Office of Health Standards Compliance 2022/23 Annual Performance Plan

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Health

30 March 2022
Chairperson: Dr K Jacobs (ANC)
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Meeting Summary

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OHSC APP

The Portfolio Committee was briefed in a virtual meeting by the Office of Health Standards and Compliance (OHSC) on its annual performance plan and budget for the 2022/23 financial year. Key issues which came up for discussion were the challenges the Office faced in dealing with complaints at public and private health facilities, because of the shortage of inspectors due to budget restrictions.

The OHSC said the covid19 pandemic placed enourmous strain on its operational environment and it observed a significant increase in the number of complaints received. The Office was however constrained fiscally which did not allow the entity to expand its staff capacity. The entity outlined its priorities for the year.

Questions that were posed by the Committee included how the OHSC set their targets, which a Member suggested were too low. They pointed out the high costs of the lease payments for the OHSC's office accommodation, and asked when they were going to purchase their own property to save costs. The Committee also wanted to know if the entity was experiencing problems in their relationships with private health facilities, as the number of inspections in the private sector was low.

Other concerns raised included the delay in dealing with -- and sometimes, even responding to -- outstanding complaints; the safety and cleanliness of some healthcare facilities; and the need to fill the available vacancies within the organisation. The Committee acknowledged the fact that the OHSC was experiencing budgetary constraints, but said they needed to attend to the issues and concerns that had been raised.

Meeting report

Chairperson’s opening remarks

The Chairperson welcomed all the Members and officials from the Office of Health Standards and Compliance (OHSC).

The OHSC was represented by:

• Dr Mofele Kenoshi (Chairperson, OHSC)

• Dr Siphiwe Mndaweni (CEO, OHSC)

• Mr Julius Mapatha (CFO, OHSC)

OHSC 2022/23 Annual Performance Plan

Dr Kenoshi took the Committee through the annual performance plan (APP) for the 2022/23 financial year.

The purpose of the OHSC was to protect and promote the health and safety of users of health services by:

• Monitoring and enforcing compliance by healthcare establishments with norms and standards prescribed by the Minister in relation to the national health system; and

• Ensuring consideration, investigation and disposal of complaints relating to non-compliance with prescribed norms and standards in a procedurally fair, economical and expeditious manner.

This mandate was to meet two distinct but interdependent regulatory outcomes:

• reduce avoidable mortality, morbidity and harm within health establishments through reliable and safe health services

• improve the availability, responsiveness and acceptability of health services for users

Situational analysis

The contents of the five-year Strategic Plan have not been changed and will remain as per the submission made for 2019/20 2024/25 .

The Office developed the APP for 2022/23 which is informed by the revised 2020 2024 Medium Term Strategic Framework (MTSF).

Improving the quality of health care is a critical components of the National Development Plan outcome to "strengthen health system effectiveness" through enabling external assessments of compliance with prescribed standards.

Compliance inspections, certification of compliant health establishment, investigation and resolution of complaints received by the OHSC will contribute towards improving the health system effectiveness.

The APP considered the health sector constraints experienced through the COVID19 pandemic

Organisational environment

The COVID-19 pandemic had placed enormous strain on the operational environment of the Office.

The Office observed a significant increase in the number of complaints received.

Due to the limited budgetary allocation over the MTEF period, OHSC had very limited capacity to increase human resources to:

 •Increase the number of inspections conducted

•Manage complaints and investigations

•Develop more health standards.

The presentation addressed the strategic focus priorities for the medium term 2019/20 – 2024/25 per programme: administration, compliance inspectorate, complaints management, health standards design, analysis and support and certification and enforcement.

Members were then taken through the 2022/23 MTEF budget estimates.

