by splitting the hospital as proposed. A lot of due diligence was required, and the Department would need approval from National Treasury. That year, the Department had also received national funding for the Klipfontein and Belhar regional hospitals, so it would be able to develop four massive hospitals in the metro.

The Committee adjourned for a break.

Part B: Performance information (pages 29-90)

The Chairperson asked Members to keep their questions brief, because Part B of the report was long.

Ms Bakubaku-Vos asked how the number of ambulances and ambulance personnel had changed over the last three years, and how many of the 1 551 personnel were employed permanently (page 31). She also asked for a breakdown of how ambulances were deployed across different districts or suburbs.

She asked for a breakdown of the Department’s forensic pathology personnel (page 32). Were there any staff shortages in the rural regions?

She asked whether the Department had been involved in the provincial government’s calls to have the alcohol and tobacco bans lifted and schools reopened during the first wave of COVID-19 infections.

Mr Allen asked the Department to comment on the response time for ambulances, which was 30 to 40 minutes and sometimes up to 120 minutes (page 49). He also asked how many ambulances were actually active and roadworthy. Did the Department have the optimal number of ambulances that it needed to reduce the response time?

In reference to page 67, he said that he welcomed the Department’s strategies to overcome underperformance. He wanted to hear about the “Race to Zero” champion and other champions that the Department was using.

Ms Bans asked the Department to provide a status report for each clinic, highlighting areas of concern. She asked why the number of clinics with Ideal Clinic status was declining each year (page 33). Did this indicate a general decline in the standard of care at clinics? She asked the Department to provide details about the clinics that lacked Ideal Clinic status and about the clinics that had achieved silver, gold, and platinum status. She asked what caused the significant decrease reported on page 33 and how the de-escalation of services had contributed to that. She thought it might be shocking that the Western Cape government had embraced the Ideal Clinic maintenance program, since it opposed the national government. However, she wanted to know how the Western Cape government proposed to improve service delivery and quality of care.

On the Vitamin A12 coverage, she asked why the target had not been achieved (page 42). What mitigation factors were in place to minimise the effects of COVID-19? How many children were on antiretroviral drugs in the province, and why had that target been missed (page 43)? Why had the target for resolving complaints within 25 days not been achieved, and how long did it take to resolve complaints (page 46)?

Finally, she asked what the reasons were for overspending in Eden municipality, in Cape Winelands, and in the city (page 47).

In reference to page 29, Ms Windvogel asked for an update on the integration project, and for an update on the opening of 24-hour clinics. How many clinics were currently open for 24 hours a day? How many intermediate care facilities were currently operating in rural regions?

In reference to page 30, she said that she had personally seen the disturbing picture of patients sleeping on the floor at Khayelitsha District Hospital. What was being done to address the problem? What steps had been taken to address the issues raised in the National Council of Provinces report on an oversight visit to Khayelitsha? She also wanted an update on the rebuilding of the G.F. Jooste hospital. The Committee mentioned this every year, although she understood that the COVID-19 pandemic had disrupted plans. Also, were there plans to build any more specialised hospitals soon?

Finally, she asked for a breakdown of how many staff were employed in each of the different hospital categories.

Responses on Part B

On the alcohol and tobacco bans, Minister Mbombo said that because pandemic-related matters were handled under the Disaster Management Act, it was the President who made most announcements. Other entities, such as the Department, could only make contributions. It was not the Department’s mandate to ban alcohol and tobacco. However, the Department had evidence of trauma cases competing with COVID-19 cases. With the anticipated fourth wave and upcoming Christmas and New Year celebrations, the Department already expected a high level of substance abuse-related trauma cases in the hospitals. The Department had therefore submitted suggestions to the national office in order to free up additional space in the hospitals. But the regulations were imposed, and the announcements made, at the national level. The Department had come up with warning levels, coded green, yellow, orange and red. These were used to indicate levels of COVID-19 infections, bed occupation levels, and the percentage of districts affected. Although decision-makers consulted the Department, the mandate for implementation and the custodianship of all pandemic-related matters was located at the national level. As she had said earlier, the capacity of taxis was one example – the Department had supported stricter regulations to maintain physical distancing, but had been overruled by the national Department of Health and Department of Transport. The decision was beyond the provincial Department’s control.

She said that several factors contributed to difficulties in reducing the EMS response time. Factors included the affected areas and the time at which the incident occurred – some times were busier than others. Response times were most difficult to reduce in red zones. In areas with high levels of crime, EMS needed a police escort for the officials’ safety, and that caused significant delays. Moreover, statistics showed that interpersonal injuries were most common on the last weekend of the month. On those days, the ambulance system was overwhelmed, leading to delays.

