Appointment of the Hospital Boards and Clinic Committees; Functioning & structure of District Health Council

Meeting report

Briefing by the Western Cape Department of Health

The Chairperson said the Committee requested the briefing after community stakeholders raised concerns about implementing the Western Cape Hospital Facility Boards and Committees Act during the public hearings on the Department of Health annual report in October 2022. In addition, during the oversight visits the Committee made to various health facilities, it was clear that the implementation of the Act had challenges regarding the functionality of the hospital boards and clinic committees. The Committee then resolved to request a meeting with the Department. The Committee had also requested a briefing on the existence, functioning, and structure of the District Health Councils (DHCs) in the province. The Committee had further received requests from community health forums to be allowed to make inputs and put questions to the Department during the meeting.

Dr Nomafrench Mbombo, Western Cape Minister of Health and Wellness, outlined the background of the hospital board and clinic committees. The National Health Act said that provincial health departments needed to establish the following statutory bodies: provincial consultative council, district health councils, hospital boards, and clinic committees. It further stated that the provincial Minister should be consulted about the boundaries of district health councils. The Western Cape legislation was introduced in 2016. Clinic committees were included. It was later found that there was a challenge in the rural areas where a clinic was usually run by one professional nurse who also had to facilitate committee meetings. This became too much for them because one clinic serviced four or five other areas. That was why, in terms of the regulations, the clinics had to be clustered for better management. Members of civil society were serving as volunteers before the legislation came into being. The Department met resistance from health forums on spreading the net wider. Luckily, the people involved in the past agreed to be part of the process.

Regarding remuneration, the Department compared with other provinces like the Eastern Cape, where there was remuneration for attending meetings. However, the Department later learnt they could not pay some members and were still owed money. The principle was about community participation and collaboration. It was further about the principles of primary health care: there should be a three-legged structure involving government, civil society, and community. That was why the Department had made it possible for members of these structures to claim transport expenses. Another matter concerned members who pulled out because there was no remuneration. Fortunately, the community liaison officers (CLOs) were helping the Department in the metro and districts with this matter. The hospital boards became invalid if 50 percent of the membership ship did not consist of community members.

Ms Anda Nkosi, Chief Director, Strategy, Western Cape Department of Health (WCDH), told the Committee that the purpose of the Act was to provide for the establishment, functions and procedures of hospital boards and committees at primary healthcare clinics. The boards and clinic committees were provided with a basic set of clearly defined functions, which could be incrementally expanded in the public interest as the capacity of a board or clinic committee allowed.

From lessons learnt during the COVID-19 pandemic, the Department had identified a clear need to build a health system that was agile in its response to emergent needs. It needed to be able to innovate and learn, mobilise a broad range of stakeholders, make the right choices about what to do and then do it well.

During the pandemic, everyone was told to stay at home. Consequently, communication in these statutory structures had broken down. The ministry conducted the roadshow “Nothing about us, without us” in 2022, aimed to restore communication and stakeholder relationships. There should be constant and meaningful consultation among stakeholders to strengthen working relationships for the greater good of the communities these statutory structures serve. There should be information sharing that was filtered down to communities.

In the metro district, 42 out of 45 clinic committees and 19 out of 20 hospital boards were constituted and functional. The focus during 2023 would be to continue with headhunting to get to 100 percent constitution of the statutory structures, to train all the committee and hospital facility board members, and to maintain good relationships between all stakeholders. There were delays with procurement of training material in 2022 but this has since been rectified and training was well on its way.

In the rural districts, 93 of the 104 clinic committees and 18 of the 25 hospital boards were constituted and functional. The bulk of hospital boards not constituted were in the West Coast district. The CLOs were working with the training component of the Department in training hospital boards. The Department would continue with headhunting to get to 100 percent constitution of the statutory structures.

The training of hospital boards was delayed due to a focus on training clinic committees. Training material for hospital boards was being developed. Hospital board members were not available for five continuous days of training. Also, there have been delays in the constitution of hospital boards in some areas. The master trainer who was responsible for the training of hospital boards had focused on the capacitation of CLO as facilitators. 

The focus in 2023 would be on the training of hospital boards. The Department was looking at a flexible training plan, including self-learning, online learning, face-to-face training and staggering the training days. It was also expected that there would be greater capacity of the CLOs to train.,

Ms Nkosi said they would continue to support facilities with unconstituted statutory structures through physical visits to conduct talks with communities and headhunting. The Department would continue to provide training to members to better understand their roles and functions.

All six districts in the province had structured and fully functioning district health councils. Each district health council was chaired by the district mayor and the WCDH district director who played a more secretarial role. Each district had sub-district representatives that were nominated by their councils. 

(Tables and graphs were shown to illustrate district health council status and appointments; training conducted for clinic committees and hospital boards per district; and overall clinic committees and hospital boards for rural and metro districts.)

Discussion

Mr C Fry (DA) asked how effective the “Nothing about us, without us” campaign had been in restoring stakeholder relations and communication and how this had been measured. He asked how far training for the hospital facility boards had gone and whether there was a detailed plan.