Key considerations of the budget

• Over the MTEF period, the budget increases by an average of 1.7%

• The compliance inspection division receives the highest allocation in line with the OHSC’s founding legislation of conducting inspections of health establishments

• Increased inspection targets over the MTEF period, as well as implications for re inspections and certification

• The need for continued guidance and support on norms and standards, as well as inspection tools, at both national and provincial levels, to increase compliance with norms and standards

• A large portion of administration allocation relates to the provision of adequate office space, tools of trade, business continuity plan, as well as training and development

•Due to the nature of the OHSC services, staff members are key to achieving the OHSC objectives, hence personnel cost remains the highest cost element

•Staff complement increased from 127 to 129 over the MTEF period, with 72% of staff members are in the core operations of compliance inspections, certification and enforcement, complaints management, and standards design, analysis and support 28% of staff members are allocated to the CEO’s office, communications and stakeholder relations, finance, supply chain management, human resource management, information technology, and administration

 (See attached document for details).

Discussion

Ms N Chirwa (EFF) asked the OHSC to provide the Committee with a breakdown of what informed each target that they set, and who made these decisions.

Payment for leased accommodation was a concern. The last time the OHSC presented their APP, the Committee had recommended that it purchase property, rather than lease it. Was the OHSC’s working towards something like that, or was it going to be leasing its offices for a long time. The Committee had brought up their concern about the OHSC’s finances time and again, and had recommended that it cut down on some of its cost in order to cover other expenses, of which accommodation was one.

Another area where the Committee had recommended the OHSC cut down on expenses was outsourcing, such as the cleaners and security guards, and this had not happened. The cost and finance issues kept coming up at Committee meetings, and they needed to be addressed seriously by the OHSC. She acknowledged that cutting costs in these areas would not amount to a lot of money, but it would amount to something, as opposed to not having money available.

She asked for clarity on the allocation for complaints management and ombudsman and rule change showing a decrease of almost 2%. What was the OHSC’s timeline for resolving cases? Did they have a document with a timeline of which cases were still pending, based on severity of the cases? What was the probability that cases from ordinary people would be resolved by the ombudsman? She did not think enough marketing was being done by the ombudsman, or that sufficient information was available. However, this could also be an error on part of the Department of Health (DoH). There should be some measure that compelled the OHSC to reach out to the public so that they knew there were resources such as the ombudsman available to them. For example, on the grievance cases, there should be phone numbers available, such as a complaints centre. She wanted to know what the OHSC was going to do to ensure that there was a better relationship with ordinary people who did not necessarily have access to people higher up, such as the Members of Parliament.

She said it was the OHSC’s responsibility to address these matters, and to raise them with the DoH. There should be a lot more effort to ensure that accountability took place, because that was part of the responsibility of the Committee and Parliament as well.

Ms H Ismail (DA) indicated that an increase from 15%-20% over the MTEF on the inspection of private healthcare facilities was very low. She asked if there was a particular reason why these targets were so low, and if they could not be scaled up over the MTEF period.

She brought up the fact that the DoH wanted to implement the National Health Insurance (NHI) scheme, and asked how this was going to be achieved if the OHSC could inspect only 20% of private healthcare facilities in this budget period.

There was a noticeable decrease in the 2022/23 budget allocation to health standards design, analysis and support -- how would this deficit be mitigated, and how would it impact on the programme’s activities?

She asked for clarification on how the OHSC sets its annual targets, because some of the targets seemed small -- or maybe the Committee just expected a lot from the OHSC. Therefore, it would be beneficial to the Committee to know how it set the targets.

She also referred to the lease payments. In 2021/22, the lease payments were R12.5 million. That was was the highest expenditure in the goods and services programme, and it was projected to increase to R15.6 million over the MTEF. Had the OHSC considered purchasing its own premises, as this could be a much more cost-effective option?

The safety of healthcare professionals and patients in healthcare facilities remained a challenge. Did the OHSC, through its norms and standards, assess the safety of hospitals and clinics? A few incidents had been mentioned in the media of doctors and nurses being shot. She asked where the OHSC stood on this matter, and how it was planning to address it.

In light of the negative impact of COVID-19 and budget constraints, she asked what active steps the OHSC had taken to fill their vacancies. She argued that the shortage of staff lay at the core of hindering the OHSC from reaching its optimum performance, and wanted to know how they were going to address this issue.

Ms Ismail said she had personally received many complaints. A healthcare facility was where cleanliness was the most important. She referred to a few examples of where the hospitals had a bed-smell, and where patients were turned away and not treated fairly. How did the OHSC deal with matters like this? She found it unacceptable that the complainants did not receive any responses at all. How was the OHSC going to ensure that the hospitals actually adhered to the necessary requirements of the complainants as they were required?

