Western Cape Appropriation Bill: Health

Meeting report

The Chairperson greeted the Members and everyone in attendance. He outlined the purpose of the meeting – to discuss the 2023 budget for the Western Cape Department of Health. He then called on the Minister responsible for health in the province to provide a few introductory remarks.

Introductory Remarks by the Minister

Dr Nomafrench Mbombo reported that, for the past nine years, the provincial Department of Health had seen a steady increase in the population. An increased population translated into more patients visiting healthcare facilities, yet the budget had not kept track of this reality.

The burden of disease had placed additional stress on the health budget. The Department welcomed the increase in the provincial health budget. This was the first post-COVID budget for the Western Cape provincial health department.

Since the state of disaster had ceased in South Africa, resources were diverted to other areas within the budget. These were trauma injuries from violent crimes and other pertinent and pressing issues.

South Africa’s crippling energy constraints and the almost-daily loadshedding across the country pose a significant risk. Only a few healthcare facilities had been exempted from loadshedding, and the provincial Department had mitigated this risk through funding allocations from their own pocket.

The Department was also about to conclude 400 contracts it signed with healthcare workers who were on the frontline during the COVID pandemic. The contractors knew that their contracts would only last for the duration of the State of Disaster. The funds which were allocated for their compensation had seized. These rules were not drafted by the Department, which lamented its absence from the bargaining council where labour relations issues were discussed.

Additional funds to the tune of R30 million had also been allocated for mental health, and R20 million for surgeries. Other highlights included operationalising the Violence Prevention Unit within the Department. Efforts to enhance employee wellness have also been prioritised. 

Vaccinations would continue as part of various projects in the rural areas of the Western Cape.

The provincial Department of Health were excited about the use of robotic surgeries, despite the astronomical cost attached to this procedure.

The Minister highlighted the positive benefits, such as reduced length of stay and decreased surgical backlog.

The Department's budget was not aligned with the ever-growing population, yet it was responsible for providing health care to all citizens, and operating 24 hours a day.

She said that the Department continue to liaise with private institutions and eyed an expansion of community indabas, especially as it related to the rollout of the National Health Insurance (NHI). It was important that the Department provided equitable and quality healthcare services to residents. The Minister indicated that the Head of Department (HOD), Dr Keith Cloete, would elaborate on this in detail.

Patient transport continued to pose a challenge, not only to the Department itself, but also to patients. Patients from West Coast communities paid exorbitant amounts for transport to and from healthcare facilities in Cape Town.

The Department was not amenable to ambulances being tasked with such a transport request. Using vehicles for patient transport impacted the Department's resources and operations.

Putin's war in Ukraine sparked inflation. This had a knock-on effect on the price of pharmaceuticals from China, which had become more expensive.

The Department remained committed to the Green Global Hospital Initiative (GGHI). The GGHI encouraged sustainability within the health industry and was premised on environmental protection principles.

The Minister concluded her remarks, and the Chairperson then invited the Department’s HOD, Dr Cloete, to deliver opening remarks.

HOD Remarks

Dr Cloete touched on the emergence of Covid-19, and the Declaration of a State of Disaster from 01 April 2020 to 31 March 2022.

Dr Cloete said that the provincial administration, like the rest of the country, had grappled with four Covid-19 waves that severely impacted the public healthcare system over the last two years.

The next three years were definitely going to be a period of economic uncertainty. This uncertainty impacted the Department of Health’s bottom line. The Department had tough decisions to make, and these decisions always impacted the most vulnerable and the poor. For the foreseeable future, austerity will reign. This called for a collective response to health and wellness, in close cooperation with stakeholders like the Children's Commissioner.

The Department had already engaged with academic hospitals expected to feel the biggest impact, especially on highly specialised services at Groote Schuur, Tygerberg, and the Red Cross. Plans are afoot to strengthen the capacity of district hospitals and primary healthcare facilities to buffer the impact on citizens.

The Department remained cognisant of its responsibility towards the poor and the vulnerable in South African society, saw itself as a safety net for the poorest of the poor and remained committed to relationship-building and stakeholder relations management too.

Discussion

Ms A Bans (ANC) welcomed the inputs from the Minister and the HOD.

