Department of Health and Wellness 2022/23 Annual Report

Meeting report

Opening remarks

The Chairperson welcomed the members and the delegation from the Western Cape Department of Health and Wellness led by MEC Nomafrench Mbombo, and the Head of Department Dr Keith Cloete to the meeting. A moment of silence was observed and members of the Committee as well as representatives from the Department and members from the public were asked to introduce themselves.

The Chairperson said the purpose of the meeting was to deliberate on the annual report of the Department of Health and Wellness for the 2022/23 financial year and allowed the MEC the opportunity to give her overview remarks on the annual report.

MEC Health’s opening remarks

Ms Mbombo reminded members that the report was from the 1st of April 2022 to the 31st of March 2023, so that members do not ask about things that happened from the 1st of April in the current financial year. This is the first post-COVID-19 year even though the challenges with COVID-19 were still prevalent, coupled with debts and the severity that landed the health system to the pressures of the pandemic in the past few years. The Department managed to breathe a little during the financial year, but it was also a year where almost all other services that were not prioritised during the pandemic had to be brought back.

It might seem like it was a better year because there was no COVID-19, but it was a year that was riddled with a lot of pressure on the Department. It was also a time for the Department to sit and reflect on the challenges posed by COVID-19 to the health system in the province, and in the foreword, the MEC spoke about her engagements with the private sector and civil society to come up with a ‘health is everybody’s business’ approach to try and do things differently. It was also a frustrating year because some of the conditions were worse than before the pandemic, especially in mental health.

HOD’s opening remarks

Dr Cloete said 2022/23 became a transitional year and it is important to understand what the Department was transitioning from and what it is transitioning to. In the previous three years of tabling annual reports, the Department tabled mostly the impact of COVID-19, so this year, the Department is tabling a report on the post-Covid reality, and in that year, there were a few things to note which will be important building blocks going forward.

The first one is that because the Department was transitioning out of the pandemic, one of the important things that it had to do was to deal with the impact of disease profile that it could not sufficiently get through because of the pandemic, meaning the Department had to catch up on multiple fronts. However, this was not just a mere catch-up because the pandemic deepened socio-economic challenges for people on the ground, so during the catch-up year, the Department found that where the socio-economic conditions worsened, the conditions that it had to respond to were worse than it had to respond to before the pandemic. Therefore, mental health surfaced as a massive challenge for the Department, as exacerbated by COVID-19 and accelerated by socio-economic problems.

The second thing that was accelerated by COVID-19 and the social conditions was trauma and violence which reset at a new baseline that was much higher than before the pandemic. One of the most important things in the Western Cape is dealing with the issue of Tuberculosis (TB) because the Department did not test as many people for TB during the pandemic, so it had to catch up by testing more people for TB. The focus of the Department after the pandemic was an initiative called ‘health is everybody’s business’. The Department wanted to use what the pandemic afforded it, which was the opportunity to design a new health system which is better than what it was before the pandemic. This was aimed at ensuring that the Department can respond to challenges as they come in a different and more resilient manner.

Community-oriented primary care has become an important building block that the Department need to expand and work well with. Members of the Committee had asked on many occasions how community-oriented primary care services would be consolidated in the province, and the year under review was the one where 10 primary care facilities’ services from the City of Cape Town (CoCT) were transferred to the province. This was the Department’s initiative to set up a commitment to consolidate a primary care footprint for the province and within the city.

During this time, the Department learnt a few things, as some of the innovations that were fast-tracked included the introduction of robotic surgery at Groote-Schuur and Tygerberg Hospital, and the Department did emergency medical services in a slightly different model by working with the private sector. The Department also did telemedicine, where it provides services to people by calling them through their contact centre and working with them. There are also differentiated models of care and different ways of doing things, as well as a service redesign to have the Western Cape Department of Health and Wellness do things better, smarter, and ultimately with the needs of the clients that it serves in mind.

Discussion

Mr D Plato (DA) said the MEC and HOD did not refer to their good audit findings and thanked them and the entire Department for a job well done, especially considering where they started a few years ago. Mental health issues do seem to be on the rise as was mentioned because of the pandemic and socio-economic conditions. How must society respond to the mental health issue?

Mr T Klaas (EFF) was happy that the MEC and HOD mentioned prioritising TB because it is a dangerous disease that affects people. He asked for an update on COVID-19 and whether it is still a concern for people in the post-pandemic period.

Ms R Windvogel (ANC) said when the MEC spoke of a year of reflection, she hoped that a hall of remembrance in honour of the fallen heroes and heroines were part of the reflections. In her foreword, the MEC mentioned the province experiencing four waves of COVID-19, so what is the Department doing to remind the people that COVID-19 is still a reality? The MEC also mentioned the R30 million used in 2022/23 for strengthening mental health facilities in the province and the high prevalence of substance abuse in society in increased hospitalisations for mental health, and there are referral problems at Lentegeur Hospital, causing patients to stay longer than necessary. Some patients who are ready to be discharged refuse to leave and as a solution, the hospital management proposed a step-down facility. Why is it difficult to build the step-down facility? How is the Department comprehensively addressing the challenge of substance abuse and its impact on health using Khayelitsha as a case study?

MEC Mbombo said the Department is not only referring to mental health as pathology but also as a state of mental well-being for the community. The majority of people being affected are outside the health system because the focus is not only on those who are certified as having mental illness and the major contributing factors include socio-economic matters, such as unemployment. Research from the Health Impact Assessment found that during the pandemic, anxiety and depression levels, especially among middle-aged women and upwards were high, which is why the Department prioritise geriatric mental health and adolescents. The focus is not only on the illness in terms of mental health, but the overall mental well-being of society, which is why this has been taken up as a priority by the Western Cape government.

Regarding health services, before the new laws and the Mental Health Care Act, hospitals were not built to accommodate an Acute Psychiatry Unit (APUs) within district hospitals. In Khayelitsha, a Psychiatry Unit is currently being built, and the one in Eester Rivier is almost complete. These APUs are being built as new complete infrastructure and in places like Vredendal, the walls have been rearranged to add more beds because in some cases take longer than 72 hours and might not be ready to be referred to specialised hospitals. Research shows that clinical aspects of diseases count less compared to their socio-economic aspects.

MEC Mbombo said she had visited Khayelitsha many times and found that they had to put psychiatric patients in mattresses both upstairs and downstairs just to create space for them as there were too many of them. The major contributing factors to them being there include substance abuse and alcohol, especially among male youth. The Department could implement as many interventions as it can, but if it does not close the tap which is substance abuse, the health problems will continue to rise. Substance Abuse is also a custodian of the Department of the Social Development Act, and section 45 deals with how the Department of Heald could help to bridge the gap in terms of detoxing and rehabilitation of people.

Testing and treatment are crucial because they have made things easier and bridged the gap where people would get tested and could not be given treatment, but with the introduction of the Gene expert machines and the dashboards for TB tracking as well as the app for self-screening for TB, things have become easier. 

Dr Cloete said that TB is not always visible through the classic or known symptoms, but a lot of people must be tested to be detected on people. The Department learnt about smear positivity during the pandemic, where if they test 10 people, they look at the number of positive results that come out of those 10. Through the TB dashboard, the Department knows where the majority of TB cases are every month and targets those places, for example, there is a high TB caseload in Khayelitsha and other areas. The Department also has a high percentage marker, where the Department decides that if 20% of all the cases they tested are positive, then it has not tested enough people.

The aim is that it wants to get to a place where it has tested 10 people for TB, then 1 person or less should be positive. If out of all the testing done by the Department, less than 10% of people are positive, then the Department will know that it is testing enough people. The Department still wants to test more people in some areas, but it knows the areas where it must test more people.