Ms A Gela (ANC) raised the issue of the low rate of inspections that had been carried out by the OHSC in the private sector. They were in the process of finalising the NHI Bill and had heard stories of babies who had been stolen from private hospitals and nothing was done by them, because they did not cooperate. She asked if the OHSC had experienced any problems when it came to dealing with private hospitals.

As Members of Parliament (MPs), they received a lot of complaints from the public on how they were treated by private and public hospitals. She asked how many complaints the OHSC had received, where they were from, whether they had been resolved, and if not, why not. She asked the OHSC to provide a breakdown of complaints involving private and public facilities.

She said officials were not reaching the targets, and the Committee was only getting excuses. She asked whether the targets were achievable, and what the challenges were that prevent the targets from being reached.

She asked for the names and contact details of officials to whom the MPs could refer the complaints that they receive from the public.

Dr S Thembekwayo (EFF) said that when it comes to the condition of the clinics and hospitals and the patients' experience, people were not being treated well. She gave a few examples, such as a case at the Mandela Sisulu Clinic, where patients were being chased out of the clinic so that the nurses could enjoy their lunch. Patients were not being attended to, and were being neglected. She asked how the OHSC was going to address these complaints, as there was a backlog on addressing them, and this was unacceptable. When the issues were raised to the Minister, they were not attended to either, as he did not seem to care at all. She asked the OHSC to provide some form of intervention, or to provide names and contact details to whom they could raise these issues and complaints, so that they could see service delivery happening in the hospitals and clinics.

The presentation had mentioned that there were vacancies in critical positions, and filling them depended on the availability of funds. She asked the OHSC to provide the Committee with the number of positions that were vacant, and when they would be filled.

Ms E Wilson (DA) commented that the issues remained disturbing, and had been so for some time now. While the OHSC was experiencing an increase in complaints, the Committee was also being overwhelmed with complaints from the healthcare sector. She mentioned a few examples, such as a hospital where there was no oxygen available for the patients who needed it. Some patients had been unable to receive their prescribed medication. Other hospitals and clinics were being told not to refer people to them. There was also an instance where there was a death of patient at Steve Biko Hospital, who was left unattended with infected wounds. There was also the bad delivery of babies, and one questioned whether or not the complaints actually reached the OHSC’s offices, because people were not always aware of the fact that they could raise their complaint to the OHSC. Some of these issues may be because of budgetary constraints, but they had to be addressed urgently.

The reduction in inspections was visible. The OHSC was under-staffed and was dealing with budgetary constraints. She commented that the NHI scheme was not going to work from the looks of things at this moment because the OHSC did not have accredited facilities and the necessary staff available. The future goal had to be to build a health infrastructure for service delivery, but with no money, no budget, no inspectors, she doubted that the OHSC would ever be able to meet its goals with its current facilities, resources, management and leadership.

The OHSC had mentioned that they were going to have engagements with various stakeholders, and that this was mandated. She asked for a list of where and when the stakeholder engagements were going to be taking place, so that Committee Members could attend and ensure that the correct stakeholders were invited to these meetings.

She did not envy the OHSC’s job, as they had many issues to address. If they were unable to do their job properly, everything else would fall away. She suggested that some of these issues had to be raised to Parliament.

Ms M Clarke (DA) said that the OHSC had mentioned that they had 'inspection tools,' and asked what these tools looked like -- for example, what exactly was ‘inspection software’?

She noticed that there had been a decrease in performance over the last year, from 10.14% to an estimated 8% in 2021/22. What was the reason for the decrease in the number of public healthcare establishments inspected for compliance?  What were the effects of the low compliance inspections on the quality of healthcare provision?

She pointed out that 2025 was the year projected for NHI implementation, and according to the Bill only those facilities that met the compliance requirements would be allowed to operate. However, the OHSC estimated that only 22% of facilities would be inspected, and this was rather concerning, because how would that align with the NHI Bill’s requirements?