She recalled the Minister's comments about the budget being “unappetising’, but pointed out that the Minister's comment about patient transport was a highlight, as it touched on the role of other government agencies in delivering this vital service.

Patients from as far as the Karoo travelled for almost two days to get to Groote Schuur to consult with specialists. She questioned how such a state of affairs could still exist.

Her next question was related to the 1.91 % reduction in the budget for Compensation of Employees (COE) and the one-per cent increase during the 2023 MTEF on page 2223.

Ms Bans asked what rationale had informed the COE budget cut and its impact on the organisation and jobs. She also asked for information on the Department’s municipal services expenditure.

On page 225, the Department spoke about the 2023/2024 outlook and Covid-19 monitoring. Ms Bans asked what happened to local vaccine procurement and whether more funds could not have been made available for mental healthcare.

On the Department’s overreliance and subsequent expenditure on agency staff, she asked how much the Department spent on these services.

Ms R Windvogel (ANC) recalled that the Minister had, in her introductory remarks, said that almost 400 nursing staff members were about to lose their jobs within the next month. She wanted to touch on that particular matter, especially about developments related to Brackengate. She said that these healthcare workers had been at the forefront of the fight against the COVID pandemic, and asked whether the Department had any other options and/or other avenues that these workers could possibly explore. She saw this as backstabbing, and notified fellow Members that the ANC intended to ask for a special sitting of the Committee to discuss Brackengate.

According to Public Service and Administration regulations drafted in 1994, she recounted that allowances could be made for these workers to be absorbed as full-time personnel.

She wanted to ascertain how much money had been allocated to Brackengate for the year under review and how much of that money would be spent on filling vacancies. She requested clarity on the matter since Brackengate would transition to an intermediate care facility and obviously had to be staffed.

She inquired about the state of affairs since she had seen no advertisements for the vacant positions, and why the Department overlooked these heroic frontline workers who should have been given first preference.

The Member also said that she had seen the Memo the HOD had sent the contracted staff at Brackengate in July 2022 that their contracts had been tied to the National State of Disaster funds for COVID and would thus not be renewed. Given the circumstances, the Department had to inform the Committee on the budget for Brackengate, how the budget would be spent, and the staff complement.

The Chairperson thanked Members and asked his own question before the Department took the floor.

He asked a question related to page 225 of the report, under heading 5, with the caption “Prioritisation". He requested more information about the Department’s comment that the equity resource allocator sought to limit and balance the impact of budget constraints on programmatic areas where the greatest need existed.

Mr C Fry (DA) asked questions related to page 257 of the document – the sub-programme on nutrition and the breakdown on page 258.

He lamented the 8.7 % decrease in the nutritional budget that now stood at R 57 million. He said that it was probably a difficult exercise for the Department to have arrived at such a decision, especially since Dr Saadiq Kariem, Health COO, had highlighted the financial constraints. He expressed concern with the rise in patients who were malnourished, especially children, and wanted to ascertain how such a decision had been taken.

His second question related to page 242 which dealt with Emergency Medical Services (EMS) Programme 3. He expressed his encouragement at the 1.06% increase. He also commented on police escorts for the EMS in high risk areas where EMS personnel had become targets for assault and robberies.

He then proceeded to page 244 of the document that touched on mental health-related issues and noted the 1.34% increase in the budget, translating into R14.3 million. The total allocation was R1.1 billion. He recalled an unannounced visit in September 2022 to Lentegeur and Valkenberg. At both institutions, staff called for increased resources.

He also welcomed the R198 million to fund the increase in intermediate transitional care. He wanted to know how these facilities would fit into the broader mental health sector and where they would be located.

The Chairperson asked whether it was customary for violence prevention to be part of the health portfolio.

Replies by the Department

Dr Cloete replied that his Department, in conjunction with the provincial Department of Mobility and Public Works, had begun work on solutions and alternatives to patient transport challenges.

The joint effort recognised the challenge that immobility and rural geographical distances posed to patients who travelled far distances to urban areas to access medical care. The team leveraged what had been done during Covid-19 with the red dot system for QNI and explored other options as well.

On COE, Dr Cloete said that, although it indicated a 1.9% decrease, the Department had always intended to keep staff numbers balanced.

The mental healthcare budget had increased from R30 million to R70 million.