The members were correct to point out that COVID-19 is not gone. In the first wave, there was not sufficient immunity to the disease in the province, country and globally, and because of that, the variants or strains of the disease put people who were more vulnerable than others at risk of being severely and needing hospitalisation or dying. There was a big correlation between the number of people who got infected, the number of people who got severely ill and were hospitalised, and the number of people who died. This was the reason for the need for oxygen, CTICC beds, etc., this was also in the second and third wave of the pandemic.

Between the second and third wave of the pandemic, vaccinations were introduced and the more people were vaccinated, the more they were protected against the disease. During the fourth wave of the pandemic, which was in the 2022/23 financial year, there was a dissociation between the number of people who got infected, people who got severely ill and hospitalised, as well as people who died. Although there were many people who got infected, there were many fewer people who needed to be hospitalised and few people because of the disease, and there was community immunity.

The COVID-19 strain has continued to mutate and every now and then, there is a new variant, but the Health Department measures whether there is any new strain that increases the need for hospitalisation or increases the number of deaths. However, after the fourth wave, every new variant or strain of the disease that was found has not led to increased hospitalisations or deaths, which is the reason for the discontinuation of the COVID-19 beds and no increased need for oxygen points for the disease. The Department continues to monitor the disease and holds meetings every two weeks where it provides updates on the COVID-19 strains and the number of hospitalisations caused by it.

When the Department say post-COVID, the strains of COVID-19 have now got to a point where its impact is not any different to the circulating influenza. COVID-19 has become an infectious agent like all other infectious agents, but the Department continues to monitor any spikes of new strains that might cause a pandemic. The message sent to the public by the Department is that when there is any new strain that carries hospitalisation risk with it, the Department will trigger the appropriate response to it.

The wall of Remembrance is an important issue and the Department took a management decision that it must centrally recognise the people who passed away because of COVID-19, and also at a decentralised level in each respective hospital and district. The centralised process does not only focus on the Department of Health in the Western Cape, but also other government officials from other Departments who also passed away due to the pandemic, and the process for this is ongoing with the Department of the Premier. The challenge is getting consent from the families of the people to put the name of their family members on the Wall of Remembrance, which is a long process because it is an individual consent process across the Western Cape government. The decentralised process involves making small gardens of remembrance with the names of the people, and they also invite people to do the recognition related to that.

The Department is proud of the clean audit, and the clean audit for the 2022/23 financial year is different from the clean audits for the previous four years. The major difference is that the current clean audit is the first clean audit with no significant findings for the predetermined objectives. The Auditor General of South Africa (AGSA) says what is in the report is highly credible information as they did not pick up any significant challenges with the information and the data team worked extremely hard to achieve that.

Regarding mental health, he said in the committee alongside Social Development, Education, Culture and Sport, the realisation was that everyone has mental health and mental well-being, even though they might not have mental disorders, but mental health is on a spectrum of either very good mental health, or a mental disorder. It is about creating the best environment for people to have the best mental health that they can have across all sectors, and when there are mental disorders, it is about ensuring that they are detected quickly and there are interventions are made to get the best results.

Substance abuse is a key driver of mental disorders, and the Western Cape government has made two interventions in that regard. The regulations for alcohol in terms of availability and access to alcohol are at an advanced stage. These processes are also focused on changing the powers of the Liquor Authority. The Department of Social Development (DSD) has played a key role in countering substance abuse, but the biggest intervention is working together with all sectors to give the youth options other than substance abuse.

There are two pilot projects that the DSD and other Departments are working on, including Planet Youth in George where the Department works with the community and asks children via surveys whether they use substances and have unsafe sex, their relationship with their parents, etc. The entire George community has come together to try and find alternatives for the youth and to change the trajectory. Where this has worked in other places across the world, substance abuse and unsafe sex have dropped significantly, and the Department is keen to learn from that experience so that it can be extended to other areas within the province.

Dr Saadiq Kariem, COO: WCDHW, said for the 2022/23 financial year, the R30 million was used effectively, as R18 million was used for metro services and R12 million was used for rural services. In the metro, the funding was used to strengthen the Acute General Psychiatric Platform across the metro, including Lentegeur and Khayelitsha, and there were additional posts for the primary healthcare platform and several people were appointed in Khayelitsha and Lentegeur and the rest of the metropole. The community mental health services were also strengthened as a key part of the spectrum of services offered by the Department. The Department increased the budget for mental health services to R72 million for the next financial year.

Mr Klaas asked whether the Department is spending a lot of money on its continuous monitoring of COVID-19. He said when the Committee visited Nkqubela in Robertson, they were in the process of building a clinic, but they could not get funding to do that in a good environment and wanted to know whether the good audit findings meant that the funding was provided for the clinic.

Mr Plato referred to the first paragraph on page 6 of the MEC’s foreword and wanted to know what the Cardiff model referred to and whether the Violence Prevention Strategy is transversal, as it was strange that it would be run by the Department of Health.

Ms Windvogel said the MEC mentioned that substance abuse was not entirely the mandate of the Department of Health, but the MEC of Social Development also said that it was not her mandate. She said it becomes the mandate of the Health Department at the end of the day and that it was important that the Departments engaged and worked together. She appreciated the work of the Department and its efforts to exempt hospitals from load shedding. The premier announced a R1.2 billion investment towards the alleviation of load shedding earlier this year, did this have an impact on hospitals being exempt from load shedding? The MEC mentioned 285 infrastructure projects in various stages of implementation, what is the update on some of the projects? In the context of widening health inequalities which resulted in patients sleeping on floors in the public health facilities, how does the Department excel?  

MEC Mbombo said the nature of health makes the Department absorb every issue because, at the end of the day, it is always needed in most situations. She made an example of the Rugby health parks and how health is also needed to have a presence in such situations, even in situations where people are expected to be happy because there are always unforeseen health hazards such as violence, crime, etc, that eventually lead to the need for health officials to intervene. In many instances, if a person is mugged and gets injured, they are less likely to report the case, but they will go to the nearest health facility to get help, which is why the Department will take steps to ensure that it has the various prevention units to collect data and share it with other stakeholders for implementation.

The Department is not the custodian of the Substance Abuse Act, but the custodian of the Act is the DSD, but the Act does refer to which sector or Department is responsible for what, for example, the Health Department is responsible for the detoxing as well as section 44. The Department of Health is a custodian of the National Health Act to render services. As much as leaking drains and lack of water will inevitably and eventually affect the Department of Health, the Department of Health cannot be expected to use its budget to invest in bulk water systems as it is not the custodian of environmental health. The Department is part of the transversal mental well-being and transversal safety.

The Department does not have a policy that says a hospital must send patients away when they do not have space for them, but they must prioritise patients that are in the red, meaning even if they are full, they cannot send people away, hence there are people sleeping on the floors. The public hospitals are overstretched because even wealthy people in most cases do not go to private hospitals because they might not be available in their areas, so they use public hospitals. In most instances, the hospitals must prioritise whose situation is more dire for them to get access to a bed in the hospital, but they cannot send people away.  

Dr Cloete said the Department works with a network of scientists whose job is to monitor the strains of COVID-19, so it costs very little for the Department to Monitor the disease. There is a scientific network in the country that does DNA analysis from samples that the Health Department sends to their laboratory to detect new variants. The costs associated with what the Department has done in response to COVID-19 have dropped significantly because the costs that it incurred before were for increased testing, additional beds, and oxygen, which are much lower now.

The Cardiff model says if one depends on police statistics, they will see a very small part of real violence in a community, but if they go to an emergency centre, they will pick up many more cases of assault and violence because not everyone who goes to the emergency centre goes to report violence to the police. A study conducted in Khayelitsha showed that 16% of the cases they saw in Khayelitsha Hospital resulted in SAPS cases being opened, meaning that tracking through health data gives a better understanding of the quantum of assaults, etc. If the Department wants to ensure that everyone is healthy and well, it must address all the things that make them unwell and unhealthy, meaning it must work with the various departments and sectors to ensure that people are healthy and well, not through its budgets and resources, but through its influence.