Minister Mbombo said the campaign covered all the districts and stockholders, which was a success. Ms Nkosi added that there was ongoing engagement with the communities because the Department needed their support to get members to sit on the clinic committees.

Regarding the training plan, the focus for the year would be on driving the training for the hospital boards. The Department was still finalising all the details about how they would do the training. Making use of technology would enable them to train more hospital boards.

Ms R Windvogel (ANC) wanted to know the reasons for delays in constituting the hospital boards. She asked what constituted and functional meant and whether there was a system to monitor that. She asked if hospital boards and clinic committees were aware of the process to claim travel allowances. What were the terms of the hospital boards and committees?

Minister Mbombo said that 50 percent of the members of all these structures should be from the community. For instance, there would be a clinical person nominated by the hospital. The management would nominate an admin person and the CEO of the hospital. Then there would be an expert, such as a lawyer or accountant. There might be a university representative. If the committee or board consisted just of these five or six people, it was not properly constituted; 50 percent of the membership should come from the community. It was not quorate if the required 50 percent was not present at a meeting. For this reason, a constituted committee ended up being not functional. She stated that the matter of remuneration would be discussed at a presidential health summit.

Ms Nkosi said the constitution of hospital boards depended on things like the availability of suitable people and willingness to serve on the boards. People with criminal records were precluded. The problems were largely in the West Coast and Winelands districts. The focus was getting closer to the communities through CLOs to find people who wanted to serve on these boards.

On the issue of constitution versus functionality, she said that, first, the drive was to have people on committees. Secondly, it was to check if they were functioning as they should. In the community liaison forums, the CLOs provided updates on the constitution of committees, whether people were still attending meetings and whether meetings were held. With that feedback, the Department was able to intervene and provide support or decide whether dysfunctional committees needed to be dissolved. The situation was continuously changing. 

The terms of the clinic committees and hospital boards were three years. The terms of most would end in June 2024. She stated that a circular was provided to the CLOs to share with clinic committees on travelling costs. The process of paying for the travelling costs had already started.

Mr T Klaas (EFF) sought clarity about why some boards were not implemented. He asked if there was a template that could be looked at to see if meetings had taken place. He wanted to understand how the Department would ensure it was doing well with stakeholder engagement. How were the district health councils appointed and how were they structured?

Minister Mbombo said the appointment of district councils was part of the District Health Council Act and an amended version which focused on the metro sub-councils. Regarding the Act, a municipal council nominated a councillor to represent it on the district health council. The district mayor was the chairperson of that council. In the presentation, it was stated that there was a vacancy in the Witzenberg district health council. In Central Karoo, no district mayor or person was chairing the district health council. The Department would write to the council so that it could name its preferred person, who the Department would then appoint.

She said there were deliberations on the statutory bodies at the presidential health summit and it was resolved to go back to the drawing board. During public hearings, it was agreed appointments should not be left in the hands of politicians, even though the process was open and vetting was done.

Ms A Bans (ANC) asked whether there was a guarantee that one would get training if one was on a hospital board or clinic committee. How many hospital boards are functioning currently? What kind of support did the Department give to the committees and boards? Was there a mechanism to manage conflicts between the hospital boards and clinic committees that resulted in dysfunctional structures? Was there a monitoring mechanism to ensure the boards were functioning? How did the Department get to the point of dissolving a committee or board?

Ms Nkosi explained that the idea was to provide training after the board had been constituted. Covid-19 delayed things, but the Department was trying to catch up. The commitment was that people would have been trained before they finished their term of office. The training was fast-tracked.

She did not have information on boards that were not complying with prescripts. She would respond in writing. The commitment of the Department was to support these statutory structures. Disagreements between hospital boards and clinic committees could be escalated to the directorate to identify the challenges and restore work relations and confidence. 

Mr D Plato (DA) said he supported the initiative and it was long overdue. It was high time for it to gain recognition and start functioning well.

Ms Windvogel enquired when the outstanding boards and committees would be finalised. She remarked that clinic committee members were unaware they could claim travel costs because the information was not shared. She asked the Department to ensure information was shared with these structures, especially in rural areas.

Ms Nkosi said there had been big strides in constituting outstanding clinic committees and hospital boards. The remaining aspect concerned the communities. If the Department could not find people in the communities, it would continue to plead for volunteers to serve on the structures. The matter of travel costs would be raised with the CLOs to see if it had been raised during committee meetings.

Questions from the public

Members of the public were also given an opportunity to ask questions.

Ms Nosipho Daniels, from the Western Cape Rehabilitation Centre hospital board, said they were not made aware of payments for travel costs. She also pointed out that interaction was mainly through emails rather than physical meetings. Approval of budget matters was done in emails. This resulted in members not discussing things and just agreeing. This was something the Department needed to look at seriously in supporting them as board members.

Ms Nkosi said the Department would talk with the CLOs to ensure they knew about the circular on travel costs and that people knew the process for making claims. The CLOs would be expected to state how many meetings were held and the number of members who had been paid. She said that meetings should ideally be in person or held virtually. This would be addressed through the CLOs and the Department would ensure meetings were being constituted properly. A lot got lost through emails.