Mr Simon Kaye, CFO, was tasked to provide an in-depth explanation to the Committee.

He said that the Department was asked the same question every year on its agency staff policy. The Department’s policy was centred on recruiting and selecting new staff.

A total of 2 342 additional posts were created to combat Covid-19. These contracts fell under specific conditions that stipulated their employment would be terminated at a specific time. A total of 471 of the 2 342 contracts were not renewed. The 471 also included contracted workers stationed at Brackengate.

The budget clearly showed a big reduction as Covid-19-related funding had terminated. He stressed once again that the additional allocation in the national conditional grant had ended. All contracts remunerated according to that budget line had ended.

The Department had always encouraged contracted staff to apply for permanent positions at Brackengate included. Anyone had the right to apply, and they would be absorbed if proven successful. There was a specific transitionary period for Brackengate, and specific posts had already been filled. The Department had built a rapport with Brackengate, with whom an internal arrangement had been made. The Department was not heartless.

On Klipfontein Regional Hospital, the former J.F. Jooste, the Committee heard that hub activities had already begun there. When both Khayelitsha and Mitchells Plain Hospitals were launched, hub activities were already in place.

Hub activities in Heideveld formed part of the future upgraded Klipfontein facility. Staff members would be recruited as the different units came online. The Department was working with the implementing agent to bring the facility online soon.

Mental health and violence have skyrocketed since the Covid-19 onset. The economic consequences of the virus had impacted the social order of the country, especially in poor communities with dire socioeconomic conditions, which fuelled an increase in mental illnesses and violence.

The abuse of various substances such as alcohol and narcotics were also associated factors. The free access to firearms precipitated violence too. Through the Violence Unit, the Department aimed to establish the determinant factors which drove violence. From these, policies would be drafted to combat violence and facilitate violence prevention. The Department welcomed Ms Windvogel’s interest in the matter and called for deepened cooperation on violence prevention.

The Department’s position on vaccinations had been clear. News about a talk hosted by the provincial legislature with the controversial British cardiologist, Dr Aseem Malhotra, only reached the Department after the event. Those who falsely claimed that vaccines were dangerous were wrong, and the Department totally distanced itself from the fracas. The Department was committed to proven science and would continue its vaccination programme.

The equitable resource allocator allocated resources to where the biggest need existed. Both primary and district healthcare facilities would see a readjustment of their allocations. Some facilities would see decreased budgets whereas others would increase. The entire system rested upon where the needs were in the budget and on the ground.

Mr Kaye spoke to developments at Brackengate and explained that, of the 2 342 healthcare workers appointed at Brackengate, 819 had left of their own volition. That left the Department with 1 523 healthcare workers. Of these, 819 had undergone a selection and recruitment process and were absorbed as permanent or another contract. A total of 694 were left, 166 were at Brackengate, and 57 were at Sonstraal.

The Department agreed to fund intermediate care at Brackengate and was now expected to embark on a process that would turn something that was temporal into one that is permanent.

The Department of Public Service and Administration had prescripts that the provincial Department had to follow. The Department had always intended to put these healthcare workers through a selection and recruitment process. The healthcare workers’ contracts were funded under the State of National Disaster regulations. The State of Disaster was implemented from 31 March 2020 until 31 March 2022. During this period, the Department received about R197 million to fight the pandemic in the province.

R428 million from the Department’s service cash money also funded Covid-19-related interventions. These amounts were no longer within the Department's budget as the State of Disaster had ended. The Department continued to face budgetary constraints as conditional grants at national level continued to be slashed. This affected the provincial equitable share. He conceded that service delivery had been affected by these budgetary constraints and had acutely been felt in compensation of employees, as well as goods and services. The latter had received a one-percent increase.

On municipal services, the Committee was informed that the Department would provide a written response on the R600 million.

Whenever the Department contracted agency workers, it normally depended on whether there was an immediate need for agency staff. The Department kept abreast of challenges experienced at healthcare facilities, and managers were given the responsibility of administering healthcare facilities effectively.

The Department had exercised caution in the budget allocation. In some instances, it had disproportionately shifted some funds from one programme to another to balance any anomalies. The Department had embarked on a journey from historical to impact budgeting. This aided the Department in measuring the impact of expenditure on a programme.