Referring to the presentation, she asked why only 2.46 complaints were being resolved within 30 days. There seemed to be a drastic decrease in the indicators, from 49.42% in 2018/19 to 7.3% in 2020. She acknowledged that COVID-19 had played a role, but wanted to know what the OHSC was going to do about this in order to effectively achieve their mandate in the new health environment, when compliance in healthcare was even more necessary.

She asked what the OHSC’s current vacancy rate was for compliance inspectors.

She said that service delivery was seriously compromised by employing contractors for service delivery. Contracts were not being renewed and services were not being delivered adequately to healthcare facilities, and this must be looked into urgently

Ms M Hlengwa (IFP) wanted to know why the human resources of the OHSC were not absorbed into the clinics or hospitals so that they could do their jobs properly. She referred to an OHSC office where cases were being reported and complaints were logged, but the issues were not being resolved. She asked how the OHSC was going to address this situation.

How many vacancies existed in KwaZulu-Natal (KZN) in all the districts? What was being done about the shortage of nurses? Clinics and hospitals in KZN had been closed down -- in the St. Francis and Zululand districts -- and this was a serious problem. What was the OHSC going to do to address this issue? For example, in Pietermaritzburg, people with cancer were lying in the hospital and there was no oncology ward to give the people the treatment that they needed. There had also been complaints about a shortage of blood in hospitals. What was the OHSC going to do about all of these problems?

The Chairperson noticed how the OHSC’s targets were rather static, and asked for clarity on how their targets were set. On the inspection of private healthcare facilities, there was a target of only a 5% increase --did the OHSC think that was adequate?

He asked for an update on the OHSC’s decentralisation project.

He asked if it was necessary for them to have a section for the ‘relocation of expenses.' R75 000 was already indicated in the 2021/22 budget allocation, and this year it had been increased again -- why was this so?

OHSC's response

Dr Kenoshi addressed the question on the decentralisation project, and said that the board had actually addressed this matter. They would decentralise its projects in other provinces within the next year or two, and would be able to cover more hospitals and deal with the cost of travelling and accommodation.

Dr Mndaweni (CEO) described how the OHSC sets its targets. She said that they went through a timely process annually, where a number of variables were considered, one being the budget that was allocated to the OHSC and the staff that they had available for conducting inspections. They also looked at their representation, as they had to cover the entire country, taking into consideration which healthcare facilities had been inspected and which still needed to be inspected. They also looked at the size of the population and the number of clinics and hospitals in each province, so the bigger provinces with more healthcare facilities would therefore have more targets when it came to inspections.

She emphasised that one of the challenges that the OHSC faced was that they did not have adequate funds to conduct all the inspections, or even to be able to reach their annual targets. In addition to this the OHSC needed to cater for those inspections that came from the early warning system, and these include inspections that are reported in the media. They also look internally at where they could save funds.

She understood the frustration of the Committee that the inspection numbers were low. This was a critical matter that the OHSC was trying to address. They were looking into the decentralisation process, but all of this was difficult to achieve because of their limited budget, and this also made it difficult for the OHSC to expand on their mandate.

The reason for the lower number of targets in the private sector was because the total number of hospitals in the private sector was 431, according to its current database, and this would increase with time. They look at the allocation based on the overall numbers, and it was indeed a source of concern for the OHSC.

Responding to the recommendation to purchase property rather than lease, she said they still had an ongoing lease. However, when the lease was over, they would review their options and consider other options based on the amount the board allocated to them in order to purchase a building.

They would reconsider the in-sourcing of cleaners and security personnel when the contractual agreements were reviewed after the contracts had ended.

On the timeline for resolving cases, she said that the complaints and management unit had the least staff, so the resolution of cases would be delayed because there were not enough people available to resolve them. There were cases that could be resolved in the complaints centre, where they were able to resolve 80%, but the unavailability of the staff in the centre had a serious impact on the resolution of cases.

They did need to do more in terms of marketing, and had a communication strategy that they were revising. They had reached out to radio stations and other media as possible marketing options.

She said their relationship with the private sector was fine, but they would become aware of issues only when they had finalised their inspections. They had received complaints from the private sector that they still needed to resolve.