Regarding the excellence of care and the excellence of service, he said whether the Department is rendering excellent services or not depends on the people who are receiving those services and their experiences. It is from that perspective that the Department decided that it wants to work with the people who receive the services because health is everybody’s business.

Dr L Angeletti Du Toit, Chief Director: Infrastructure and Technical Management, said the Department discussed with the local municipality in Nonkqubela, Khayelitsha for finding a site for the clinic, and the Department is in advance talks to get approval for the design and construction. They also looked for an alternative location like they did in Mfuleni where the Department rented a warehouse and built a clinic underneath, but apparently, there is nothing available in the Nonkqubela area. The Department’s idea to speed up the construction of the clinic is to do the same thing it did in Mfuleni, and the Department hopes the site will be available within the current financial year, 2023/24 as it is one of its top priorities.

Page 120 of the Annual Report contains the list of all the Department’s capital investments and all the projects that are due to be completed for construction as well as their dates. The report mentions progress until the end of March, but it can be updated to show the progress made this far in the current financial year. Regarding Eskom and load shedding, the Department has 10 facilities that are exempted from load shedding, and the Department has a good working relationship with the City of Cape Town and Eskom in that regard, and it is working on exempting Khayelitsha Hospital as it has a profoundly embedded network and Eskom is not agreeing with that. The Department is working with Eskom to create a feeder that will take the input of energy from the substation directly to the Khayelitsha Hospital to help it stay on during load shedding.

Mr Plato asked for a clarification of the fruitless and wasteful expenditure considering that the Department received good audit findings, noting that the public may not understand. The Department mentioned a shortfall of funding for mental health Non-Profit Organisations (NPOs), how is it affecting the NPOs and what is the situation in that regard?

Ms Windvogel asked for more clarity on the exemptions of hospitals and whether Khayelitsha Hospital will be exempted as she did not hear that clearly during the response given.

Mr Klaas said his question regarding infrastructure and finance was left unanswered.

Dr Cloete said when the Department negotiates with Eskom and the City, it can go to them and say it wants a specific facility to be exempted when there is load shedding stage 2, 3, 4, 5, and 6. Eskom and the City of Cape Town can respond by saying they can do that because they still must shed a lot of power usage, but the way the hospital is connected to the grid allows them to switch it off to a point where the lights can be kept on at the hospital the power that needs to be shed is shed.

The power supply to Khayelitsha Hospital is part of almost the whole of Khayelitsha, so there is no way to keep the Hospital lights on while the rest of Khayelitsha is switched off. This makes it difficult for Eskom to get the number of megawatts that it wants to save by load shedding. The Department worked with Eskom to create a pipeline to go to the substation to isolate Khayelitsha Hospital so that once that happens, Eskom can keep the line on while they switch off the rest of Khayelitsha during load shedding.

Regarding the infrastructure and finances, he said there is no expenditure against Nonkqubela for the current financial year because it is scheduled to happen in the future.

Mr Simon Kaye, CFO, WCDHW, said the fruitless and wasteful expenditure was R18 000 on a R29 billion budget, it happens, and the Department may not be 100% perfect on everything, but they still will investigate it and consequence management will be done.

Dr Kariem said as part of the mental health funding that was spoken about earlier and part of strengthening the whole spectrum of mental health care, the Department had additional funding to close the gap in NPO funding of R7.3 million because NPOs in rural areas were funded at a lower gap than the metros, so the Department used the R7.3 million after the R30 million to close that gap. The Department also has a tight process of licensing going to mental health facilities, especially because it does not want another Life in Esidimeni crisis.

Mr Klaas appreciated seeing a representation of the rainbow nation from the Department.

Public comments on MEC’s opening remarks

Ms D Kiewiets, a member of the public from the Community Engagement Unit: UWC asked if there was an alternative to the system that has been rolled out and is very successful according to the Department in the case where there is load shedding and the system shuts down. She made an example of facilities where she saw the system go off because of load shedding, which caused delays in how the process worked because there were no generators in the facilities.

The Minister spoke about good governance over the years in her foreword, where are the statutory bodies affiliated and appointed by the Department as part of their good governance because they should also be in the meeting to see how their oversight played a role in the report? If health is everybody’s business, is everybody included? The Minister always says there are different communities for different collaborations, but the concern for health committees is that when social capital was part of the Department’s mandate, health was everybody’s business because Parliament would be packed with members during the annual reporting period, so it was concerning that the statutory bodies were absent.

Regarding the School Health Programme, the Department spoke about the services provided to schools. At how many schools were these services provided and was this only in the metro or across the province? Looking at the 202 309 learners as opposed to the total number of learners across the province, is the School Health Programme effective? How many school nurses are available to match the services provided in the schools?

Regarding the Home-based Care and Community-based Services, there were 7. 342 million contacts in home-based care and community-based care services, but the numbers do not clarify the number of bedridden clients and the number of children under the age of 5. Community-based care is supposed to cover a comprehensive package of care for both children under the age of 5 and bedridden clients. Does the drug-sensitive tuberculosis refer to the MDR and XDR clients? Is the medication for children dealt with in the management of TB in the province?

Response

MEC Mbombo said the hospitals that are exempted from load shedding are exempted up to stage 6 and there has not been any stage beyond that impacted on the system being delayed, unless it affected mostly radiology, and nuclear medicine in terms of their rebooting. In some other primary health clinics, the systems that usually get affected are computer-related matters and administration records, but generally in the non-metros, they do not utilise as much electricity.

The roll-out of inverters in the primary clinics is still in progress for those that have generators. Some of the clinics and hospitals have had generators for a long time, but now because of the frequency of the load shedding, it meant they needed to upgrade to bigger generators, in some instances, they have had to improvise by switching off other areas where they do not need much electricity usage when they are running low on capacity.

Regarding statutory bodies, she said it was a similar question as to the whereabouts of the CEO of Khayelitsha or the Nursing Service Manager of Tygerberg, but the people who were in Parliament are from the Head Office, representing all the other statutory bodies. Statutory bodies are appointed as per Chapter 6 of the National Health Act, meaning they must be attached to a health establishment, so the answer to the question is that they are working in the facilities that they are attached, but this does not mean there is no provincial and district engagement with the Department. The fact that they were not in the meeting did not mean that they were not effective where they needed to be, but they needed to be effective wherever they were assigned to represent the people on the ground. Whether they participate in terms of the information presented to Parliament, is not as important as the work they do on the ground.

Dr Cloete said there is a National Integrated School Health Policy, and in the Western Cape province, the Department established a formal engagement with the Education Department around the implementation of the Integrated School Health Programme. every year, officials from the WC Department of Health and Wellness in their district teams, alongside the education officials describe and decide on the schools and the number of children in each school that will be targeted and visited during the specific calendar year. They use the quintile schools as a basis for consultation for greater need, but they also work their way through to get maximum coverage of the children that must be covered.

Each district then has school health targets with their education counterparts and they decide which staff members will be deployed on specific days to visit the schools, as part of that programme, they use school mobiles to get to far outling schools that are on farms. The data provided in the report is a combination of data reporting from multiple report points. Regarding home-based and community-based care, the 7 million visits are substantive and are similarly significant with the data system that records every person, and the data system is verified at the decentralised offices. Bedridden clients, which are classified as between category 1 and category 4 clients, are included in the data, as well as the number of children under the age of 5 years.

Drug-sensitive TB means that a person who has TB responds to the first line of TB medication and anyone who does not respond to the first line of TB medication is either single-drug resistant or multi-drug resistant. Drug-sensitive refers to non-drug resistant clients, and the figures show the results of the first-line treatment for TB. 