Dr Cloete said he was aware of Khayelitsha District Hospital's expenditure on agency concerning its staff establishment. The hospital management made the relevant decision to deliver on its service delivery mandate.

The international best practice on violence prevention was based on what happened in Cardiff, Wales. According to this school of thought, violence prevention was a public health matter. It is the standard by which violence prevention projects are designed these days. The Violence Prevention Unit in the Western Cape would be a first for South Africa.

Mr Kaye said that R94 million, R118 million and R350 million, respectively, had been spent on municipal services.

Follow-up questions

Ms Windvogel said that the HOD had missed her question about Khayelitsha and Mitchells Plain Hospitals being upgraded to District Hospitals whilst waiting on the refurbishments at J.F. Jooste to be completed.

The Member said she also understood the explanation provided and asked why the contract workers could not be absorbed through the People Management Delegations that allowed the Department to fill posts without having to advertise it, especially since workers were already in the system.

Replies by the Department

Dr Cloete said that the next three years were to be a period of economic uncertainty, and the resulting impact on the Department of Health and resource allocations would be felt. The Department had to make tough decisions and, of course, these decisions always impacted the most vulnerable and the poor. Financial austerity will reign for the next three years, and this called for close cooperation with stakeholders like the Children's Commissioner.

The Department had engaged with academic hospitals like Groote Schuur, Tygerberg and the Red Cross on their ability to perform highly specialised services being affected.

Plans were afoot to strengthen the capacity of district hospitals and primary healthcare facilities to buffer the impact on citizens. The Department were cognisant of its responsibility towards the poor and the vulnerable in South African, and regarded itself as their safety net.

The Department remained committed to relationship-building and stakeholder relations management.

On upgrading Khayelitsha and Mitchells Plain Hospitals to District Hospitals, Dr Cloete said he had already addressed the same question at a Committee meeting in 2022.

The Department envisaged a dispensation based on acute hospital care and was moving away from the current status quo. Designations are thus irrelevant. The whole thing depended on specialist care. Both Khayelitsha and Mitchells Plain Hospitals already provide specialist care.

The only difference between the former and Somerset Hospital boiled down to ICU bed capacity. All patients received the same level of care at all three hospitals.

On Brackengate, it was informed that the facilities would be turned into an intermediate care facility. A whole new staff complement would then report for duty as the contracts of workers funded by a special allocation under the now-terminated National State of Disaster had concluded.

From 01 April 2023, Brackengate would function as an intermediate health care facility. Covid-19 would now be treated as any other disease.

The Department had to abide by its own policies and regulations. These contract workers had been contracted for a specific period. It was impossible to move them to other posts with a whimper.

As of 31 March 2022, the R197 million allocation was no longer in the Department's baseline, nor was the R428 million appropriation from the Service Pressure Money that funded Covid-19.

He said that the Department had a tridemic of financial challenges. Cuts on conditional grants at national level cascaded downwards and affected the provincial equitable share. Budgetary cuts affected service delivery.

Pressures were being felt in Employee Compensation and Goods and Services.

Agency personnel was only used at specific times when quick interventions were needed. The discretion solely rested with the leadership of healthcare facilities. The Department kept abreast of challenges healthcare facilities experienced.

The Department had allowed for maximum opportunity to participate in a fair process for permanent employment.

Follow-up questions

Ms Bans recalled that Dr Cloete had indeed provided an explanation to the Committee in 2022, yet Khayelitsha and Mitchells Plain still had no ICU beds capacity.

She said that 9.2.J dealt with the summary of payments connected to the estimated budget decreases for District Hospitals in the province, and asked for a detailed breakdown.

District Hospitals, she added, fulfilled an important function within the public provincial healthcare system.

One of her questions also pertained to the Compensation of Employees page 239 (9.2.1) and the reason for the decreased budget.

She also wanted to establish the breakdown of categories that will be affected in quarter two and the number of recorded attacks.

Ms Windvogel enquired about the National Measles Campaign and the plans for 2023 in the Western Cape and the R18 million spent on violence prevention programmes in the Western Cape thus far.

Mr Fry’s questions related to page 257 of the document, 2.7, the sub-programme on nutrition and the breakdown on page 258.