She said that the Ideal Clinic model was not only about statistics and the number of clinics which achieved gold status. One had to look at the overall picture and care package. For example, people now had easier access to eye care specialists – they no longer had to wait on long waiting lists at the district or regional hospitals. The Ideal Clinic now also included physiotherapy and occupational therapy – previously, it had just been about primary care.  

She was not sure what Ms Bans meant about the Western Cape government opposing the national government. South Africa had one health system and one health policy. The difference, however, was that Western Cape had better results than other provinces in implementing the policies, standards and norms. The national Department of Health did not “own anything.” The national policy was all about how it was implemented by the provinces. She had been a consultant for the national Department of Health when the district specialist teams system was introduced. The Western Cape had implemented that policy differently – instead of having specialists sit and wait for deployment, it had stationed specialists at local hospitals and enabled them to conduct community outreach. The Western Cape looked at primary healthcare as involving multi-sectoral collaboration – it did not leave out NGOs.  It used the same national policy, but applied differently according to the context. There was no competition between the national government and the provincial government – they just had different roles.

Minister Mbombo said that city integration had been an ongoing debate for more than 20 years, especially since the rural health services had been provincialised. However, the goalposts kept shifting as other things, especially leadership, changed. Everybody understood that according to the Constitution and the National Health Act, the mandate for health services lay with the provinces. National, provincial, and local government each had a role. The Department had agreed to take a phased approach, starting with about nine areas, including Nyanga, Nolungile, and Khayelitsha Site C. In all those areas, both the local government and the provincial government were active, which confused patients – instead, one sphere would take over.

On overwhelmed facilities, such as the Khayelitsha District Hospital, she said that some places had many clinics belonging to the city, some of which were very close together. Like most city-run clinics, they closed in the afternoon and offered limited primary healthcare packages. The care packages were especially limited in respect of adult chronic illnesses, which left many people with no choice but to travel long distances to receive care. Under these circumstances, people preferred to bypass the clinic altogether and go to the district hospital. That was why there was so much pressure on Khayelitsha District Hospital and others – it was about a lack of local clinics with comprehensive care packages. The problem would be mitigated by the integration of services. In 2019/20, the number of hospital beds at Khayelitsha had increased, but the beds filled up very quickly, especially with patients who needed to remain under observation for some time. There was a similar situation in Atlantis as in Khayelitsha. She thought it crucial to re-integrate as soon as possible, to ease the pressure on the hospitals. One weekend, she had visited Khayelitsha District Hospital and had seen that there were almost 160 mental healthcare patients who could not be accommodated in the observational ward.

However, she was not pleased about the negative media publicity around overcrowded hospitals – people reported on these matters without getting proper background information. Sometimes it just happened to be a busy weekend, when there were many substance abuse patients waiting to receive assistance, and while they were waiting they asked for a blanket and needed some space to rest. Then somebody took photos and posted them publicly, reporting as though the hospital was not doing its job. That was why she asked people not to take pictures of strangers in hospitals – it was inhumane and violated human rights. There was an official hotline at which people could report their complaints. Matters of health affected everybody. The Department would continue to do its best to improve care, but the public should meet the Department halfway.

To Ms Bakubaku-Vos’s questions, Dr Cloete said that ambulances and forensic pathologists were distributed across the province. In fact, the annual report showed (from page 49 onwards) that the Department had performed better on its targets in rural areas than in the metro – its response times were better in rural areas, and it carried out autopsies more effectively in rural areas.

To Mr Allen’s question, he said that the Western Cape’s ratio of operational to non-operational ambulances was better than that in other provinces – he had been quite shocked to hear the statistics from some of the other provinces. There had been a benchmarking exercise in Gauteng with shocking results. In the Western Cape, there were always at least 250 active ambulances at any given time, except for a few that might be out of service for maintenance or repairs.

He said that the Race to Zero was an innovation. Remarkably, during the COVID-19 pandemic, the hospitals had over-performed on their targets for reducing energy consumption.

