Western Cape Department of Health and Wellness Annual Performance Plan for the 2024/25 financial year

Meeting report

The Chairperson thanked the colleagues for being in attendance, acknowledging that it was their maiden meeting and emphasised the importance of setting a foundation for cooperation and collaboration moving forward. He invited everyone to introduce themselves, starting with himself and proceeding to his left. He then introduced himself as Mr M Booysen (DA), the Chairperson of the Committee and indicated the direction in which the introductions would proceed.

Members present:

• Mr L van Wyk (DA)
• Mr T Walters (DA)
• Ms B van Minnen (DA)
• Ms D Stephens (PA)
• Ms R Windvogel (ANC)

The Chairperson acknowledged the introductions and invited the Member who was attending online to introduce himself.

Mr D Jacobs (NCC) apologised for earlier connection issues and introduced himself as a Member of the Committee.

The Chairperson thanked Mr Jacobs and informed him that there had been concerns about his ability to follow the proceedings due to earlier connectivity issues but assured him that he had the capacity with his device. He requested that he inform them if he encountered any difficulties during the presentations.

Opening remarks

The Western Cape Minister of Health and Wellness, Ms Mireille Wenger, expressed her gratitude to the Chairperson and the Standing Committee, introducing herself as the Provincial Minister responsible for Health and Wellness. She then asked Dr Keith Cloete, Head of Department, Western Cape Department of Health and Wellness (the Department), to make the introductions.

Dr Cloete introduced himself and gave the Committee a brief overview of his role within the Department. He then proceeded to introduce Mr Simon Kaye, Chief Financial Officer (CFO), Western Cape Department of Health and Wellness, and Ms Nonhlanhla Nkosi, Chief Director: Strategy and Health Support, Western Cape Department of Health and Wellness.

The Chairperson thanked everyone for their introductions. He noted for the record that the Minister had to leave by 11:00 and assured the Minister that the meeting would conclude by then, commending the efficiency of the team. He also congratulated the Minister on recent achievements, including the opening of the new Emergency Medical Services Centre in Dysselsdorp, which he noted as evidence of a caring government committed to delivering services to the people of the province.

The Chairperson thanked Mr Jacobs for attending the event in Bellville and acknowledged the other Members for their support, even in spirit. He then handed over to the Minister for her introductory remarks, indicating that they would proceed through the agenda as planned.

Minister Wenger expressed her gratitude to the Chairperson and the Members, stating that they were very happy to kick off the new term in this manner. She looked forward to a constructive working relationship between the Committee and the Department. She indicated that the presentation would primarily focus on the Department's Annual Performance Plan (APP), which would provide insights into the targets set for the current financial year and would cover the strategy guiding the Department, the organogram, the legal framework under which the Department operated, and the intended legislative reviews where the Committee would be a key partner. Additionally, she mentioned that information on the budget, particularly the constraints and their impact on the Department, would be shared. She emphasised the importance of being frank with the Committee about these challenges and expressed eagerness to engage with the Members and address their questions. She then handed over to Dr Cloete to lead the presentation.

Western Cape Department of Health and Wellness 2024/25 Annual Performance Plan presentation

Introduction and acknowledgements

Dr Cloete began by thanking the Chairperson and acknowledging the Minister's earlier remarks. He noted that the primary aim of the presentation was to guide the Committee through the APP document tabled in Parliament, assuming that each Member had access to it. The presentation was structured to highlight key issues within the document, with a particular focus on budget details due to their significance.

Dr Cloete explained that the APP started with an executive authority statement by the former Minister, Dr Nomafrench Mbombo, followed by his accounting officer statement in Part A. Part A focused on legislative policies, strategies, and court rulings guiding the Department's actions. Part B detailed the Department's strategic focus, including its vision, mission, values, and analysis of the external environment. Part C outlined the Department's operations within nationally determined programmes (programmes one to eight). Each programme included outcomes, outputs, targets, planned performance, and associated risks.

A significant portion of the document was dedicated to infrastructure projects and public-private partnerships. Part D contained technical indicator descriptions for each of the Department's indicators, reflecting the comprehensive nature of their work.

Vision, mission, and values

The Department's vision was centred on providing access to person-centred quality care. Dr Cloete noted that they were in the final year of a five-year cycle, and the vision would likely be adapted in the next cycle. The mission aimed to provide equitable access to quality health services in partnership with relevant stakeholders within a balanced health system. The values of the Department included innovation, care, competence, accountability, integrity, responsiveness, and respect, the latter being a unique addition to the health sector.