The Member lamented the 8.78 % or R5.7 million decrease in the nutritional budget. The Member noted the constraints highlighted by Mr Kaye and was compelled to express concern with the reduction given the rise in malnourished patients admitted to hospital.

His second question related to page 242, which dealt with Emergency Medical Services (EMS) as a whole under programme three.

He expressed his encouragement at the 1.03% increase or R13.4 million. Member Fry asked whether some of that amount would go towards escorts for the EMS in high risk areas where EMS personnel had become targets for assault and robberies.

He then proceeded to page 244 of the document that touched on mental health-related issues and noted the 1.34% increase in the budget that translated into R14.6 million and R1.1 billion in total is called an unannounced visit in 2022 to learn to add Folkenberg Mental Health Institutions here.

The Chairperson asked whether it was customary for violence prevention to be part of the health portfolio.

Replies by the Department

Dr Cloete noted that departmental expenditure on nutritional products, as detailed in the report, hardly reflected the reality on the ground. The Department contracted non-profit organisations to deliver nutritional educational programmes such as breastfeeding support and the like.

The Department had provided supplementary nutritional support for years, though this function now fell under the Department of Social Development (DSD).

This particular budget item pertained to funds provided to non-profits that conducted nutritional awareness campaigns in communities. The Department managed to engage non-profits to broaden their scope and include nutritional awareness. The DSD non-profit network was used to further these aims.

Dr Cloete said that the EMS had embarked on a streamlined operation. It was a very impressive process, as experienced by Dr Kariem and himself. They have streamlined all calls and relevant dispatches within geographical areas. This predictability ensured efficacy as calls could then be staggered with a response timeframe allotted to each call.

On geriatric mental health care, Dr Cloete said that different activities were funded across the four hospitals mentioned by Mr Fry. These hospitals were also streamlining their operations across other loads to relieve pressure in district hospitals.

Dr Kaye responded to the question about a detailed headcount of District Health Services personnel on page 259. There had been a decrease, from 13 888 personnel to 13 411.

A total of 400 posts could not be absorbed as it was tied to Covid-19 funding. Covid-19 was a district health service-related programme.

Follow-up questions

Ms Windvogel asked a follow-up question about EMS. She wanted to ascertain the shortages of ambulances and personnel and what the Department was doing to address these shortages.

 

Replies by the Department

The HOD replied that the Department had two plans. The one plan involved a more modern fleet of ambulances that the right fleet was on the road, that maintenance and repairs of the existing fleet be excelled, and phasing out redundant ambulances.

He said tmany staff members suffered from post-traumatic stress disorder due to being violently attacked and threatened. The Department was working closely with affected staff members and one option that was being explored involved transfers to other districts. Ongoing counselling was also being provided. The need also existed for recruiting new staff members as there were staff shortages.

Follow-up questions

Ms Windvogel referred to the College of Nursing's accreditation from the Council on Higher Education. She wanted to ascertain when the Council had granted the college accreditation and whether students would be forced to study there.

The Member also said that many people or patients that visited healthcare facilities sometimes had to wait in the rain and cold from the wee hours of the morning. Enclosed waiting areas seemed to be a luxury, yet facilities had those. The Member ascertained who had oversight over facilities and access management.

Ms Bans asked about the medical depot indicated on page 251 of the report which stated that plans were underway to replace the medical depot in Chiappini Street in Green Point.

She wanted to ascertain the rationale behind the construction of a new medical depot for the provincial Department, how much it would cost, and when it was expected to be completed.

She wanted the reasons for the decreased budget on page 252 (109.7), which dealt with laundry services.

Replies

Dr Cloete replied that the current warehouse was not in good condition nor fit for purpose. The Department wanted to invest in a state-of-the-art facility that the Green Point building was not.

Dr Cloete then called upon Mr Glenn Carrick, Director: Financial Accounting, to address questions on expenditure, particularly related to the legal costs as well as the communication services budget.

He informed that the adjusted appropriated amount for 2022 till 2023 stood at R153.4 million, whereas for the 2023 to 2024 financial year, R65.5 million had been adjusted for the service. This represented a reasonable 2.5% increase.

He said it may be that confusion had crept in as the two tables were actually a requirement from Treasury. Those columns had to do with projections of the adjusted budget, which was the most reliable budget of the previous year. It serves as the basis for the new budget.