He agreed with Minister Mbombo that he was not sure what was responsible for the narrative that the Department disagreed with the national Department of the Health. To his knowledge, the Western Cape team worked well with the national team. Perhaps the national Department should provide feedback on its experience working with the Western Cape Department. He could assure Ms Bans that the Ideal Clinic model was taken seriously in the Western Cape and was “a matter of pride” among primary healthcare workers. The reported reduction in performance was the result of downscaling primary healthcare services during the COVID-19 pandemic. The COVID-19 response had affected the Ideal Clinic scores, the measurement of which had been devised before the onset of COVID-19. That is, when devising the system of measurement, there had been an assumption that there would not be such dramatic disruptions. The Department was now working with the national team on redesigning the system and metrics so that they would be more adaptable to situations like the COVID-19 pandemic. The national Department had already shown interest in that suggestion.

On Vitamin A uptake, he said that during the COVID-19 pandemic, people had been unwilling to come into clinics just to get vitamins for their children. To some extent, this had been inevitable during the pandemic, but the Department was working on finding a solution. Similarly, it was extremely difficult for caretakers to bring children into clinics just for reporting purposes, though that did not necessarily mean that the children were not still taking their antiretroviral drugs.

On complaints, he said that complaints in regional hospitals were still processed within 25 days. However, district hospitals had been completely overrun with COVID-19 patients during the second wave, and the achievement of the 25-day target had fallen from 90% to 88%.

On the overspending in areas like Eden, he said that some areas, especially in the Garden Route, had been affected disproportionately during the second wave of the COVID-19 pandemic.

To Ms Windvogel, he said that the Department’s position was that healthcare services in Cape Town should be integrated under one authority and rendered by the provincial Department. Under such a system, the provincial Department would be able to unburden the hospitals in places like Khayelitsha by expanding clinic services. The City of Cape Town currently provided a limited service package, in clinics which operated for limited hours. Resources had to be used wisely to get better outcomes. For example, when that approach had been taken in Grassy Park about five years ago, three facilities – two city clinics and one provincial clinic – had been consolidated into a single new facility. The new facility cost less and rendered more care to more people. 

He said that there were 28 intermediate care facilities across the province, in all districts. A small proportion were in the metro, but the rest were in rural areas. The 1 440 beds were distributed accordingly.

On the situation at Khayelitsha District Hospital, he said that there were more beds available now than before. It took less time to get a CT scan at Khayelitsha than at other hospitals in the metro. Some of the services and facilities at Khayelitsha were among the best in the metro. It was unfortunate that people had a negative perception of the care – it meant that they had a kind of confirmation bias when they visited. The management team was quite “exasperated” by it. However, he could guarantee the hospital provided good quality care. As Minister Mbombo had said, the hospital absorbed the societal pressures of the surrounding area. The impact of substance abuse and alcohol was a societal problem, but it burdened the hospital. Society had to work together to shield the hospital from these pressures.

He said that the G.F. Jooste or Klipfontein Hospital was one of three – the other two were Belhar Hospital and Helderberg Hospital – but it was being prioritised. A tender had been advertised for the building, but there had been an “objection” to the process, which had resulted in the tender not being awarded. A new tender was now in place, with a new schedule. The Department was working closely with the Department of Transport and Public Works to fast-track all three projects.

He said that the Department had no specific plans to increase the number of specialised hospitals. For example, the Department held that building more specialised psychiatric hospitals was not necessarily the best way to deal with mental health problems. As Minister Mbombo had said, mental health called for a whole-of-society approach. The Western Cape government was prioritising mental health through whole-of-society interventions across all departments.

He said that the Department used an approved post list at each hospital, which was updated monthly. Each list detailed exactly which posts were filled and vacant at any given time for all categories of staff across all departments at the hospital.

Dr Saadiq Kariem, Chief Operating Officer, Western Cape Department of Health, said that 550 EMS vehicles were currently operational. That included ambulances and rescue vehicles. There were 250 operational ambulances. Some were out of operation for maintenance and downtime, leaving roughly 85 ambulances actually on the road. Those were split between the metro and rural areas. 

On the Race to Zero campaign, Dr Laura Angeletti du Toit, Chief Director: Infrastructure and Technical Management, Western Cape Department of Health, said that the Department aimed to achieve net-zero status by 2050, in order to reduce carbon emissions and mitigate climate change. However, in order to achieve that aim, it needed to recruit someone – the “champion” – to a role which did not currently exist in the Department’s organogram. The Department was working to create this new post which could coordinate, monitor, and report on this long-term goal.

Ms Bernadette Arries, Chief Director: People Management, Western Cape Department of Health, said that ten intermediate care facilities were based in the metro, and the other eighteen were spread across the rural districts.  Most of their clients were in sub-acute care, respite care, palliative care, and end-of-life care.