Ms Nonhlanhla Nkosi, Chief Director: Strategy and Health Support, WCDHW, said the system referred to in the report referred to big hospitals and the facilities that also provide EC Services, and in those facilities, there are backup UPS systems, so in the event that a hospital is not exempt from loadshedding, or the generators are not working, there is still time for uninterrupted power supply. Generally, at the PHC level, where there are no backup facilities, for downtime purposes, facilities are able to use the recorded downtime procedures which include capturing some of the information manually and the information is backed up when the systems are back online.

The systems are designed to support back-capturing of information which is designed to ensure that the information is not lost. The Department is working with the Department of Infrastructure to put inverters into its primary healthcare facilities so that there is an uninterrupted power supply during load shedding.

Tabling of Annual Report of the Department of Health and Wellness for the 2022/23 financial year

The Chairperson thanked the MEC and the HOD for the report, noting that it was the combination of strong, focused, and dedicated leadership, management, governance, and stewardship. The report was tabled and the members of the Committee were allowed to pose questions to the Department, starting from Part A (pages 5 to 32), then the Committee will deal with Part B, C, and D.

Mr C Fry (DA) started with a comment on page 15 on the mental healthcare services in the George region and commended the Department on hearing the Committee’s cry about the shortage of psychiatric beds in George Regional and the Beethoven Municipality. He said the Red Cross Memorial Children’s Hospital is very close to his heart as it is where he was diagnosed with a scar in the macula of his left eye. The surge in the re-emergence of vaccine-preventable diseases is a problem that is solvable, but what is the awareness level that has been put at the Hospital? Are there any awareness drive programmes or posters to encourage people to vaccinate their children against mumps, measles, etc? Have there been any eye transplants at Red Cross Children’s Hospital in recent times? He commended the fact there is a weekend waiting list initiative that brings down the waiting time for children for access to Hospital theatres and wanted to know how it works in practical terms.

Ms A Bans (ANC) asked in respect of project 2 on page 11, why are metro NPOs receiving higher funding over the rural NPOs and why are district hospitals not catered for additional beds? She asked for an update regarding the status violent crime unit which was not finalised in the previous annual report of the Department as well as the adequacy of the R10 million budget expenditure. She asked them to also highlight the significant achievements of the unit in the past financial year. The perinatal working group made recommendations for strengthening perinatal services. What are the details of the recommendations and what progress was made in implementing them?

Ms Windvogel appreciated the positive trend shown in the report regarding home and community-based care but was concerned by the declining service standards in home and community-based care, maternal deliveries, and the rise of mother-to-child HIV transmission. Could the HOD provide insight into these challenges and explain the circumstances underlying the increase in mother-to-child HIV transmission?

30 950 patients were reported by facilities as having started on drug-sensitive TB treatment, which is an alarming rate. What are the underlying causes and what measures are in place to mitigate such issues? Could the Department provide data on the total number of children with TB, including those under treatment for drug-sensitive TB, as well as the total number of child fatalities?

Ms Windvogel was disappointed to not see Vanguard Hospital on the list as the Committee visited it earlier in the year and saw several infrastructure challenges at the hospital, including folders being in the corridors, in admin blocks, the filing systems were a mess, and the hospital was awaiting infrastructure updates. Can the Department provide an update to the Committee in that regard?

MEC Mbombo said Red Cross Hospital is a Tertiary hospital not only for the province but for all other children including those outside of the country. It is a level 3 hospital and it is also a referral hospital where referrals are made by other hospitals, so immunisation awareness campaigns, as much as they can be done by the hospital, must also be done by the primary healthcare facilities. They do work with NPOs and other hospitals, such as Khayelitsha, especially regarding the issue of burning houses in informal settlements, and they provide awareness about how people can use sand and avoid candles falling off, etc. The peace run done by the MEC and the other Department officials during the Cape Town Marathon was part of the fundraising process.    

Dr Cloete said the 7. 3 million home and community-based care visits in home and community settings in 2022/23 compared to 7.4 million in 2021/22 means that is the number of people the Department reached in each respective year. The 90 000 maternal deliveries in 2022/23 and the 96 000 in 2021/22 mean fewer people delivered babies, and for the Department, that is a good sign because fewer people were pregnant and fewer babies were delivered. The deliveries are combined data from all the birthing units in the province. However, the Department would like the home and community-based visit numbers to grow accordingly because the phc facility visits will become less. According to the Department, these are just numbers and not a reflection of a drop in performance.

30 900 people were reported and started in drug-sensitive TB treatment in 2022/23, and in 2021/22 there were 27 000, meaning the Department is starting more people on TB treatment, but it should be finding even more people. 3 000 of the 30 000 people that the Department found and started on TB treatment, 10% were under the age of 5 years, and the lack of follow-up was 19%, which is unreasonably high. The reason for the 19% is that at the facility they record people as they are registered, but the people do not get their medication from the same facility. However, through the electronic system, the Department is able to trace the people from the data from other facilities.

Dr Kariem said regarding the Department underfunding rural NPOs, there was a historical discrepancy in the funding because rural areas have fewer NPOs and offer fewer services, so with the project money, the Department wanted to correct the historical inequities so that both metros and rural areas are funded equally. The Department puts out a call for proposals annually and the rural and metro-based NPOs are part of that call for proposals for funding and that has since been corrected.

There is a detailed report on the perinatal outcomes and there was a Committee in the Department that dealt with the outcomes, and a lot of the proposed perinatal outcomes did not require additional funding. The Department worked with some of its NPO partners who provide birthing partners, which are women who go into labour with a partner during birth because research shows that those women tend to do better and the children born to those women tend to be healthier due to the support they receive. Training is important in this project, and the Department trains its staff on Essential Steps for Medical Obstetric Emergence (ESMOE) for managing obstetric emergencies, as well as community health workers. The Department also provides information regarding antenatal care, coming early for booking visits, etc.

Some of the additional funding that the Department received for the current financial year was to provide staffing to support the entire process of strengthening the perinatal services and provided significant amounts of money. The metro received R72 million in additional reallocated funding and a large portion of that R72 million was sent into women and child health services to strengthen the service platform, and rural health did the same. There is a pediatric surge season every year, especially around medical respite cases, and during this season, the Department ensures that additional surge loads can be accommodated on the service platform by moving the patients around the service platform according to where the capacity exists.

Transplants are listed in that process and Red Cross Hospital is one of the only hospitals that can do it, but the Department has been trying to strengthen the transplant programme going forward. Part of the funding that went to the 2022/23 period and the following year was also to support additional staff so that the staff could provide extra support at the district hospitals, and the Department went further to put time limits on when district hospitals can refer patients to the next level for specialised care because part of the Department's analysis was that patients were waiting for up to 11 days before they were transferred. The Department brought the limit down to about seven days to ensure that with the additional staff, the care would be stronger and better clinical quality, so the funding was not necessarily used for extra beds but for the quality of service and care in the district hospitals.

Ms Juanita Arendse, Chief Director: Emergency and Clinical Services, WCDHW, said the organisational design process for the Violence Prevention Unit was concluded at the beginning of 2023 around February. The Department appointed a Director, who commenced duties on the 1st of September, and the filling of the rest of the posts of the unit will be done between the 1st of November and the 1st of December and there is only one person outstanding. Of the Violence Prevention Coordinators across the province, there are 12 posts that have been funded, 10 of the posts are filled, and two had to go back for advertising.

There is an alignment between the area-based team and how the entire government’s approach comes together at the local level that is aligned with the community-oriented primary care approach. Four of the sites have already started working together and the Department received some feedback, there are four more sites that will start working in December and the balance of the 18 precincts that were identified as violence prevention hotspots will start working by the first of April, so this has become like a phased approach. The 10 violence prevention coordinators that were appointed went through an orientation programme, and there is an ongoing capacity-building process that is happening between now and December, and there is also a whole of government collaboration around the communications plan.