Departmental structure

Dr Cloete presented the organogram of the Department, describing it as the leanest head office structure for a health department in the country. The structure was divided into three broad streams reporting directly to him. Ms Marika Champion, Director of Communications, Western Cape Department of Health and Wellness, and Mr Kaye, were mentioned as key figures. The structure included units for Infrastructure, Supply Chain, Finance, and People Management.

Healthcare services and priorities

The province’s healthcare services catered to 7.4 million residents, 75% of whom were uninsured. The provincial priority for the coming year was expanding the immunisation programme in response to the decline in vaccine coverage post-Covid-19. The Department's community-oriented primary care approach focuses on collaboration, community engagement, and responding to local needs through area-based teams.

Strategic objectives

The province's five strategic objectives under Healthcare 2030 included reducing infectious diseases like HIV and TB, improving healthy lifestyles, addressing injuries and violence, improving maternal and child health, and tackling the mental health burden. The strategy would eventually evolve into a 2050 plan aimed at creating a high-performance provincial health system.

Challenges and focus areas

Dr Cloete highlighted the significance of addressing chronic diseases, such as diabetes, and the challenges posed by recent global issues, such as the insulin pen production shortage. He emphasised the importance of maternal and child health, particularly the first 1 000 days of a child's life, as a critical period for reducing inequality. He also acknowledged the need for environments that supported individuals with HIV, TB, and mental health issues, noting that living conditions significantly impacted health outcomes.

Budget overview

Mr Kaye provided an overview of the Department's budget, noting that the current budget stood at approximately R30.5 billion, representing a 2.21% increase from the previous year. However, this increase fell short of matching inflation, posing significant challenges for financial planning and service delivery. He explained that the Department was starting the fiscal year with a baseline deficit of R807 million, necessitating a dual approach of seeking additional funding and reducing costs.

Cost-saving and revenue measures

The Department had developed a comprehensive framework for fiscal consolidation, focusing on efficiency targets, service redesign, and policy enablement. Mr Kaye discussed cost-sharing initiatives and partnerships with private sector entities and educational institutions. He also highlighted the importance of pooling resources across the healthcare system to enhance efficiency and the Department's efforts to incorporate equity into its funding models.

Conclusion and strategic focus

Mr Kaye stressed the importance of adaptability and strategic planning in navigating the current financial constraints. The Department was actively lobbying for increased allocations and exploring additional revenue streams. Despite the challenges, the Department airmed to sustain and enhance its service delivery through a combination of funding acquisition, cost-efficiency measures, and collaborative partnerships.

Dr Cloete provided a practical example of cost-sharing in the healthcare system, highlighting an initiative involving orthopaedic surgeries at Freudenburg Hospital, supported by private volunteers, which enhances access to healthcare services without delays.

The presentation underscored the need for innovative solutions and collaboration in addressing the Department's financial and operational challenges while ensuring equitable and quality healthcare services for all residents of the Western Cape.

(See attached presentation for further details)

Discussion

The Chairperson expressed gratitude to the Minister and Dr Cloete, acknowledging the team’s contributions and the mixed results they had presented. He then opened the floor for questions and comments.

Mr van Wyk thanked the Department for the valuable review, noting its importance in highlighting the hard facts and realities within the sector. He appreciated the Department's efforts to address these issues but indicated that more work would be required. Drawing from his municipal experience, he likened the situation to an urgent call for assistance, suggesting that a broader strategy and better documentation of improvements might help secure international support. He also emphasised the need for collaboration with the private sector and a long-term approach to resolving the challenges, acknowledging that the national budget would require time to adjust. He expressed concern over the difficulty of filling positions and the current financial outlook, urging a focus on macro issues to navigate the financial year better.

Mr Walters complimented the clarity of the presentation and the ease with which it communicated the indicators. He suggested exploring transversal aspects, such as linking demographic data with trauma and dropout rates, and encouraged investigating cost drivers among suppliers. He expressed concern over the financial difficulties related to accounts payable and receivable and warned of the challenges of managing these issues. He also highlighted the importance of understanding the cost drivers for suppliers, especially if the Department was exploring public-private partnerships. He further enquired about the retention rate for staff trained through bursaries and the training model for nurses, expressing interest in understanding how these elements could serve as potential revenue streams.

Ms van Minnen expressed her appreciation, stating that most of her concerns had been addressed. She raised two additional points regarding transversal issues and data. First, she enquired about the issue of fetal alcohol syndrome (FAS) disorder, noting that despite extensive discussion over the years, there had been limited control of it, even in mild cases, and of its impact on violence prevention. This topic was of particular interest to her.