Part D: Human Resources (pages 117-128)

The Chairperson said that Part C of the report would be presented in a scoping meeting, so the Committee could move directly to Part D.

On the staff who had resigned during the period under review (page 134), Ms Botha asked what positions they had filled. She wanted to know the content of the grievances listed on page 151. She also wanted to know whether the number “96” given on page 134 was part of the listed personal grievances.

Ms Bakubaku-Vos asked whether the Department had a danger allowance policy (page 117). If so, what did it contain and how did it apply to employees that contracted COVID-19 in the line of duty? Her second question was on the status of human resources as reported on page 118. Was there a specific reason why 11% of the workforce were not permanent? Which positions did those workers fill? Why were there so few Africans, especially women, on the staff? What was the race profile of the people recruited to fill the vacancies mentioned in the report? What were the plans to attract more Africans to fill existing vacancies in the senior management and top management? She suggested that the Department should appear before the Committee at the end of next year to give a presentation on employment equity targets. Finally, she wanted clarity on bullet point six on page 118, on the 89% employed.

Ms Bans said that it was easy to understand how staff working “at the coal face” could become mechanistic in performing their work (page 129). She asked for an update on the transformed organisational culture and how it had addressed bad attitudes and the mistreatment of patients. She also wanted to know the guidelines regarding quarantine and isolation for frontline workers (page 125), especially for nurses, who complained that they were forced to continue working even when their colleagues contracted COVID-19.

She noted that the personnel budget was not sufficient to fund all posts (page 126). How many posts were unfunded and how much budget did they require?

In reference to page 119, Ms Windvogel wanted to know the plans to convert the positions to a full-time basis. She asked for update on cases in which doctors had stolen broken chairs and nurses had been fired for dressing inappropriately. She also wanted to know some of the highlights from the latest staff satisfaction survey.

Mr Xego noted that the number of filled posts was lower than the number of vacant posts (page 131). Why was that? He noted that there had been many resignations in the Department, with a total of 1 292 employees having resigned (page 134). What categories of staff made up those resignations? What was being done to retain high-skilled employees? What was going on with the funding of the upgraded posts? Why had only one out of 3 020 lower-skilled employees received a promotion? What was the Department’s promotion plan? Finally, there had not been any employees with disabilities in senior management positions (page 137). Why was that?

Responses on Part D

Dr Cloete said that some people did not state specific reasons for resigning and others just cited personal grievances or a lack of satisfaction. 

He said that there was a specific dispensation for danger allowances. However, the danger allowance and COVID-19-related matters were separate – the former was a specific dispensation which had been formally negotiated in the bargaining chamber. Mr Kaye would expand on occupational health and safety in relation to COVID-19 – the Department used the Occupational Health and Safety Act to define its responsibilities as an employer during the pandemic. He had already addressed the issue of contract appointments – as he had said, many of the contracts were with interns and short-notice personnel, and additional contract workers had been recruited during the pandemic.

On the issue of low African representation in the senior management, he said that the Department had a deliberate recruitment and selection policy. It was specifically looking at addressing the representativeness of senior management. Department officials were very passionate about the development of the Department’s organisational culture.

On quarantine and isolation, he said that there were specific guidelines that were followed on the advice of scientists. As far as he knew, the Department was very strict in enforcing the guidelines, including the timelines dictating how long people should isolate or quarantine, and after how long they should be tested and return to work.

He said that Ms Ban’s question about the optimal staff complement was a very difficult one. No health service anywhere in the world would ever have enough staff and resources – it was just not possible to meet all the healthcare sector’s needs. It would be unrealistic for him to try to give exact figures. He thought that a better approach was to try make the best possible use of the resources that were already available to the Department.

On the specific disciplinary cases mentioned by Ms Windvogel, he said that he could not provide the details, but that the issues had been resolved and due process had been followed.

He said that the staff survey measured the “entropy level” in the Department – the higher the number, the higher the discord in the organisation. According to the results, the Department’s score had dropped by four points, indicating an improvement in the organisational culture. When entropy was lower, people’s values were more aligned, and they were better able to express their values in the workplace. There were some sections in the Department which had entropy levels lower than ten, indicating a very harmonious environment.

He said that one of the difficulties with disability profiling was that many people with disabilities were not willing to disclose their disability status.