Dr Kariem said the weekend team is basically the same staffing where people volunteered their own time. The staff initiated it and they go to work over the weekends to do catch-ups because during the week they have other competing work.

MEC Mbombo said Vanguard Hospital has been prioritised as priority 1, meaning they have done minor work on the infrastructure, but regarding the service flow, it has changed completely and improved. Part of what used to frustrate people in the hospital was the delays in accessing the folders where people ended up having multiple folders. What is happening now is that they are taking folders according to the batches and numbers and are trying to put them in temporary moving shelves so that when the storeroom is completed and ready to use, they can store the folders that have not been used for a long time. The other folders will be backed up through an electronic system. The construction will commence soon, starting from the security entrance and right through to the rest of the infrastructure, but the excitement for the Minister was that the entire flow has completely changed and service has improved.

Mr Klaas asked for some clarity on the dividends on page nine, and on page 11, on the elimination of TB, he wanted to know what was done about malnutrition. On page 14, he asked about the discontinued activities and wanted to know the reasons for the discontinuation of transport from Cape Town to George. He said there is always a staff challenge when the Committee does oversight visits to hospitals, and they would tell the members that even when they employ more staff, there are not enough funds to pay them so they end up working with less staff. What is the Department doing to address this? He was unhappy that the government always says it has no money when hospitals are short-staffed.

Ms Bans welcomed the response received regarding the appointment of violence prevention units but did not hear about the activities and the significant achievements of the units. Regarding mental health, she said the MEC had said the Department cannot build more mental institutions, but should rather look at promoting a healthy lifestyle for the people. What programmes were implemented to promote a healthy lifestyle because whenever the Committee goes on oversight visits, there is an overflow of mental health cases? How is the message regarding a healthy lifestyle being communicated to the people on the ground?

Ms Windvogel wanted to know why the transport service between George and Cape Town was ended and how this decision affected the patients who rely on it, as well as whether there will be a replacement for the service. On page 15, she appreciated that the Department is going to add social workers to become part of the district component and asked whether there is a possibility that the Department will also add psychologists to the component. On page 20, she wanted to know the number of people who were employed to form part of the Community First Aid (CFA) Response Intern Programme and also asked for a breakdown between the metro and rural communities, as well as the stipend received by the interns. Is there a pathway that is created for young people to be trained to become EMS personnel in the future?

MEC Mbombo said when a child is malnourished, it is often a community issue and means that the parents and other family members are also malnourished, so as part of the transversal well-being priority, the Department raises these issues to other Departments such as DSD or the Department of Agriculture to assist. The Health and Wellness Department calls upon other Departments to assist in that regard because it does not have the budget to feed the communities and the malnourished children, even though it does have a nutrition component in some of its programmes.

The transport between George and Cape Town was one of the MEC’s pet projects and it was about cutting the travel time for the people between the places they are from to the level 2 hospitals in other areas, as it took them nearly an entire day to travel to these hospitals and back to the remote areas that they live in. This project was an extra service that the Department was offering to people as part of its EMS services, which it had to find funding for from alternative measures. The health department had to fix some of the inequalities and challenges that are happening outside the health system in the country whether they are perpetuated or ignored. The situation is different between the metros and the remote areas because they have no other means of accessing transport going to a different area.

With the new technology and telemedicine and outreaches with the superspecialist, the need for the people to travel from George to Groote Schuur can be reduced, so the discontinuation of the transport was not about ending the programme, but about finding alternative means to ensure the people in remote areas receive the services they need without having to travel far. The Department is short-staffed and started the financial year with a budget that was reduced by R1.5 billion, which would have employed about 2 000 staff members. In some of the hospitals, wards had to be reduced and patients moved to one ward so they could access help from the available staff.  

Dr Cloete said the Department’s intention is to get hospitals and clinics to a point where the files are ready before they can see patients and that people go to their appointments and are seen as quickly as possible.

Mr Kaye said the dividends is a standard descriptor that is used across all government departments, and the Department does not have investments, so it does not apply to them, and the estimate is also wording that is used as the Department estimates what budget it will receive and finds out later what budget it received. The table shows that the Department collected revenue from various sources than it thought it was going to, which is something that has been happening frequently in the Department.

Dr Cloete said a research study that shows that a person’s nutrition level is a powerful determinant of a good TB outcome was released, so the Department must raise the point that nutrition is important for the treatment of TB. The Department must go back to its targeted intervention for HIV and TB, but as part of pockets where TB is prevalent, the Department must look at nutrition and availability of food.

The 48-hour turnaround to see someone for 15 minutes in Groote Schuur causes disruption in a person’s life. One of the exciting pilots the Department is working on is that it is looking at subspecialist care from Groote Schuur being rendered at George rather than the outpatient having to go the other way. For an intensive care doctor, there is a low-cost robot going on a ward round, meaning an intensive care doctor sits at an office at Groote Schuur seeing through the eyes of the robot doing a ward round and can hear what they are saying and can ask questions about the patients, and they can respond to the doctor. In a sense, the doctor becomes part of the ward round and can give specialist advice to a patient without having to be physically next to the patient. The other intervention is telemedicine where a patient can be seen by a doctor in Groote Schuur while in George without having to make the trip to Cape Town.

Dr Cloete said he would be surprised if any of the health facilities in the Western Cape said they have enough staff because of the workload that is visited upon the staff and that the staff is very thinly spread. The Department has a system to provide resources for staffing, and one of the things that happened in the 2022/23 financial year is that there was an approved post list, meaning the money that the Department had was translated into the number of staff that it could employ, and then it was voted upon by Parliament. All the posts that the Department could afford were distributed fairly across the province, and that approved post list was what the Department had to work with. Preferably, the Department would like to look at things that could be done outside of health services to prevent the numbers of people utilising health services so the staff could not be so overworked.

There are three intended outcomes for the Violence Prevention Unit. The first one is to strengthen the local response in the geographic area that is localised to violence. The 10 posts that were referred to were for people to go into a local geographic area and bring all the role players together to find solutions to violence. Since the coordinators were appointed, in Delft there has been a response as the local players are coming together and looking at what they can put in place, and people are keen on working together to try and make a difference in Delft. The other one is in Hanover Park and is linked to the Philippi Police Station, and the third one is in Swartland on the West Coast.

The second intended outcome is to look at evidence of what will make a difference, and the one big breakthrough in this is the parenting programmes, working with DSD and several NPOs. If the parenting programmes are done well and can reach out to the parents and their young children and teenagers, a huge difference can be made in terms of violence prevention. The third intended outcome is to use all the data sources so they can be used to make a difference.

On mental health, there are positive stories in Witzenberg and Klipfontein because in those areas first they talked to teenagers between the ages of 13 and 18 years and asked them what would work for them. There are two things that the Department is helping 13- to 18-year-olds with, and the first one is how to manage their emotions, emotional regulation, and how to solve problems. The psychologists are part of the district component and that is making a huge difference to mental health in areas such as Overberg.

Ms B Arries, Chief Director: Project Management, WCDHW, said the CFA programme is not an intervention to employ people, but it is a community outreach intervention of the Department, and to date, it has trained 109 individuals from the community and has heard great feedback on how it is empowering people. The Department plans to extend the programme across the province so that it empowers people in communities to be the first aid response.

Dr Cloete added there is no stipend with IFA because the Department is training people within the communities with skills of how to do emergency, but CFA is an internship programme that offers a stipend of R4 100.