The Department's budget for legal services had increased from R17 million to R21 million. The Department currently faces significant legal cases against it in the form of claims for medical malpractice.

The Department viewed legal costs expenditure as money well spent, especially since it was under pressure with all of these claims. The legal Department would assess all claims and ask the state attorney for further assistance in negotiating a lesser amount. It was noted that valid claims would not be rejected outright as the Department simply wanted a reasonable conclusion to the claims process.

The Department's Entertainment budget decreased from R277 000 to R272 000. This adjusted appropriation was a very small amount and rarely spent.

On the travel and subsistence budget of R70 million vs R66 million, he stated that one of the pandemic's benefits was introducing new working methods, such as Zoom and MS Teams, that did not require physical attendance at meetings. Nevertheless, Departmental officials and healthcare workers would need to travel to various districts within the province. The budget was also seen as a reasonable amount.

Dr Cloete indicated that the columns just indicated a percentage change in the revised budget. The technicality of the change in percentage against the adjusted estimates in terms of the final appropriations. He also emphasised that the amounts were quite reasonable regarding the overall operational functions of the Department.

Ms Laura Angeletti Du Toit, Chief Director: Infrastructure and Technical Management, spoke to the question on laundry services and informed that the Department had a contract for laundry services that expired at the end of May 2023. The service had not been reviewed and related to COVID facilities.

On the medical depot, she informed Members that the current building was impractical to act as a warehouse. Ideally, a warehouse should only have one floor. The Department had embarked on a high level design process and the new building would be close to the big pharma warehouse by Tygerberg Hospital. The idea was to appoint or get a contractor familiar with the Department's requirements. R250 million had been allocated for this purpose.

The Chairperson thanked the departmental officials for their responses and then proceeded to ask members of the public present if they had any questions.

Questions by Members of the Public

Ms Tamara Kiviet (sp) from the Cape Metropolitan Health Forum said the meeting was the 25th health budget deliberations she had attended. A total of 14 of the 25 years had been under a Democratic Alliance government. The less she said about that, the better, Ms Kiviet disapprovingly noted.

She recalled that both the Minister and HOD spoke about tough decisions they had to make on behalf of the poor when it came to the provision of equitable and free healthcare services.

She charged that currently services in the Western Cape were not provided in an equitable manner.

The Department spoke about stakeholders. She wanted to ascertain who these stakeholders were and how they had been identified. She also wanted to be apprised of their contribution to the provision of equitable healthcare services in the Western Cape.

On health services to children, she said that children under five were still suffering from severe malnutrition.

The Department had instituted a programme in communities to assist with this. However, these services had not yet reached the areas where she worked in.

She also wanted to know where the Department found money to extend the contracts by two months when it pled poverty.

She also wanted to know who provided ICAS services to two citizens.

Mr Graham Liddles (sp) from the Tygerberg Sub-District Health Forum thanked the Committee for the opportunity to address them. His intervention cautioned on the side of offering help to the Department.

As the Chair of the Bishop Lavis Community Police Forum and his team had built a good rapport with Mr Newman and the EMS team in the area. His organisation had proposed that it assist the EMS in coordinating escorts into Bishop Lavis, considered a red zone. EMS waited up to an hour at police stations for escorts and sometimes these were not even provided.

News had since reached him that such an offer of help would not be accepted due to policies and procedures. He wanted to know whether the Department would accede to the request since the community had expressed they wanted it.

Ms Christina Nomdo, Western Cape Children's Commissioner, asked whether the Department would be open to engaging on the Health portfolio budgeting process.

Dr L Lake from the Child Health Priorities Association said that she represented 20 organisations, 500 physicians, and five Schools of Pediatrics who called for austerity budgeting restraint as early as 06 February.

Malnutrition remains a big problem in the Western Cape, with about one in five children suffering from malnutrition. There had been an increase in malnourished children admitted to hospital. Stunting was not only a physical and also led to mental health decline.

Rising food prices and a child support grant under inflation continued to impact poor households.

She was pleased by the additional funding for mental health services, especially since many children have a treatable diagnosable mental health disorder. About 46% of all adults develop a mental health disorder before age 14. Given these figures, how much of that budget would be spent on mental health services for children?