The Manenberg/Heideveld health cluster chairperson asked who was supposed to pay the transport allowance, and whether members would get back pay. She said staff members of her structure needed to be trained on their responsibilities. The facility managers were not trained like the committee managers.

Ms Nkosi said it was important that roles and responsibilities of each party were clearly defined. The Department would take up the matter.

Another representative of the Manenberg/Heideveld cluster said the training offered to the committee members had been good but the problem was that functionality was reduced after training. Members met four times a year. She suggested a workshop should be held to find ways of reporting on the functionality to make it more responsive.

Ms Nkosi said having a workshop to discuss the functionality of the structures was a good idea. It was something that committee members should agree on so that the Department could be on their side. The issue would be prioritised.

Ms D Kieviet asked how many clinic committees were functioning and enquired how many terms a member could serve.

Ms Nkosi said a person could serve six years.

A member of the public asked how they could get councillors involved because they needed their political involvement; He asked why jobs were advertised on the government website when it was well known that the Department would appoint an internal person.

Ms Nkosi said councillors played a pivotal role in the local government sphere. The Department would put measures in place to ensure councillors attended meetings to address matters that fell within their jurisdiction. Regarding job advertisements, the Department followed due processes when recruiting people. The most suitable person was appointed, whether the candidate was internal or external, as long as the process was fair and sound. Vetting was done. Where challenges were identified, they should be discussed with facility managers.

A member of the Gugulethu Health Clinic remarked the facility was very small and promises were made that it would be expanded. They were promised renovations would be completed in 2023, but now they were told it would be 2026. That clinic was a 24-hour facility that served other surrounding areas.

Ms Nkosi said there had been an active process about where the new facility would be. An alternative site was shown but there were challenges around it. She noted the frustrations of the community and the matter was receiving top priority from the Department.

A member of the Manenberg/Heideveld cluster said that during the COVID-19 pandemic, they had to seek their own training to give advice to communities on COVID. As members of the committee, they had been asking for stipends and nothing had been shared with them. This was a serious concern for them.

Ms Nkosi said the Department would look into the matter of providing other types of training to the committee members so that they could act as an extension of the Department.

A member of the Gugulethu health facility remarked people with disabilities were disqualified when they made job applications and had to apply for disability grants every six months. People in these facilities should be empowered about matters of disability.

A member of the public commented that the Act should be revisited. Most questions were about communication and stakeholder engagement, the role of councillors and the fact that young people were not interested in serving on these structures. There was a need for the Department to engage with unemployed young people to be on these platforms. She noted that young people would not be part of the structures without stipends. People were giving their time and should be compensated. There should be more meetings than the required number in a year. Committee members sometimes met weekly because of community challenges. They would have been dysfunctional had they waited for the quarterly meetings. The Department should relook the frequency of meetings. She asked if hospital board members in the Western Cape were given a stipend.

Ms Nkosi said the Department would make sure it was sensitive to the needs of the communities. Councillors who were not doing their work in committees would be replaced by those willing to do the work. The Act made provisions for the committees to meet regularly if needed. Quarterly meetings were a minimum. She was unaware of remuneration regulations, and it was not happening in the Western Cape. The Department did not know where the budget for this would come from. There had been budget cuts for the departments and the Department was recovering from the five waves of COVID-19. At this point, the Department pleaded with community members to volunteer their services and claim for travelling.

A member of the TAC in Mitchells Plain said people did not know about the clinic committees. People were badly treated in the clinics but did not know where to report their grievances. The facilities had to provide committee members with administrative support because their concerns were not taken seriously. She suggested minutes of meetings should be sent to the Department or MEC so that they could be given attention. Calls were not answered when people called the emergency units. People become violent and rude when their concerns are not addressed. Attention was paid only when people burnt tyres. It was unfair that the clinic committee had to provide answers when there were problems in the clinics.

Ms Nkosi said the public would be made aware of the existence of the clinic committees through signage and other forms of communication. The CLOs would be made aware of the administrative support. If that was not happening, members should inform the Department. Contact details of the ministry staff were on the website.

A member of the public stated he was not happy about the slow pace of building a better hospital for Gugulethu. The whole matter was becoming political. The City of Cape Town created conflict between the people and the Department. Whenever the hospital was discussed, the community was not consulted.

In his closing remarks, the Chairperson said that the Committee and Department did not have all the answers. Nothing would be done if officials were not in the know about a particular matter. Members of the public should try to report matters so that they could be attended to.

Committee Resolutions

The Committee resolved that: the Department should send it a list of hospital boards and clinic committees that were functional and dysfunctional; it agreed to send recommendations to the Department to show support for the initiative and its implementation plan; the Department could use the services of the Committee for getting information out to the people about the circular for claiming travel costs; the Department should inform the Committee how it planned to roll out training of hospital boards; members should visit the Gugulethu health facility and ask relevant structures of the Western Cape government to give an update on the new clinic to be built in Gugulethu.

The meeting was adjourned.