Ms Windvogel said the Minister mentioned that there is no money, and the Department must work with what it has, and noted that R180 million is just a fraction of the R29 billion, but the reality is that R180 million is a lot of money, and a lot could have been done to expand services at the facilities. What is the reason for the under-expenditure?

Dr Cloete said considering that the Department started the 2022/23 financial year with a shortfall of R1.5 billion, the R180 million was not spent so that it could be used in the current financial year to offset the shortage of R1.5 billion. This was a deliberate attempt to save as much money as possible for the future of the sustainability of the Department.

Mr Kaye said as part of the Department’s organisational ethos and culture, it does not spend money for the sake of it, but it spends money on the things that it needs to spend money on and then returns everything that it doesn’t use to Treasury. The Department also did this during the pandemic, but the Department is allowed to use the money in the future to invest in something that will help health services. One of the discussions the Department is having with Treasury is how to mitigate the unfunded wage agreement that it has in the current year by using its savings from the past.

MEC Mbombo said it is not about waking up and realising that the situation is bad and deciding to act on it, but it is about weighing the options that are possible, considering the changes that are looming.

The Chairperson allowed members to take a short break and the Committee continued with the deliberation thereafter.

The Chairperson informed Ms Kiewiets that the procedure followed to advertise and mobilise for the meeting was the same for all the other portfolios, many of which were well attended by stakeholders, so it was inexplicable why there was not a better turnout by stakeholders and members of the public in the meeting. He then asked Mr Klaas to ask the question he intended to ask before the break.

Mr Klaas said he wanted to request that the Department must apply for the need of the staff to the government and offer training where necessary so that the services can be provided.

Dr Cloete said in healthcare systems globally, the fundamental point of departure is that healthcare needs exceed healthcare resources. The Department’s point of Departure in this case is that the healthcare needs of the people in the Western Cape will exceed the healthcare resources that are available. The point made by Mr Klaas that the Department can take going forward is to understand the healthcare burden in terms of what makes people ill, their needs for optimal health outcomes, and to translate that need into a mix of people and the scale that would be required to do it.

The Department is starting a five-year planning process and part of that is to take the planning into the smallest geographic unit that it can plan from, which is the subdistricts. The issue is even with that framework, people normally would say the Department needs everyone to help respond to the healthcare needs of the area, including the public and private sector, as well as the citizens to also take a certain responsibility. A people-centred plan to address the challenges in the area as well as the skills that would be needed could be discussed, but the long shot of that is going to come to one practical reality, which is that the resources that are available at any time are going to be exceeded by the need.

The Chairperson said the members were left with limited time to deliberate on the report warning that they might have to continue the meeting after the SCOPA meeting in the afternoon and pleaded with the members to be precise with their questions.  

Ms Windvogel asked if there were any tenders that were challenged in court and what the outcomes of the cases were.

Dr Cloete said whenever the Department places a tender, it goes through a legal process and whenever they award a tender, some of the unsuccessful bidders challenge the process, but not all that goes through the court process.

Ms Santie Roy, Chief Director: Supply Chain Management, WCDHW, said there are currently no cases, but there were issues that were reported to the PFS that are still due for investigation which may lead to litigation processes in the future.

The Chairperson asked members to ask questions on Part B of the report, on performance information from pages 34 to 133.

Ms Windvogel wanted to know the latest update regarding the struggles with community healthcare workers and their relationship with the Department and NGOs. Were the demands of the healthcare workers accommodated, considering that the MEC mentioned in a previous meeting that the Department is not in charge of healthcare workers, but they fund the NGOs that employ them? If the Department funds the NGOs, then it must be expected that the NGOs take care of the needs of the healthcare workers. Was there any engagement with the NGOs by the Department in that regard?

Are the any plans to transfer facilities to the provincial government soon? Regarding the intermediate COVID-19 care facilities for long-term conditions, she asked for an update on the Brackengate Hospital staff contracts, and whether all vacancies were filled. She also wanted to know the number of COVID-19 healthcare heroes who were employed permanently as well as what happened to the rest of the workers. On page 36, she wanted to know how the number of ambulances has increased since 2019 and whether the number was enough to handle over 625 000 cases that were attended in the 2022/23 financial year. To what extent was the crisis of long waiting times for ambulances addressed?

Mr Klaas asked for clarity on page 39 on the service delivery improvement plans, on the targets versus achievements. Is the Department building or closing clinics? There was a strike that happened and led to people dying in a hospital, how did it affect the Department and was the Department able to manage the effects of the strike?

Dr Cloete said the process that the Department went through regarding the community healthcare workers was to relook its policy in relation to the contracting of NPOs. The Department updated its policy specifically on what is expected of the NPOs, and the steps put by the Department in terms of contract management with the NPOs. This was done after the pandemic and because of the community healthcare workers felt that their rights were not protected. That activity has crossed over to the current financial year and the HOD was given the last update all contracts are now in place, and they are managed in line with new stipulations, including what the healthcare workers are expected to do, the skills they need to have, the resources they need to have, and support they receive from NPOs.

The Department also considered the working hours of the healthcare worker as well as remuneration per hour of their work. The second part, which is out of the control of the Department, is the national dispensation to give one national dispensation for fairness for community healthcare workers. The Western Cape Department gave detailed input on the dispensation based on its policy and recommendations on how to make a fair dispensation for community healthcare workers. The Department will receive an update on the national dispensation in November this year.

Regarding the City of Cape Town’s health facilities, the Department is very clear with its counterparts in the city having received 10 facilities in the 2022/23 financial year and additional facilities in Atlantis will be consolidated under the Department in the current financial year. The Department is clear in that it wants to move into a consolidated decision for the primary healthcare facilities to be consolidated under the province. That final decision has not been made yet between the Western Cape government and the City of Cape Town, but there is ongoing communication and lobbying from the Department to ensure that this happens.

The Brackengate situation as of the 31st of March 2022/23 was that the official contract of people employed at Brackengate under COVID-19 resources ended, all the COVID-19 money ended, and the need for the use of Brackengate for the extended hospitalisation because of COVID-19 subsided. Brackengate as a COVID-19 facility closed on the 31st of March, and all the resources for the staff that was employed on contract ended on the 31st of March.

There was a contested process around it, but the Department opened Brackengate as an intermediate facility or a transitional car facility on the 1st of April. The facility changed its nature and the Department advertised for all the posts to be filled at the transitional care facility and encouraged all the staff members whose contracts had ended to apply for the posts and to apply for other posts in the Department. The staff has been established to operate a 100-bed facility and all the staff that was needed for the facility was employed. The balance of what is left over is that not all the staff that had contracts were employed at Brackengate, but the Department encouraged them to apply for other posts and assisted them through that process.

The Department has a schedule of activities and is planning for new and replacement PHC facilities, clinics, and community day centres. The general principle is that there is a need for more service points than there will be fully staffed clinics and CBCs, including wellness points, outreach centres, and satellite clinics. Those are all part of what the Department needs to provide care for people, but sometimes gets confusing is that people equate a new facility opening with an old facility closing. What usually happens is that with the opening of a new facility, the nature of an old facility might shift.

Regarding the strike action, he said not all disciplinary action and recovery of monies that were warranted were implemented. The impact was that the Department was able to maintain service levels to such an extent that it did not gravely put the health of the public or the patients at risk. In most instances, they were able to go and provide the services, but in some instances, it became difficult, but no services were completely stopped because of the strikes. In instances where no one reported to duty, disciplinary actions were taken against employees accordingly. 

Dr Kariem said the EMS personnel is a combined strategy of the Department and there are about 1700 operational personnel and roughly 120 vehicles on the road on any given day, but in addition to providing that service, there was a significant increase in the AP1 urban response as well as the AP1 rural numbers. The metro went from about 93 000 to about 130 000 over the last three years. The Department is also busy with the contracting of a service tender for the private providers because a lesson learnt during the pandemic was that sometimes it is easier to contact private providers to partner with during surge. The Department is putting out a tender for three years to ensure that it can have additional response time from using private sector providers.
Mr Plato said he picked up on various pages in the report that the Department focused on underperformance and asked whether these were a major problem and whether the Department could deal with them.