Secondly, she mentioned a concern related to regional hospitals dealing with mental health patients. She noted a previous requirement for a 72-hour hold before patients could be moved, which affected bed availability, especially when patients might leave after 24 or 48 hours, only to re-enter the system later. She highlighted the operational challenges this posed for regional hospitals.

Ms Stephens stated that there was a significant problem in her area, where there appeared to be no detailed maintenance plan, only a focus on technical efficiency. She highlighted that due to rainfall, several day hospitals had been flooded, particularly affecting citizens' access to the hospitals. She mentioned the faulty stormwater pipes and poor maintenance at various day hospitals, specifically pointing out the one in Kraaifontein. She expressed concern about the long waiting times for appointments and noted that there were specific days when entry into the hospital was not possible. She then enquired about the plans in place to address these issues.

Ms Windvogel thanked the Chairperson and welcomed the presentation delivered by Minister Wenger, and her team. She extended her appreciation for the Department's proactive management of the budget deficit, particularly how they had prepared for potential worsening conditions, such as patients being accommodated on the floors. She expressed her admiration for the Department’s approach and took the opportunity to congratulate Minister Wenger on her achievements.

She acknowledged the numerous challenges faced by the Department, including ageing infrastructure in hospitals and delays in rebuilding, specifically mentioning the GF Jooste Hospital. She expressed confidence in Minister Wenger’s experience and academic background, hoping it would be beneficial in addressing these concerns. She was eager to learn about Minister Wenger’s vision for the Department and their strategy for tackling these issues.

Regarding the Department’s employment equity targets, she enquired whether these targets were being successfully met and, if not, what strategies were in place to achieve them. She also requested information about the current vacant positions within the Department, how long these positions had been vacant, and the latest updates on the recruitment process.

She then referred to slide 6 of the presentation, where she mentioned the 564 service points identified by the Department. She highlighted Khayelitsha District Hospital, noting that several challenges had been identified during a visit last year, including unfunded mandates, with the hospital accommodating patients from Eerste River. She was particularly concerned that the rapid population growth in Khayelitsha had not been met with a corresponding budget increase. She mentioned that the hospital management had requested an additional R150 million to ensure optimal and effective operations and asked Minister Wenger to shed light on this issue.

Finally, she referred to slide 7, and asked about the status of the monkeypox outbreak, which had been declared a global health emergency, including in Africa. What was the current status of the monkeypox outbreak both within the province and across the country? What measures had been and were being put in place to ensure preparedness and readiness to contain its spread in the province?

The Chairperson mentioned that the Premier of the Western Cape, Mr Alan Winde, had consistently boasted about robotics. He noted his surprise that no Member had mentioned or raised this. He asked the Department to advise the Committee on what was happening in the robotics space within the health and wellness field.

Responses

Minister Wenger thanked the Chairperson and mentioned the need to tag team on certain issues. She proposed that Dr Cloete could take the first set of questions, and she would address the questions directed at her. Alternatively, they could switch roles depending on what Dr Cloete preferred.

Dr Cloete responded by expressing gratitude for the engagement with the content and intent of their presentation. He noted that they had spent just over an hour presenting and could have used an additional three hours to cover everything thoroughly. He acknowledged the compliment on their effort to present the information coherently. He highlighted the importance of creating a solid financial case and suggested defining the goals more clearly to effectively leverage funds.

He appreciated the approach to repurposing the issue and explained that the Violence Prevention Unit was placed in the Department due to its data capabilities. This data helped pinpoint the geographical areas and factors contributing to violence, such as school dropout rates and alcohol abuse. Based on this data, he emphasised the need to make a cogent case for necessary actions.

He also acknowledged the concern about accruals, agreeing that escalation could be problematic. He noted the importance of articulating this risk more clearly to manage resources effectively and prevent financial issues from worsening.

Regarding suppliers, Dr Cloete suggested exploring options like discounts for prompt payments and considering how to work with suppliers to optimise resources.

He mentioned that the data on birth rates, dropout rates, and accommodation helped refine business strategies and improve outcomes. Dr Cloete highlighted the significant impact of FAS and stressed the importance of addressing alcohol availability and its long-term societal effects as part of their strategy to reduce violence and improve public health.

Dr Cloete addressed the issue of the regional hospital's capacity and mental health services, noting that mental health conditions, including acute psychiatric manifestations, contributed to hospital pressure. He highlighted that substance abuse, including alcohol and other drugs, exacerbated these issues. Dr Cloete called for effective measures to address these drivers. He discussed the damage caused by recent floods, noting that they had assessed and quantified the damage to health facilities and had submitted a request for disaster relief. He mentioned that they were implementing measures to prevent future flooding disruptions but acknowledged the pressure on the maintenance budget and the challenge of balancing preventative and corrective maintenance.