On the issue of safety in the hospitals and clinics and of the healthcare workers, and what was being done by the OHSC, the OHSC regulation 17 and this regulation requires that the healthcare establishment must protect the users and staff from security threats. This was a regulation and standard that was being monitored by the OHSC, and based on their inspections, the majority of healthcare establishments were not complying with the regulations. They also monitored this through the early warning systems, where they continued to engage with the people who were in charge to ensure that security issues were addressed, such as the availability of security personnel, whether they had got closed circuit TV cameras, and whether there were palisades and fences in the areas where they were necessary. However, their recent inspection the healthcare establishments had not produced satisfactory results.

They would follow up on the two hospitals that were mentioned by the Committee, determine what the issues were, and would follow up on them.

The OHSC had records of complaints, and would submit them to the Committee. They would be written reports on the complaints that they had resolved, those they had received from the private and public sector, and how they were planning on resolving the outstanding cases. They would also submit a list of names and contact details of the officials who could be contacted to log complaints that they wanted to lodge with the OHSC and the Health Ombud.

She emphasised that they did not want to replace the complaints resolution mechanisms at the local level, They still encouraged complaints to be resolved at the local level and in doing so, when the OHSC provided feedback to the healthcare establishments, it emphasised that the provinces and districts had to attend to them in order to strengthen their resolution at the local level. However, when complaints did reach the OHSC’s office, they did try to attend to them and they did not turn complainants away.

She admitted that conditions in hospitals and clinics were worrisome, and they would follow up at the clinics and hospitals that had been mentioned by the Committee, as closing hospitals and clinics was unacceptable.

The OHSC had been affected by Covid-19, but their inspectors out in the field had worked overtime to reach the targets.

The critical vacancies that had been filled that were on the old organogram. They had a new and improved organogram that included various new positions that needed to be filled. However, it was difficult to fill several of them due to the limited funds that were available.

They were unable to proceed with decentralisation due to the limited budget that was available to them, but they were looking into it. They would look at available locations, but would first need to secure the available human resources to occupy the offices to allow the OHSC to expand their inspections.

Regarding feedback on complaints, the OHSC had a system for how they provided feedback, but they would look into areas for improvement.

The questions on KZN and the issues there would be referred to the province so that they could provide feedback to the OHSC.

Mr Mapatha (CFO) addressed the issue of lease payments, and said the current office space lease was a five-year agreement that would come to an end next year. The OHSC would take this issue into account when they were doing their planning for next year, considering the borrowing restrictions. It would need support from other financial institution institutions in order to purchase a property, as at this stage they did not have the capacity to do so. In order for the OHSC to borrow money, they would need permission and guarantees from the National Treasury

The contracts for the in-sourcing of services were coming to an end, and would then be revised by the OHSC.

The CEO had touched on the filling of vacancies, but he wanted to add that the new organogram that had been approved by the board indicated that a fully capacitated OHSC would have a total staff of 223, and currently there were 129 that were funded. In the inspectorate, there should be 95 where currently they had 55, meaning that there was a shortage of 40 inspectors.

Referring to the decrease in the budget, he said that from 2023/24 the overall budget would decrease from R157 million to R152 million and that would necessitate overall adjustments across all the programmes.

One on the innovative ways that the division had come up with, in terms of guidance and support for stakeholders, was to have virtual meetings, whereas in the past the OHSC had conducted workshops in the various provinces. In this way, it had been able to save expenses.

Dr Kenoshi said that over and above all the questions that had been addressed, the board was considering going on a road show in the near future with the DoH to the different provinces in order to discuss and to engage with the heads of the different provincial Departments of Health.

Dr Thembekwayo asked the OHSC to provide the number of an inspector to ensure that the matters she had raised were addressed and handled correctly.

Ms Wilson said that one of the most important faculties in health was dentistry, and there were serious problems within the dentistry divisions of the hospitals. This needed to be addressed urgently.

Dr Kenoshi said that they had taken note of the hospitals mentioned by the Members. They would make the contact details available to the Committee and provide feedback in due course.

Committee minutes

The Committee considered and adopted the minutes of its previous meeting.

The meeting was adjourned.

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