Mr Klaas asked for clarity on whether the posts for the Brackengate facility that was changed from a COVID-19 facility into a transitional facility were advertised because of that. When people do good work at a facility, they often do not all get chosen even if they have done good work because the leadership chooses the people that it likes, and this is embarrassing and demoralising. How many people who worked at the Brackengate COVID-19 facility did the Department employ to continue working at the Brackengate transitional facility? There are a lot of NPOs and NGOs that profited, in Mbekweni there is an NGO that checks on children and TB patients. Is this one NPO used by the Department for both functions?

Ms Windvogel wanted to know the turnaround time for the arrival of ambulances once they are called by people. How long are the ambulances supposed to take to get to the pick-up points? What are the details of the facilities that did not achieve the ideal clinic statuses and the reasons in that regard? While she acknowledged the improvement from the previous year in terms of linking performance with budgets, she noted that R54 million is a lot and there is nothing to be celebrated about failing to spend such an amount. What is the number of funded vacancies that were not filled?

Dr Cloete said the R54 million is one line of the R180 million that Ms Windvogel previously asked about and it is on programme 1, which is the Head Office function. This is based on what the Department does at the centre as a Head Office, and a lot of that R54 million is money that is held by the department at the Head Office to do certain things. Part of the reasons it is withheld is that the Department does not want to spend it unwisely or just because it has it to spend.

The ideal clinic status is 84% and the balance of 28 facilities is spread over different places, and some of them are extremely small spaces. The ideal clinic status is a rigorous and detailed checklist of things that must be considered and one of the main reasons for some clinics do not receive the ideal clinic status is infrastructure-related. There is nothing major that is preventing the 28 facilities from getting the ideal clinic status.

Regarding the turnaround time for ambulances, he said the delays in the arrival of the ambulances at pick-up points can be pinpointed to a specific time, and the need for EMS is not even all the time. For example, if one calls for an ambulance at 10am on a regular Wednesday morning, the ambulance will probably arrive on time, but if one calls it on a Saturday afternoon at the end of the month, they will wait for a long time.

The issue is that if the need and the calls that are registered on the performance could be plotted out, they would show how the calls run at a certain level and then suddenly there is a peak of calls coming in, which is the main cause of the delay because the capacity available is overwhelmed by the volume of calls that come in. The Department is trying to find ways of responding during those peaks through redeployment based on availability, but it is not easy to predict the peaks because of the once-off accidents that could happen at any time as well as the red zones. The answer is that the turnaround times are never the same.

On Brackengate, he said the Department took a list of all the people who were employed at the facility and undertook to check which of the people had got jobs and those who had not, so out of all the people who were previously employed at Brackengate, less than 30 of them are without a job. There is an ongoing process to encourage those people to continue to apply and to go for interviews, and currently at the facility, there are 154 posts filled out of 160.

The Department does not normally work with one NPO, but it prefers to work with NPOs in communities where they already have a footprint and communities know them. Some NPOs go through difficult times and some of them function very well, but if there is a problem in the capacity of the NPO and it cannot perform its intended functions, the Department must stop working with it and find another NPO partner with the capacity to perform the functions.

One of the requirements for the Annual Report is for the Department to explain when it is not reaching some of its targets. The Auditor-General South Africa (AGSA) has actioned an audit report and they said there is no concern from them in terms of underperformance in the Department. Considering the number of indicators that have not been reached and how far indicators have not been reached, there is no concern from the Department, but it was also good to receive the same response from the AGSA. When the Department does not achieve a target, it rigorously finds ways to perform better, hence it reports the underperformance on its annual reports.

Ms Windvogel asked for an update regarding the JF Jooste project in terms of the progress made this far and how much was spent during the 2022/23 financial year.

Dr Cloete said progress has been made with contract times have been confirmed and the process is underway.

Dr Angeletti Du Toit said the consultants were appointed last year and the project is currently on stage 2 of the Facility Infrastructure Delivery Management System (FIDMS), meaning it is currently in concept design. There is a full team of consultants, architects, engineers, etc, that are working on the concept design, and the Department spent about R5 million in consultant fees last year.

Dr Cloete said stage 2 is focused on design, including the layout, the services that will be rendered, how it will fit on the site, as well as the fees that must be paid which are the consultant fees.

MEC Mbombo said this is a standardised process for professional services and it is not only done for the JF Jooste project.

The Chairperson asked if it would be correct and fair to suggest that consultants refer to professional services rendered.

Dr Cloete said when consultants are employed, a tender is put out requiring specific skills, such as architects, engineers, quantity surveyors, etc., and they need to be able to do the technical specifications for designing the hospital. The Department can also provide a formal report on the technical specifications of the process.

Dr Angeletti Du Toit said the professional service provider and the tender are being done by the Department of Infrastructure because the DHW is the client, and the implementing agent is the Department of Infrastructure.

Ms Windvogel asked for an update on the Ladysmith clinic.

Dr Cloete said he visited it recently and it was virtually finished.

Ms Kiewiets said the Department’s future plans speak to the Department’s Strategic Plan for 2020-2025 and wanted to know what happened to the strategic plan for 2030. How many mental health community health workers in the NPOs have been trained to render effective mental health community-based service and if they are trained, where are they placed? Regarding the additional hospital beds to be made available at Lentegeur Hospital and George Regional Hospital, how were the two facilities identified and are they the hotspots in the province? On the community outreach programmes for TB, previously there was a dot system which worked effectively, but it is no longer there and although there are improvements happening in other places, there are no improvements in Uitsig. Are the Department relooking programmes that worked previously to better the services around TB?

Have the surgical backlogs been reduced since the pandemic, and if not, what are the challenges in that regard? There are no Sustainable Development Goals (SDGs) around perinatal services, so how are community services programmes integrated into the services? On vaccination integration, was there a reduction in the vaccination defaults in children especially regarding the recent measles outbreak? On community-orientated primary care, is the Department on par with ensuring that in the rural communities, people understand a nurse-driven service? Is the Observatory Forensic Services commissioned and if it is commissioned, is it running without the challenges that it had prior to the commissioning?

The Department’s slogan is health is everybody’s business, and that means nobody is left out, but the Department has bilateral agreements with universities, which are not effective in terms of community-driven services because the bilateral agreements speak to student placements as well as numbers. The reset agenda must include everyone who wants to ensure that health is everybody’s business.


Dr Cloete said Healthcare 2030 is the Department’s long-term plan until it is replaced by something else, but what is referred to in the report is the Department’s five-year plan, which is until 2025, and the Department is currently in the process of discussing the last five years of the long-term plan. The Healthcare Plan 2030 is the guiding frame for the Department and many things have moved since its adoption, but the original idea of the plan is still observed and guides the five-year adoptions. The 2030 plan was adopted in 2013 and the last five years from 2025 will be a full fifteen years of three five-year plans to 2030.

Ms Arendse said the community-based mental health programme has its own service set of community health workers within the residential facilities within the group homes and they are trained within the mental health space. As far as the integrated community-based services community healthcare workers are trained, there is a module of mental health which focuses mainly on prevention and support, which is also linked to making every contact count, which is a new strategy that the Department is moving towards in the province.

According to the differentiated models of care, all the patients are aligned to the model of support that they require, so while the Department can acknowledge that it does not use the dots method like before, the proportion is a lot smaller in some of the facilities and depends on the patients. Some of the patients still have dots at the facilities and within the community, but a vast proportion of the patients receive their medication through other mechanisms and are supported more remotely than they used to be supported in the past.