He continued by updating the outbreak status, stating that they had been monitoring all outbreaks in the province since Covid-19. He confirmed two cases of monkeypox and mentioned a focus on HIV patients with low CD4 counts, encouraging them to return to the system and adhere to antiretroviral therapy to improve their immunity. He highlighted that this was the largest group affected. He noted that a significant issue currently, which was also being addressed internationally, involved the availability of vaccines and determining who would have access to them. He observed that the situation was similar to the pattern seen with Covid-19 vaccines, with competition between countries for access. Despite this, he assured that their surveillance systems and response mechanisms were in place to effectively manage outbreaks, similar to responses for diseases like Congo fever or typhoid. He emphasised that their preventive system included recommendations to encourage people to improve their immunity and targeted vaccination once vaccines became available. He assured that their programme was well-defined and that the risk in the Western Cape was currently relatively low. He added that if there were more cases in specific areas, they would raise their risk rating and respond as they would in normal settings.

He further explained that College Hospital served as an interesting case study for a new approach within their Department, called understanding ecosystems. He described how the hospital was part of a larger ecosystem, Metro East, which included surrounding areas like Helderberg and Tygerberg. He mentioned that data showed higher trauma and mental health issues at College Hospital due to social conditions. The ecosystem approach ensured that resources were allocated effectively within this broader system. Dr Cloete stressed that the resources needed for College Hospital were specific to its needs within the ecosystem. A balanced response was necessary to avoid overwhelming the healthcare system with demands for 24-hour facilities across all communities. He acknowledged the pressures faced and assured the Committee that they were addressing these within the context of the ecosystem.

Regarding staffing, Dr Cloete noted that there were currently only three vacancies in senior management, which were actively being filled. He explained that two vacancies in corporate services had been advertised but no suitable candidates had been found, and these positions were being re-advertised. He mentioned a vacancy for information and communication technologies (ICT) that was awaiting acceptance, and another potential vacancy due to a retirement in the West Coast. Dr Cloete assured the Committee that the recruitment and selection process was ongoing to address these needs.

Finally, he addressed the issue of innovation and service redesign. He acknowledged the importance of being explicit about innovations and their impacts. He highlighted that robotics was just one of many innovations and that they needed to be more detailed about what had been tried and its effects.

Minister Wenger began by expressing her gratitude for the comments and support received during the presentation. She shared her experience on her recent visit to George Hospital, where she encountered an innovative robot linked to a specialist at Groote Schuur Hospital. She noted that the robot, which she could not recall the name of, was capable of navigating around the hospital and facilitating teleconsultations with the specialist. This technology allowed for more efficient patient consultations without requiring specialists to travel, which she described as quite extraordinary and very useful.

She then extended her thanks to all the Members for their comments and understanding of the complexities faced by the Department. She acknowledged the multifaceted nature of the issues and emphasised the need for a collaborative approach from both society and government to address them. She recognised that while formal budgeting processes existed, broader economic factors, including South Africa’s fiscal emergency and lower tax revenues, also played a significant role. However, she highlighted opportunities for partnerships and efficiency gains as crucial for solving these problems.

Regarding ministerial priorities, she addressed the question about developing the provincial strategic plan. She explained that the plan, which included policy strategies and budgets, was currently under development and would be ready for launch on 1 April 2025. She indicated the plan would be discussed in the legislature in March 2025. She expressed her willingness to share her focus areas, which were still under development and may change. Her priorities included a strong emphasis on children's well-being, particularly addressing malnutrition and low birth weight in children under five. She highlighted that stunting was a significant factor (60%) in child deaths and could lead to long-term negative outcomes, such as poorer educational attainment and increased poverty. She stressed the importance of breaking these negative cycles.

Further, she discussed the Capital Build programme, focusing on accelerating the construction of both Klipfontein and Belhar regional hospitals. She stressed the importance of understanding and improving mechanisms to speed up these projects, as they were crucial for better healthcare provision, reduced waiting times, and overall ecosystem improvement.

Minister Wenger also addressed violence prevention, linking it to her background. She planned to focus on making communities safer by partnering with mobility and police oversight departments. She acknowledged the need for both immediate and long-term prevention strategies to reduce violence.