Replies by the Department

The Minister said that the HOD had spoken about health care being a societal issue.

Health was not only about facilities and medicine. Health was a cross-sectorial issue.

The Committee, the Minister said, was the voice of the Department and society at large. The Committee, as a stakeholder, had to ensure that adequate funding be allocated for equitable health care. The reality was that the Health budget had continuously been cut.

In deep rural areas, private healthcare facilities were non-existent and even well-heeled residents accessed public healthcare facilities there.

In an area like Hout Bay, where the poor live in Hangberg and Masiphumelele with the rich in the Valley, it might be assumed that only the poor accessed the public health care system, yet some Valley residents, especially older women on chronic medications, also accessed the public healthcare system.

The public healthcare system operated around the clock, and it was up to a healthcare practitioner to prioritise which patients should be prioritised. If a facility was faced with a choice between a rich person admitted with a code red and a poor person with code yellow, the doctors would prioritise the code red patient.

She further said that areas like Khayelitsha experienced high levels of interpersonal violence and injuries due to its largely young population, whereas cardiovascular problems were more common on the other side of the mountain.

She saw cooperation as a “drie been potjie" - each leg representing a sector of society.

On the safety of EMS staff, the MINISTER lamented the constant finger-pointing at the Department of Health and EMS staff when its mandate was to save lives.

This core function was hamstrung by the unsafe working environment for EMS staff who have become victims of crime in the execution of that core function. Health services should not be made to militarise. Other sectors had to step up to the plate and fulfil their mandate as described. The EMS were lured into situations where they were robbed and assaulted.

They are seen as easy targets by drug addicts and other criminals. She said that, should healthcare workers and other departmental officials down tools, there simply would be no healthcare service to talk of. She continued that the Police had designated certain areas as red zones, and this meant that staff could not enter these areas.

Staff members had been trained to save lives. As much as their conscious and oath might be a driving force to attend to an emergency in a red zone unaided, the risks to their personal safety were far too high. Staff members struggled with the morality of being robbed and assaulted and their safety compromised when saving lives. It was a moral issue in an abnormal society like South Africa. The social determinants of health fell outside of the Department's core mandate.

She recalled that Gugulethu had a similar arrangement with the EMS on public-private partnerships. In far-flung inaccessible areas, people brought patients to a certain point to be collected by ambulance.

On child health services, she noted that the Department focused on a person’s entire life cycle from the cradle to the grave. Health starts at the unborn stage. During pregnancy, the mother would attend consultations with doctors specialising in different disciplines.

She said that the Department currently had a 72 hour hold on mental health. For patience and would not want to be accused of trying to institutionalise people. During the first 1 000 days of the unborn stage, one would “want the mother and the family to be healthy and living in conducive environments”.

In more affluent households, would-be parents had discussions about Planned Parenthood, whereas, in others, these discussions were not had, especially in scenarios where women had been raped.

On child immunisations, she said that the immunisations received within the first two years were also part of the INI, so too were those received during the early childhood development phase.

On responsive child healthcare budgeting proposals, the Minister said that the social determinants of health fell outside the scope of the Department.

The Department had however allocated an additional R30 million towards child adolescent mental health care. Red Cross and Groote Schuur had received funds from this allocation to address child adolescent mental healthcare. Adolescents, who are neither adults nor little children, also require their own wards. These were also critical issues to look at.

She informed Members that she had recently visited Alexander Hospital which specialised in geriatric mental healthcare, with Stikland being the other. These were the only two facilities that catered for geriatric patients. The Department had to ensure balance budgeting based on priorities.

Malnutrition is beyond the Department’s control. What she had found interesting was that the Western Cape prided itself on agricultural production and exports, yet the very children of the people who worked on farms and produced this agricultural produce were malnourished.

In the old days, farmers practised the dop system. Why was it impossible now to provide supplementary nutrition? She felt that workers had to be provided with supplementary nutrition.

Similarly, the Department was also not responsible for teenage pregnancies. Teenage pregnancies occurred under the watchful eye of communities. Teenagers came to healthcare facilities already pregnant.

The HOD said that the Department had data which backed the latter’s policy interventions. This data suggested that those citizens in the lowest income brackets have the highest obstacles in accessing public healthcare facilities and care. Resources were disproportionately allocated across the budget to cater for the poorest of the poor. The Department conceded challenges within the system.