Dr Cloete said the intention of the integrated community healthcare worker is to have the ability to go into a household and manage the people in the household according to the needs of the people they found in the household. Every community healthcare worker should go through the module so that they can ask questions about mental well-being and support generally in the household. Every community health worker must know that someone in the household has a chronic condition, if it is TB, they must know what support to provide, and if it is HIV, they must know what support to provide, and even if it is hypertension or diabetes, etc. It is about giving skills to community healthcare workers to be able to support and know where to refer if the situation is not ideal for the household. Making every contact count is designed to ensure that the healthcare workers can look at the need and respond accordingly.

Dr Kariem said surgical backlogs were a major consequence of COVID-19, and during the 2020/21 financial year, the backlog was estimated at 37 000, in 2021/22 it was estimated at about 31 000. For 2022/23, the backlog significantly dropped to just over 11 000. The Department put in significant effort with additional funding, as well as the hospital and facilities’ own funding as they all had catch-up plans for the surgical backlogs. The focus was on the urgent cases first, like cancer care or the ones that urgently required theatre.  

Dr Cloete said because the perinatal work is looking at pregnancy for mothers, the outcomes of pregnancy in terms of birth, and the outcomes of the children being born, there are two major indicators that are tracked. The first one is maternal mortality, which is linked to the SDG objectives. The maternal mortality in the province significantly decreased over the years, but unfortunately, because of the pandemic, it peaked because COVID-19 also specifically affected pregnant women. It has since decreased again in the post-COVID-19 era. The other big indicator that is tracked by the Department within the perinatal work is neonatal mortality, which refers to deaths that happen within 28 days after birth. The neonatal mortality in the province is by far the lowest in the country.

Regarding vaccine integration, the big focus was that COVID-19 vaccines should not stand alone, and the Department wanted to ensure that the COVID-19 vaccine is part of their vaccine offering. The tragedy is that one of the unwanted parts of the COVID-19 vaccination is all the unwanted attention of people using disinformation and misinformation against COVID-19 vaccination, which had a negative impact on people taking up general vaccination for their children. The Department has had to go back to parents to reassure them about having to immunise their children against childhood illnesses, which has been a big challenge.

Regarding the community-oriented primary care (COPC), the Department must go back to communication to explain to people what it means about COPC and what it entails. The main thing about the COPC is that in the local community where people live, there must be community-based healthcare workers and a nurse-driven service to achieve the most that can be achieved to ensure that people live healthily and do not have to go to the hospital to get services. There is a lot of work to be done and work to work will all partners of health is everybody’s business.

The Observatory Forensic Pathology Centre is commissioned and is fully functional even though there were a few challenges, it is currently in service. The reset agenda was signed in a bilateral agreement based on a multilateral agreement. The multilateral agreement was signed in 2012, and the bilateral agreement in 2020. Health is everybody’s business was signed in 2021, so the issue is that the Department went into a relationship with its partners and challenged them to go beyond what the bilateral agreement entails. Health is much broader than just placing students and paying staff salaries across the two. The universities have been very good at rising to the challenge, and they agreed with the Department on its agenda to focus broadly on a wellness agenda, and an outcomes agenda, and it goes beyond what was signed in the bilateral and multilateral agreements. 

The pressure points in terms of mental healthcare beds were disproportionately felt at Lentegeur Hospital and George Hospital. George Hospital was chosen because of its distance to the metro so the pressure in mental health builds up in that space because it is in a remote area. Lentegeur like the three psychiatric hospitals is a combination of the places at range to Lentegeur have a range of social burden in the geographic areas. Lentegeur is surrounded by a combination of Khayelitsha, Mitchell’s Plain, as well as parts of Klipfontein, as well as parts of the Cape Winelands which have a higher burden than other areas. One of the key challenges is that the accrued mental healthcare burden is driven by social determinants as well as substance abuse, and because of that, there is more pressure at Lentegeur than anywhere else on child and adolescent psychiatry.

Ms Kiewiets referred to page 32 on forensic pathology a total of 52 bodies were unidentified, what pressure did that put on facilities if that amount of bodies were unidentified and how can communities assist? On page 39, the ideal clinic has been very interesting since its inception. Is it still part of the staffs’ key performance areas that part of an ideal clinic is the existence of a functioning clinic committee? The City of Cape Town clinic is also not a part of the ideal clinic, so were the 10 clinics that were incorporated in the previous financial year part of the ideal clinics?

Dr Cloete said part of the main requirements for an ideal clinic is the functioning of a health facility board. The City of Cape Town does ideal clinics and does the office of standards compliance, which follows on from ideal clinics. The biggest hold-up for forensic pathology was DNA analysis and being able to run the fingerprints of the deceased through a DNA database that is held nationally. They persisted until they managed to clear most of the number of bodies that were unidentified. The basis on which they operate is that they do not close a case until they can bring peace to a family. 

The Chairperson asked the members to comment on Part D: Human Resource Management, page 152 to page 206.

Ms Windvogel wanted to know the reasons for the 7% vacancy rate on page 166, and on page 175, she wanted to know the difficulty with filling the pharmacy vacancies.

Mr Klaas said on page 196, the Department said they assist people equally in South Africa, but what do they do in situations where a foreigner needs assistance in a health facility but does not have documentation?

Dr Cloete said the 7% vacancy rate is very low compared to other Departments, but there are two reasons for the vacancy rate. The first one is that in highly specialised areas, the vacancy rate is disproportionately higher compared to other categories of staff, for example in big Hospitals, the vacancy rate for theatre nurses is very high. The other reason is the gap between the post being vacant and it being filled because of the process of advertising for the post, and then conducting interviews until the post is eventually filled. The pharmacist vacancies are the one category where there are more people wanting jobs than what the Department can accommodate and it has always been like that, and the 3.7% vacancy rate for pharmacists is half of the 7% total vacancy rate. It is mainly about getting an individual to work at a remote area.

One of the Department’s philosophies has always been that if someone goes to a hospital, they are assisted according to their need and the services are provided to them, and they do not want foreign nationals to feel that they are targeted by not aiding them or creating barriers for them to access the service. However, there must be a process for the person to be registered in the system, so if the person is not a South African citizen, they are asked for their passport number and their formal papers. If they do not have the formal papers nor a passport, they are not denied services, but if the person requires care beyond emergency services, like surgery, their country of origin is required so the expenditure can be claimed from their country of origin.

The Chairperson asked if the foreign nationals are currently paying for the services because according to the new National Health Insurance (NHI) Bill, they will have to pay for the services.

Mr Kaye said they do bill the foreign nationals, but they also do a means test on the individuals and if they are unable to pay, then they are unable to pay because trying to pursue it with the embassies has been a non-starter.

MEC Mbombo said even with South African citizens, the payment of services also counts based on the income they earn.

The Chairperson asked for a mover for the adoption of Parts A, B, and D of the report.

Mr Fry moved for the adoption and was seconded by Mr Klaas.

The Chairperson thanked the Minister, HOD, and the officials from the Department, and allowed them to exit the meeting as the members continued with internal matters.

Resolutions/Actions

Ms Windvogel asked for the total number of hospitals that are exempted from load shedding.

The Chairperson said he thinks there are 10, but they can request confirmation of that from the Department.

Mr Klaas said regarding the discontinuation of transport services between George and Cape Town, the Department also mentioned several places, so the point must be clarified on whether the services are discontinued only between George and Cape Town or if there are also other places involved.

Mr Fry said on the appointment of additional staff that can deliver mental health services as well as training and equipment of psychologists in rural areas, he needed clarity on the number of staff that will be employed and where they will be allocated.

The Chairperson said the date for the consideration and adoption of the Committee report would be communicated later.  

The meeting was adjourned.