Finally, she discussed expanding access to healthcare and the importance of a sustainable budget for the Department. She emphasised the need to explore various mechanisms to increase healthcare access, including partnerships with non-governmental organisations and the private sector. She concluded by promising to share her ministerial priorities with the Committee once they were finalised and after undergoing the necessary processes.

Further discussion and responses

Ms Windvogel asked for an update on the Violence Prevention Unit, specifically enquiring whether all positions had been filled and what tasks had been accomplished so far. She requested this information to gain a clearer understanding of the unit's current activities.

In response, Dr Cloete provided an update on the Violence Prevention Unit. He stated that the unit was now staffed with a director, a deputy director, and two to three additional staff members, making a total of about six to seven people in the central unit. The unit employed safety coordinators who were not part of the central unit but worked within the decentralised system. Those five safety coordinators had been appointed in rural districts, with each having been assigned to specific towns, namely: George; Beaufort West; Caledon; Wellington; and Swartland.

He added that in metropolitan areas, one coordinator was focusing on Atlantis, two coordinators were covering the Tygerberg northern areas, including Kraaifontein, Delft, and Bishop Lavis, and two were working in the Cape Flats, including Gugulethu, Hanover Park, Mitchells Plain, and Nyanga. Dr Cloete also mentioned that two coordinators had recently started work in the eastern areas, focusing on Harare and Site B.

Dr Cloete highlighted that the primary activities of the coordinators involved building relationships and coordinating local efforts. They were tasked with integrating various aspects of violence prevention, including law enforcement, social interventions, and urban design improvements. He expressed enthusiasm about the progress made and anticipated positive results as the unit’s structure was now established.

The Chairperson conveyed to Minister Wenger and her team that it was evident they could count on the Committee's support. He noted that the meeting was on schedule and granted permission for the Minister and her staff to be excused. He then announced a 10-minute break for the Members.

Committee matters

Draft Committee programme

The Chairperson thanked everyone and indicated that the session was resuming. He then asked the Members if any resolutions were to be formulated from the presentation or if anyone had suggestions. He mentioned that there appeared to be numerous opportunities within the Department related to internal operations, which could be explored further. He noted that the draft Committee programme would be an interesting one, with potential for visitations. He questioned whether specifics were needed or if the Committee should adhere to the draft programme as it evolved.

Mr van Wyk proposed that the Committee should stick to the existing programme. However, he emphasised the importance of being mindful of the fiscal constraints and suggested a proactive approach to address the challenges. He acknowledged the severity of the budget cuts, equating them to significant financial reductions, and expressed concern over the impact of these cuts on the overall situation. He suggested that while the programme was in place, there would be a need to follow through on the necessary actions and address issues on platforms outside of the Committee.

The Chairperson acknowledged Mr van Wyk’s input and noted that the Committee had already addressed an item contained in the programme. He confirmed that the programme would remain a living document, subject to changes as needed.

Adoption of minutes

Minutes dated 04 July 2024

The Chairperson then moved on to the adoption of the minutes from the meeting held on 4 July 2024. He requested a proposal for the adoption of the minutes, and Mr van Wyk offered to propose to adopt.

Ms Stephens seconded the proposal.

The minutes were accordingly adopted.

The Chairperson then asked if any other matters needed to be addressed.

Unannounced visits request

Ms Windvogel requested that oversight visits be unannounced to ensure authenticity, expressing concern that advance notice might lead to preparatory measures that could affect the outcomes of the visits.

The Chairperson sought clarification, asking if she proposed that all visits should be unannounced.

Ms Windvogel responded that the decision should be situational, depending on the specific visit.

The Chairperson agreed to consider the suggestion and stated that the Committee would decide whether visits should be announced or unannounced as specific visitation points were determined.

Mr Walters expressed satisfaction with the responses and indicated that he was content with the information provided, though he had not suggested it as a resolution but rather sought to understand the thinking behind it.

The Chairperson affirmed his support and agreed to facilitate the provision of the necessary information.

Ms Nomonde Jamce, Procedural Officer, Standing Committee on Health and Wellness, Western Cape Provincial Parliament, outlined that information would be provided to Members and noted the addition of Khayelitsha and Groenfontein to the list of unannounced visitations. She also mentioned a joint visit by the Standing Committees on Social Development and Health to the Southern Cape, provisionally scheduled from 30 September to 4 October 2024, pending approval. This joint visit would allow coverage of both committees' areas of interest.

The Chairperson explained that the joint visit was proposed because some Members served on both committees, making it more efficient to cover both areas in a single visit. He concluded the meeting by expressing gratitude and announcing its adjournment.

The meeting was adjourned.