On the question about the stakeholders, the HOD recalled the Minister’s comments on this matter and added that everyone within the province had been considered a stakeholder. The Department welcomed partnerships and informed the meeting that a history had existed between the Tygerberg Sub-Metro Health Forum and the Department on the subject of stakeholders. The Department remained committed to engaging with the Forum on how differences could be ironed out.

On food insecurity, he noted that households in the province had seen a rapid rise in food insecurity. Food insecurity was a societal determinant that influenced the well-being of citizens.

The Department also had to confront food insecurity and implement measures against malnutrition.

Regarding how the two-month extension of contracts at Brackengate would be funded, the HOD replied that it had a budget for intermediate care.

In this case, the extended contracts would be funded by the recruitment and selection budget as the Department embarked on recruitment and selection.

The ICAS tender is a month-to-month contract by Metropolitan, who, for the last four years, had provided this service. They provide transversal contact across the province and a special dispensation for health workers would be implemented from July.

Dr Cloete commended Mr Liddles and his team for their commitment to active citizenry and constructive working relationship with Mr Newman and the team. He conceded the point by Mr Liddles on EMS assistance. It had obviously existed for the Department to be more adaptive and agile with policy. The proposal was under discussion. The Department had also explored training community members and first responders as another possible alternative.

On the proposal by the Children's Commissioner, Dr Cloete said he welcomed the proposal that the Department apprise the child advocates on the health budget. He commended the Children’s Commissioner for the manner in which the Commissioner had engaged with the provincial Departments of Education and Social Development.

On the questions and observations by Dr Lake, he said that child healthcare would not exist without a healthcare system. He encouraged Dr Lake to appreciate the position of the Department. The Department took a systems approach and holistically looked at things. The Department prioritised the most vulnerable in the community and ring-fencing funds never worked. His view had been informed by his experience in the HIV/AIDS field and other chronic diseases. The end goal had always been an integrated healthcare system that responded to realities on the ground.

Dr Cloete then recalled a working visit to the Breede River Valley, where he visited an area called Sandy Hills. Sandy Hills was the epitome of how social determinants impacted the healthcare service in that area. It was noted that children in this neighbourhood were subjected to high levels of violence. This indicated what was said previously that an interrogation of the budget, line by line, would not be helpful at all. Child health was a priority and malnutrition reflected a challenge within the health system that had to be addressed. Food security, of course, was vital to stem malnutrition in communities.

The Chairperson thanked the Department for the responses and allowed for another round of questions by members of the public.

Ms Kiviet was unimpressed with the departmental responses and charged that the Department had actually failed the Committee and threw cold water on the comments by the Minister. The Minister, she said, had a penchant for quoting policies and procedures, yet had failed to deliver. She advanced that statutory committees such as District/Provincial Health Councils had, in fact, not been set up as the Minister claimed.

She expressed grave concern that the authorities were talking about stakeholders ‘in the air' and that no stakeholders had been engaged on the compilation of the annual performance plan as well as the Annual Reports of the Department.

Ms Amanda Davis, an activist and trauma and substance abuse counsellor, expressed her concern with the widespread use of Ritalin by young children. Ms Davis recalled a school visit where one class had five children who had Ritalin prescribed. About 9/10 adult substance abusers were prescribed Ritalin as children. This was a worrying trend. She asked the Department why Ritalin was the preferred medicine and what the Department planned to do about it.

Replies
The Minister said she had to follow the National Health Act as the political accounting officer. There was a history with Ms Kiviet’s organisation but she would not want to be drawn into it.

She called for greater cooperation between all stakeholders in the province. That was the only way equitable and accessible health care could be delivered to the public.

The HOD extended an olive branch to Ms Kiviet and offered to meet with her and her constituents to work towards a solution. Stakeholders were important blocks in public health care. He thanked them for their attendance and interventions.

The Chairperson thanked the Minister, Members, departmental officials, and public participants for their attendance.

They were excused from the meeting.

Committee Resolutions/Actions

Ms Bans asked that the Department provide the Committee with information on the measures that would address patient transport issues. The Minister and HOD mentioned that they were working on a plan.

The Committee also adopted the Report on Vote 6.

The meeting was adjourned.