Mr Kaye said that COVID-19 had taught the Department the elements of occupational health and safety. Its first approach had been to give everyone PPE, but it had later realised that it should have conducted a risk assessment first. After the risk assessment was conducted, all high-risk individuals were removed from the frontlines, although the Department continued to make PPE and other preventative measures available to all staff. The first wave of infections had presented a learning curve on occupational health and safety. The quarantine and isolation procedures were quite rigid. There had been confusion and multiple revisions to the guidelines as the science evolved. That had led to a lot of anxiety and many grievances.

He said that the Department had needed to find a way to address the raw human emotion that had surfaced, particularly in the first wave.  The second wave had hit hard and fast – many Department employees had died, including 50 in December and 26 in January. That had left the staff shocked and numb. The Department had then begun to initiate a process of intentional grieving, telling employees that it was okay to cry and to express their feelings. It had prepared structured and informal sessions at which people could express their grievances. There had been a series of 44 grievance sessions, with between 20 to 300 people attending each. COVID-19 had amplified the fact that people were interconnected and needed to share their feelings. After the sessions, the levels of grievances had fallen significantly. The Department was very clear on its processes in respect of grievances, scarce skills queries, allowance queries, and so on. It took pride in that, because it knew that people would be treated fairly and equitably.

He said that there seemed to be a positive change in the interest level of African women in positions at the Department. While recruiting for the current vacancies, the Department had received applications for senior management roles from exceptional black African women. When making appointments at a senior level, there had to be multiple checks and balances, and the correct processes had to be followed – that sometimes took time.

Ms Reygana Shade, Director: People Strategy, Western Cape Department of Health, said that the danger allowance was nationally determined. There was a standard danger allowance and a special danger allowance, both of which were paid discretionally. The most exposed group during the pandemic had been the EMS staff and the forensic pathologists. The nurses were most exposed in the psychiatric wards.

She said that the organisational culture of the Department had been on a long journey over the last decade, and it had transformed positively. The Department was “spoiled” in that it had strong team cohesion and strong alignment of values between the staff and the organisation. Its values included community leadership, respect, responsibility, commitment, and honesty. This was important to front-line workers, who were now confident in addressing the public. The Department had also been taking time to listen carefully to people about their grievances during the pandemic.

A Department official said that the Department looked at scarce skills based on supply, considering the number of offered bursaries, the attrition rate, and the difficulty in filling posts within 90 days. It also looked at potential retirements and compared them to actual retirements.  Primarily, the scarce skills were in the no-speciality category – sonographers, radiographers, forensic pathologists, technical engineers, and medical case managers.

Concluding remarks

Minister Mbombo thanked Members for keeping the Department on its toes with their questions. She applauded the Department’s management team for attending in large numbers – she had not expected all of them to attend in person. As Dr Cloete had said, the management represented not only themselves but also the more than 30 000 people who worked for the Department, as well as the entire population of the Western Cape. Being human, they were bound to make errors, and it was important for them to understand and forgive one another.

She hoped that more people would be vaccinated before the start of the fourth wave of COVID-19 infections. The Department was the last line of defence – the first line of defence was in the communities themselves. She honoured the service and bravery of those who had died of COVID-19-related illness while in the line of duty.

Dr Cloete thanked Members for being understanding. He thanked Ms Botha, Mr Allen, Ms Bakubaku-Vos, Ms Windvogel, and the Chairperson for contacting him during a time of difficulty he had experienced. It was good that the Committee and Department had a common understanding that they were working for the betterment of the people of the Western Cape, and he appreciated that they could work together with such a high level of mutual respect. Minister Mbombo’s humanity had kept the Western Cape strong in its darkest moments, and he was grateful for how she had supported the Department between 24 December 2020 and 3 January 2021. He was also very proud of the management team who were present in the meeting, and especially recognised one official who had driven from Mossel Bay to attend.

In response to Mr Allen’s earlier question, he added that the provincial data centre had confirmed during the meeting that the 9.6 million primary care contacts included the provision of services to a total of 2.5 million patients.

The Chairperson said that the legislature’s oversight had revealed the unwavering efforts of every official and healthcare practitioner who had helped to reimagine the healthcare system to respond to COVID-19, while maintaining the provision of other essential healthcare services. The Department’s governance and financial situation directly affected its delivery of services, and she congratulated it for having performed well even during the pandemic, and for having remained passionate about continuous improvement. In her whole parliamentary career, she had never attended a session like this one. It had helped provide a clear picture of what the situation on the ground had been like during the pandemic. She blessed the Department and told them to keep doing what they were doing.

The meeting was adjourned.

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